"Defensive Medicine": The sword of Damocles on Hippocrates' head

Complaints against doctors are increasing, leading to the so-called 'defensive medicine', hoping to prevent the risk of legal complaints from patients, or relatives.

Translated from the original Italian version.

Saddened? No, concerned

Having just returned from a long day on duty at the hospital, my wife asks me: "How did it go?". My dark face anticipated my mood. "I am worried," I tell her. We move to the kitchen to talk and I tell her about a birth gone wrong. The newborn was resuscitated for over an hour, to no avail. I tell her that I did everything possible, that I was sure I had not forgotten anything, that I had not made any mistakes, that I had followed the guidelines. I tell her that I wrote everything down on the medical chart, that everything seems impeccable.

"I have also discussed it with colleagues, but I am worried," I repeat to her. I share with her, as we dine now at ten o'clock in the evening, my anxiety about a situation that will almost certainly not end today for me. I know that this medical file will go to the Carabinieri (Italian police) and probably a judge will decide if what I did, together with my colleagues, was a crime or not.

"How are you?" she asks me, as if afraid that my concern hides something else. "I'm worried, I'll almost certainly be sued, because a dead baby in the delivery room will take us to court, that's how it works now."

After a few moments of silence, she tells me: "It is strange to hear you say that you are worried. After what you experienced, I would have expected you to be sad, exhausted, frustrated, angry. You tried to save, for an hour, a dead infant. You spoke to the grief-stricken parents. A family was ready for a big party; now they have to prepare a funeral. How can it be that the first (and it seems the only) feeling you have is concern about a lawsuit that is not yet there? And even if it comes, can't you explain that you and your colleagues did your job, that no one could have saved that child?"

An inevitable death

First pregnancy at 36 years old, normal-term pregnancy, uncomplicated gestational diabetes controlled by dietary therapy. Regular spontaneous labour. Following exit of head there is failure to disengage shoulders. Immediate request for assistance from senior staff, requested paediatrician and anaesthetist in delivery room; use of obstetrical manoeuvres according to protocol. After 8 minutes from the exit of the head, extraction of atonic fetus with no vital signs...

My wife goes to bed to read, I lay down on the sofa. I review in my mind all the events I have witnessed since I was called at 5.01 p.m. There is nothing I could or should have done differently. Perhaps the midwife's chart could have been written better, but the data were all there, the procedures noted, the times too. I would have added more to make the diary clearer. There are those who think that writing too much on the medical record affects you, I, on the other hand, think that's what exonerates you.

It seems strange to her that I did not return home heartbroken over the grief of two parents who have just lost their child. I have been in this profession for years and, rightly or wrongly, I have developed a certain defensive armour towards the pain of others. The resuscitation of an infant does not leave me indifferent, of course, but I am used to tragic events. As I peel a tangerine, I think, however, that perhaps she is not wrong.

My soul should now be like this tangerine in my hand. It should be divided into many segments, each with a different shade of what I feel: frustration, sorrow, anger, compassion, and worry should animate my inner turmoil. But no, I am only worried that a judge will sentence me to compensation that would bring my family to its knees. I am sure my colleagues are struggling with the same thoughts as me. A gynaecologist, a paediatrician, two anaesthetists, three midwives, everyone who was in that room now is sharing the same concern as me, I am sure.

It may seem absurd. I have done everything I could and should have done, like my colleagues, but I am afraid that my actions may be taken into consideration by a magistrate and that maybe a trifle, a technicality, maybe a sentence not clearly written in the medical file, may be found that could disrupt my life and that of my loved ones. Probably as early as tomorrow this child's death will end up in the newspaper, the news will talk about it, the comments on social media will arrive. It will be reported as a malpractice, because a baby at the end of a physiological pregnancy cannot die. Surely, someone did wrong, and those who did wrong will have to pay.

I realise that I have no confidence in those who will tell and comment on this story, nor do I have confidence in the judge who will judge my actions and those of my colleagues. Not even the grandparents in the waiting room, angry, already talking about lawsuits and the court, had confidence in what we had done, in our skills and professionalism, I recognise that.

