Defensive medicine: A symptom of uncertainty?

Finucane, Laura; Greenhalgh, Susan; Mercer, C. F.; Selfe, James

doi:10.1016/j.msksp.2022.102558

Cited by 9 publications

(6 citation statements)

References 33 publications

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“…Although it is difficult to find accurate data on the subject, it is common to consider that tests carried out for defensive purposes are of the order of 30% of all tests performed 93 which adds up to $25.6 billion to the overall annual medical costs in the United States (i.e., 34% of annual health care costs 94 ), and up to 13 billion euros in Italy (i.e., 10% of overall health care spending 95 ). We suggest that this can be partly attributed to the IU and encourage consideration of this variable in medical decision‐making research 96 …”

Section: Discussionmentioning

confidence: 89%

“…We suggest that this can be partly attributed to the IU and encourage consideration of this variable in medical decision-making research. 96 To conclude, critical thinking, clinical reasoning and IU seem to be three highly interrelated concepts that we need to study intensively. The COVID-19 crisis has reminded us how important health is and that health care teams are human.…”

Section: Discussionmentioning

confidence: 99%

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Impact of uncertainty intolerance on clinical reasoning: A scoping review of the 21st‐century literature

Brun

Zerhouni

Akinyemi

et al. 2022

Evaluation Clinical Practice

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Rationale, Aims and Objectives Clinical reasoning is currently extensively studied to find out how to make proper diagnoses. Literature indicates that intolerance of uncertainty (IU) may have a strong negative impact on clinical reasoning. We summarize the various consequences of IU on clinical reasoning. Methods A scoping review was conducted using relevant keywords to scientific databases (i.e., Google Scholar, Medline, PsycINFO and PBSC) from September to November 2021. Complementary research included relevant articles and articles retrieved through Google Scholar's alert system. We included articles about healthcare professionals as defined by the French Public Health Code (As defined here: https://www.vie-publique.fr/fiches/37855-categories-de-professionnels-de-sante-code-se-la-sante-publique), and articles reporting on the impact of IU or uncertainty management on clinical reasoning. Results We retrieved 1853 articles, of which 8 were kept for final analysis considering our inclusion criteria. Two behaviour categories were affected by uncertainty intolerance: investigative and prescriptive behaviours. Regarding the investigation process, mismanagement of uncertainty appeared to lead to reasoning bias, potentially resulting in diagnostic errors. IU was associated with withholding information, more referrals to peers and less use of new medical interventions. Regarding prescription behaviours, IU among health professionals could lead to overprescribing unnecessary or dangerous tests. IU was also associated with more antibiotic prescriptions for conditions where antibiotics are to be used carefully. Conclusion Few studies have yet addressed the impact of IU on clinical reasoning. IU's influence is primarily observed on investigative and prescribing behaviours. More studies are needed to fully understand the impact of IU on clinical reasoning itself, and not only on practical consequences.

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Section: Discussionmentioning

confidence: 89%

Section: Discussionmentioning

confidence: 99%

Impact of uncertainty intolerance on clinical reasoning: A scoping review of the 21st‐century literature

Brun

Zerhouni

Akinyemi

et al. 2022

Evaluation Clinical Practice

View full text Add to dashboard Cite

show abstract

“…The use of investigations is a common method to guide decision‐making when faced with uncertainty, but this can lead to an over‐cautious approach or ‘defensive medicine’ (Vento et al., 2018). The worry of missing serious pathology and concerns related to litigation has been proposed as a potential reason for over‐investigating in the MSK FCP role (Finucane et al., 2022; Paling & Hebron, 2021). The findings from this research offer some support to this with similar experiences noted by the participants, illustrating the potential for a defensive medicine culture amongst MSK FCP's.…”

Section: Discussionmentioning

confidence: 99%

“…Diagnostic uncertainty relates to the necessity for broader medical knowledge beyond the MSK system (Langridge, 2019). Uncertainty may also contribute to over‐investigations (Finucane et al., 2022), concerns related to missing serious pathology and increased potential for litigation claims amongst FCPs (Goodwin et al., 2021; Greenhalgh, Selfe, & Yeowell, 2020).…”

