616
WJ, Smith DS, Ratliff TL, et al. Measurement of prostate specific antigen in serum as a screening test for prostate cancer. N Engl J
11. Catalona
Med 1991; 324: 115-61. 12. Lee F, Littrup PJ, Torp-Pederson ST, et al. Prostate cancer: comparison of transrectal ultrasound and digital rectal examination for screening. Radiology 1988; 168: 389-94. 13. Cooner WH, Mosley BR, Rutherford CL, et al. Coordination of urosonography and prostate specific antigen in the diagnosis of non-palpable prostate cancer. J Endourol 1989; 3: 193-99. 14. Chadwick DJ, Gillatt DA, Gingell JC, Abrams PH. Screening for carcinoma of the prostate. Br Med J 1990; 301: 119-20. 15. Kemple T. Rectal examination in general practice. Br Med J 1990; 301: 667-68. 16. Pierce M, Lundy S, Palanisamy A, Winning S, King J. Prospective randomised controlled trial of methods of call and recall for cervical cytology screening. Br Med J 1990; 299: 160-61. 17. Williams EMI, Vessey MP. Randomised trial of two strategies offering women screening for breast cancer. Br Med J 1990; 299: 158-59. 18. George NJR. Natural history of localised prostatic cancer managed by
conservative therapy alone. Lancet 1988; i: 494-97. 19. Lowe BA, Listrom MB. Incidental carcinoma of the prostate: an analysis of the predictors of progression. J Urol 1988; 140: 1340-44. 20. Johansson J, Andersson S, Krusemo UB, et al. Natural history of localised prostate cancer. Lancet 1989; i: 799-803. 21. Marteau TM. Psychological costs of screening. Br Med J 1989; 299: 527. 22. Nathoo V. Investigation of non-responders at a cervical cancer screening clinic. Br Med J 1988; 296: 1041-42. 23. Haynes RB, Sackett DL, Taylor DW, Gibson ES, Johnson AL. Changes in absenteeism and psychosocial function due to hypertension screening and therapy among working men. N Engl J Med 1978; 299: 741-44. 24. Mossey JM. Psychosocial consequences in labelling in hypertension. Clin Invest Med 1981; 4: 201-07. 25. Bloom JR, Monterossa S. Hypertension labelling and sense of well-being.
Am J Public Health 1981; 71: 1228-32. Screening in practice: reducing the psychological costs. Br Med J 1990; 301: 26-28.
26. Marteau TM.
CLINICAL PRACTICE Change in obstetric practice in response to fear of litigation in the British Isles
The increased number of medical negligence claims against obstetricians and gynaecologists has led to concerns about a trend towards defensive medical practice in the UK. The attitudes of obstetricians in the British Isles to tests of fetal and maternal wellbeing, which may influence decisions about patient care, were investigated in 3194 Fellows and Members of the Royal College of Obstetricians and Gynaecologists. Perceived accuracy of tests ranged from 86·3% for fetal blood sampling to 25·9% for biochemical tests. Despite some tests being perceived as having poor accuracy, all were widely used even by those who deemed them inaccurate. The most frequent explanations given for this paradoxical finding were that such tests were an aid to clinical judgement and were necessary for medicolegal reasons. Our data indicate that tests deemed to be inaccurate are used in clinical practice because some obstetricians fear litigation. Our findings were not influenced by age, gender, grade of doctor, or site of practice.
Introduction The increased number and costs of medical negligence claims in the UK have aroused fears that a crisis similar to that being experienced in the USA may soon take placed Complaints about obstetric and gynaecological practice account for 30% of all claims of negligence against UK health authority doctors. The largest proportion of claims concern misfortunes that occur during operations in either gynaecological practice or childbirth.4 Some observers have argued that the malpractice crisis in US medicine cannot be understood in isolation from other national economic and social factors. Litigation is precipitated by features of both
the American health care and social security systemsS and, compared with the UK, there are few barriers to court access. Patients who have paid for their care may be more likely to feel aggrieved if treatment fails.6 Moreover, the decision to enter litigation in the USA is fuelled by the high cost of care after iatrogenic injury.7 Anecdotal reports suggest that these trends have led to changes in clinical
practice.
