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Cited by 19Medical Malpractice and Liability IssuesHealth, Medicine and SocietyHealthcare Decision-Making and Restraints

Vox clamantis in deserto: a survey among Italian psychiatrists on defensive medicine and professional liability

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Scognamiglio, Pasquale, Morena, Donato, Di Fazio, Nicola, Delogu, Giuseppe, Iniziato, Valeria, La Pia, Silvestro, Saviano, Pasquale, Frati, Paola +1 more·2023·Frontiers in Psychiatry
DOI 10.3389/fpsyt.2023.1244101PMC PMC10469623
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Abstract

Due to recent events, professional liability for psychiatrists in Italy is currently a matter of lively debate. Specifically, overwhelming pressure on psychiatrists’ duties has been brought by regulatory developments, such as the closure of forensic psychiatric hospitals, with the consequent return of offenders to community-based care, and the mental health consequences of the pandemic. According to Italian courts, psychiatrists are not only responsible for diagnostic and therapeutic appropriateness but also for the effects of their interventions on patients, and their behaviors. The aim of this study was to explore the attitude and behaviors of Italian psychiatrists regarding defensive medicine and professional liability. A total sample of 254 psychiatrists was surveyed by means of a quantitative online questionnaire. Most psychiatrists reported practicing defensive medicine (no. 153/254, 60.2%) and felt that their position of guarantee compromised their work in healthcare for patients (no. 138/253, 54.3%). Age correlated inversely with acknowledgment of defensive practices ( r = −0.245, p < 0.001), with younger physicians more prone to defensive medicine ( p = 0.013), particularly for patients at risk of suicide or violence. Psychiatrists in ‘closed’ settings (hospital wards, residential and rehabilitation centers, mental health service units in prison) reported more malpractice claims ( p = 0.037) and complaints ( p = 0.031), as well as a greater propensity to act defensively. In the treatment of patients with violent behavior, suicidal ideation, dual diagnoses, and criminal convictions, defensive practices were associated more with perceived legal risks ( r = 0.306, p < 0.001) than actual legal involvement ( p > 0.05). Anxiety, anger, and restlessness were common reactions to legal complaints, involving no. 50/254 (19.7%) respondents, with 40% reporting impaired functioning. Most psychiatrists (no. 175/253, 68.9%) were concerned about both civil and criminal laws regarding their professional responsibility, but many were not fully informed about recent legislative regulations and younger physicians resulted scarcely trained in risk management ( p < 0.001). In conclusion, our findings suggest that defensive medicine is a common phenomenon among psychiatrists and their position of guarantee drives this attitude. Education on legal implications and risk management should be provided starting from the university and continuing over time, to improve the knowledge of young and senior doctors on professional liability and inform their decision-making processes. This would also reduce defensive practices and improve the quality of healthcare. Considering the concerns of younger physicians, as well as of professionals working in acute and high-intensity medical care facilities, there is also an urgent need for a revision of the medical liability to ensure the sustainability of the National Health Service.

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  • From a legal perspective, a structured exploration of suicidal ideation/behavior and the factors influencing it is a standard of care in many countries, and failure to do so could have legal consequences in the event of a suicide.

    “From a legal perspective, a structured exploration of suicidal ideation/behavior and the factors influencing it is a standard of care in many countries, and failure to do so could have legal consequences in the event of a suicide [e.g., (41–43)].”

    From Suicide risk assessment: clinical implications of the unpredictability of suicidal behavior (2026) · cites this paper as [43]

    The Introduction links patient suicide or attempted suicide to malpractice claims, and the Discussion says deviation from the standard of care can create a negligence risk. But the paper does not establish that structured exploration of suicidal ideation and its influencing factors is a standard of care in many countries. Its Discussion instead says suicide-prevention protocols in Italy often lack standardized risk-assessment tools; no page numbers were available in our copy. (LLM, conf=0.84)

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  • Surveys in different countries report that the majority of interviewed psychiatrists acknowledged resorting to defensive practices that compromised the quality of care they provided.

    “Although psychiatry is at low risk of malpractice claims in comparison to other specialties 275 , surveys in different countries report that the majority of interviewed psychiatrists acknowledged having resorted to defensive practices, which, in their opinion, compromised the quality of the provided care 274,276,277 .”

    From Ethical challenges in contemporary psychiatry: an overview and an appraisal of possible strategies and research needs (2024) · cites this paper as [274]

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  1. [43]Hasan B Abdulrahim H AlMukhtar M AlAsfoor R Mandeel M Aub M. The practice of defensive medicine by doctors in primary health care in the Kingdom of Bahrain. Saudi J Med. (2018) 3: 2518– 3389. doi: 10.21276/sjm.2018.3.10.8 · DOI

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Authors
Scognamiglio, P., Morena, D., Di Fazio, N., Delogu, G., Iniziato, V., La Pia, S., Saviano, P., Frati, P., & Fineschi, V.
Affiliations
  • Sapienza University of Rome (IT)
  • Regione Campania (IT)
ORCID
Venue
Frontiers in Psychiatry
Publisher
Frontiers Media SA
Published
2023-08-17
Volume
14
Pages
1244101-1244101
ISSN
1664-0640 (ISSN-L)
DOI
10.3389/fpsyt.2023.1244101
PMC
PMC10469623
OpenAlex
W4385972613
Cited by
19
References
40
Citations by year
2026: 10 · 2025: 4 · 2024: 3 · 2023: 2
FWCI
7.83
Type
journal article
Language
en
Open access
Licence
Locations
  • Frontiers in Psychiatry (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • IRIS Research product catalog (Sapienza University of Rome) (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Health Sciences › Health Professions › Pharmacy › Medical Malpractice and Liability Issues
  • Health Sciences › Health Professions › General Health Professions › Health, Medicine and Society
  • Social Sciences › Psychology › Clinical Psychology › Healthcare Decision-Making and Restraints
Keywords
defensive medicine, professional liability, psychiatrists, legal risk, malpractice claims, forensic psychiatric hospitals, community-based care, suicide risk, violence risk, risk management training, legal education, physician attitudes, Italian psychiatry, dual diagnosis, criminal conviction, prison mental health services, civil and criminal liability, forensic psychiatry

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