Defensive medicine through the lens of the managerial perspective: a literature review

Defensive medicine can be defined as the avoidance of specific high-risk procedures or patients or the ordering of unnecessary procedures, tests, or visits assessment [64]. For this reason, defensive medicine represents a cancer in the health system, as it does not allow patients to receive high-quality care in line with physicians’ moral, legal, and ethical duties [10]. Additionally, defensive medicine practices aimed at minimising malpractice liability may negatively affect the system by lowering the quality of care and increasing costs. Studies conducted by authors from Harvard University and the University of Melbourne estimated that defensive medicine costs America $45.6 billion annually (in 2008 dollars), accounting for more than 80% of the $55.6 billion total yearly cost of the medical liability system. Michelle Mello, one of the authors from the Harvard School of Public Health, estimates defensive medicine costs both for hospitals ($38.8 billion) and for physicians ($6.8 billion) [19]. In Europe, the number of litigations for medical malpractice has increased significantly over the last decade (from 50% in Britain, Scandinavia, the Baltic countries and Eastern Europe to more than 200% in the Mediterranean Area countries) [61]. A study published in 2015 by the Italian Ministry of Health estimated that defensive medicine costs represent the first category of healthcare waste, representing 0.75% of the Italian GDP. Nevertheless, accurately determining the cost of defensive medicine can be complex, as its computation occasionally approximates the entire healthcare wastage, of which defensive practices represent just one facet [38]. Nonetheless, more recent research has proposed that the comprehensive expense associated with defensive practices spans from $46 billion to $300 billion, with most estimates falling within the $50 to $65 billion bracket [15, 39, 46].

The critical thing is that this situation seems destined to worsen especially following the Covid-19 pandemic. Indeed, the limited treatment algorithms and the absence of guidelines for managing the disease, caused by the extraordinary nature of the event, face the highest malpractice claims, particularly for specialists such as surgeons, obstetricians, and gynaecologists with a consequent potential increase of defensive medicine [18, 49].

Although multiple contributions have been made to the study of defensive medicine in the literature, it is difficult to find a complete and systemic vision of the problem due to its multifaceted issue that concerns medical, economic, and legal considerations and the beliefs and values of a society. In medical contributions, on the one hand, the topic is often discussed within individual medical specialities, particularly regarding those with a high risk of litigation, such as emergency medicine, general surgery, orthopaedic surgery, neurosurgery, obstetrics/gynaecology, and radiology [25, 34]. On the other hand, some contributions focus on physicians, highlighting the different approaches they could take toward their patients or defensive medicine’s emotional and psychological impact shield [12].

The economic and business contributions, instead, emphasise the phenomenon’s implications for the whole health system, especially in terms of extent and costs [74].

Many studies on defensive medicine have aimed to grasp the relevance of defensive medicine and its consequent problems through interviews with physicians working in specific contexts. Although this is the primary way to identify defensive medicine behaviours, it is not without limitations: the defensive behaviours that emerge are only those self-declared by physicians and are therefore affected by numerous subjective elements. For this reason, we still lack a full understanding of the defensive medicine problem, and further clarification has been requested. This point is stressed by a recent literature review that concluded that defensive medicine is confusing from several points of view, causing problems for policymakers, practitioners and the management of healthcare companies when they try to find means to reduce the phenomenon [51].

The present work aims to respond to this research call, addressing defensive medicine by analysing the phenomenon from a managerial perspective. To the best of the researcher’s knowledge, the few literature reviews on this issue pertain to the medical field and patient safety [3] and deal only marginally with its managerial impacts and possible available solutions. Awareness of the phenomenon at an organisational level, including through the implementation of managerial practices and tools able to control and limit defensive medicine and negligent behaviours, is, in fact, important to make health systems more effective and efficient as well as safer. In addition, observing the defensive medicine considering managerial practice could give more unbiased results, not strictly linked to the subjectivity of interviewees.

Thus, inspired by the identified gap, the current work attempts to offer a different perspective on the phenomenon to offer further development possibilities for more targeted research.

In order to achieve that goal, a literature review is performed. This approach examines the features of available knowledge before determining how it can be improved [53]. Only documents at the organisational level (meso) will be considered to keep defensive medicine to a managerial overview, following the classification proposed by Ries & Jansen [26]. In addition, to ensure analytical rigour, only literature on managerial practices will be considered [35, 52, 65, 80]. The paper is organised as follows. The following section presents the theory focused on managerial practices. The third section outlines the methodology, followed by the results. Discussions, future developments, limits of the present research and conclusions are given in the last section.

