The present study revealed a spectrum of suggested underlying and contextual factors, examples, and preventive strategies for addressing DM. Study participants highlighted some issues which in their views could be counted as potential causes of DM. While such causes could be significantly diverse in the viewpoint of various stakeholders, including healthcare professionals, patients, and health policymakers, ascertaining causality in the realm of social science poses even more significant fundamental challenges, as there is no objective means to definitively determine the truth. Therefore, such issues should be considered as causes that were attributed by study participants. Social scientists may also hold differing interpretations of the dynamics within medical practice. Consequently, attributing causality within the realm of social science can be highly problematic, and there is no objective way to determine what is really happening. In this area what causes or generates DM can be understood in diverse ways, depending on various social ontology and overarching social theory. Therefore, we preferred to use the language of underlying and contextual factors instead of causes which directly implies a causality relation. As an example, while exploring the causes of DM, two contrasting social theories could emerge. One theory places physicians’ decision as the pivotal factor, suggesting that they are the ultimate deciders shaping defensive practices. The decision-making process they encounter may influence their choices, but the responsibility lies with the physicians. In contrast, another theory emphasizes the decision architecture of the situations in which physicians make decisions. This second theoretical point of view reduces the individual physicians’ agency. As we can see, these theories offer valid perspectives from a social science standpoint, and it is unrealistic to expect any study to definitively resolve this tension between macro-level (structural, collective) and micro-level (individual, personal) explanations of causes that could generate DM.

Regarding the causes, the present study mentioned underlying factors like concerns about complaints, physicians’ fear of the trial litigation process due to their or their colleagues’ unpleasant experiences, and lack of proper liability insurance, which have been previously discussed in other studies [23]. This finding was also reported in a retrospective 12-year analysis of medical malpractice claims of the Taiwan civil courts. This study found that medical malpractice lawsuits increased physicians’ stress and reduced their job satisfaction, which could result in defensive practices to prevent complaints [24].

However, some underlying factors of DM found in this study were less addressed in the literature. These include refusal of insurance companies to provide full liability insurance coverage for physicians, physicians’ concerns about being insulted or harassed by patients or their companions, fears of being humiliated or marginalized by colleagues, concerns about their dignity being violated, doubts about their competence, anxieties over losing their social and scientific status, lack of sufficient scientific and practical skills, shortages of equipment and facilities in less affluent centers compared to referral university hospitals where doctors are trained and skilled, multiplicity of complaint-handling organizations, an increasing familiarity of patients with their rights leading to more medical complaints, projecting a negative image of physicians in society, low self-confidence among some doctors, and the conservative or obsessive personality of some physicians.

Based on the insights provided by study participants, one of the primary sources of fear among physicians regarding legal litigations and complaints seems to be connected to concerns about their dignity. Consequently, the idea of dignity restoration emerges as a promising approach, given that accusations of improper practice can have enduring consequences on an individual’s life and professional journey, even after being legally exonerated. In such scenarios, physicians become more susceptible to stigmatization, leading to potential marginalization within the medical community. Within this context, two types of stigmas can be discerned: legal stigma and moral stigma. Legal stigma often accompanies moral stigma, but not vice versa. Carrying the weight of legal stigma, if it persists, can be immensely burdensome. However, even in cases where legal stigma does not endure, there remains the possibility of moral stigma lingering, affecting an individual’s reputation and self-perception.

Another contextual factor that exacerbates DM in Iran’s health system is the fragmented approach to handling medical errors or ethical misconduct. The current system lacks integration, resulting in multiple organizations being involved in addressing medical malpractice cases, including courts, the Medical Council, the Ministry of Health, and the Governmental Discretionary Punishments Organization (GDPO). This lack of a cohesive and streamlined system can lead to confusion and inefficiencies, further contributing to the practice of DM among healthcare professionals. Addressing this issue and establishing a more coordinated and transparent framework for handling medical errors is essential to alleviate the burden of defensive practices and improve the overall quality of healthcare in the country.

