Bir üniversite hastanesinde çalışan hekimlerin defansif tıp uygulama durumları, nedenleri ve sonuçları; karma araştırma
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Date
2022
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Hatay Mustafa Kemal Üniversitesi
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Abstract
Amaç: Bu araştırmada hekimlerin defansif tıp uygulama (DTU) durumunu, nedenlerini ve sonuçlarını karma yöntemle tespit etmek amaçlanmıştır. Yöntem: Araştırma nicel ve nitel yöntemlerin bütüncül kullanıldığı karma bir çalışma olup nicel aşama kesitsel araştırma yöntemiyle, nitel aşama ise fenomenolojik desende görüşmeler ve gözlem yöntemiyle ardışık olarak gerçekleştirilmiştir. Nicel aşamanın evreni, Hatay Mustafa Kemal Üniversitesi Sağlık Uygulama ve Araştırma Hastanesi'nde Nisan 2022'de dahili ve cerrahi branşlarda çalışan araştırma görevlisi ve öğretim üyelerinden oluşan 326 doktordur. Nicel aşamada örneklem seçilmemiş, evrenin tamamına e-anket ya da yüz yüze görüşme yöntemiyle ulaşılması hedeflenmiştir. Nitel aşamanın evreni; nitel aşamaya katılmayı kabul eden 61 katılımcı, örneklemi ise; nitel aşamaya davet edilen fenomenolojik desen ve amaca yönelik örnekleme ile seçilen 11 katılımcıdır. Nicel aşamada veri toplama aracı olarak "Sosyodemografik ve Mesleki Durum Anketi", "DTU Tutum Ölçeği", "Maslach Tükenmişlik Ölçeği (MTÖ)" ve "Minnesota İş Doyumu Ölçeği (MİDÖ)" kullanılmıştır. Nitel aşamada derinlemesine yarı yapılandırılmış yüz yüze görüşmeler ve gözlemler yapılmıştır. DTU Tutum Ölçeği'nden (14 madde, 5'li likert) alınan puanlar 14-27; Zayıf, 28-41; Orta, 42-55; İleri ve 56-70; Çok ileri DTU olarak sınıflandırılmaktadır. Ölçeğin Pozitif (PDT;9 madde) ve Negatif (NDT;5 madde) alt boyutlarında bir soruya "evet" yanıtını verme DTU olarak kabul edilmektedir. MTÖ'nün Duygusal Tükenme (DT), Duyarsızlaşma(D) ve Kişisel Başarı(KB), MİDÖ'nin Toplam Doyum, İçsel Doyum(İDD) ve Dışsal Doyum(DD) boyutları bulunmaktadır. İstatistiksel analizlerde; SPSS-22 ve NVIVO programları kullanılmıştır. Bulgular: Hekimlerin %67,5'i çok ileri-ileri DTU düzeyindedir. PDT ve NDT sıklığı sırasıyla %96,2, %97,1'dir. DTU puanı asistanlarda, 35 yaş ve altında, mesleki yılı 5'ten az olanlarda ve aylık 5'ten az nöbet tutanlarda yüksektir (p<0,05). DTU puanı ile DT, D puanı arasında pozitif, MİDÖ puanı arasında negatif korelasyonlar saptanmıştır (p<0,05). Lineer regresyon modelinde DTU puanı ile D (β=0,85) ve DD (β= -3) puanları arasında ilişki bulunmuştur (p<0.05), Logistik regresyon modelinde çok ileri-ileri DTU'yu DT puanı (OR=1,12), asistan/uzman olma (OR=3,79), 30 yaştan büyük olma (OR=0,40), aylık nöbetin 5'ten fazla olması (OR=2.08), klinikte sık DTU olduğunu düşünme (OR=2,59) ve sağlık hizmet modelinin DTU'yu arttırıcı etkisi olduğunu düşünme (OR=2,4) etkilemekteydi(p<0,05). Çalışmanın nitel kısmında görüşmelerin küme analiziyle; hekimlerin sıklıkla dava ve hata korkusu, imaj kaygısı, basındaki haberler, hasta yoğunluğu, huzur ve gelecek kaygısı nedenleriyle DTU'ya yöneldiği saptanmıştır. Hekimlerin sıkça başvurduğu uygulamalar ise kayıtları düzgün tutma, ekstra tetkik, konsültasyon, görüntüleme isteme ve abartılı anlatımdı (Överek ya da korkutarak kaçırma vb). Hekimler DTU'nun sonuçlarıyla ilgili olarak; maliyet artışı, hasta şikâyeti ve yoğunluğunda