Table 1 Summary of results
General views on defensive practice | ||
|---|---|---|
Defensive practice is: of moderate to significant concern in Australian healthcare underpinned by anxieties about “missing something” and “getting into trouble” influenced more by the fear of peer criticism than the threat of formal legal sanctions just one of multiple drivers of low value care (LVC) |
Domain | Factors | Strategies |
|---|---|---|
Specific factors that influence defensive practice and ameliorative strategies | ||
Knowledge | Poor knowledge of the law Insufficient understanding of harms of LVC at patient and system levels | Education on core legal standards and requirements (e.g. law requires reasonable care, not perfect care) Education to improve knowledge of LVC and recognition of downstream harms |
Skills | Inadequate skills in clinical reasoning and patient communication Time constraints and patient characteristics can hinder application of skills | Training and mentorship, especially for junior doctors, in clinical reasoning and communication Recognise value of investing time to avoid LVC Support patients to develop health literacy skills |
Professional role and identity | Professional identity as a “doer” leads to pro-intervention bias LVC perceived as reassuring anxious patients | Reinforce patient safety as core to physicians’ role and identity Challenge habitual practices that are of low value |
Beliefs about consequences | Belief that tests and procedures will protect against negative outcomes Risks of under-investigation seen as higher than risks of over-investigation | Increase awareness of harms of over-investigation, including broader recognition of what ‘harm’ can mean for patients (e.g. physical and emotional toll, time burden, financial costs) |
Environmental context and resources | Inadequate organisational support Poor processes for managing complaints and investigations | Foster collegiality and openness Ensure timely and supportive processes that address environmental context |
Social influences | Desire to avoid peer criticism Conformity to culture of defensive practice and over-investigation | Challenge norms of ‘just in case’ interventions Avoid ‘blame-and-shame’ culture of practice |
Emotions | Fear of ‘missing something’ Takes bravery to resist LVC | Strengthen tolerance of uncertainty Leadership and support from senior clinicians |