{
  "abstract": "Objectives Defensive Medicine (DM) is traditionally understood as medical practice motivated by fear of liability. Its increase in recent years has been called an epidemic, leading to low-quality medical care, harming of patients, and increased financial burden in the healthcare system, owing to overdiagnosis, overtreatment and its consequences. The development of this behaviour might already start in medical studies. It is not fully understood and may be connected to observed context factors in the medical work field. These context factors strongly influence the education of medical students who learn about medical behaviour by watching role models in clinical practice. Aim of this study was to explore students’ experiences of DM to gain a better understanding of the context factors that may lead to defensive practices such as overdiagnosis and overtreatment.Methods We chose a qualitative study design based on Grounded Theory as developed by Corbin and Strauss. Using a semi-standardized interview guide, medical students from Erlangen University in Bavaria, Germany, were questioned in interviews or focus group discussions. Following ‘theoretical sampling’, participants were recruited and selected stepwise to generate a diverse sample and a broad collection of perspectives. Recordings of the interviews were transcribed verbatim and analysed using the three-stage coding procedure according to Corbin and Strauss.Results While not being taught about it in their theoretical studies, students immediately understand and frequently encounter defensive practices in clinical internships. However, juridical liability was not a relevant reason to them. The clinical setting for their experiences is significantly shaped by two phenomena which we have inductively named ‘the hospital system’ and ‘medical culture’. ‘The hospital system’ as a future workplace is perceived as daunting due to perceived ill-preparedness for looming responsibility as well as a felt lack of support within strong hierarchies. Medical culture in the students’ eyes is characterized by perfectionistic expectations along with intolerance of uncertainty and error in medicine. These two phenomena lead to a strong desire for assurance behaviour as well as rigid adherence to guidelines to cope with the overwhelming responsibility. Consequently, this lays the foundation for defensive practices, such as overdiagnosis and overtreatment, to become ingrained in medical decision-making.Conclusions The original definition of DM with its fear of juridical liability does not adequately reflect its causes as perceived by students. We presume that the main drivers of DM and thereby overdiagnosis and overtreatment are more likely to be intolerance of uncertainty and error in the face of perfectionistic expectations and a lacking error culture in medicine. Therefore, our findings underscore the need for educational reforms that better prepare students for their future workplace and a change of culture at these workplaces. More thought should be given to the implicit learning outcomes that students take away from observing interactions in the clinical setting. Educators should focus on strengthening students’ affective skills and their dealing with errors and tolerance of uncertainty, whilst also counteracting the perception of medicine as a ‘perfect science’ by teaching the principles of evidence-based medicine.",
  "authors": [
    {
      "affiliations": [
        "Friedrich-Alexander-Universität, Erlangen, Germany"
      ],
      "name": "Lara Kube"
    },
    {
      "affiliations": [
        "Friedrich-Alexander-Universität Erlangen-Nürnberg, Institute of General Practice, Erlangen, Germany"
      ],
      "name": "Thomas Kühlein"
    },
    {
      "affiliations": [
        "Friedrich-Alexander-Universität Erlangen-Nürnberg, Institute of General Practice, Erlangen, Germany"
      ],
      "name": "Maria Sebastiao"
    },
    {
      "affiliations": [
        "Friedrich-Alexander-Universität Erlangen-Nürnberg, Institute of General Practice, Erlangen, Germany"
      ],
      "name": "Constantin Unger"
    }
  ],
  "title": "020 Defensive medicine and overdiagnosis under the law of the hospital – a qualitative study of medical students’ experience in their studies and clinical internships",
  "uid": "a06ed899-8601-52f5-9b8f-8fd7aa819f1d"
}