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86 Medico-legal experts’ views on psychosocial drivers of defensive practice: a qualitative interview study
  1. Nola Ries1,
  2. Charlie Hacker1,
  3. Kirsten McCaffery2,
  4. Adam Elsaug2,
  5. Jenny Doust3,
  6. Jesse Jansen2
  1. 1University of Technology Sydney, Sydney, Australia
  2. 2University of Sydney, Sydney, Australia
  3. 3Bond University, Robina, Australia


Objectives Doctors’ fear of legal liability and defensive practices are commonly cited as drivers of low value care. Defensive practices involve ordering tests and procedures, making referrals, and prescribing drugs to reduce perceived legal risks, rather than to advance patient care. Survey data report that defensive medicine is prevalent in countries across the world and significantly contributes to health care costs. This project aimed to understand psychosocial drivers and features of defensive practice.

Methods Qualitative research with three groups of participants with medico-legal expertise purposively recruited from: (1) medical defence organisations/indemnity insurers, (2) medical colleges and societies and (3) peak healthcare consumer organisations, in Australia. Around 10 participants will be interviewed in each group (n=30–35 in total) using a semi-structured interview schedule grounded in the Theoretical Domains Framework of behavior change. The interview elicits participant’s views on e.g. drivers of defensive practice and low value care; barriers to and enablers of high value care; medical practices that are highly defensive (ie, driven mostly by legal fear); and potential interventions to address these problems. Interviews are audio-recorded, transcribed, and analysed thematically using Framework Analysis.

Results Note that recruitment and interviews are ongoing at the time of abstract submission but will be completed in time for the conference. So far we have conducted 5 interviews of around 60 minutes each. Initial findings reveal that participants perceive defensive practice as a persistent problem, with drivers of low value care identified at the patient, clinician and policy level. According to the participants, strategies to reduce defensive practice should address factors such as: clinicians’ lack of knowledge of legal risks and responsibilities; challenges around doctor-patient communication and shared decision-making; and intolerance of uncertainty. Several participants emphasised the need for clinical leadership in this area and the importance of senior, respected clinicians setting examples and sending messages about avoiding defensive practice.

Conclusions Defensive practice is driven by a complex constellation of factors. Our results so far suggest that interventions to address this problem should focus on promoting clinicians’ knowledge of legal duties and risks, enhancing their communication skills and changing their behaviour with the help of role models and peer support.

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