https://orcid.org/0000-0002-8838-6889
Figures
Abstract
Background
Defensive medicine has two forms: positive (assurance behavior) or negative (avoidance behavior), depending on the clinical situation. Defensive medicine minimizes the risk of litigation and tends to vary between surgical and non-surgical specialties due to the nature of the risks involved and the potential for litigation. This study aimed to investigate the prevalence and patterns of defensive medicine practice among Egyptian physicians, compare surgical versus non-surgical specialties, and examine their correlation with medico-legal complaints and occupational determinants.
Methods
This cross-sectional study was conducted among physicians from surgical and non-surgical specialties working in different Egyptian hospitals. A self-administered online questionnaire was distributed using the snowball sampling technique. The Defensive Medicine Behavior Scale (DMBS) was used to assess the practice of defensive medicine.
Results
A sample of 210 physicians with a mean age of 39 ± 7 years was included; 51.4% held the highest qualification of M.D. or Ph.D., with an equal sex distribution (1:1). There was a high level of defensive medicine practice in both surgical and non-surgical specialties: 41.7% and 39.5%, respectively. However, the difference between the two groups was not statistically significant (P-value >0.05). Regression analysis showed that working at university hospitals and having workplace insurance coverage for medico-legal claims were associated with fewer positive defensive medicine practices. Conversely, concerns about the financial implications of medico-legal claims and negative reactions from patients or families were associated with a greater prevalence of positive defensive medicine practices.
Citation: Tawfik AM, ElZoghby S, Elsherbiny NM, Salem MR (2026) Comparison of accusations against physicians and the practice of defensive medicine between surgical and non-surgical specialties. PLoS One 21(3): e0343807. https://doi.org/10.1371/journal.pone.0343807
Editor: Massimo Finocchiaro Castro, Mediterranean University of Reggio Calabria: Universita degli Studi Mediterranea di Reggio Calabria, ITALY
Received: April 6, 2025; Accepted: February 10, 2026; Published: March 5, 2026
Copyright: © 2026 Tawfik et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Malpractice claims against physicians, whether justified or not, have increased in recent years [1]. Such legal cases have a devastating effect on physicians’ thoughts, emotions, and behaviors, particularly when claims are unfounded [2,3]. Furthermore, legal proceedings consume considerable time, adding to the burden of physicians already overburdened with professional responsibilities and negatively affecting their social lives [4]. Additionally, litigation may cause physician distress, depression, and burnout, which negatively impacts their interactions and communication with patients and their families, as demonstrated in many studies [5–7].
Defensive medicine (DM), defined as medical practices primarily designed to minimize the risk of malpractice litigation rather than to enhance patient care, is a well-documented response to this litigious climate [8]. Its prevalence, typically measured through physicians’ surveys and healthcare utilization studies, is widespread across numerous specialties [9]. The practice is influenced by a complex interplay of factors including the legal environment, clinical uncertainty, and physician risk management. DM represents a significant burden on healthcare systems, leading to resource waste, potential patient harm from overdiagnosis, and moral distress among health professionals [10].
A survey of physicians in six lawsuit-prone specialties (emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology) showed that nearly 93% had altered their practice due to the fear of impending or pending lawsuits. The most common change reported was the adoption of DM, a practice that often deviates from or contradicts established standards of appropriate medical care [11].
DM can manifest as either positive (assurance behavior) or negative (avoidance behavior). The positive form involves undertaking excessive diagnostic tests and invasive investigations, prescribing treatment without a clear medical need, and hospitalizing patients unnecessarily. Conversely, the negative form entails failing to perform high-risk procedures that would benefit patients, thereby potentially denying them necessary treatment or hospitalization [12].
DM is performed primarily to mitigate litigation risk [13]. While the denial of necessary interventions is unethical and impedes accurate diagnosis and treatment, positive DM also threatens patient safety [14]. Such practices can expose patients to unnecessary risks, such as radiation exposure or invasive procedures, and generate additional costs as well as prolonged hospital stays [15].
The practice of DM tends to vary between surgical and non-surgical specialties, influenced by the inherent nature of clinical risks and the specific litigation exposure associated with each field [16]. The invasive nature of surgical procedures and the potential for physical harm often place surgeons in a defensive stance, while non-surgical professionals may resort to over-testing or excessive documentation as a means of self-protection. Nonetheless, both strategies can lead to increased healthcare spending and unnecessary patient exposure to medical procedures [17].
