La mediazione trasformativa nell’era della patient revolution. Un modello per la gestione del rischio clinico e legale nelle ASL italiane

  • Antonio Dodaro Giurista e mediatore sanitario, Lecce
  • Virginia Recchia Ricercatrice esperta in comunicazione medico-paziente, CNR-IFC Consiglio Nazionale delle Ricerche, Istituto di Fisiologia Clinica, Lecce
Parole chiave: Patient revolution, Transformative mediation, Physician-patient communication, Engagement, Risk management


[Transformative mediation in the era of the patient revolution. A model for the management of clinical and legal risk in Italian health facilities]

Nowadays, too many patients do not perceive that their doctors are exclusively dedicated to care them. This is probably because current health systems are too focused on physicians and diseases, rather than on patients. Such systems are also expensive, fragmented, inefficient and often cynical, generating not only the anger but also the willingness to bring legal claims from many patients. Many scholars, in fact, claim that "too much medicine" can bring more harm than good to the patients and to the health systems themselves, therefore promoting a more sober and respectful medicine. This is the vision of the "patient revolution" and the idea that inspires some other movements that aim to break the vicious circle of greed and cynicism that damages not only patients but also health professionals. Within the same vicious circle, an exponential increase in litigations takes place, as an additional negative effect of the system focused on the disease and on the doctors instead of on the patient.

In the present article, we assume that a greater participation of the patient in the choices concerning his/her own health is the fertile ground in which concrete solutions can be found to many problems arising from the current medicine. We therefore analyze the main advantages of active patient participation, which in turn generate a reduction in health conflicts. Based on this analysis, we propose a model in which through various approaches, tools and methods - starting from the upstream prevention of the conflicts - we can also manage them downstream, for the benefit of both patients and health professionals. Finally, we show that within this framework, transformative mediation is an essential approach for weakening many legal disputes and repairing the relational damage generated upstream, where communication has failed or is completely lacking in the clinical practice.

Riferimenti bibliografici

Richards T, Montori VM, Godlee F, et al. Let the patient revolution begin. BMJ 2013; 346: f2614;

Cassel CA, Guest JA. Choosing Wisely - Helping Physicians and Patients Make Smart Decisions About Their Care. JAMA 2012; 307: 1801-02;

Fritz Z, Holton R. Too much medicine: not enough trust? J Med Ethics 2019; 45: 31-5;

Lipitz-Snyderman A, Bach PB. Overuse of health care services: when less is more… more or less. JAMA Intern Med 2013; 173: 1277-8;

Bonaldi A, Vernero S. Italy’s Slow Medicine: a new paradigm in medicine. Recenti Prog Med 2015; 106: 85-91;

Shaheen NJ, Fennerty MB, Bergman JJ. Less is more: a minimalist approach to endoscopy. Gastroenterology 2018; 154: 1993-2003;

Embrett M, Randall GE. Physician perspectives on Choosing Wisely Canada as an approach to reduce unnecessary medical care: a qualitative study. Health Res Policy Syst 2018; 16: 95;

Ries NM. Choosing Wisely: Law’s contribution as a cause of and a cure for unwise health care choices. J Law Med 2017; 25: 210-28

Dodaro A, Recchia V. La bi-direzionalità funzionale tra processo di consenso informato e mediazione sanitaria. Pratica Medica & Aspetti Legali 2014; 8: 75-81;

Dodaro A, Recchia V. Mediazione in sanità. L’arbitrarietà dell’atto medico di imaging ionizzante, il consenso informato e l’opportunità stragiudiziale del D.Lgs. n. 28/2010. Pratica Medica & Aspetti Legali 2012; 6: 91-9;

Berlin L. Medical errors, malpractice, and defensive medicine: an ill-fated triad. Diagnosis (Berl) 2017; 4: 133-9;

Pellino IM, Pellino G. Consequences of defensive medicine, second victims, and clinical-judicial syndrome on surgeons’ medical practice and on health service. Updates Surg 2015; 67: 331-7;

Baruch Bush RA, Folger JP. The promise of mediation: responding to conflict through empowerment and recognition. San Francisco: Jossey-Bass Publishers, 1994

