For personal use. Only reproduce with permission from The Lancet Publishing Group. ARTICLES 1258 THE LANCET • Vol 357 • April 21, 2001 Summary Background Negative experiences are not uncommon among doctors in Norway. Our aim was to find out about the various types of negative reactions (eg, complaints, negative exposure to the media, financial claims, and notification to the police) received by physicians from patients or relatives in response to treatment, to identify their cause, and to study their effects on subsequent clinical decisions. Methods We posted questionnaires about negative reactions of patients to a random sample (n=1260) of Norwegian doctors. Each doctor was additionally sent five written case simulations and asked to choose one of several proposed clinical strategies. Half (630) the physicians received cases containing threats from the patient or their relatives. Findings 988 (78%) physicians returned the questionnaire, 463 (47%) of whom reported negative experiences. Such experiences were reported more frequently by men (357 [51%]) and family physicians (157 [58%]) than by other participants. Negative experiences did not affect choice of strategy for case simulations. For the first case, chest pain, 217 (44%) physicians presented with a threat chose a defensive strategy compared with 145 (30%) of those who were not (difference 14%; 95% CI 8–20). For the second case, a headache case, the corresponding numbers were 278 (57%) and 118 (25%) (32%; 26–38). Physician age, sex, specialty, or experience of negative reactions of patients did not alter the effect of threats received during our study. Interpretation Negative experiences do not affect subsequent decision making. However, doctors do comply with wishes from patients or relatives when presented with direct threats. Lancet 2001; 357: 1258–61 Introduction Understanding what affects a physicians’ decision-making process is important because of its impact on outcome in patients and health-care costs. Ideally, different doctors should make the same decisions when faced with similar clinical scenarios. However, studies of medical practice 1,2 show that decisions vary more than patients’ needs or provider capacity require. This variation in medical practice could be caused by patients’ preferences, available resources, uncertainty about diagnosis or effectiveness of the treatment options, or variation in physicians’ attitudes to taking risks. Factors in the decision-making environment also play a part. One such factor is the medicolegal climate. Malpractice lawsuits and formal complaints affect decision making by doctors and promote defensive medicine—ie, “the ordering of treatments, tests and procedures for the purpose of protecting the doctor from criticism rather than diagnosing or treating the patient”. 3 However, results of studies of the effects of malpractice claims on subsequent medical decisions are conflicting in that some show an effect 4–8 and others do not. 9,10 In medicine, malpractice lawsuits are common in USA, 11 and little has been published to suggest that they are less common in Europe. Direct threats aimed at influencing doctors’ decsions are an informal type of reaction that also occur worldwide. Such threats can be fairly harmless, such as a person threatening to seek a second opinion. However, if a doctor does not comply with a patient’s wishes, threats could also have the form of retaliation—such as a formal complaint. Case reports suggest that threats are common in clinical practice, but we have not been able to identify studies investigating the frequency or effects on decision making. Our aim was three-fold: first, to describe doctors’ experiences with various types of negative reactions from patients or relatives (formal complaints, negative mass- media reports, claims for financial compensation, or notification to the police); second, to identify the causes of the negative reactions; and third, to study the effects of such experiences, and of threats, on doctors’ decisions. We postulated that physicians would choose more defensive strategies when they had negative experiences or when they were threatened with retaliation. Methods Study population In 1993, a random sample of 2000 of the 11 266 members (18%), aged 26–70 years, of the Norwegian Medical Association (NMA) was invited to form a study panel (95% of doctors working in Norway are NMA members). This panel was part of a comprehensive research programme investigating physicians’ health and working conditions, started by the NMA because of an increase in the number of reports made by physicians about stress and dissatisfaction. The purpose of the panel was to follow-up prospectively a representative sample of physicians through their career, and to do cross-sectional studies on their attitudes and opinions at different points in time. 1272 (64%) physicians accepted positions on the Threats from patients and their effects on medical decision making: a cross-sectional, randomised trial Ivar Sønbø Kristiansen, Olav Helge Førde, Olaf Aasland, Ragnar Hotvedt, Roar Johnsen, Reidun Førde Institute of Public Health, University of Southern Denmark, Odense DK-5000 C, Denmark (I S Kristiansen MD, O H Førde MD, O Aasland MD, R Hotvedt MD, R J Johnsen MD, R Førde MD) Correspondence to: Dr Ivar Sønbø Kristiansen (e-mail: isk@sam.sdu.dk)