DM encompasses distinct aspects, including social and structural elements, and should not be solely attributed to physicians’ behavior. Several participants argued that it is a systematic problem, and the healthcare system needs restructuring to ensure physicians are not compelled to resort to DM as a means of self-protection or to avoid consequences related to objections and complaints from patients and their companions. Multiple factors, such as policymaking, laws, and managerial and administrative influences, contribute to the development and practice of DM. Therefore, it is essential to devise proper policies and enact necessary laws and regulations to garner support from relevant organizations and authorities for standard medical interventions performed by physicians and to prevent the occurrence of DM. Successful reduction of DM requires collaborative efforts across different sectors. In this regard, one of the most crucial interventions suggested as a strategy in various parts of the world is the decriminalization of medical errors [11, 25].

One of the factors related to the management of health centers and health system policymaking is “the lack of an efficient legal and coherent system to support physicians“. The concern for safeguarding the rights of medical professionals led to the enactment of the Bill of Rights of Iranian Medical Professionals by the Supreme Council of Iran Medical Council in 2021. This Bill addresses various aspects of the rights of medical professionals, including facilitating access to an efficient support system. Article 9 of the Bill states that “Members of the medical profession have the right to access the consultation system and legal supports of the Medical Council of Iran if their rights, as mentioned in the Charter, have been violated. The Medical Council must establish an appropriate mechanism to guide its members and facilitate their access to legal consultation services. Moreover, the Medical Council is obligated to defend the professional and personal dignity and security of its members when it becomes evident that they are facing prosecution, summons, etc. due to or as a result of carrying out their professional duties correctly and in accordance with scientific, technical, and ethical standards” [26]. Legal support would be particularly valuable, especially in reducing the prevalence of negative DM practices.

Promoting a protective and supportive umbrella of comprehensive liability insurance, which includes removing the time limit for reimbursement in professional liability insurance, increasing insurance coverage, and extending the time limit after medical interventions, was another strategy proposed by the interviewees. Currently, liability insurance is bound to reimburse the costs of any medical intervention within 4 years after the procedure. However, it refrains from reimbursement if the physician is sentenced to pay indemnity after this time for any reason, including the late complications of some medical errors and lengthy trials. Moreover, increasing the amount of insurance commitment alleviates physicians’ concerns and encourages them to practice without worrying about patients’ complaints and the financial consequences that may follow.

Another significant contextual issue, related to the legal system, contributing to the prevalence of DM in Iran’s health system is the quality and specificity of medical laws. Currently, these laws are inadequately developed and in need of updating. The existing legal framework may not sufficiently address the complexities and nuances of modern healthcare practice, leaving healthcare professionals uncertain about their liabilities and legal protections. Similar to medical guidelines, the lack of clear and up-to-date laws can create an atmosphere of uncertainty, prompting healthcare providers to adopt defensive practices as a precautionary measure to protect themselves from potential legal challenges. In addition to the content pf laws, our findings indicate the necessity for clarifying the rules and the process of handling patients’ complaints in courts of law.

Another example of cultural issues that significantly influence the prevalence of DM is the prevailing misconception in society that doctors with greater knowledge and skills tend to prescribe more drugs and para-clinical procedures. This misguided belief inadvertently drives healthcare providers towards adopting a positive defensive approach. Under the weight of this misconception, physicians may feel compelled to overprescribe medications and diagnostic tests as a protective measure. The fear of being perceived as less knowledgeable or competent by patients or colleagues pushes them to take a more cautious approach, even when it may not be clinically necessary.

