|
Potential
impact of guidelines discouraging prostate cancer screening on general
practitioners' perceptions of medicolegal risk
| par 0 |
|
Needs
Assessment & Health Outcomes Unit
| par 1 |
|
Seham
Girgis MBChB MPH, Public Health Officer
| par 2 |
|
Jeanette
Ward PhD FAFPHM, Director
| par 3 |
|
Australian
Institute of Health, Law and Ethics
| par 4 |
|
Colin
Thomson BA LLM, Executive Officer
| par 5 |
|
Objective:
To
ascertain GPs' perceptions of medicolegal risk when screening for
prostate cancer and explore the potential impact of three national guidelines
on these perceptions and test-ordering.
| par 7 |
|
Design:
Postal
survey
| par 8 |
|
Participants: 219
randomly selected GPs in NSW (65% response rate)
| par 9 |
|
Main
outcome measures:
Self-reported
response to case scenarios; perceptions of medicolegal risk and protection
afforded by national guidelines before and after reading extracts of three
national guidelines; ratings of current and potential strategies.
| par 10 |
|
Results: 198
(90%) would screen an asymptomatic male patient and 170 (78%) of the
respondents would advise that DRE & PSA in combination was the best
available test to screen for prostate cancer. 133 (61%) indicated GPs would be
at risk if they did not screen. Only 53 (24%) were aware of all three
guidelines about prostate cancer screening. While significant changes in
responses were found after respondents' had read guideline extracts, 101 (46%)
respondents continued to perceive medicolegal risk if screening was not
performed. Propensity to screen was significantly associated with perceptions
of protection. To increase a sense of medicolegal protection, there was most
support (n=145, 66%) for a clear statement about the legal status of guidelines
in a court of law.
| par 11 |
|
Conclusions:
Even
when made aware of national evidence-based guidelines against prostate cancer
screening, GPs perceive limited medicolegal protection if complying with their
recommendations. This lack of confidence in a legal defence derived from
national evidence-based guidelines must be addressed by government, medical
defence organisations and opinion leaders before unfounded perceptions
undermine evidence-based health care.
| par 12 |
|
In
Australia, the risk of medical litigation has increased. For general
practitioners (GPs), the risk of being sued has doubled from 1:160 in 1990 to
1:84 in 1994
1.
While many are concerned about the increase
2,
not everyone agrees there is a crisis
3.
If doctors believe that these risks are substantial however, this belief alone
is likely to have an undue influence on their clinical behaviour
4-7. | par 14 |
|
By
synthesising all available evidence, evidence-based guidelines have the
potential to reduce medicolegal risk when clinical practice is within such
guidelines
8.
Prostate cancer screening represents a 'test-case' for such guidelines
9.
Although there is no evidence that premature mortality from prostate cancer
will reduce with mass screening, men report high rates of testing
10,11.
GPs use prostate specific antigen (PSA) assays as a screening test, either
alone or in combination with digital rectal examination
12-14.
As described fully elsewhere
15,
neither PSA alone or in combination with DRE is defensible as a screening
strategy. At best, prostate cancer will be present in about one-third of men
in whom a PSA test is considered raised and, at worst, in less than one in ten.
Current tests do not distinguish innocuous from aggressive prostate cancer.
Treatment options currently available are
'unnecessary
for some and insufficient for others'
16.
On current evidence, men's quality of life will be deleteriously affected
by anxiety, unnecessary treatment and adverse complications if screening is
recommended
15. | par 15 |
|
Unsurprisingly,
39% of GPs surveyed in 1995 indicated that prostate cancer screening guidelines
would be 'extremely' or 'very' useful for their practice
17.
Three sets of guidelines ensued, each one recommending against screening
18-20.
Yet Pinnock
et
al
recently reported
'anecdotal
evidence that general practitioners are concerned that if a PSA test is not
offered, and prostate cancer is later diagnosed, they may be seen as negligent'
11.
American physicians perceiving a successful malpractice suit by a patient
developing prostate cancer who had not previously been screened by his GP are
significantly more likely to perform PSA tests than those who perceive such a
scenario as unlikely to be successful in court
21.