Whereas there is no formal economic estimate of the cost of DM in Egypt, despite its widespread practice, in the United States, annual costs are estimated to range from $50 to $100 billion. At the patient level, this adds approximately $226 per hospital stay, representing 13% of the average stay cost of $1,695 [18,19]. Similarly, an Italian study calculated that DM accounted for up to 10% of total annual national health expenditure [20].
Recently, in 2025, Egypt enacted Medical Responsibility Law No. 13/2025, which establishes rules to improve physician accountability by distinguishing unavoidable complications from true malpractice. While intended to enhance patient safety, the law’s unclear definition of malpractice may prompt physicians to practice more cautiously to avoid punishment [21]. Previous research has documented widespread DM among Egyptian physicians [22–26], but without comparing the incidence of accusations and defensive practices between surgical and non-surgical specialties.
This study aimed to investigate the prevalence and patterns of DM among Egyptian physicians, compare surgical versus non-surgical specialties, and examine their correlation with medico-legal complaints and occupational determinants. It also sought to identify physicians’ concerns regarding potential medico-legal accusations, thereby providing insights into the institutional and professional determinants of DM within Egypt’s healthcare context.
Materials and methods
Study design and participants
This cross-sectional study was conducted over a three-month period from February to April 2024. The inclusion criteria were currently licensed physicians of any age and from either sex, working in surgical or non-surgical specialties at the following types of hospitals: university, military, health insurance organization, Ministry of Health, private sector, or Primary Health Care Units (PHCUs). Exclusion criteria comprised physicians who were retired or temporarily not practicing at the time of the study, including those on leave, interns, and medical students. Specialties were classified as either surgical or non-surgical to distinguish between physicians whose practice is primarily high-procedure and higher-risk (surgical) and those whose work is mainly non-operative (non-surgical), thereby capturing major contrasts in risk exposure. We acknowledge, however, that some overlap inevitably exists [14].
Egypt’s health sector is characterized by a dual structure comprising a resource-constrained public sector, which serves the majority of the population, and an evolving private sector that typically offers better facilities and shorter waiting times. The Universal Health Insurance system is being implemented progressively across Egypt, with the goal of covering all governorates by 2032. The implementation will occur over six phases, each focusing on a distinct geographic area (i.e., a cluster of governorates).
Medico-legally, medical practice is governed by the Egyptian Physicians’ Syndicate Law and the Penal Code, which establish the paradigms for professional conduct and medical negligence. However, the prevailing malpractice lawsuit system is generally regarded as time-consuming and complex; this can negatively affect clinical decision-making and the reporting of complications.
Sample size and design
The sample size was determined using the CDC’s Epi-Info software calculator, with a 95% confidence level and an alpha error of 5%, based on differences in DM practices between specialties reported in a previous Egyptian study [21]. The calculated sample size was 210 physicians. Data were collected using a self-administered online questionnaire and the snowball sampling method. The process began by distributing the survey to known contacts, who were then asked to share it with their colleagues. This technique was appropriate for investigating this sensitive topic, as physicians may be hesitant to openly discuss such issues or participate in research unless referred by trusted peers, the initial “known individuals” from whom the snowball sampling began. No ex-post filtering was applied.
Data collection tool
We chose to collect data online to facilitate access, accommodating physicians’ busy schedules and ensuring participants felt comfortable and unpressured when responding. The questionnaire was distributed as a digital Google Form and sent to participants via various social networks, including Facebook, Twitter, WhatsApp, and others. The estimated completion time was approximately 10–12 minutes. The questionnaire comprised four sections (see “S1 Appendix”).
- A. General characteristics of the studied population: age, sex, current marital status, and highest academic qualification.
- B. Work-related information: medical specialty, current clinical position, primary work shift, workplace location, type of healthcare facility, employment type, years of experience in the current specialty, and average number of patients seen per day.
- C. Questions to assess the medico-legal claims raised by patients against physicians: frequency, insurance coverage, and their consequences.
