Triggers of defensive medical behaviours: A cross-sectional study among physicians in the Netherlands

Erik Renkema*, Kees Ahaus, Manda Broekhuis, Maria Tims

*Corresponding author for this work

Research output: Contribution to JournalArticleAcademicpeer-review


Objectives This study investigated whether the attitudes of physicians towards justified and unjustified litigation, and their perception of patient pressure in demanding care, influence their use of defensive medical behaviours. Design Cross-sectional survey using exploratory factor analysis was conducted to determine litigation attitude and perceived patient pressure factors. Regression analyses were used to regress these factors on to the ordering of extra tests or procedures (defensive assurance behaviour) or the avoidance of high-risk patients or procedures (defensive avoidance behaviour). Setting Data were collected from eight Dutch hospitals. Participants Respondents were 160 physicians and 54 residents (response rate 25%) of the hospital departments of (1) anaesthesiology, (2) colon, stomach and liver diseases, (3) gynaecology, (4) internal medicine, (5) neurology and (6) surgery. Primary outcome measures Respondents' application of defensive assurance and avoidance behaviours. Results € Disapproval of justified litigation' and € Concerns about unjustified litigation' were positively related to both assurance (β=0.21, p<0.01, and β=0.28, p<0.001, respectively) and avoidance (β=0.16, p<0.05, and β=0.18, p<0.05, respectively) behaviours. € Self-blame for justified litigation' was not significantly related to both defensive behaviours. Perceived patient pressures to refer (β=0.18, p<0.05) and to prescribe medicine (β=0.23, p<0.01) had direct positive relationships with assurance behaviour, whereas perceived patient pressure to prescribe medicine was also positively related to avoidance behaviour (β=0.14, p<0.05). No difference was found between physicians and residents in their defensive medical behaviour. Conclusions Physicians adopted more defensive medical behaviours if they had stronger thoughts and emotions towards (un)justified litigation. Further, physicians should be aware that perceived patient pressure for care can lead to them adopting defensive behaviours that negatively affects the quality and safety of patient care.

Original languageEnglish
Article numbere025108
Pages (from-to)1-11
Number of pages11
JournalBMJ Open
Issue number6
Publication statusPublished - Jun 2019


  • medical ethics
  • quality in health care
  • risk management


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