Other than anecdote
11,
no Australian research has elucidated the influence of medicolegal concerns on
prostate cancer screening. We designed this study to ascertain GPs'
perceptions of medicolegal risk when asked to screen for prostate cancer and,
by using case scenarios, to assess the potential impact of national guidelines
on their views.
| par 16 |
|
Questionnaire
development and content
| par 18 |
|
The
first section of our self-administered questionnaire commenced with the
following case scenario:
'Mr
Smith, a 58-year-old employed repairman, presents to his regular GP after
prompting by his wife to have a test for prostate cancer. He has no urinary
symptoms, no family history of prostate cancer and has not had a vasectomy'
.
GPs were asked when they last had a similar request; what
should
be done; whether the GP would be at a risk medico- legally if s/he either
did
or
did
not
perform either or both tests for screening purposes; what they would do if
they
were the GP and which test(s) they would advise as being the best available.
We also randomised respondents to receive one of two versions of the case
scenario which were identical except that, in one, the patient was an architect
and, in the other, he was a whitegoods repairman.
| par 19 |
|
We
next provided
verbatim
the policies of the ACS
18,
NHMRC
19
and RACGP
20
about screening for prostate cancer and asked if GPs were already aware of each
guideline and, having read excerpts from all three, whether respondents would
change their answers to the initial case scenario. We then repeated the first
scenario and questions.
| par 20 |
|
Our
second case scenario read as follows:
'Imagine the following scenario with the earlier patient, Mr Smith. Having
presented for a PSA test, you discouraged him from having it. Imagine that six
months later, he is diagnosed with prostate cancer after a blood test organised
by a locum. He then proceeds with a formal complaint against you because you
did not do the test when he first requested it'
.
We asked respondents to indicate if the three guidelines would protect them in
the event of such a complaint; the extent to which such a possibility
influenced their practice and their perceptions of the likelihood of such a
scenario.
| par 21 |
|
We
next asked respondents to indicate their opinion of each of seven statements
about prostate cancer screening, using a five-point Likert scale. Respondents
then ranked five current and fourteen potential strategies to increase GPs'
sense of medicolegal protection in this aspect of clinical practice. The
questionnaire concluded with six socio-demographic questions.
| par 22 |
|
Survey
administration and analysis
| par 23 |
|
We
purchased a list of all NSW general practitioners from a commercial company
(Permail) and randomly selected 400 names. A questionnaire and reply-paid
envelope was mailed to each in mid 1997 after an advance telephone prompt
22.
At Day 16, non-responders received a reminder letter. At Day 35, a second
questionnaire with a covering letter and reply paid envelope were posted to
remaining non-responders. Two weeks after the second mail-out, a research
assistant telephoned non-responders.
| par 24 |
|
The
initial sample size was calculated to yield at least 200 questionnaires for
analysis, thereby permitting independent and paired univariate analyses.
Descriptive statistics were performed, using SPSS version 6.0. We used
chi-squared to examine differences in GPs' responses to either repairman
or architect scenarios. Univariate analysis using chi-squared also was
performed to determine significant associations between respondents'
beliefs and five nominated outcome variables. For these analyses, categories
were collapsed into dichotomous variables.
| par 25 |
|
Of
the 400 randomly selected general practitioners, 64 (16%) were ineligible.
From the 336 eligible GPs, 219 (65%) useable questionnaires were received (161,
74% male; 55, 26% female). Median age of respondents was 47 years (range 28-70
years); half had been in general practice for more than 17 years (range 1-47
years) and 127 (58%) worked in the Sydney metropolitan area. Our sample
over-represented male GPs, those in full-time practice and those in rural
practice
23. | par 27 |
|
GPs'
response to a request from an asymptomatic 58-year-old request for prostate
cancer screening before and after guidelines
| par 28 |
|
Of
the total GPs participating, 116 (53%) had received the repairman version of
the case scenario and 103 (47%), the architect. There was no significant
difference in GPs' answers to management of patient's request for
screening before reading the guidelines (chi-squared=0.81, 1df, p=0.4) or after
reading the guidelines (chi-squared=0.49, 1df, p=0.5). Responses to all
scenarios were combined, therefore, irrespective of patient occupation.