Section: Introductionmentioning

confidence: 99%

The experiences of uncertainty amongst musculoskeletal physiotherapists in first contact practitioner roles within primary care

Ingram

Stenner

May

2023

Musculoskeletal Care

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AimThe aim of this research was to explore the experiences of uncertainty amongst Musculoskeletal First Contact Practitioners working in primary care.BackgroundThe Musculoskeletal First Contact Practitioner role involves advanced physiotherapists providing an alternative to the GP by acting as first point of contact for people presenting to primary care with musculoskeletal conditions. Limited research into the role exists but the first‐contact aspect, clinical complexity and time pressures are deemed to contribute to uncertainty within the role.MethodA qualitative research design was undertaken using a hermeneutic interpretative phenomenological approach. Data was collected using semi‐structured interviews with subsequent thematic analysis of the data.FindingsEight participants working as Musculoskeletal First Contact Practitioners across England were recruited using purposive sampling. Five themes were identified: (1) Role clarity within primary care, (2) Burden of responsibility, (3) Preparedness for the primary care environment, (4) ‘I'm not really sure how long I am going to stay in this role’, (5) Mitigating uncertainty.ConclusionThis study demonstrates the multifaceted phenomenon of uncertainty amongst Musculoskeletal First Contact Practitioners. Uncertainty appeared to be influenced by the primary care environment, preparedness for the role and perceived burden of responsibility. Diagnostic uncertainty was prevalent with concerns of missing serious pathology evident. The impact of uncertainty on wellbeing was linked to possible burnout and retention issues. Consultation approaches, access to support networks and a cultural shift in tolerating uncertainty were reported to mitigate uncertainty. Further research into possible differences in experiences related to employment models appears warranted.

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“…The aim of our work was to analyze the correlation between the number of performed CT scans of the head and the radiological results in the search for misuse of imaging examinations. Multiple studies have proven that this is a common problem, but few current reports exist on the above-mentioned issues in radiology [ 24 , 25 , 26 ]. In 2013, it was estimated that around a third of all CT and MRI scans worldwide were considered misused [ 8 ].…”

Section: Introductionmentioning

confidence: 99%

The Assessment of the Rationale for Urgent Head CT—Comparative Analysis of Referrals and Results of Examinations without and with Contrast Enhancement

et al. 2022

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The study analyzes the correlation between the indications and results of head CT examinations in search of evidence of the excessive use of this diagnostic method. In total, 1160 referrals for urgent head CT were analyzed retrospectively, including the following parameters: patients’ sex and age, type of scan (C−, C+, angio-CT), description of symptoms and presence of diagnostic target. Pathologies identified by the radiologist were assigned to four classes, regarding the severity of diagnosed conditions. The analysis of the CT results has shown that over half (55.22%) of the examinations revealed no deviations or showed chronic, asymptomatic lesions. As many as 73.71% referrals constituted group 0 in terms of the lack of a diagnostic target of a specific pathology. The presence of specific clinical targeting in a referral correlated significantly with a higher frequency of acute diagnosis. Contrast-enhanced follow-up examinations allowed the unequivocal classification of patients into extreme classes (I or IV) and accurate identification of patients requiring urgent or chronic treatment. Excessive use of diagnostic imaging is harmful, not only to patients, who often are unnecessarily exposed to radiation, but also to the quality of healthcare, since it increases the costs and radiologists’ workload.

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Defensive medicine: A symptom of uncertainty?

Cited by 9 publications

References 33 publications

Impact of uncertainty intolerance on clinical reasoning: A scoping review of the 21st‐century literature

Impact of uncertainty intolerance on clinical reasoning: A scoping review of the 21st‐century literature

The experiences of uncertainty amongst musculoskeletal physiotherapists in first contact practitioner roles within primary care

The Assessment of the Rationale for Urgent Head CT—Comparative Analysis of Referrals and Results of Examinations without and with Contrast Enhancement

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