Fig 1-Perceived accuracy of ultrasound according analogue scale.
to a
visual
Litigation may not be the only causal factor for the observed changes in practice. Training, work environment, peer esteem, and the physical stress or fatigue of the doctor also have an important role; litigation may simply be one of ADDRESSES: Department of Psychology, University College London, Gower Street, London WC1 E 6BT (M. Ennis, BSc); and Academic Unit of Obstetrics & Gynaecology, The London Hospital Medical College, Whitechapel Road, London E1 1BB, UK (A. Clark, MRCOG, Prof J. G. Grudzinskas, FRCOG). Correspondence to Prof J. G. Grudzinskas.
617
availability, usefulness, and perceived accuracy of the current methods of fetal surveillance and monitoring in daily clinical practice. The questionnaire was sent anonymously with a postage paid reply envelope. Questions were asked about fetal movement charts (FMC), ultrasound, cardiotocography (CTG), biochemical tests of fetal wellbeing, fetal scalp and umbilical blood sampling, and doppler blood-flow studies. Respondents were asked about availabilty of tests, on which patients the tests were used, and the indications for their use. Respondents were also asked to indicate their attitudes towards the accuracy of each test by marking a visual analogue scale from one to seven-a score of one indicated "very inaccurate" and a score of seven indicated "very accurate" (figs 1 and 2). Clinicians who used a test despite believing it to be slightly, moderately, or very inaccurate or not being sure of its accuracy were asked why they did so. Data on respondents’ age, gender, grade, and current site of practice were also collected. We applied frequency statistics to analyse the data and a chi-square test to examine the relation between characteristics of doctors and clinical practice. Student’s t test was used to assess whether differences in response concerning antepartum and intrapartum tests were statistically
Fig 2-Perceived accuracy of biochemical tests of placental function according to a visual analogue scale. many factors that interact to influence clinical
practice.8
significant.
there have been anxieties about defensive clear definitions and reliable estimates of its extent medicine, have previously been hard to find.9 However, the Harvard Medical Practice Study has confirmed a trend toward defensive medical practice in New York State.1o
Although
Results
TABLE I-AVAILABILITY OF TESTS OF FETAL SURVEILLANCE ACCORDING TO PERCEIVED ACCURACY AND USE
In the UK, anxieties about defensive medicine have been
strongly voiced in obstetric and gynaecological practice. The increasing number of caesarean sections and other interventions in labour may partly be a response to the rise in number of claims alleging negligent management of labour.11 How justified are these anxieties and is defensive medicine a universally bad practice? We have sought attitudes to the most commonly adopted tests of fetal wellbeing, together with view on their accuracy, their reason for use, and why these tests are used even when deemed to be
most
inaccurate.
Subjects and methods A questionnaire to assess the current state of fetal surveillance in obstetric practice was sent to all Fellows and Members of the Royal College of Obstetricians and Gynaecologists who are practising in the UK and Eire. The aim of the questionnaire was to survey the
3194 questionnaires were sent and 1841 (57-6%) were returned. 649 (20-3%) of these were excluded from analysis because respondents indicated that they were retired or no longer practised obstetrics. A comparison of these figures with 1989 Royal College of Obstetricians and Gynaecologist’s census data showed that 599 (72%) consultants, 124 (82%) senior registrars, and 198 (66-4%) registrars, who were then in practice in England and Wales, responded. Accurate figures for practitioners of all grades in Scotland, Northern Ireland, and Eire were not available but, from the incomplete figures provided, we concluded that a similar proportion of active practitioners in each grade responded when compared with their colleagues in England and Wales. 51-5% of respondents worked at district general hospitals and 32-9% worked at teaching hospitals at the time of the questionnaire. 5-5% were wholly in private practice, 2% worked in full-time research, and 8-1% declined to state their site of practice. The perceived accuracy of the highest and lowest scoring tests of fetal surveillance using the visual analogue system is shown in figs 1 and 2. Respondents judged ultrasound at booking to be the most accurate test for detection of multiple pregnancy; biochemical tests of placental function to detect fetal compromise were thought to be the least accurate. The availability of tests in relation to perceived lack of accuracy and continuing usage is summarised in table 1. FMC, ultrasound, and CTG were the most available tests. Over 80% of respondents who perceived FMC (39-1%), ultrasound (16-2%), doppler blood flow (49-7%), and CTG (20-5%) to be inaccurate continued to use these tests. The reasons given for continued use of tests perceived to be inaccurate are summarised in table II. "Aid to clinical
