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Defensive Medizin – unnötige Medizin?

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Abstract

Es lässt sich oft nicht klar definieren, wo «vorsichtige Medizin» aufhört und die medizinisch nicht mehr gebotene «defensive Medizin» beginnt. Es erscheint nicht zielführend, diese Grenze mit messerscharf formulierten Richtlinien ziehen zu wollen. Vielmehr müssen die Rahmenbedingungen des Systems so gestaltet sein, dass medizinisch sinnvolle Massnahmen nicht aus budgetären Erwägungen unterlassen und rein defensive Massnahmen dagegen aus Furcht vor rechtlichen Konsequenzen ergriffen werden.
ARTIKELSERIE 814
Therapien, um das Risiko einer straf- oder haftpflichtrechtlichen Verantwortung zu reduzieren
Defensive Medizin
untige Medizin?
Johann Steurera, Thomas Gächterb
a Horten Zentrum für praxisorientierte Medizin und Wissenstransfer, Universität Z ürich
b Rechtswissenschaftliches Institut, Universität Zürich


   
  

  

 
  

     


    
 
 

  
 


    





    

   

   


    


   

  
  
  

Unterschiedliche Motivation
r medizinisches Handeln
 
 
    
 
    
  

 





    
   
  



  

SWISS MEDICAL FORUM – S CHWEIZERISCHES MEDIZIN-F ORUM 2015;15(37):814–816
ARTIKELSERIE 815
   

 
  
 




  
   

   
  
 



  

Eine verhrerische Kombination




    





     



  


  

  



   

   

     

 

Defensive Medizin auch in der Schweiz
ein Thema

 
    



    
  

   

   




    



    


    

 
 
   
   

     
 


   
 

 


 
  


In einer Umfrage beurteilten die Ärzte fast ein
Drittel ihrer Verordnungen im weitesten Sinne
als defensive Medizin
SWISS MEDICAL FORUM – S CHWEIZERISCHES MEDIZIN-F ORUM 2015;15(37):814–816
ARTIKELSERIE 816
Juristisch zentral: der informed consent
  

informed consent

   
    
  
    





  

    
     

    

    


 

 
  

   
 




  
    
  



  





Wo liegt die Grenze zwischen «vorsichti-
ger Medizin» und «defensiver Medizin»?
   

 


   
 
  
   
 


   
    




    

  

    

 
      

   
 


    


    
 



 