| par 29 |
|
More
than two thirds (69%) of the participating GPs had had a request for prostate
cancer screening from an asymptomatic man within the previous week (n=48, 22%)
or the previous month (n=102, 47%). Of the total sample, 115 (53%) GPs
mentioned that PSA and DRE in combination
should
be done if a man requested a screening test and 121 (55%) GPs would perform the
two tests in combination if they had such a request (Table 1). For men
insisting on having the 'best available' screening test, 170 (78%) of the
respondents would advise both DRE and PSA in combination; 25 (11%) DRE alone
and nine (4%) PSA alone although nine (4%) still advised neither test. The
proportion of GPs perceiving that the GP would be at medicolegal risk if s/he
did
not
screen for prostate cancer (61%) was significantly higher than that perceiving
a risk if s/he
did
screen (15%) (chi-squared=13.83, 1df, p<0.01) (Table 2).
| par 30 |
|
Less
than a quarter of the sample was aware of all three guidelines extracted in our
survey (n=53, 24%). Of the remaining 166 GPs, 121 (73%) would still perform
any or both tests for screening in the case scenario after having read all
three guidelines for the first time in our survey. After reading the
guidelines, significantly fewer of all respondents indicated that the GP in the
case scenario was at risk medicolegally if s/he did not perform either or both
tests for screening (Table 2). Further, significantly fewer perceived a
medicolegal risk if the GP did screen, after reading the guidelines. Only 61
GPs (28%) indicated that, given the three sets of guidelines, the GP would be
protected medico-legally if screening tests were not performed (Table 2).
| par 31 |
|
GPs'
reaction to a threat of legal action by a patient with prostate cancer
| par 32 |
|
In
the second case scenario (patient diagnosed with prostate cancer initiating a
formal action against his doctor for not previously ordering a screening test),
only 32 (15%) thought that the three guidelines 'most likely' would
protect them in the event of such a complaint. Respondents who thought such a
scenario would 'most likely' or 'likely' influence their
test-ordering (n=151, 69%) were significantly more likely than those indicating
it 'unlikely' (n=52, 24%) to consider such a scenario 'most likely' to
happen (chi-squared=10.7, 1df, p=0.001). Nevertheless, GPs who reported the
guidelines would influence their approach to a request for screening by an
asymptomatic man perceived that the guidelines 'most likely' or
'likely' would protect them in formal complaint (chi-squared=8.33, 1df,
p=0.004).
| par 33 |
|
After
reading the guidelines relevant to prostate cancer screening, respondents who
then specified they would not do any screening test for an asymptomatic patient
were significantly more likely to indicate that guidelines were 'most
likely' or 'likely' to protect them than those would perform at
least one test (chi-squared= 43.81, 1df, p<0.01). Respondents who indicated
that the GP would be at risk medicolegally if s/he
did not
perform any screening test were significantly less likely to consider that the
guidelines would protect them in the event of formal complaint compared to
those who did not consider the GP at risk (chi-squared=45.40, 1df, p<0.01).
| par 34 |
|
Respondents
who self reported they would change their response to the case scenario after
reading the guidelines presented in the survey were significantly more likely
to think that the guidelines would protect them compared with those who would
not (chi-squared=8.3, 1df, p=0.003). Likewise, respondents who, having read the
guidelines, considered the GP was protected medicolegally if s/he did not
perform any test also were significantly more likely to perceive that
guidelines would protect themselves legally compared with those who consider
the GP unprotected (chi-squared=43.12, 1df, p<0.01).
| par 35 |
|
GPs'
views about influences on prostate cancer screening
| par 36 |
|
Table
3 summarises responses to seven statements about prostate cancer screening in
general practice. Of the sample, 191 GPs (88%) 'strongly agreed' or
'agreed' that patients' decisions to be screened should be based on
full disclosure of what is known about diagnosis and treatment of early
prostate cancer. While 189 (87%) of the sample either 'strongly agreed'
or 'agreed' a positive PSA test may cause unnecessary anxiety for
patients, 130 (59%) also indicated that a GP could be sued for not ordering a
PSA test for someone who subsequently develops prostate cancer (Table 3).
