Australian-first research - The rise of defensive practice

A patient walks into a consult having already googled their symptoms and asks for a blood test and scan. As the doctor, you’re not clinically convinced these are warranted but think, “Maybe I should do it just in case there’s something I’m missing or in case they end up making a complaint”.

Associate Professor Nola Ries at the University of Technology Sydney says doctors have been reporting defensive practice as far back as the 1970s. Citing surveys in Australia, she suggests up to 60% of GPs engage in defensive practice, including providing tests, procedures and referrals to reduce perceived legal risk.

Defensive practice drives low-value care, with harm to patients and health systems. Yet little work has been done in Australia to explore what’s driving this behaviour or how change can be instigated at the doctor-patient relationship level.

Ries, a researcher with the Law, Health, Justice Research Centre at the Faculty of Law, University of Technology Sydney, alongside colleagues in behavioural science, recently won an Avant Foundation Grant to investigate these drivers of low-value care.

This ground-breaking research will eventually deliver online CPD-training resources to educate clinicians and ultimately reduce low-value, defensive practices.

Filling the gaps

The first part of this rigorous research project is an extensive literature review which Ries and colleagues have just completed.

The current international research on low-value care identifies myriad contributing factors. These include technology, financial incentives, media reporting and consumer expectations. Defensive practices are just one part of a complex puzzle.

“Our international literature review turned up surveys in various countries and lots of opinion pieces on defensive medicine. But there are gaps in qualitative research to give us a deeper understanding of what’s happening in practice,” Ries comments.

The next step is qualitative research to interview medico-legal experts, clinicians and consumer representatives to find what they think is driving defensive practice and their ideas on ways to reduce it.

Shifting perceptions to shift behaviour

Ries acknowledges that understanding and tackling the drivers of defensive practice will be tricky.

"The legal risks and clinicians’ perceptions are part of it, and that's the part we’re looking at. But we see the need for a range of strategies to shift behaviour to deliver higher-value care… there are some promising entry points.”

Ries says it is gratifying to contribute to the improvement of healthcare delivery. She adds there is a perfect synergy between her project and the Avant Foundation’s goal – “That’s really the central focus of what we’re doing”.

Dr Penny Browne, Chair of the Avant Foundation Board, said “The Avant Foundation was established in 2017 to invest in research, education and leadership programs that improve quality, safety and professionalism in medicine.”

“We’re pleased to be able to fund A/Prof Ries’ important research through our Avant Foundation Grants, which will contribute towards enhancing patient care and reducing clinical risks in practice.”