Recchia V, Dodaro A. Innovare il consenso informato e la comunicazione del rischio nelle Unità Operative ASL. Un’analisi SWOT. In: De Benedetto M, Preite G (a cura di). La governance del rischio in sanità tra comunicazione e consenso informato. Trento: Tangram Edizioni Scientifiche, 2017

Jenerette CM, Mayer DK. Patient-provider communication: the rise of patient engagement. Semin Oncol Nurs 2016; 32: 134-43;

Menichetti J, Libreri C, Lozza E, et al. Giving patients a starring role in their own care: a bibliometric analysis of the on-going literature debate. Health Expectations 2016; 19: 516-26;

Graffigna G, Barello S, Riva G, et al. Patient engagement: the key to redesign the exchange between the demand and supply for healthcare in the era of active ageing. Stud Health Technol Inform 2014; 203: 85-95

Terranova G, Ferro M, Carpeggiani C, et al. Low quality and lack of clarity of current informed consent forms in cardiology: how to improve them. JACC Cardiovasc Imaging 2012; 5: 649-55;

Neuwirth ZE. An essential understanding of physician-patient communication. Part II. J Med Pract Manage 1999; 15: 68-72

Posner KL, Severson J, Domino KB. The role of informed consent in patient complaints: Reducing hidden health system costs and improving patient engagement through shared decision making. J Healthc Risk Manag 2015; 35: 38-45;

Hamasaki T, Hagihara A. Physicians’ explanatory behaviours and legal liability in decided medical malpractice litigation cases in Japan. BMC Medical Ethics 2011; 12:7;

Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centered care. Health Affairs (Millwood) 2010; 29: 1310-8;

Correia NG. Adverse events: reducing the risk of litigation. Cleve Clin J Med 2002; 69: 15-7, 23-4

Moore PJ, Adler NE, Robertson PA. Medical malpractice: the effect of doctor-patient relations on medical patient perceptions and malpractice intentions. West J Med 2000; 173: 244-50

Levinson W, Roter D, Mullooly JP, et al. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997; 277: 553-9

Jung B, Stoll C, Feick G, et al. Prostate cancer patients’ report on communication about endocrine therapy and its association with adherence. J Cancer Res Clin Oncol 2016; 142: 465-70

Bull SA, Hu XH, Hunkeler EM, et al. Discontinuation of use and switching of antidepressants: influence of patient-physician communication. JAMA 2002; 288: 1403-9;

Lin G, Redberg R. Addressing overuse of medical services one decision at a time. JAMA Intern Med 2015; 175: 1092-3;

Rothberg MB, Sivalingam SK, Kleppel R, et al. Informed decision making for percutaneous coronary intervention for stable coronary disease. JAMA Intern Med 2015; 175: 1199-206;

Tulsky JA. Decision aids in serious illness: moving what works into practice. JAMA Intern Med 2015; 175: 1221-2;

Recchia V, Dodaro A, Braga L. Event-based versus process-based informed consent to address scientific evidence and uncertainties in ionising medical imaging. Insights Imaging 2013; 4: 647-53;

Dodaro A, Recchia V. Inappropriateness in ionizing imaging. The central node of the informed consent: from “event” model to “process” model. Recenti Prog Med 2011; 102: 421-31;

O’Connor AM, Bennett CL, Stacey D, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews 2009; 3: CD001431;

Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ 2016; 353: i2139;

Ho AL, Klassen AF, Cano S, et al. Optimizing patient-centered care in breast reconstruction: the importance of preoperative information and patient-physician communication. Plast Reconstr Surg 2013; 132: 212e-220e;

Suarez-Almazor ME. Patient-physician communication. Curr Opin Rheumatol 2004; 16: 91-5

Wallace J, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009; 374: 1714-21;

Kinnersley P, Edwards A. Complaints against doctors. BMJ 2008; 336: 841-2;

Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA 2000; 284: 1021-7;

Langewitz W, Denz M, Keller A, et al. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ 2002; 28 September, 325 (7366): 682-3;

Ellis P, Abbott J. Strategies for managing conflict within the team. J Ren Nurs 2011; 3: 40-3;