TABLE II-REASONS FOR CONTINUED USE OF FETAL SURVEILLANCE TESTS DEEMED TO BE INACCURATE I
*p
WJ, Smith DS, Ratliff TL, et al. Measurement of prostate specific antigen in serum as a screening test for prostate cancer. N Engl J
11. Catalona
Med 1991; 324: 115-61. 12. Lee F, Littrup PJ, Torp-Pederson ST, et al. Prostate cancer: comparison of transrectal ultrasound and digital rectal examination for screening. Radiology 1988; 168: 389-94. 13. Cooner WH, Mosley BR, Rutherford CL, et al. Coordination of urosonography and prostate specific antigen in the diagnosis of non-palpable prostate cancer. J Endourol 1989; 3: 193-99. 14. Chadwick DJ, Gillatt DA, Gingell JC, Abrams PH. Screening for carcinoma of the prostate. Br Med J 1990; 301: 119-20. 15. Kemple T. Rectal examination in general practice. Br Med J 1990; 301: 667-68. 16. Pierce M, Lundy S, Palanisamy A, Winning S, King J. Prospective randomised controlled trial of methods of call and recall for cervical cytology screening. Br Med J 1990; 299: 160-61. 17. Williams EMI, Vessey MP. Randomised trial of two strategies offering women screening for breast cancer. Br Med J 1990; 299: 158-59. 18. George NJR. Natural history of localised prostatic cancer managed by
conservative therapy alone. Lancet 1988; i: 494-97. 19. Lowe BA, Listrom MB. Incidental carcinoma of the prostate: an analysis of the predictors of progression. J Urol 1988; 140: 1340-44. 20. Johansson J, Andersson S, Krusemo UB, et al. Natural history of localised prostate cancer. Lancet 1989; i: 799-803. 21. Marteau TM. Psychological costs of screening. Br Med J 1989; 299: 527. 22. Nathoo V. Investigation of non-responders at a cervical cancer screening clinic. Br Med J 1988; 296: 1041-42. 23. Haynes RB, Sackett DL, Taylor DW, Gibson ES, Johnson AL. Changes in absenteeism and psychosocial function due to hypertension screening and therapy among working men. N Engl J Med 1978; 299: 741-44. 24. Mossey JM. Psychosocial consequences in labelling in hypertension. Clin Invest Med 1981; 4: 201-07. 25. Bloom JR, Monterossa S. Hypertension labelling and sense of well-being.
Am J Public Health 1981; 71: 1228-32. Screening in practice: reducing the psychological costs. Br Med J 1990; 301: 26-28.
26. Marteau TM.
CLINICAL PRACTICE Change in obstetric practice in response to fear of litigation in the British Isles
The increased number of medical negligence claims against obstetricians and gynaecologists has led to concerns about a trend towards defensive medical practice in the UK. The attitudes of obstetricians in the British Isles to tests of fetal and maternal wellbeing, which may influence decisions about patient care, were investigated in 3194 Fellows and Members of the Royal College of Obstetricians and Gynaecologists. Perceived accuracy of tests ranged from 86·3% for fetal blood sampling to 25·9% for biochemical tests. Despite some tests being perceived as having poor accuracy, all were widely used even by those who deemed them inaccurate. The most frequent explanations given for this paradoxical finding were that such tests were an aid to clinical judgement and were necessary for medicolegal reasons. Our data indicate that tests deemed to be inaccurate are used in clinical practice because some obstetricians fear litigation. Our findings were not influenced by age, gender, grade of doctor, or site of practice.
Introduction The increased number and costs of medical negligence claims in the UK have aroused fears that a crisis similar to that being experienced in the USA may soon take placed Complaints about obstetric and gynaecological practice account for 30% of all claims of negligence against UK health authority doctors. The largest proportion of claims concern misfortunes that occur during operations in either gynaecological practice or childbirth.4 Some observers have argued that the malpractice crisis in US medicine cannot be understood in isolation from other national economic and social factors. Litigation is precipitated by features of both
the American health care and social security systemsS and, compared with the UK, there are few barriers to court access. Patients who have paid for their care may be more likely to feel aggrieved if treatment fails.6 Moreover, the decision to enter litigation in the USA is fuelled by the high cost of care after iatrogenic injury.7 Anecdotal reports suggest that these trends have led to changes in clinical
practice.