artış ile iş doyumunda düşme üzerine durmuşlardır. DTU'yu azaltmak için; koruyucu sağlık hizmetlerinin güçlendirmesine, sevk zincirine, triaja, malpraktis xv ön kurulu ile personel eksikliğine dikkat çekmişlerdir. Mesleğin icrasında korku ve kaygı ifadelerinde sıklıkla can güvenliği ve şiddet ile dava ve tazminat konularına değinmişlerdir. Küme analizinde hekimlerin korku ve kaygısının azaltılabilmesi için yaptıkları önerilerde alt yapı ve personel eksikliğinin giderilmesi, çalışma koşullarının düzeltilmesi, hasta yoğunluğunun azaltılması ve hekim eğitimi sıklıkla beraber geçmiştir. Gözlemlerde hekimlerin %9'unun hastalarına ayırdıkları süre ≥20 dakikadır. Hekimlerin %45,4'ünün fizik muayeneden önce, %15,1'inin anamnez almadan önce istemlerde bulunduğu gözlemlenmiş, istemlerin %21,2'sinin sosyal endikasyon dahilinde olduğu saptanmıştır. Katılımcıların %81,8'i araştırmacının poliklinikte gözlemde bulunmasının klinik yaklaşımlarını etkilemediğini belirtmiştir. Sonuçlar: Çalışmamızda hekimlerin yaklaşık üçte ikisinde çok ileri-ileri düzeyde DTU saptanmıştır. Genç hekimlerde, ağır çalışma şartlarında, tükenmişliğin yüksek ve iş doyumunun düşük olduğu durumlarda DTU artmaktadır. DTU'nun azaltılması için hekimlerin iş doyumunda artış ve psikolojik iyilik halinde sağaltım çalışmaları üzerine odaklanılmalı, sağlık sistemi koruyucu sağlık hizmetlerini güçlendirdiği, personel eksikliğini giderdiği ve hekimine sahip çıkıldığının hissini verdiği ölçüde DTU'da azalacaktır.
Aim: In this study, it was aimed to determine the defensive medicine practice status, reasons and results of physicians with a mixed method. Method: The research is a mixed study in which quantitative and qualitative methods are used holistically, and the quantitative stage was carried out with the cross-sectional research method, and the qualitative stage was carried out sequentially with the phenomenological design interviews and observation method. The universe of the quantitative phase is 326 doctors, consisting of research assistants and lecturers working in internal and surgical branches at Hatay Mustafa Kemal University Health Practice and Research Hospital in April 2022. The sample was not selected in the quantitative stage, and it was aimed to reach the entire universe by e-survey or face-to-face interview method. The universe of the qualitative stage; 61 participants who agreed to participate in the qualitative stage, the sample is; 11 participants selected by phenomenological design and purposive sampling invited to the qualitative stage. In the quantitative stage, "Sociodemographic and Occupational Status Questionnaire", "Defensive medicine practices (DMP) Attitude Scale", "Maslach Burnout Scale (MBS)" and "Minnesota Job Satisfaction Scale (MJSS)" were used as data collection tools. In the qualitative stage, in-depth semi-structured face-to-face interviews and observations were made. The scores obtained from the Attitude Scale for DMP (14 items, 5-point Likert) are classified as 14-27; Poor, 28-41; Moderate, 42-55; Advanced and 56-70; Very advanced DMP. Answering "yes" to a question in the Positive (PDM; 9 items) and Negative (NDM; 5 items) sub-dimensions of the scale is accepted as DMP. Emotional Exhaustion (EE), Depersonalization (D) and Personal Achievement (PA) dimensions of the