Respondents were significantly more likely to agree that a GP could be sued by
a patient who subsequently developed prostate cancer for
not
performing a PSA test than by a patient who subsequently experienced adverse
consequences of treatment resulting from a PSA test which
had
been performed (chi-squared=6.6, 1df, p=0.01).
| par 37 |
|
GPs'
views of guidelines and other current or potential strategies to increase their
sense of medicolegal protection
| par 38 |
|
Of
current strategies in place to increase their sense of medicolegal protection,
respondents indicated strong support for guidelines based on systematic reviews
of the evidence (Table 4). Consumer companions were also highly rated by more
than one third. There was most support however for a clear statement about the
legal status of guidelines in a court of law and a requirement that expert GPs
as well as specialists appear as expert witnesses in court as future strategies
to diffuse anxiety about medicolegal risk (Table 5).
| par 39 |
|
Evidence-based
guidelines appear to have little influence on prostate cancer screening by GPs.
As recalled by respondents in our survey, a request by an asymptomatic man for
such testing appears frequent. While there was no discrimination in the
provision of a screening test on the basis of a patient's occuption, at least
90% of respondents would proceed with at least one screening test (DRE, PSA or
both in combination). Furthermore, a significant majority of respondents
considered the GP in the first scenario would be 'at risk' medicolegally if s/he
did
not
screen and moreso than if s/he
did
screen.
Not unexpectedly, awareness of national guidelines was low. Surveys
repeatedly demonstrate poor recall of national guidelines
24,
prompting proposals for greater resourcing of their implementation
9,25,26. | par 41 |
|
Further,
our proxy for assessing guidelines impact on test-ordering augurs poorly for
their influence in reducing perceptions of risk. Although (having read the
guidelines) significantly fewer considered the GP was at risk if s/he did not
screen, only 28% indicated the GP was protected medicolegally by three sets of
evidence-based guidelines, even when complying with their recommendations
against screening. Even fewer (15%) considered protection would be afforded
them if a man, having been diagnosed elsewhere with prostate cancer, then
proceeded to initiate a legal action for previous failure to screen. Those who
perceived such a situation was likely were also more influenced by such a
situation in their test-ordering. In contrast, those who would not screen were
more likely to feel protected by guidelines. Those who adopted this view point
after reading the guidelines appeared to place greater faith in the medicolegal
protection afforded by them.
| par 42 |
|
Respondents'
views differ from those of participants at a forum held in 1997 to examine
legal implications of guidelines
27.
While most respondents supported a clear statement about the legal status of
guidelines in a court of law, it was not recommended at the forum. To ensure
that guidelines '
are
best used within the current legal framework'
27,
perhaps other strategies found to be well-regarded by respondents in our survey
such as increasing the routine use of GP experts, reference to evidence-based
guidelines whenever possible and increasing public information could be pursued.
| par 43 |
|
Our
results also confirm the anecdotal feedback observed by Pinnock
et
al
that prostate cancer screening can be motivated by medicolegal concerns
11.
In the US, physicians self-reported PSA testing practices correlate with their
views on a medical malpractice case vignette
21.
Our findings suggest this to be the case also in Australia, prompting us to
agree that '
if
physicians perform PSA tests at least to some extent out of fear of
malpractice, then the standard of care may eventually be set by these defensive
practices'
21
.
| par 44 |
|
Our
findings reaffirm the need for interventional trials to diffuse public and
professional anxiety about prostate cancer screening
18.
