Defensive medicine – a symptom of fear

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I feel one of the reasons why many are disillusioned with their veterinary career – and thereby fuelling the negativity pervading the profession and increasing retention issues – is the constant background fear of a complaint being made to the RCVS, being struck off and excluded from the profession they have dedicated most of their lives to.

The perception seems to be that this has been growing steadily worse, but is that true? I don’t know; I was certainly taught as I left vet school that the RCVS was the vet police, there to protect the public against vets doing wrong.

Messages from SPVS at the final-year student seminar and new graduate reunion of The Veterinary Defence Society (VDS) were on how not to incur a complaint or avoid having it escalated to a disciplinary. No one was there to say that it is actually rare to get a full complaint, even rarer to end up in front of the disciplinary committee (DC) and vanishingly rare to be struck off unless you had deliberately deceived or lied.

That, though, was 20 years ago – and the world has changed. It feels as though the concept of finding someone else to blame for mishaps is much more prevalent, “no-win-no-fee” lawyers are advertising everywhere and, consequently, the culture shift has followed – if you are not happy with the situation then you not just deserve, but are entitled to, financial compensation if only you can find someone to accuse.

News in the veterinary press in late January 2020 that the RCVS was looking at reducing the standard of proof in disciplinary matters is only likely to make this climate of fear worse.

These proposed changes to the level of proof will make it easier for complaints to make it from the preliminary investigation committee to the DC as they are more likely to reach the required standard of evidence to make an offence provable.

It also makes it more likely that, at the DC stage, the complaints will be upheld based on likelihood of it occurring rather than the former standard of “so as to be sure” – that is, did the event occur.

Part of the problem is that many of the functions and processes to do with the RCVS are hidden and mysterious to the majority in the profession. We also know it is not uncommon for people to be flexible with the truth, even if not malicious, and it is common that events are remembered inaccurately (read about memory errors and bias if you want to know more).

My concern is that the increased fear this will create will lead to an increase in the practice of defensive medicine, which will not help the animals, clients, our colleagues or the profession. I already see how those who are scared of the potential of litigation change their behaviour to be more defensive; I know because I have done it myself – both consciously and unconsciously – when I felt the practice, business or boss did not have my back.

I did not trust that they would support me, if a complaint was made, over covering their own backs at my expense. I see how defensive medicine reduces our ability to provide a speedy, evidence-based and affordable veterinary service, and everyone loses out.

The problem of defensive medicine is well-documented and studied in the human medical world (Bourne et al, 2015; Sonal Sekhar and Vyas, 2013; Vento et al, 2018). It is worrying how infectious defensive medicine is – it is common in doctors who have had complaints made against them, naturally, but also almost as common in those who were not directly involved; who simply had colleagues who had received complaints.

In the super-connected world we live in now, all our colleagues are online – not just in our own practices, but also the group of practices, the country, the EU and the western world. Not all may openly discuss complaints and the DC, but as an example, some Facebook groups allow anonymous postings, and discussion in those groups is commonly about complaints being made against veterinarians.

I also worry that the peer pressure of these groups and the judgement they pass – intentionally or unintentionally – is artificially inflating the fear felt in the profession, caused by the RCVS’ opaque “we’ll tell you if you’ve done wrong once you do so” method of setting acceptable standards.

What is defensive medicine?

Defensive medicine in simple words is departing from normal medical practice as a safeguard against litigation, or defensive actions undertaken as a result of succumbing to various sources of pressure derived from the system, the clients, the regulator and our peers and colleagues, rather than focusing on the patient. The focus shifts from doing the best thing for the patient to covering your own back and then using the least risky of whichever options remain, regardless of efficacy.

This includes overcautious behaviours usually seen as harmless – such as performing unnecessary diagnostic tests and investigations, prescribing unnecessary treatment and needless procedures or hospitalisation. It also covers the avoidance of anything risky, perhaps by not giving the owner the option, putting him or her off from consenting with a long list of possible and worrying complications, or requiring referral for treatment when in the past a primary care vet would have been able to provide this care.

I also include in this the consultation style of giving clients a list of options and letting them make the decision on how to proceed, rather than guiding them through the decision-making process using experience, knowledge and assessment of risks, and it being a collaborative experience.

My personal act of defensive medicine was to make longer, significantly more detailed notes even though these took much longer to write, taking time away from other tasks. I also became more controlling over cases that I had any – even peripheral – involvement in, double‑checking that everything had been done rather than trusting my colleagues to fulfil my instructions, effectively and unfairly treating competent staff as “guilty until proved innocent”.

Where do these fears come from?

If we are going to address this fear, we first need to learn the causes of it before we can know whether it is justified or nothing more than fear of the unknown. Although each member of the profession will have his or her own instigating factors, some themes are definitely more common than others.