MASLACH BURNOUT SCALE, and Total Satisfaction(MJSS), Intrinsic Satisfaction (IS) and Extrinsic Satisfaction (ES) dimensions of the MINNESOTA JOB SATISFACTION SCALE. In statistical analysis; SPSS-22 and NVIVO programs were used. Results: 67.5% of the physicians are at the level of very advanced-advanced DMP. The frequency of PDM and NDM was 96.2% and 97.1%, respectively. DMP score was higher in residents, aged ≤35, with <5 professional years and >5 monthly shifts (p<0.05). There were positive correlations between DMP score and EE and D scores, and negative correlations between MJSS scores (p<0.05). In the linear regression model, a correlation was found between DMP score and D (β=0.85) and ES (β= -3) scores (p<0.05). In the logistic regression model, very advanced DMP, EE score (OR=1.12), assistant/specialist (OR=3.79), age >30 (OR=0.40), number of monthly seizures >5 ( OR=2.08), thinking that there is frequent DMP in the clinic (OR=2.59) and thinking that the health care model has an increasing effect on DMP (OR=2.4) were affected (p<0.05). In the qualitative part of the study, with the cluster analysis of the interviews; It has been determined that physicians often turn to Defense Medıcıne Practıces due to fear of lawsuits and mistakes, image anxiety, xvii news in the press, patient density, peace and anxiety for the future. The practices frequently used by physicians were keeping records properly, extra examination, consultation, requesting imaging, and exaggerated expression (hijacking by praising or scaring). Physicians regarding the results of DMP; They focused on the increase in cost, increase in patient complaints and intensity, and decrease in job satisfaction. To reduce DMP; They drew attention to the strengthening of preventive health services, referral chain, triage, malpractice pre-board and staff shortage. In their expressions of fear and anxiety in the practice of the profession, they frequently mentioned the issues of life safety and violence, litigation and compensation. In the cluster analysis, the suggestions made by physicians to reduce their fear and anxiety included eliminating the lack of infrastructure and personnel, improving working conditions, reducing patient density, and physician training. In the observations, 9% of the physicians allocated time to their patients ≥20 minutes. It was observed that 45.4% of the physicians made requests before the physical examination, 15.1% before taking anamnesis, and it was determined that 21.2% of the requests were within social indications. 81.8% of the participants stated that the researcher's observation in the polyclinic did not affect their clinical approach. Conclusion: In our study, very advanced-advanced DMP was detected in approximately two-thirds of the physicians. In addition, burnout and low job satisfaction were found in physicians. DMP increase in young physicians, under heavy working conditions, when burnout is high and job satisfaction is low. In order to reduce DMP, it should be focused on the increase in the job satisfaction of physicians and treatment studies in psychological well-being. DMP will decrease to the extent that the health system strengthens preventive health services, eliminates the lack of personnel, and gives the feeling that its physician is taken care of.