Physicians often find themselves facing criticism, objections from patients and their families, and even social and media harassment if treatment objectives are not met. Additionally, they may have to attend different commissions and hearing sessions to defend themselves and explain the reasons behind their medical decisions. Furthermore, the tariffs for high-risk surgeries are often similar to those of simple surgeries or aesthetic procedures, despite the fact that high-risk surgeries are much more complex, take several hours to perform, carry a higher risk of complications, and result in significant stress for the physician during and after the procedure. As a result, physicians may choose to avoid admitting high-risk patients or performing such surgeries to preempt future problems and complaints. Based on our findings, the social structure of the society, the prevailing culture in clinical environments, the level of public trust in the medical society, and the social capital of the society all influence the DM behavior of physicians. In addition, unrealistic tariffs and the absence of a well-implemented referral system have led to an increase in working hours and patient visits for some physicians, leading to fatigue and burnout. Consequently, they may end up taking incomplete medical histories from patients and resorting to defensive practice. This problem is less prevalent in countries with better economic conditions and where physicians’ income is satisfactory.

While it may be challenging to ascertain the precise empirical approach for achieving this goal, the notion of fostering trust in physicians, nurturing patient-physician trust, and bolstering overall trust in the healthcare system is highly commendable. Trust plays a pivotal role in shaping the dynamics between physicians and patients, either mitigating or exacerbating litigious tendencies in their interactions. In essence, viewing the physician-patient relationship through a litigation lens is often associated with diminished trust, while a heightened level of trust between them tends to reduce the inclination towards litigation. Although the exact psychological mechanisms driving this phenomenon remain unclear, it aligns with existing research on litigious behavior and resonates with the experiences of seasoned lawyers well-versed in handling legal matters. Ultimately, cultivating an environment of trust has the potential to positively influence the nature of physician-patient interactions and promote a more harmonious and collaborative approach to healthcare. While the path to achieving this may be multifaceted, acknowledging the significance of trust represents a crucial step in fostering a constructive and patient-centric healthcare landscape.

The demand and satisfaction of patients and their dependents with multiple paraclinical tests sometimes lead physicians to prescribe unnecessary treatments. In some cases, physicians respond positively to patients’ demands and prescribe drugs and tests without scientific indications to appease their patients and prevent objections and complaints. The issue of defensive practice due to patients’ demands was also addressed in a study conducted in the United States in 2017. The survey found that 20.6% of medical care provided in the United States was unnecessary, and requests or pressure from patients was identified as one of the two significant reasons for unnecessary care [13]. These unnecessary treatments may result in unwanted side effects. For instance “in a patient with an infection a physician practicing DM may prolong antibiotic duration, prescribe unnecessary broad-spectrum antibiotics or combinations of agents, or prescribe unnecessary antibiotic treatments which may contribute to the alarming spread of antibiotic resistance” [27].

In recent years, there has been a rise in the education and literacy level of people, and their awareness of their social rights has also improved. This progress has led to an increase in patients’ demands and complaints from healthcare providers, causing physicians to worry about the consequences of such complaints and practice defensively. While the improved health literacy of people and their awareness of their rights are significant achievements, it is crucial to foster an appropriate culture and provide proper education and training to prevent unfounded complaints about physicians. While this social change is not properly understood and responded to by medical professionals.

Despite the study participants suggesting that increasing health literacy among the general public could be a potential strategy to address DM, a crucial point to consider is the complexity of gauging the required level and types of health literacy necessary for patients to fully comprehend their physicians’ actions. In essence, much of what physicians do involves intricate clinical judgment that may not be entirely understandable to non-physicians. The inherent gap between the knowledge of physicians and patients can best be bridged by fostering trust. Trust plays a pivotal role in filling the void of understanding, preventing the emergence of baseless hypotheses, presumptions, or assumptions that might question the physician’s integrity, intentions, or the healthcare system as a whole. While enhancing health and science literacy is undoubtedly beneficial, its effectiveness in reducing DM remains uncertain and requires further exploration. While the study participants’ perspective on the role of health literacy level may be subject to challenge and evolution over time, being aware of this prevailing sentiment among physicians enables researchers and other stakeholders engaging with them to delve further into the implications of their proposals. It also encourages a deeper reflection on the assumptions surrounding the potential achievements of health literacy in healthcare.