- D. Questions assessing positive (Assurance Behavior) and negative (Avoidance Behavior) DM practices using the Defensive Medicine Behavior Scale (DMBS). The DMBS comprises 14 items: the first nine assess positive DM, and the remaining five assess negative DM. Responses were recorded on a 5-point Likert scale ranging from “1: strongly disagree” to “5: strongly agree.” A total score was calculated for each participant, with a possible range of 14–70. These total scores were categorized as follows: very high (56–70 points), high (42–55 points), moderate (28–41 points), and low (14–27 points) [24].
The usability and technical functionality of the electronic questionnaire were tested by the authors and their colleagues prior to distribution. A feature in Google Forms was used to prevent duplicate submissions by notifying participants when they attempted to resubmit if their responses had already been submitted.
Ethical considerations
The study was approved by the Research Ethics Committee (REC) of the Faculty of Medicine, Suez Canal University (approval code: 5532). All participants were required to provide informed consent prior to participation using a written consent process at the beginning of the self-administered questionnaire. The questionnaire’s introductory section outlined the study’s purpose, emphasized the voluntary nature of participation, and assured participants of data confidentiality and exclusive use for research purposes. Additionally, responses were collected anonymously, and participant data were coded to ensure confidentiality. No incentives were offered for participation. Participants retained the right to refuse or withdraw from the study at any time without providing a reason and without facing negative consequences. Furthermore, the authors’ contact information was provided for participants to request clarification if needed.
Data management and statistical analysis
Data were coded and entered using Microsoft Excel 2016. Only fully completed responses were included in the analysis, which was performed using IBM SPSS Statistics, version 22.0. Descriptive statistics were used to summarize participant characteristics and work-related information. Numerical variables are presented as mean and standard deviation, as well as median with range (minimum–maximum), while categorical variables are expressed as frequency and percentage (%). The prevalence of DM was calculated as the percentage of participants who reported practicing any DM behavior on the DMBS. The normality of data distribution was assessed using the Kolmogorov–Smirnov test.
Analytic statistics were applied based on the nature of the data and variables to compare surgical and non-surgical specialties. The Mann-Whitney U test was used to evaluate differences in non-normally distributed numerical data, while the Chi-square test was applied to analyze categorical data. A P-value < 0.05 was considered statistically significant. To identify potential determinants of DM practices, a multivariate logistic regression analysis was performed, with results expressed as odds ratios (OR) and 95% confidence intervals (CI). A bar chart was used to present the prevalence of DM and the differences between the surgical and non-surgical specialties.
Results
The study enrolled 210 physicians with a mean age of 39 ± 7 years, with a nearly equal sex distribution (1:1). Most participants were married (79%), and approximately half (51.4%) held the highest qualification of Doctor of Medicine or a Ph.D. in Philosophy (Table 1).
The participants were categorized into two groups: 114 (54.3%) from non-surgical specialties and 96 (45.7%) from surgical specialties. A majority (61.9%) were consultants, and approximately half (51.4%) worked both day and night shifts. Regarding their workplace, most (59%) were employed in urban settings. The most common workplaces were university hospitals, the private sector, and health insurance organizations, which accounted for 60.5%, 40%, and 35.2% of participants, respectively (Table 2).
Throughout their careers, physicians in surgical specialties faced a higher average number of malpractice accusations than those in non-surgical specialties. Surgical specialists, however, had significantly lower workplace insurance coverage for such medico-legal claims (P-value <0.05) (Table 3).
Regarding physician concerns following an accusation, both groups reported high levels of concern across multiple categories. However, only the concern about “loss of reputation among colleagues” was reported significantly more frequently by physicians in non-surgical specialties (P-value <0.05) (Table 4).
The prevalence of DM was 94.8% for positive practices, 85.7% for negative practices, and 96.7% overall (Fig 1). Physicians in surgical specialties reported engaging in positive DM practices more frequently than those in non-surgical specialties, specifically in behaviors such as “ordering additional tests for legal protection,” “utilizing imaging techniques more often to avoid legal issues,” and “emphasizing informed consent forms to protect themselves legally” (P-value <0.05). In contrast, there were no statistically significant differences between specialties in the practice of negative DM. Furthermore, the overall prevalence rates of positive, negative, and total DM practices showed no statistically significant difference between the two groups (Table 5).