Aim: In this study, it was aimed to determine the defensive medicine practice status, reasons and results of physicians with a mixed method. Method: The research is a mixed study in which quantitative and qualitative methods are used holistically, and the quantitative stage was carried out with the cross-sectional research method, and the qualitative stage was carried out sequentially with the phenomenological design interviews and observation method. The universe of the quantitative phase is 326 doctors, consisting of research assistants and lecturers working in internal and surgical branches at Hatay Mustafa Kemal University Health Practice and Research Hospital in April 2022. The sample was not selected in the quantitative stage, and it was aimed to reach the entire universe by e-survey or face-to-face interview method. The universe of the qualitative stage; 61 participants who agreed to participate in the qualitative stage, the sample is; 11 participants selected by phenomenological design and purposive sampling invited to the qualitative stage. In the quantitative stage, "Sociodemographic and Occupational Status Questionnaire", "Defensive medicine practices (DMP) Attitude Scale", "Maslach Burnout Scale (MBS)" and "Minnesota Job Satisfaction Scale (MJSS)" were used as data collection tools. In the qualitative stage, in-depth semi-structured face-to-face interviews and observations were made. The scores obtained from the Attitude Scale for DMP (14 items, 5-point Likert) are classified as 14-27; Poor, 28-41; Moderate, 42-55; Advanced and 56-70; Very advanced DMP. Answering "yes" to a question in the Positive (PDM; 9 items) and Negative (NDM; 5 items) sub-dimensions of the scale is accepted as DMP. Emotional Exhaustion (EE), Depersonalization (D) and Personal Achievement (PA) dimensions of the MASLACH BURNOUT SCALE, and Total Satisfaction(MJSS), Intrinsic Satisfaction (IS) and Extrinsic Satisfaction (ES) dimensions of the MINNESOTA JOB SATISFACTION SCALE. In statistical analysis; SPSS-22 and NVIVO programs were used. Results: 67.5% of the physicians are at the level of very advanced-advanced DMP. The frequency of PDM and NDM was 96.2% and 97.1%, respectively. DMP score was higher in residents, aged ≤35, with <5 professional years and >5 monthly shifts (p<0.05). There were positive correlations between DMP score and EE and D scores, and negative correlations between MJSS scores (p<0.05). In the linear regression model, a correlation was found between DMP score and D (β=0.85) and ES (β= -3) scores (p<0.05). In the logistic regression model, very advanced DMP, EE score (OR=1.12), assistant/specialist (OR=3.79), age >30 (OR=0.40), number of monthly seizures >5 ( OR=2.08), thinking that there is frequent DMP in the clinic (OR=2.59) and thinking that the health care model has an increasing effect on DMP (OR=2.4) were affected (p<0.05). In the qualitative part of the study, with the cluster analysis of the interviews; It has been determined that physicians often turn to Defense Medıcıne Practıces due to fear of lawsuits and mistakes, image anxiety, xvii news in the press, patient density, peace and anxiety for the future. The practices frequently used by physicians were keeping records properly, extra examination, consultation, requesting imaging, and exaggerated expression (hijacking by praising or scaring). Physicians regarding the results of DMP; They focused on the increase in cost, increase in patient complaints and intensity, and decrease in job satisfaction. To reduce DMP; They drew attention to the strengthening of preventive health services, referral chain, triage, malpractice pre-board and staff shortage. In their expressions of fear and anxiety in the practice of the profession, they frequently mentioned the issues of life safety and violence, litigation and compensation. In the cluster analysis, the suggestions made by physicians to reduce their fear and anxiety included eliminating the lack of infrastructure and personnel, improving working conditions, reducing patient density, and physician training. In the observations, 9% of the physicians allocated time to their patients ≥20 minutes. It was observed that 45.4% of the physicians made requests before the physical examination, 15.1% before taking anamnesis, and it was determined that 21.2% of the requests were within social indications. 81.8% of the participants stated that the researcher's observation in the polyclinic did not affect their clinical approach. Conclusion: In our study, very advanced-advanced DMP was detected in approximately two-thirds of the physicians. In addition, burnout and low job satisfaction were found in physicians. DMP increase in young physicians, under heavy working conditions, when burnout is high and job satisfaction is low. In order to reduce DMP, it should be focused on the increase in the job satisfaction of physicians and treatment studies in psychological well-being. DMP will decrease to the extent that the health system strengthens preventive health services, eliminates the lack of personnel, and gives the feeling that its physician is taken care of.
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Keywords
Halk Sağlığı, Public Health, Defansif Tıp, Doktor, İş Doyumu ve Tükenmişlik, Defensive Medicine, Doctor, Job Satisfaction and Burnout