Marquis BL, Huston CJ. Leadership roles and management functions in nursing: theory and application. Philadelphia: Wolters Kluwer, 2014

WHO World Health Organization. Health Promotion Glossary. Geneva: WHO, 1998. Disponibile online su (ultimo accesso dicembre 2018)

Schapira MM, Walker CM, Cappaert KJ, et al. The numeracy understanding in medicine instrument. A measure of health numeracy developed using item response theory. Med Decis Making 2012; 32: 851-65;

Coleman C, Kurtz-Rossi S, McKinney J, Pleasant A, Rootman I, & Shohet L. Calgary Charter on Health Literacy 2011. Disponibile online su (ultimo accesso dicembre 2018)

Ratzan SC, Parker RM. Introduction. In: Selden CR, Zorn M, Ratzan SC, Parker RM (editors). In National Library of Medicine current bibliographies in medicine: Health literacy. Bethesda, MD: National Institutes of Health; 2000. (NLM Pub. No. CBM 2000-1)

WHO World Health Organization Regional Office for Europe. Health 2020: a European policy framework supporting action across government and society for health and well-being, 2012. Disponibile online su: (ultimo accesso dicembre 2018)

Prey JE, Woollen J, Wilcox L, et al. Patient engagement in the inpatient setting: a systematic review. J Am Med Inform Assoc 2014; 21: 742-50;

Hardyman W, Daunt KL, Kitchener M. Value co-creation through patient engagement in healthcare: a micro-level approach and research agenda. Public Manag Rev 2015; 17: 90-107

Recchia V, Dodaro A, Maglie RB, et al. Communication and education processes involved in COPD patient engagement within the Italian health system. In: Graffigna G (editor). Transformative Healthcare Practice through Patient Engagement. Hershey, PA: IGI Global, 2016, p. 29-65;

Barello S, Graffigna G, Savarese M, et al. Engaging patients in health management: towards a preliminary theoretical conceptualization. Psicologia della Salute 2014; 3, 11-33

Elwyn G, Coulter A, Laitner S, et al. Implementing shared decision making in the NHS. BMJ 2010; 341:c5146;

Dodaro A. Appropriatezza clinica e consenso informato nel contesto ospedaliero italiano. Problematiche giuridiche e tutela dei diritti. Recenti Prog Med 2011; 102: 296-301

Tereanu C, Bettega S, Regalia E, et al. La mediazione volontaria nelle controversie in sanità: l’esperienza della Fondazione IRCCS Istituto Nazionale dei Tumori - Milano. Ig Sanita Pubbl 2014; 70: 29-40

Quattrocolo A. Mediare i conflitti nella relazione medico-paziente. Quaderni di mediazione. Cagliari: Puntodifuga Editore, 2006, n. 3

Fascia MR, Quattrocolo A, Trombini V. La mediazione in materia sanitaria: opportunità e criticità del D.Lgs.28/2010. Le Guide - il fisco - Marzo 2012. Roma: Wolters Kluwer, p. 78-83

Decreto Legislativo del 4 marzo 2010, n.28. «Attuazione dell’articolo 60 della legge 18 giugno 2009, n. 69, in materia di mediazione finalizzata alla conciliazione delle controversie civili e commerciali». Gazzetta Ufficiale n. 53 del 5 marzo 2010

Gulino M, Bassetti C, Frati P. The key role of mediation in the medical malpractice litigation. Med Secoli 2010; 22: 377-91

Ania, Associazione Nazionale fra le Imprese Assicuratrici. Malpractice, il grande caos. Roma, 2014. Disponibile online su (ultimo accesso dicembre 2018)

Reason J. Human Error. New York: Cambridge University Press, 1990

Leape LL. Error in medicine. JAMA 1994; 272: 1851-7

Burton JW (editor). Conflict: human needs theory. New York : St. Martin’s Press, 1990

Come citare
Dodaro, A., & Recchia, V. (2018). La mediazione trasformativa nell’era della patient revolution. Un modello per la gestione del rischio clinico e legale nelle ASL italiane. Pratica Medica & Aspetti Legali, 12(1).
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