There also appears to be widespread support among GPs for informed
decision-making by men themselves. Specifically, 88% of our respondents
'agreed' or 'strongly agreed' that men's decisions to be screened should be
based on full disclosure of what is known about the diagnosis and treatment of
early prostate cancer. Prerequisite information before making such a decision
has recently been established through expert survey
28. | par 45 |
|
Two
methodological caveats are recognised. First, the validity of our survey
method involving the use of scenarios before and after exposure to guidelines
has not been formally tested against actual behaviour. While such a study
needs to be conducted, we know of no other feasible method to examine the
influence of medicolegal risk on test-ordering in general practice. Second,
our response rate was modest (65%). Nonetheless, the majority of our
respondents were male, consistent with the reference population and indicating
that typical response bias resulting in samples over-representative of female
GPs was overcome.
| par 46 |
|
In
summary, GPs perceive limited medicolegal protection from national
evidence-based guidelines. This lack of confidence in a legal defence derived
from national evidence-based guidelines must be addressed by government,
medical defence organisations and professional opinion leaders before unfounded
perceptions undermine evidence-based health care. Those strategies suggested
by GPs as important are recommended for implementation.
| par 47 |
|
The
study was conducted while the first author was completing the NSW Health
Department PHO Training Program. We thank Geof Hirst for advice; Drs Buhagier,
Stan, Gordon, Foran, Reid, Young, McGuigan and Sladden for their comments as
GPs on questionnaire drafts; Nancy Harding for research support; Margaret
Lesjak for assisting with telephone prompts and Neil Donnelly for statistical
advice. The study was funded by NAHOU and approved by the RPAH Ethics Committee.
| par 49 |
|
1. Keaney
M. Is there a medical litigation crisis? Individual viewpoints on the perceived
medical litigation crisis. Is litigation increasing?
Med
J Aust
1996;164:178-182
| par 51 |
|
2. Nissel
P. Is there a medical litigation crisis? Individual viewpoints on the perceived
medical litigation crisis. Is there a crisis?
Med
J Aust
1996;164:178-182
| par 52 |
| 3. Dunn I. Is
there a medical litigation crisis? Individual viewpoints on the
perceived medical litigation crisis. Crisis or beat- up?
Med J Aust 1996;164:178-182
| par 53 |
| 4. Weisman C,
Morlock L, Teitelbaum M, Klassen A, Celentand D. Practice changes in
response to maplractice litigation climate. Results of a Maryland
physician survey. Med Care
1989; 27: 16-24
| par 54 |
| 5. Kessler D,
McClellan. Do doctors practice
defensive medicine? National Bureau
of Economic Research working paper series, Cambridge, 1996
| par 55 |
| 6. Summerton N.
Positive and negative factors in defensive medicine: a questionnaire
study of GPs. Brit Med J
1995; 6971: 27-9
| par 56 |
| 7. Hancock L.
Defensive medicine and informed
consent: a research paper. Review of professional indemnity
arrangements for health care professionals. Canberra. AGPS. 1993
| par 57 |
| 8. Barratt A,
Bates P. O tell me the truth about evidence. Aust NZ J Pub Hlth 1997; 21: 441-4
| par 58 |
| 9. Ward J.
Prostate cancer screening: too much, too soon? Cancer Forum 1998; 22: 18-23
| par 59 |
| 10. Ward J,
Hughes AM, Hirst G, Winchester L. Men's estimates of prostate
cancer risk and self-reported rates of screening. Med J Aust 1997; 167: 250-3
| par 60 |
| 11. Pinnock C,
Weller D, Marshall V. Self-reported prevalence of prostate-specific
antigen testing in South Australia: a community study. Med J Aust 1998; 169: 25-8
| par 61 |
| 12. Sladden M,
Dickinson J. General practitioners' attitudes to screening for
prostate and testicular cancer. Med J Aust 1995; 162: 410-3
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| 13. Ward J, Young
J, Sladden M. General practitioners' views and use of tests to
detect early prostate cancer. Aust NZ J Pub Hlth 1998; 22: 374-80
| par 63 |
| 14. Ward J, Gupta
L, Taylor N. Do general practitioners use prostate-specific antigen
as a screening test for early prostate cancer? Med J Aust 1998; 169: 29-31
| par 64 |
| 15. Hirst G, Ward
J, Del Mar C. Prostate cancer screening: the case against.
Med J Aust 1996;
164: 285-287
| par 65 |
| 16. Whitmore W.