Overall, a high level of DM practice was observed among physicians in both surgical and non-surgical specialties, with prevalences of 41.7% and 39.5%, respectively. However, this difference between the two groups was not statistically significant (P-value > 0.05) (Fig 2).
The regression analysis assessing factors associated with the practice of positive DM began with an unadjusted parsimonious model, which indicated that specialty type was a statistically significant predictor (Table 6). After adjusting for general characteristics—including age, sex, marital status, and the physician’s highest qualification—specialty type became non-significant, suggesting that the inclusion of additional independent variables influenced the outcome. In this adjusted model, male sex and holding only a bachelor’s degree were also identified as statistically significant predictors (Table 7).
Subsequent adjustment for work-related information (Table 8) showed that male sex, holding only a bachelor’s degree, and being a consultant were statistically significant predictors. Finally, adding data on medico-legal claims raised against the participants (Table 9) revealed that working at university hospitals (β = −0.178) and having workplace insurance for medico-legal claims (β = −0.153) were statistically associated with fewer positive DM practices. Conversely, concerns about the financial implications of medico-legal claims (β = 0.26) and negative reactions from patients or families (β = 0.157) were statistically associated with more positive DM practices (P-value < 0.05).
In contrast, the unadjusted parsimonious model evaluating the predictive role of specialty type for negative DM showed no statistical significance (Table 10). This remained the case after sequentially adjusting for the physicians’ general characteristics (age, sex, marital status, and highest qualification; Table 11), work-related information (Table 12), and medico-legal claims against participants (Table 13). No statistically significant predictors of negative DM were identified in any of these adjusted models.
Multivariable-adjusted regression analyses were conducted separately for surgical and non-surgical specialties (Tables 14–17). The results showed that, among surgical specialists, only concerns about the financial implications of medico-legal claims (β = 0.299) were significantly associated with a greater likelihood of positive DM practices (P < 0.05). Among non-surgical specialists, however, working in the private sector (β = 0.27) and a higher average number of malpractice claims filed against the physician (β = 0.202) were significantly associated with more frequent negative DM practices (P < 0.05).
Discussion
The present study offers an in-depth analysis of DM practices among physicians in both surgical and non-surgical specialties. The findings demonstrate that DM is widespread, with a substantial proportion of physicians in both groups engaging in such practices, particularly in the form of positive defensive strategies. Despite this high prevalence, no statistically significant difference in overall engagement was observed between the surgical and non-surgical groups.
These findings are consistent with a similar study in Egypt, which reported that DM is deeply ingrained in the clinical routines of Egyptian physicians [25]. Likewise, a previous study conducted among Egyptian residents at Kasr Alainy Hospital found a high prevalence of DM practices and associated feelings of insecurity [23].
Similarly, a study at Tanta University Hospitals in Egypt during the COVID-19 pandemic revealed a highly evident prevalence of DM, primarily driven by physicians’ legal self-interest [19]. Furthermore, a comparative study of DM practices between Egypt and Saudi Arabia reported that Egyptian physicians engaged in these behaviors more frequently than their Saudi counterparts [20].
Globally, a cross-sectional study involving 220 physicians at a university hospital in Turkey found that an overwhelming majority (94.2%) reported engaging in some form of DM [14]. Another study assessing DM among surgeons in Ethiopia found that a majority (74%) engaged in such practices, most commonly avoiding high-risk procedures and ordering unnecessary tests [26]. Furthermore, a scoping review revealed that the prevalence of DM among physicians ranges widely, from 6.7% to 99.8% [13]. A recent systematic review and meta-analysis further reported a pooled prevalence of 75.8% [27].
In the current study, surgeons reported practicing positive DM, including behaviors such as ordering extra tests for legal protection, using imaging techniques more frequently to avoid legal problems, and placing greater emphasis on informed consent forms for legal self-protection. This increased engagement in positive defensive practices may be explained by the higher incidence of medico-legal claims against surgeons and their relatively lower workplace coverage for medico-legal insurance.
This finding aligns with the recent systematic review by Ries and Jansen [28] of empirical research on physicians’ views and experiences of DM. Their review found that the provision of unnecessary services to mitigate perceived legal risk, a hallmark of DM, is frequently reported, particularly in the United States, Europe, and within surgical and obstetrical fields. This pattern may be explained by the higher frequency of damage claims and the greater financial burdens associated with claims in surgical specialties such as general surgery, orthopedics, and gynecology, compared to non-surgical specialties [29].