Fig 1-Perceived accuracy of ultrasound according analogue scale.
to a
visual
Litigation may not be the only causal factor for the observed changes in practice. Training, work environment, peer esteem, and the physical stress or fatigue of the doctor also have an important role; litigation may simply be one of ADDRESSES: Department of Psychology, University College London, Gower Street, London WC1 E 6BT (M. Ennis, BSc); and Academic Unit of Obstetrics & Gynaecology, The London Hospital Medical College, Whitechapel Road, London E1 1BB, UK (A. Clark, MRCOG, Prof J. G. Grudzinskas, FRCOG). Correspondence to Prof J. G. Grudzinskas.
617
availability, usefulness, and perceived accuracy of the current methods of fetal surveillance and monitoring in daily clinical practice. The questionnaire was sent anonymously with a postage paid reply envelope. Questions were asked about fetal movement charts (FMC), ultrasound, cardiotocography (CTG), biochemical tests of fetal wellbeing, fetal scalp and umbilical blood sampling, and doppler blood-flow studies. Respondents were asked about availabilty of tests, on which patients the tests were used, and the indications for their use. Respondents were also asked to indicate their attitudes towards the accuracy of each test by marking a visual analogue scale from one to seven-a score of one indicated "very inaccurate" and a score of seven indicated "very accurate" (figs 1 and 2). Clinicians who used a test despite believing it to be slightly, moderately, or very inaccurate or not being sure of its accuracy were asked why they did so. Data on respondents’ age, gender, grade, and current site of practice were also collected. We applied frequency statistics to analyse the data and a chi-square test to examine the relation between characteristics of doctors and clinical practice. Student’s t test was used to assess whether differences in response concerning antepartum and intrapartum tests were statistically
Fig 2-Perceived accuracy of biochemical tests of placental function according to a visual analogue scale. many factors that interact to influence clinical
practice.8
significant.
there have been anxieties about defensive clear definitions and reliable estimates of its extent medicine, have previously been hard to find.9 However, the Harvard Medical Practice Study has confirmed a trend toward defensive medical practice in New York State.1o
Although
Results
TABLE I-AVAILABILITY OF TESTS OF FETAL SURVEILLANCE ACCORDING TO PERCEIVED ACCURACY AND USE
In the UK, anxieties about defensive medicine have been
strongly voiced in obstetric and gynaecological practice. The increasing number of caesarean sections and other interventions in labour may partly be a response to the rise in number of claims alleging negligent management of labour.11 How justified are these anxieties and is defensive medicine a universally bad practice? We have sought attitudes to the most commonly adopted tests of fetal wellbeing, together with view on their accuracy, their reason for use, and why these tests are used even when deemed to be
most
inaccurate.
Subjects and methods A questionnaire to assess the current state of fetal surveillance in obstetric practice was sent to all Fellows and Members of the Royal College of Obstetricians and Gynaecologists who are practising in the UK and Eire. The aim of the questionnaire was to survey the
3194 questionnaires were sent and 1841 (57-6%) were returned. 649 (20-3%) of these were excluded from analysis because respondents indicated that they were retired or no longer practised obstetrics. A comparison of these figures with 1989 Royal College of Obstetricians and Gynaecologist’s census data showed that 599 (72%) consultants, 124 (82%) senior registrars, and 198 (66-4%) registrars, who were then in practice in England and Wales, responded. Accurate figures for practitioners of all grades in Scotland, Northern Ireland, and Eire were not available but, from the incomplete figures provided, we concluded that a similar proportion of active practitioners in each grade responded when compared with their colleagues in England and Wales. 51-5% of respondents worked at district general hospitals and 32-9% worked at teaching hospitals at the time of the questionnaire. 5-5% were wholly in private practice, 2% worked in full-time research, and 8-1% declined to state their site of practice. The perceived accuracy of the highest and lowest scoring tests of fetal surveillance using the visual analogue system is shown in figs 1 and 2. Respondents judged ultrasound at booking to be the most accurate test for detection of multiple pregnancy; biochemical tests of placental function to detect fetal compromise were thought to be the least accurate. The availability of tests in relation to perceived lack of accuracy and continuing usage is summarised in table 1. FMC, ultrasound, and CTG were the most available tests. Over 80% of respondents who perceived FMC (39-1%), ultrasound (16-2%), doppler blood flow (49-7%), and CTG (20-5%) to be inaccurate continued to use these tests. The reasons given for continued use of tests perceived to be inaccurate are summarised in table II. "Aid to clinical
TABLE II-REASONS FOR CONTINUED USE OF FETAL SURVEILLANCE TESTS DEEMED TO BE INACCURATE I
*p