Disclosure statement


Titelbild

Literatur











Ein gut aufgeklärter Patient, der um die Vor- und
Nachteile zusätzlicher Massnahmen weiss,
wird sich häug gegen rein defensive Massnah-
men entscheiden
SWISS MEDICAL FORUM – S CHWEIZERISCHES MEDIZIN-F ORUM 2015;15(37):814–816
LITERATUR / RÉFÉRENCES Online-Appendix
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9 Lobsiger M, Tondelli T, Kägi W, Felder S, Pfinninger T.
Auswirkungen von SwissDRG auf die ambulante
Versorgung. Schweizerische Ärztezeitung. 95(39):14434.
SWISS MEDICAL FO RUM
... However, studies emphasized the importance of a positive, trusting physician-patient relationship, especially to mitigate the effects of legal fears and defensive medical behaviour [17]. Moreover, a positive physician-patientrelationship was seen as the key to differentiate between "cautious" medicine and purely defensive medicine [18]. Unfortunately, comparative data regarding the question of how many physicians have already been sued under civil law is not yet available in Germany. ...
Article
Full-text available
Background Medical decisions are influenced by a variety of factors also by legal requirements and feelings of uncertainty, which results in the term defensive medicine. The aim of the study was to evaluate the influence of fears of perceived legal consequences on the practice of defensive medicine from the perspective of German general practitioners (GPs). Methods A cross-sectional study was performed from April to May 2022. GPs were invited via an e-mail newsletter of the Institute for Continuing Education in Family Medicine in the German Association of General Practitioners and via an online platform of the German College of General Practitioners and Family Physicians. The evaluation of legal fears, the general assessment of defensive medicine and reasons for and the frequency of defensive medical measures were surveyed in this study. Beside descriptive analyses, a stepwise linear regression analysis was used to explore potential associations between for the primary outcome variable ‘fears of legal consequences’ on the practice of defensive medicine. Results 413 general practitioners with an average age of 50 years (51% female) responded. The majority rated their fears of legal consequences as low to average whereas for almost a third (27%, n = 113) the fears were strong to very strong. Regarding legal fears, the physician-patient-relationship played a fairly to very large role for 48% (n = 198) of the respondents. One third estimated the probability of being sued civilly in the next 10 years as rather high to very high. 47% (n = 193) of the participants assumed that the risk of being sued could mostly to very much be reduced by defensive medicine. Legal self-protection was for 38% of the responders (n = 157) quite frequently to very frequently a reason for acting defensively. Consequently, half of the respondents stated that they performed unnecessary laboratory tests at least once per week and 40% indicated that they referred patients for radiological diagnostics without medical indication once per month. Conclusions As legal fears have an influence on medical practice and legal self-protection being a frequent reason for defensive behaviour, understanding and knowledge of the law should be improved by legal education at university and further training of post-graduate trainees and practicing physicians should be implemented. Additionally, a more in-depth enlightenment of society about the phenomenon of Protective and Defensive Medicine and its consequences could be a possibility to decrease the perceived fears of legal consequences on the physicians’ side.
... Die Intention dieser Handlungen liegt allein darin, rechtliche Sicherheit zu erlangen. Beispiele hierfür können unnötige Röntgenuntersuchungen, aber auch nicht notwendige Transporte sein(Steurer & Gächter, 2015).Die nun in ihrer Ausbildung nicht auf diese Situationen vorbereitete NotfallsanitäterIn steht in der Praxis also häufig vor der Frage, wie mit subakut erkrankten oder verletzten PatientInnen zu verfahren ist. Faktisch übernimmt sie somit eine Art Lotsen-und Filterfunktion, um PatientInnen in adäquate Versorgungspfade zu führen. ...
... Dieses Vorgehen beruht alleine darauf, rechtliche Sicherheit zu erlangen. Dies kann beispielsweise die unnötige Herzkatheteruntersuchung oder der nicht notwendige Transport ins Krankenhaus sein [2]. ...
Article
Das rettungsdienstliche Einsatzgeschehen wird immer komplexer. Daraus resultiert, dass Entscheidungen sich nicht mehr linear aus den Untersuchungs- und Anamneseergebnisse ergeben, sondern verschiedene Faktoren zu berücksichtigen sind. Der Artikel stellt Clinical Reasoning als Instrument der Entscheidungsfindung sowie Shared Decision Making u.a. als Instrument der rechtlichen Absicherung vor. Beide Ansätze ermöglichen es, Erfahrung sowie Algorithmen im rettungsdienstlichen Alltag in Einklang zu bringen.
... Kürzlich mahnte ein Redaktor des Swiss Medical Forum [2] ebenfalls, dass die Medizin keine Wissenschaft sei. Und in vier Artikeln wurden in der folgenden Ausgaben des SMF mehr oder weniger bekannte Schwierigkeiten dargestellt, mit denen die praktizierte Medizin konfrontiert ist: Schäden durch Screenings [3], unnötige defensive Medizin [4], irreführend konzipierte Wirksamkeitsstudien [5] und die Tatsache von Unter-und Überversorgung [6]. ...
... Kürzlich mahnte ein Redaktor des Swiss Medical Forum [2] ebenfalls, dass die Medizin keine Wissenschaft sei. Und in vier Artikeln wurden in der folgenden Ausgaben des SMF mehr oder weniger bekannte Schwierigkeiten dargestellt, mit denen die praktizierte Medizin konfrontiert ist: Schäden durch Screenings [3], unnötige defensive Medizin [4], irreführend konzipierte Wirksamkeitsstudien [5] und die Tatsache von Unter-und Überversorgung [6]. [9]. ...
Article