Interestingly, the study found that non-surgical specialists were more concerned about losing their reputation among colleagues. This may be because patient trust when selecting a non-surgical specialist depends heavily on professional reputation. In contrast, for surgical specialists, a patient’s choice is dominated more by the physician’s technical skills and procedural expertise [30,31].
The regression analysis showed that working at university hospitals and having workplace insurance coverage for medico-legal claims were associated with reduced positive DM practices. This may be explained by the fact that large, hierarchically structured healthcare institutions [32], along with those providing reasonable medico-legal insurance coverage, likely play an important role in mitigating physicians’ defensive practices [9].
On the other hand, concerns regarding the financial implications of medico-legal claims and about negative reactions from patients or their families were associated with increased positive DM practices. This may be attributed to the fact that some medico-legal claims result in physicians paying substantial compensation out-of-pocket, particularly in the absence of insurance coverage. This financial risk, in turn, incentivizes physicians to practice more defensively, as ordering additional tests or imaging may protect them from future financial liability [8]. Furthermore, negative reactions from patients or families can seriously damage a physician’s reputation, potentially making them less preferred by future patients [30].
This study represents a significant initial step toward elucidating critical associations within the Egyptian context, while acknowledging that DM is a multifactorial phenomenon.
Limitations
The findings of this study should be interpreted within the context of several limitations. The primary limitation is the cross-sectional design; while appropriate for the study’s objectives, it does not allow for the determination of a temporal relationship between medical specialty and the practice of DM. Additionally, the relatively small sample size, the potential for volunteer bias, and the lack of random sampling may limit the generalizability of the findings. Furthermore, the binary categorization of specialties into “surgical” and “non-surgical” groups is an oversimplification that could introduce dilution bias, as many specialties incorporate both procedural and non-procedural elements to varying degrees. Nevertheless, this classification allows for a meaningful comparison between physicians who primarily work in high-risk, procedural environments (surgical) and those whose practice is largely non-operative (non-surgical), despite some inherent overlap.
Moreover, although this study examined the effect of many factors on defensive medicine, other potential determinants, were not assessed including organizational culture, workload, patient expectations, and institutional support, were not fully assessed. This limitation highlights the complexity of defensive medicine and indicates the need for future research better understand the effect of these additional contributing factors.
Conclusion
Despite the high prevalence of defensive medicine (DM) practices, no statistically significant difference was observed between surgical and non-surgical groups in their overall engagement in these behaviors. Working in university hospitals and having workplace insurance coverage for medico-legal claims were associated with fewer positive DM practices. In contrast, concerns about the financial implications of medico-legal claims and about negative reactions from patients or their families were associated with a greater prevalence of positive DM practices. Therefore, curtailing these practices, specifically by reducing unnecessary healthcare services that expose patients to additional risk, could improve clinical decision-making and care quality. Moreover, reducing DM would lower overall healthcare costs and allow resources to be reallocated toward more value-based care, thereby enhancing cost-effectiveness within the healthcare system.
Recommendations
The high prevalence of defensive practices across specialties underscores the need for systemic changes to address root causes, such as the fear of litigation, rather than focusing on specialty-specific interventions. The legal framework and malpractice laws require reassessment by the Egyptian Parliament to establish a more balanced system that protects both patients’ rights and physicians’ professional integrity. Such legal reform could reduce the perceived need for physicians to practice DM. The General Authority for Health Insurance (GAHI) and private insurance companies offering professional liability coverage should also expand medico-legal insurance coverage for physicians across all specialties. Furthermore, this study recommends incorporating medico-legal training and patient safety education into medical curricula to improve physicians’ understanding of their legal responsibilities and risks, which may reduce their reliance on defensive practices. Finally, further research is needed to investigate other factors influencing DM, in order to capture the full complexity of this phenomenon, including but not limited to organizational culture, workload, patient expectations, and institutional support.
Supporting information
S1 Appendix. This appendix lists all the questions included in the data collection tool used for the study.
https://doi.org/10.1371/journal.pone.0343807.s001
(DOCX)
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