The fear of lawsuits

Undoubtedly, the situation that leads to the death of a newborn child must be investigated and controlled. It must be the health authorities that investigate, first and foremost, to analyse the facts and be certain that the death could not have been avoided. I am not shocked that an investigation file is opened per se. This is not the problem.

Unfortunately, any medical act nowadays is at risk of judicial and social condemnation, especially if media and political pressures fuel a climate of mistrust and blame-hunting. In these times, the sword of Damocles hanging over the heads of us doctors is increasingly sharp and heavy, attached to a thin and slender horsehair. So-called defensive medicine pervades the thoughts and actions of all of us, with serious consequences for the quality of care provided to patients, the management of healthcare systems, abd also for our lives.

There are several possible solutions to the problem, but fundamental, in my opinion, is the recovery of the relationship of trust, first and foremost between doctor and patient. I am convinced that correct information, sincerity and transparency are basic in this. I wonder if, during the nine months of pregnancy, anyone has ever spoken clearly with the parents I met today in the delivery room, even addressing the issue of the inherent risks of childbirth.

I don't think either the general practitioner or the gynaecologist did, I don't think they even talked about it at the pre-natal class. Yet childbirth is not a risk-free event, despite what the magazines or social media portray. Perhaps the problem is that crucial information on risks is precisely sought in magazines and social media [instead of practitioners].

Two million babies die each year from birth complications

According to data from the World Health Organisation, there are almost 2 million stillbirths every year, one every 16 seconds (the WHO recommends using the term 'stillbirth' to define a foetus delivered, or extracted from the mother, without vital signs with a gestational age of 28 weeks or more). More than 40% of all stillbirths occur during labour. The most alarming numbers, as is easy to imagine, are in developing countries. The risk of intra-partum death in Africa, for example, is 16 times higher than in Western European countries.

According to the Euro-Peristat Report 2015-2019, among the 32 European countries contributing data to Euro-Peristat, the median stillbirth rate at or after 24 weeks of gestation in 2019 was 3.2 per 1000 births, with an interquartile range (IQR) of 2.8 to 3.9 per 1000 births and a range of 1.8 (1.8 in Estonia; 2.0 in Slovenia) to 4.7 (4.7 in Cyprus; 4.4 in Belgium; 4.3 in Hungary; 4.2 in Slovakia and Wales) per 1000 births. Stillbirth rates are lower when a 28-week threshold is applied (median 2.5 per 1000 births with an IQR of 2.2 to 3.0 per 1000 births). Stillbirths at or after 24 weeks of gestation either decreased slightly or fluctuated around the same level for most countries when comparing 2019 to 2015. Stillbirth rates at or after 28 weeks of gestation across Europe from 2015 to 2019 also decreased slightly.

In Europe, losing a baby in the delivery room is therefore a rare event. Unlikely, but possible. No matter how much healthcare systems, and medico-obstetric skills may improve, the risk of this event cannot be reduced to zero. Recent as they may be, actions aimed at zeroing maternal and neonatal mortality and avoidable stillbirth in the world now exist, and it is logical to think that they will bring concrete results, especially in high-income countries like ours. But there will always remain a percentage, albeit low, of unavoidable deaths in the delivery room.

The importance of good doctor-patient communication

We live in a society where it is thought that a baby dying in a delivery room is always and only a medical error, a symptom of malpractice. The family wants justice, the judges hand down sentences, the media look for the headline, the health workers tremble, those who do not know and comment foam with anger.

I wonder whose job it is to make future parents aware of the risks involved in childbirth. I wonder who should effectively inform the community about what is being done to decrease the number of stillbirths. I wonder who has to bang their fists on the table for political agendas to address this issue and what revolves around it, for instance in terms of psychological costs for families. I wonder what those officials who lead marches of demonstrators to protest against the closure of those small birth centres that deliver a very low number of babies a year know about health.

I wonder about my wife's reflection: A doctor who has just attended a dead baby should only feel sorrow, anger and frustration, not concern about a possible court case.