Despite the major social changes, the prevailing culture in the Iranian medical system is still paternalistic, and establishing a patient-centered culture remains a distant goal. This approach in the physician-patient relationship lowers patients’ participation in medical decision-making processes and paves the ground for misunderstandings and subsequent medical complaints, perpetuating a vicious cycle. On the other hand, highlighting the negative portrayal of physicians in society and acknowledging the influence of mass and social media in shaping this perception is of utmost importance. In an atmosphere of widespread distrust, it is essential to recognize that defensive practices among physicians, driven by the fear of litigation, can be seen as a natural response.

Despite the study participants’ suggestion to limit non-professionals’ freedom to discuss medical practice in mass media as a measure to enhance social trust in medical professionals and reduce DM, this perspective could face opposition. While we can attribute such suggestions to the paternalistic approach of the particular participant, the non-liberal political system of the country, or to the paternalistic culture of medical practice in Iran, a significant concern is that such restrictions might actually erode trust in medical experts instead of reinforcing it. The reason is that when only approved experts are allowed to speak, the credibility of their opinions relies heavily on the endorsing institution. If these institutions lack trustworthiness, the experts’ credibility may be called into question, perpetuating a cycle of mistrust. Moreover, the feasibility of implementing such restrictions in the digital age and outside certain contexts, like Iran, appears highly implausible, particularly in liberal democratic societies. Additionally, the notion of allowing only properly qualified experts to publicly comment on medical practice raises the fundamental question of how one defines “properly qualified“. If designation as a qualified expert is solely dictated by medical authorities, it may lead to the imposition of an official message, which often hampers efforts to increase trust.

The problems related to the physician-patient relationship are not limited to personal relationships and have social and external manifestations and may reduce the self-confidence of the physicians and foster an obsessive caution toward prescribing diagnostic or treatment interventions. Participants in our study emphasized the significance of comprehensive practical and scientific training for medical practitioners, which plays a crucial role in influencing physicians’ self-confidence and, subsequently, impacting defensive medical practices. However, it is essential to acknowledge that clinical judgment is a multifaceted issue that often develops over years of experience. Some other study participants further supported this notion by mentioning that senior physicians tend to be less inclined towards defensive practices.

It should be noted that all of the considerations that physicians apply to protect themselves against patients’ complaints collectively known as defensive practice are not necessarily unethical. For example, measures like careful documentation of interventions, especially when there is a risk of future complaints, receiving consultation on risk management, and seeking legal consultation in the hospital if done based on defined standards, are not unethical [13]. They are considered problematic when diagnostic and therapeutic interventions have no benefits for the patients and are done solely for defensive intentions. As discussed earlier, these interventions may carry a substantial risk for patients and damage the health system. The nature of clinical judgment being case-oriented adds complexity to determining the correctness of medical practice, especially in complex cases. As a result, ethically evaluating medical interventions and practices based on defensive motivations becomes far from straightforward. Objective determination of defensive practices faces challenges as it can be highly idiosyncratic, varying from case to case, making it difficult to arrive at definitive conclusions. As a result, obtaining a comprehensive understanding of the prevalence of such practices often relies on self-reports provided by physicians.

Regarding the strategies to reduce or prevent defensive practice, the present study proposed several strategies, some of which have been reported in earlier studies, such as the need to modify liability insurance and the reimbursement system. However, the present study also revealed several strategies to control defensive practice that have been less reported before. Another strategy proposed by the interviewees was to fix the system of handling complaints in order to reduce the number of complaint-handling organizations. According to them, the presence of different organizations causes wastage of physicians’ time and energy during different stages of the trial, disturbs their peace of mind and self-confidence, reduces their willingness to take risks in performing high-risk procedures, and discourages medical interventions, particularly complex surgeries. This situation leads to increased referrals to other physicians or healthcare centers, higher patient costs, and more harm to the patient. The recommendation is to develop and expand complaint-handling centers in hospitals to prevent filing lawsuits in disciplinary and legal organizations. This way, the primary evaluation of complaints can be done in the hospitals, and the necessity of summoning the physician to the complaint-handling organization can be ascertained before summoning.