Management of clinically localised prostate cancer; an unresolved
problem. JAMA
1993; 269:2676-7
| par 66 |
| 17. Gupta L, Ward
J, Hayward R. Future directions for clinical practice guidelines:
needs, lead agencies and potential dissemination strategies
identified by Australian general practitioners. Aust NZ J Pub Hlth 1997; 21: 495-9
| par 67 |
| 18. Australian
Cancer Society. Prostate cancer screening: guidelines for health
professionals. Cancer Forum
1995; 19: 47-50
| par 68 |
| 19. Australian
Health Technology Advisory Committee. Prostate Cancer Screening. AGPS, Canberra:
1996.
| par 69 |
| 20. Royal
Australian College of General Practitioners. Guidelines for preventive activities in general
practice . 4th ed. Sydney: RACGP, 1996:26.
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| 21. Collins M,
Fowler F, Roberts R, Oesterling J, Annas G, Barry M. Medical
malpractice implications of PSA testing for early detection of
prostate cancer. J Law, Med &
Ethics 1997; 25: 234-42
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| 22. Young JM,
Ward JE. Improving survey response rates: a meta-analysis of the
effectiveness of an advance telephone prompt from a medical peer.
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| 23. Commonwealth
Department of Health and Family Services. General practice in Australia: supplementary tables 1997
. Canberra, GP Branch, 1997: 19 (Publication
no. 1838)
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| 24. Gupta L, Ward
J, Hayward R. Clinical practice guidelines in general practice: a
national survey of recall, attitudes and impact. Med J Aust 1997; 166: 69-72
| par 74 |
| 25. Hirst G.
Clinical practice guidelines - to what end? (letter). Med JAust 1997; 167: 288
| par 75 |
| 26. Puech M, Ward
J, Hirst G, Hughes AM. Local implementation of national guidelines:
what do general practitioners suggest will work? International Journal for Quality in Health
Care 1998; 10: 339-343
| par 76 |
| 27. Pelly J, Newby L,
Tito F, Redman S, Adrian A. Clinical practice guidelines before the
law: sword or shield? Med J Aust 1998; 169: 330-3.
| par 77 |
28. Ward J, Girgis S.
Making an 'informed decision' about prostate cancer screening: what
information is required? Hlth Prom J Aust 1998 (in press)
| par 78 |
| Table 1:
Tests recommended by GPs in response to a patient
request before and after reading extracts from the
national guidelines
|
|
Which test should be done?
|
|
|
Screening test
|
|
|
|
|
|
DRE
& PSA
DRE
alone
PSA
alone
Neither
|
|
|
|
|
|
#
McNemars (chi-squared=
47.02,1df, p=0.0000)
|
* McNemars (chi-squared= 22.78,1df,
p=0.0000)
|
| Bold
indicates a response consistent with the national
guidelines
|
| par 79 |
| Table 2:
GPs' perception of medicolegal risk before and after
reading the guidelines
|
|
|
Before
N(%)
|
After
N (%)
|
|
| Is the GP at risk medicolegally if s/he does NOT
perform either or both tests for screening?
|
Yes
|
133 (61)
|
101 (46)
|
McNemars (chi-squared= 20.02,1df,
P=0.000)
|
|
No
|
56 (26)
|
91 (42)
|
|
Unsure
|
29 (13)
|
24 (11)
|
| Is the GP at risk medicolegally if s/he DOES
perform either or both tests for screening?