During the last 30 years, public organisations’ landscapes have changed following globalisation, which has favoured market orientation and the adoption of managerial values, logic, and practices to improve public organisation performances. Notably, according to the new public management (NPM) orientation, the correct use of managerial practices/tools can lead to higher performance and higher service quality by simultaneously reducing citizens’ dissatisfaction [50, 56, 81]. In this new context, managerial practices derived from the private sector have been increasingly adopted by public organisations, including in the healthcare sector – see, for example, Buelow et al. [33], Ezza [67], and Johansen & Zhu [24]– for a simple reason: the adoption of correct managerial practices will guarantee greater chances of growth, success, and survival [65].

A profound performance heterogeneity between organisations – be they public or private – characterises the world economic system. These differences depend on geographical characteristics (not all areas of the world are equal) and sectorial features (organisations and firms that operate in the same sector present a profound variability of results). In this sense, it is possible to assert that these differences can also be traced to the quality of management. Indeed, performance can be affected by both unpredictable factors and more objective dynamics that are manageable through managerial actions. Considering the latter, a key role is played by the (in)correct adoption of managerial practices.

In defining managerial practices, great relevance is given to the works of Bloom and Van Reenen, who contributed enormously to our understanding of the role of such practices in guiding organisational actions and performances [77]. The relevance of Bloom and Van Reenen’s work is strictly connected to the definition of a model able to identify bad and good managerial practices [52]. Such practices are classified into four areas: operations (service delivery standardisation, formalisation, and centralisation of procedures),monitoring (ongoing improvement, performance measurement, performance control),targets (type of objectives adopted, transparency of goals, consistency of objectives including those of the organisation as a whole); and incentives (individual performance assessment, support practices for employee activities).

Since management is a complicated set of processes, technologies, and people, the current study also deals with other features that are considered to be among the most critical aspects of management: planning and budgeting (planning and scheduling of activities; the adoption of performance objectives; the presence of steps for achieving needed results); organising and staffing (adequate use of human resources; delegating responsibility and authority for carrying out the targets; providing policies and procedures to help guide people; creating methods or systems to monitor the implementation of targets and people); and controlling and problem-solving (monitoring results; identifying deviations and organising to solve the problems) [80].

To date, the managerial approach has been applied to defensive medicine only to a limited extent. Defensive medicine – since it identifies a divergence from the healthy and responsible medical practice [45] – has been mainly analysed in terms of its negative impacts on services, the reduction of the quality of treatment/outcome (e.g., lack of access to adequate care, expansion of waiting lists, etc.), and the increase in healthcare-related costs (waste of resources, mismanagement of hospital utilities, etc.) [34, 45]. In particular, recent studies have attempted to discuss the amount of defensive medicine costs [37], the impact of insurance premiums on the healthcare system [5, 19], and the impact of tort reforms on healthcare costs and defensive medicine [9, 63]. However, to the best of the researcher’s knowledge, few works have addressed the managerial side of this practice and the possible solutions available.

Nevertheless, improvements to both patient safety in the care path and the efficiency of a national health system must deal with a modern managerial and organisational culture capable of avoiding and managing errors. The inability to manage error is one of the major causes of defensive medicine [16], Miziara & Miziara,). Ensuring this awareness is present at the organisation (meso) level and planning the activities to be transferred to the level of the individual physician (micro) – who works directly with the patient – leads to safer care process management. A (better) consideration of the managerial practices selected in the current study could provide valuable information to frame the phenomenon from a different and more upstream perspective. To solve problems, it is often necessary to tackle the issue upstream. It is for this reason that the reduction of defensive medicine also involves an organisation being called to consider better the practices proposed by Bloom & Van Reenen [52] and Kotter [80], and specifically:

All the previous managerial practices, combined at all organisational levels, can improve the performance of organisations [67], as well as patient care and safety, and ensure protection from unnecessary litigation (and costs).

In this section, the results of the analysis of defensive medicine are provided for all 28 documents.

The objective of this paper was to study the defensive medicine phenomenon from a managerial viewpoint by considering managerial practices [52, 80]. Two databases, WoS and Scopus, were used, with 2011 taken as a start date, and data were selected following the PRISMA guidelines.