• As I suggested previously, fear of complaints, clients and the RCVS, which may be worsened if the standard of proof is lowered as is proposed.

I wonder if the Alternative Dispute Resolution scheme has also inadvertently increased the anxiety of practising vets, as clients now have another official way of complaining, and certainly the reports from vets who have been through the process are often critical that rather than being completely exonerated, they are left with a vague sentence of “could do better”.

The general impression that I and many others have is that the RCVS’ processes and standards are largely unknown outside the organisation, and secrecy breeds suspicion. Those with an intimate knowledge of its inner workings may find this hard to believe, but the opacity and mystery is very real for the majority of vets who do not have the time or inclination to read weighty reports from the RCVS and only see newsflash headlines on the latest “striking off”.

• Vets often lack skills to deal with criticism or failure. We know vets are often overachieving perfectionists, where negative judgement or evidence of deficiencies impacts on self-esteem.

For example, it has become not uncommon to view death or euthanasia as an outcome failure rather than inevitable or even desirable in some circumstances. Also, younger generations have often had few experiences with criticism or failure in any part of their lives, so don’t know that these will happen on a daily basis and don’t learn the skills to deal with them. This may have something to do with the increase in overprotective parenting styles (“snowplough parenting”).

• Pressure from teaching at vet school, lectures from eminent specialists and systems in practices stating that the mythical “gold standard” is always to be aimed for and is the best, implying – or sometimes even outright stating – that anything less may leave you open to liability or complaint. Clinical reasoning is replaced by guidelines and protocols, with the concomitant pressure to adhere to them.
• Fear that The VDS won’t cover you if you don’t achieve the “gold standard” in a particular way. This may seem hard to believe, but it is very much perceived as real by some and compounded by senior clinicians or referral level vets at CPD events stating that “The VDS won’t cover you unless you do it my way”.

Although The VDS newsletter is enlightening in pointing out ways that clinicians can come unstuck, my opinion is that it also increases fear – and, therefore, defensive medicine – which would actually be in The VDS’ best interests as then it wouldn’t have to defend so many complaints and pay out less compensation.

• Students and residents taught at university to take litigation into consideration as part of every clinical decision.
• Fear of criticism and peer pressure. Reflective obedience to our seniors rather than questioning authority; that is, not pointing out to someone you respect or who has a reputation that he or she may be wrong about something.
• Blame cultures within some veterinary working environments, leading to an erosion of trust, the anticipation of a lack of support if a complaint was to be made and even that blame for mistakes may be shifted to those not involved.

Critical incident reviews being more about determining who the problem may be most easily pinned to (or ignoring it as one of those things that happens from time to time) rather than preventing it happening again.

• Lack of leadership and mentoring in practices so that younger vets don’t feel supported or could expect someone to have their back if a complaint is made. A lack of training in personal skills that would help to prevent disagreement, misunderstanding or dissatisfaction from being turned into a formal complaint.
• Decreasing tolerance in society as a whole for mistakes and failures, and a demand that the treatment always has the anticipated positive outcome. A lack of understanding in clients that veterinary medicine, as with human medicine, is an imperfect art, not a perfect science.

This is compounded by the increase in service-driven society where clients no longer see that they are paying for the time and expertise of a vet – they increasingly see it as having paid for a required outcome and require that the outcome is delivered, whether it is feasible or not.

• An inability to analyse and assess risks (that is, likelihood versus impact) in both vets and clients.
• Burnout is associated with both decreased doctor well-being and increased defensive medical practice (Bourne et al, 2019), so it feels likely that similar outcomes should be expected for vets. Perhaps the practice of defensive medicine is a symptom of impending burnout as anxiety increases with this.

 

• This article first appeared on Sarah’s blog, Sarah The Vet. To read Sarah’s blogs, visit www.sarahthevet.com
• It also appeared in Vet Times (Volume 50, Issue 45, Pages 16-18).

References

Bourne T, Shah H, Falconieri N, Timmerman D, Lees C, Wright A, Lumsden MA, Regan L and Van Calster B (2019). Burnout, well-being and defensive medical practice among obstetricians and gynaecologists in the UK: cross-sectional survey study, BMJ Open 9: e030968.

Bourne T, Wynants L, Peters M, Van Audenhove C, Timmerman D, Van Calster B and Jalmbrant M (2015). The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey, BMJ Open 4: e006687.

Sonal Sekhar M and Vyas N (2013). Defensive medicine: a bane to healthcare, Annals of Medical and Health Sciences Research 3(2): 295-296.

Vento S, Cainelli F and Vallone A (2018). Defensive medicine: it is time to finally slow down an epidemic, World Journal of Clinical Cases 6(11): 406-409.