Vento Sandro, Cainelli Francesca, Vallone Alfredo
Department of Medicine, Nazarbayev University, Astana 010000, Kazakhstan.
Infectious Diseases Unit, G. Jazzolino Hospital, Vibo Valentia 89900, Italy.
World J Clin Cases. 2018 Oct 6;6(11):406-409. doi: 10.12998/wjcc.v6.i11.406.
Defensive medicine is widespread and practiced the world over, with serious consequences for patients, doctors, and healthcare costs. Even students and residents are exposed to defensive medicine practices and taught to take malpractice liability into consideration when making clinical decisions. Defensive medicine is generally thought to stem from physicians' perception that they can easily be sued by patients or their relatives who seek compensation for presumed medical errors. However, in our view the growth of defensive medicine should be seen in the context of larger changes in the conception of medicine that have taken place in the last few decades, undermining the patient-physician trust, which has traditionally been the main source of professional satisfaction for physicians. These changes include the following: time directly spent with patients has been overtaken by time devoted to electronic health records and desk work; family doctors have played a progressively less central role; clinical reasoning is being replaced by guidelines and algorithms; the public at large and a number of young physicians tend to believe that medicine is a perfect science rather than an imperfect art, as it continues to be; and modern societies do not tolerate the inevitable morbidity and mortality. To finally reduce the increasing defensive behavior of doctors around the world, the decriminalization of medical errors and the assurance that they can be dealt with in civil courts or by medical organizations in all countries could help but it would not suffice. Physicians and surgeons should be allowed to spend the time they need with their patients and should give clinical reasoning the importance it deserves. The institutions should support the doctors who have experienced adverse patient events, and the media should stop reporting with excessive evidence presumed medical errors and subject physicians to "public trials" before they are eventually judged in court.
防御性医疗行为在全球广泛存在并被践行，给患者、医生和医疗成本带来了严重后果。甚至医学生和住院医生也接触到防御性医疗行为，并被教导在做出临床决策时要考虑医疗事故责任。防御性医疗行为通常被认为源于医生的一种认知，即他们很容易被患者或其亲属起诉，这些人会因假定的医疗失误寻求赔偿。然而，在我们看来，防御性医疗行为的增长应放在过去几十年医学观念发生的更大变化的背景下来看待，这些变化破坏了医患信任，而这种信任传统上一直是医生职业满足感 的主要来源。这些变化包括以下几点：花在患者身上的直接时间已被用于电子健康记录和案头工作的时间所取代；家庭医生所起的核心作用越来越小；临床推理正被指南和算法所取代；广大公众和一些年轻医生倾向于认为医学是一门完美的科学，而不是一门仍有缺陷的艺术；现代社会无法容忍不可避免的发病和死亡情况。为了最终减少世界各地医生日益增加的防御性行为，将医疗失误非刑事化以及确保在所有国家都能在民事法庭或由医疗组织来处理这些失误可能会有所帮助，但这还不够。应该允许内科医生和外科医生有足够的时间与患者相处，并应重视临床推理。各机构应支持经历过不良患者事件的医生，媒体应停止过度报道假定的医疗失误并在医生最终在法庭受审之前对其进行“公开审判”。