In the first part of the analysis, some descriptive data were presented. Starting from these, and in line with [26] it is interesting to stress that quantitative methods dominate many of the studies considered. For this reason, information collected in the literature is not entirely reliable due to the intrinsic limit of surveys, namely their higher subjectivity and the influence of physicians’ beliefs and the organisational environment. Despite a growing interest in defensive medicine worldwide, the phenomenon has been mainly studied in the USA. This result suggests relationships between medicine practices and political-economic-cultural determinants that sometimes work cooperatively and evolve in parallel. The specific cultural (e.g., emotional mechanisms), legal, political, and economic systems of a country can foster (or hinder) the defensive medicine phenomenon. However, although the body of US research may influence – sometimes inaptly – perceptions of legal risks in other countries [26], Germany, Italy, and Switzerland have the highest impact of all countries within the research community.

Moving toward managerial practices, the analysis saw the elimination of many documents unrelated to managerial aspects and the organisational level. This suggests that the defensive medicine phenomenon is more linked to medical areas, even though it can be considered a versatile issue that also concerns economic and managerial considerations. As also suggested by a recent literature review on the definition of defensive medicine in European medical literature, defining defensive medicine is, however, complex, and different interpretations, as well as interesting proposals and possible solutions, can be derived [13].

Indeed, although in the screening phase, the search keys specifically included managerial aspects, in the eligibility phase, 345 studies were eliminated as they are more focused on a single medical specialty (with particular regard to those at high risk of litigation, such as general medicine, surgery, orthopaedic surgery, and obstetrics/gynaecology), without mentioning managerial aspects or the organisation in its purest essence. This is also confirmed by the journal publishing activities analysis (only one paper is published in a journal covering business and management) and by the authors’ affiliation (the predominant area is the medical one).

On the other hand, many contributions focused on physicians, highlighting the different approaches they might take toward their patients or focusing on defensive medicine’s emotional and psychological impacts.

The most recurrent managerial practices are operations and staff organisation. The first is mainly related to the importance and role of guidelines that can limit the repetition of mistakes, particularly when they are strictly connected to an efficient informative system among physicians and between physicians and patients. Nevertheless, if guidelines are not flexible and when the organisation itself lacks a culture able to recognise, monitor, and manage errors, guidelines are unsuccessful, favouring the adoption of defensive behaviours. Thus, another aspect that emerged is the absence of the right incentives and of education which will encourage responsible activity driven by medical ethics rather than fear of lawsuits, as also stated by the recent narrative review of Miziara & Miziara [69]. Indeed, although guidelines which aim to collect (adverse) clinical events in a specific medical area can help prevent such errors, the fear of malpractice litigation is currently too high.

Additionally, analysis of the documents suggests the lack of a culture of disclosure of information, which would identify a higher level of professionalism. Indeed, communications and reports are central aspects of clinical skills because better information leads to less malpractice, whether voluntary or involuntary.

The analysis therefore seems to show the absence of a managerial approach at an organisational level capable of grasping and reducing the problem. Perhaps it is also for this reason that the issue of defensive medicine is not dealt with under the managerial aspect but focuses mainly on the doctor–patient relationship or the macro-system level. Orientation and managerial tools, accompanied by an adequate organisational culture, must be seen as an opportunity to improve the effectiveness and efficiency of health facilities and professionalism of doctors and not, as often happens, a punitive tool. Therefore, and in line with [64], it is important to implement systems to identify some such errors before they cause harm, at either the hospital or the physician level. In other words, it is necessary to stimulate the development of a more profound culture for managing clinical risk which involves administrations and individuals in shared processes and actions. It is needed better to share information and errors, better plan activities, and create a new professional awareness that combines planning-management-reporting of events and activities to encourage the creation of a safety culture within a culture of quality [71] and the development of a new daily practice which is safer for patients and the everyday work of physicians.

This literature review addresses the defensive medicine phenomenon from the managerial perspective. As such, it aims to provide an alternative perspective on this complex phenomenon, which arises from its multifaceted nature encompassing medical, economic, and legal aspects and is influenced by the beliefs and values of a society.

Following some statistical analyses and a study of the managerial practices most frequently addressed in works published from 2011 to June 2022, this work offers a critical analysis of the phenomenon, emphasising the importance of strengthening the managerial aspect and culture to reduce clinical risks, defensive medicine, and enhance healthcare quality, as well as the well-being of both doctors and patients. In doing so, the work paves the way for new research avenues that can improve the quality of future research on defensive medicine.