|
Yes
|
32 (15)
|
42 (19)
|
McNemars (chi-squared= 4.05,1df,
P=0.041)
|
|
No
|
150 (69)
|
135 (62)
|
|
Unsure
|
36 (18)
|
39 (18)
|
| Given the three recommendations, is the GP
protected medicolegally if does NOT perform either or
both
tests
for screening
|
Yes
|
-
|
61 (28)
|
|
|
No
|
-
|
80 (37)
|
|
|
Unsure
|
-
|
73 (33)
|
|
| Bold
indicates a responses consistent with the national
guidelines
|
| par 80 |
| Table 3 -
GPs views about seven statements pertinent to prostate
cancer screening
|
|
Strongly agree
N (%)
|
Agree
N (%)
|
Unsure
N (%)
|
Disagree
N (%)
|
Strongly disagree
N (%)
|
| Patients' decisions to be screened should be based
on full disclosure of what is known about the diagnosis
and treatment of early prostate cancer
|
100 (46)
|
91 (42)
|
10 (5)
|
13 (6)
|
3 (1)
|
| A positive PSA test result may cause unnecessary
anxiety for the patients
|
54 (25)
|
135 (62)
|
6 (3)
|
20 (9)
|
2 (1)
|
| A GP could be sued for not ordering a PSA test for
someone who subsequently develops cancer of the prostate
|
35 (16)
|
95 (43)
|
27 (12)
|
44 (20)
|
15 (7)
|
| A positive PSA test result leads to investigations
and treatments of unknown effectiveness
|
22 (10)
|
97 (44)
|
31 (14)
|
59 (27)
|
7 (3)
|
| A GP could be sued for ordering a PSA test for
someone who subsequently experiences adverse
consequences from treatment
|
12 (6)
|
40 (18)
|
54 (25)
|
76 (35)
|
35 (16)
|
| A positive PSA test result will lead to
investigations associated with unacceptable morbidity
|
6 (3)
|
44 (20)
|
45 (21)
|
108 (49)
|
13 (6)
|
| Patients should sign a 'consent form' explaining
benefits and potential complications of PSA testing
before the GP orders it
|
15 (7)
|
30 (14)
|
51 (23)
|
90 (41)
|
31 (14)
|
| par 81 |
| Table 4 -
Respondents' ratings of the importance of five current
strategies to increase a sense of medicolegal protection
|
| Strategies
|
|
|
|
|
| Guidelines
|
|
|
|
|
| That guidelines are based on a systematic review
of the currently available evidence
|
|
|
|
|
| That guidelines are endorsed by NHMRC
|
|
|
|
|
| Public education
|
|
|
|
|
| Quality of information contained in pamphlets for
patients about the guidelines' recommendations
|
|
|
|
|
| Availability of pamphlets for patients about
prostate screening tests
|
|
|
|
|
| Courts
|
|
|
|
|
| The current system in which claims of malpractice
are resolved in an adversarial court system
|
|
|
|
|
| par 83 |
| Table 5 -
Respondents' ratings of the importance of fourteen
potential strategies to increase a sense of medicolegal
protection
|
|
|
|
|
|
| Guidelines
|
|
|
|
|
| Clear statement about the legal status of the
guidelines in a court of law
|
|
|
|
|
| That guidelines summarise any relevant
medico-legal judgements
|
|
|
|
|
| Public education
|
|
|
|
|
| Pamphlets for patients about prostate cancer
screening tests in languages of other than English
|
|
|
|
|
| Mass media campaign targeting men above 50 years
which reassures men that screening is ineffective
|
|
|
|
|
| A standard consent form that explains benefits and
consequences of the PSA test as a screening test for
prostate cancer, which needs to be signed by the man
before having the test
|
|
|
|
|
| A standard consent form as above but also
available in languages other than English
|
|
|
|
|
| A requirement that expert witnesses include a peer
expert GP as well as a specialist
|
|
|
|
|
| Legislation providing that a false screening
report does not of itself establish negligence
|
|
|
|
|
| Courts
|
|
|
|
|
| A requirement that all expert witnesses refer to
evidence-based guidelines when giving evidence in court
|
|
|
|
|
| A requirement that expert witnesses are peer
expert GPs instead of expert specialists
|
117 (53)
|
65 (30)
|
19 (9)
|
16 (7)
|
| Expert panels to advise the judge instead of
juries
|
108 (49)
|
72 (33)
|
8 (4)
|
24 (11)
|
| A system of 'No fault compensation'
|
101 (46)
|
51 (23)
|
19 (9)
|
41 (19)
|
| Removing cases of malpractice from the adversarial
legal system
|
100 (46)
|
63 (29)
|
14 (6)
|
37 (17)
|
| A requirement that juries in medico-legal cases
include members with medical backgrounds
|
77 (35)
|
81 (37)
|
37 (17)
|
22 (10)
|
This is the unrevised version of this article. Click here for the current version or click here for the first revision |