Good clinical care lowers the likelihood of harm to patients, making it a sound risk management practice, though not a complete strategy. Even the best doctors can start to think defensively when confronted with awkward, troubling, or life-threatening situations that could have medicolegal implications.16 For example, when an outpatient threatens to hurt someone else, it may be tempting to just confine him in a hospital (which reduces the doctor’s anxiety) even when other less coercive and more therapeutic options might better resolve the patient’s problems and the risk of violence.
Recognizing that you’re making clinical decisions out of fear of getting sued is the first step toward curtailing needlessly defensive practice. See Table 19 for more strategies.
Table
3 strategies for avoiding needless defensive medicine
| Ask yourself, “If I weren’t worried about getting sued, what would I do?” or “If I were my patient, what would I want me to do?” These questions, which help you identify the best clinical response, also may help you to implement it without taking extraneous defensive measures. |
| “Never worry alone.” This recommendation from the Massachusetts General Hospital and McLean Hospital training programs19 means that if you’re concerned about a case, ask a colleague for a consultation. In addition to being helpful and reassuring, an outside perspective can support nondefensive, patient-oriented decision making. |
| If the treatment course you think is best involves a legal matter, make sure you understand the legal issues. For example, civil commitment is often the right intervention for a mentally ill person who poses a serious risk of harm, but some patients threaten to sue doctors who propose involuntary hospitalization. Your hospital’s attorney may provide explanation and legal guidance if you do not thoroughly understand legal mechanisms or whether you are properly invoking them |
Justifiable defensiveness
Of course, it’s perfectly appropriate for psychiatrists to recognize malpractice risks and take appropriate measures to avoid successful lawsuits. For example, thoughtful documentation of your data gathering, decision making, and informed consent is an appropriate protective practice. Usually, no one sees the documentation, and it contributes little to your patients’ well-being. Good documentation can be inexpensive, however, and if done creatively, can improve data recording that in turn contributes to better treatment.20