Rationale, aims and objectives: Medical decision-making processes in primary care are influenced by defensive medical practice. This involves a high possibility for negative consequences on many levels, for example, patient's health, health care system costs and a crisis of trust in the patient-doctor relationship. Aim of this review was to identify factors of defensive medicine-based decision-making in primary care. Methods: This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews (PRISMA-ScR) guidelines and included systematic research on MEDLINE, Google Scholar and two German databases for additional grey literature. References provided further literature. Articles in English and German published from 1 January 1982 to 15 June 2022 were assessed. Results: From 911 publications screened, 13 publications [6 qualitative studies and 7 quantitative (3 cross-sectional) studies] were included. In these, four main categories of factors influencing defensive medical practice were identified: (social) media, patients adopting a consumer attitude, health care system based working conditions and physician's tolerance for uncertainty. Pressure deriving from these four different sources is exerted on the general practitioner and may result in a defensive medical decision behaviour. Conclusions: Four categories on influencing factors of defensive medicine could be identified. Strategies to tolerate uncertainty should be trained in under- and postgraduate training.
Article
Full-text available
The reimbursement system SwissDRG sets incentives for hospitals and providers to treat patients in a cost-efficient way. Arising conflicts between the commitment to the patient's well-being and the economic interests of the hospital can lead to an impairment of quality and equity of health care. We developed and used a monitoring tool to evaluate ethically relevant aspects related to DRGs by surveying physicians. We surveyed a random sample of physicians working in Swiss hospitals, exploring potentially positive and negative effects of DRGs on patient care. A total of 382 physicians completed the questionnaire (response rate 47%). More than 90% judged quality of health care "very good" or "rather good", and 83% were satisfied with their job. The majority of physicians gave more consideration to economic issues in their clinical practise than they would have liked and had experienced various forms of over- and under-provision over the past six months. Overall, physicians considered patient-orientation deteriorating since the introduction of DRGs with no gains in efficiency. Professional principles could not be applied in all instances. Two years after the introduction of SwissDRG the quality of patient care and the job satisfaction is rated as good by most physicians. However, quality of care could be seriously compromised if more economic pressure is put on physicians in the future. Careful monitoring is needed to ensure that the needed focus on cost-containment and sustainability does not come at the expense of the high performance of the Swiss health care system.
Article
The overuse of tests and procedures because of fear of malpractice litigation, known as defensive medicine,¹ is estimated to cost $46 billion annually in the United States,² but these costs have been measured only indirectly. We estimated the cost of defensive medicine on 3 hospital medicine services in a health system by having physicians assess the defensiveness of their own orders. We hypothesized that physicians who were concerned about being targeted by litigation would practice more defensively and have higher overall costs.
Article
Concerns about reducing the rate of growth of health expenditures have reignited interest in medical liability reforms and their potential to save money by reducing the practice of defensive medicine. It is not easy to estimate the costs of the medical liability system, however. This article identifies the various components of liability system costs, generates national estimates for each component, and discusses the level of evidence available to support the estimates. Overall annual medical liability system costs, including defensive medicine, are estimated to be $55.6 billion in 2008 dollars, or 2.4 percent of total health care spending.
Article
In the United States, lawsuits against physicians have had an impact on their behaviour, resulting in overdiagnosis and other forms of 'defensive medicine'. Does a similar situation exist in Switzerland? Using prostate-specific antigen (PSA) screening as an example, we surveyed Swiss physicians and assessed the extent to which liability fears influenced their recommendation for testing. At a continuing medical education conference we distributed a pilot-tested questionnaire to 552 participants. Two hundred and fifty of them (45%) completed the questionnaire. Of the participants, 158 (68%) were general practitioners and 73 (32%) specialists in internal medicine. Seventy-five per cent of both groups recommend regular PSA screening to men older than age 50. Yet only 56% of the general physicians and 53% of the internists believe that PSA measurement is an effective screening method. A substantial proportion of the physicians - 41% of general practitioners and 43% of internists - reported that they sometimes or often recommend this test for legal reasons. Defensive medicine is not a phenomenon particular to the USA, but is also observable in Switzerland. This result is surprising, given that in Switzerland and other European countries, a physician who does not recommend a test or treatment whose effectiveness is controversial need not fear litigation.
Auswirkungen von SwisDRG: Anreize, Instrumente, Wirkungen, hill. Zeitschrift für Recht und Gesundheit
  • A Leu
  • T Gächter
  • B Elger
Leu A, Gächter T, Elger B. Auswirkungen von SwisDRG: Anreize, Instrumente, Wirkungen, hill. Zeitschrift für Recht und Gesundheit [Internet]. 2013;(95). Available from: www.hilljournal.ch
Auswirkungen von SwissDRG auf die ambulante Versorgung
  • M Lobsiger
  • T Tondelli
  • W Kägi
  • S Felder
  • T Pfinninger
Lobsiger M, Tondelli T, Kägi W, Felder S, Pfinninger T. Auswirkungen von SwissDRG auf die ambulante Versorgung. Schweizerische Ärztezeitung. 95(39):1443-4.