Another suggestion was to correct the public misconception that patient referral indicates incompetence of the physician. While in such circumstances doctors usually refer the patients to an experienced colleague when find their ability insufficient for treating the patient in order to prevent damage to the patient. In the presence of such misconceptions, physicians might feel more comfortable to e.g., perform multiple paraclinical interventions.

Formulating specific standards such as national guidelines, institutionalizing their routine use by physicians, and making formal judgments based on them in complaint-handling organizations are other strategies aimed at preventing DM practice. When physicians adhere to diagnostic-treatment interventions in line with the guidelines, they fulfill their duties towards patients and have a strong defense if any complaints are filed. Consequently, there will be a reduction in defensive practice driven by concerns about patient complaints [27]. Such standards could be around issues such as reducing the number of patients or the working hours of physicians which can improve their concentration and reduces the odds of error and complaints and thus resolving their concerns about complaints and legal problems and decreasing their interest in defensive practice. Or considering DM as an issue while setting tariffs. Since unrealistic tariffs, and failure to implement the referral system has increased the working hours and the number of patient visits for some physicians, which in turn results in their fatigue and burnout, taking an incomplete medical history from the patients, and driving them toward defensive practice. This issue is less of a problem in countries where there are no important economic problems and the physicians’ income is acceptable.

DM extends beyond the realm of medical interventions on patients. According to the findings of the present study, defensive motivations not only alter physicians’ approach to medical interventions but also influence their choice of specialty and field of activity at a higher level. As a result, general physicians are less inclined to select specialty and subspecialty fields dealing with high-risk patients, leading to potential harm to this vulnerable group of patients. Furthermore, this defensive approach can manifest as routines and practical standards in clinical environments. For instance, parents’ demands for a brain CT scan in children with head trauma, lacking clinical necessity, have been considered an indication for a CT scan in emergency medicine reference books. In the ethical evaluation of DM, it should be noted that, in certain cases, this approach can be seen as a legitimate defense. Nevertheless, the prevalence of the DM approach in scientific texts underscores its wide impact on medicine. Therefore, it is essential to carefully assess medical education resources to ensure that such an approach is not imparted to medical students through medical texts. Simultaneously, increasing societal awareness regarding the negative consequences of inappropriate demands on doctors that drive them towards DM is crucial.

Considering the valuable insights gathered from a substantial number of interviewees who possess policymaking and administrative experience within the country’s health system and who are generally well-versed in medical malpractice laws and the medical litigation process, including individuals directly involved in the litigation process, the results of this study offer a strong foundation for informing policy decisions within the healthcare system. However, we acknowledge the complexity of the DM phenomenon, and there may be aspects that our study did not fully uncover. Considering the need for a multifaceted approach in policymaking, we encourage policymakers to complement the findings of this study with other available evidence to address any potential limitations and to gain a more comprehensive understanding of the policymaking process related to DM and can make well-informed decisions to effectively address the challenges posed by DM in the healthcare system”.

While the primary aim of this qualitative study was to increase comprehension and stimulate discussions about DM, it is essential to address the fact that some policy suggestions were made based on issues raised by the study participants. There are policy recommendations rather than definitive solutions to the complex and heterogeneous problem of DM, which emerged naturally from the data collected during the study. Heterogeneity could be a significant factor that complicates making macro-level claims such as policy suggestions. The study participants, being stakeholders with firsthand experience in the field, provided insights that led to the identification of potential areas for improvement to manage DM. It is crucial to acknowledge that these policy suggestions should be considered exploratory rather than conclusive. They may serve as starting points for further research and analysis. Additionally, policymakers and stakeholders should approach these recommendations with caution, understanding the limitations of the study and the need for more extensive research and empirical evidence to support any policy changes.

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