The growing number of malpractice claims is impacting medical practice globally. It leads to emotional distress and changes in clinical decision-making. Defensive medicine (DM), which focuses on minimizing litigation risk rather than improving patient care, is becoming increasingly prevalent. This practice includes ordering unnecessary tests or avoiding risky procedures, which can increase costs and compromise care quality. In Egypt, the perceived complexity of the medico-legal system, along with Medical Responsibility Law No. 13/2025, further intensifies pressure on physicians to engage in DM.
A study published in PLoS One aimed to assess the prevalence and pattern of DM in Egyptian physicians, compare practices between surgical and non-surgical specialties, and examine their association with the medico-legal concerns and occupational factors.
This cross-sectional study was conducted from February to April 2024 and included 210 licensed physicians working in different healthcare settings in Egypt. It includes university hospitals, private institutions, Ministry of Health facilities, and primary care units. Physicians who were not actively practicing, like interns or those on leave, were excluded. Participants were categorized in surgical and non-surgical specialties to reflect differences in clinical risk exposure. Data were collected using a snowball sampling method and a self-administered online questionnaire. The survey captured demographic characteristics, work-related information, medico-legal experiences, and defensive medicine practices. They were measured by using the validated Defensive Medicine Behavior Scale (DMBS). This scale includes 14 items that assess both positive and negative DM behaviors on a 5-point Likert scale with total scores categorized as low, moderate, high, or very high levels.
Ethical approval was obtained, and participation was anonymous and voluntary. Data were analyzed using statistical software with descriptive statistics summarizing participant characteristics and inferential tests used for group comparisons. For non-normally distributed numerical data, the Mann-Whitney U test was used. The Chi-square test assessed categorical variables. A P-value of > 0.05 was considered statistically significant. Multivariate logistic regression analysis was conducted to detect predictors of defensive medicine practices, with results expressed as odds ratios (OR) and confidence intervals (CI).
The study population had a mean age of 39 ± 7 years with an equal gender distribution and most married participants (79%). Over half (51.4%) held doctoral-level qualifications, and most were consultants (61.9%) working in urban settings. Non-surgical physicians included 54.3% of the sample, and 45.7% were from surgical specialties. Surgical physicians reported a higher number of malpractice accusations but had significantly lower workplace insurance coverage (P < 0.05). DM was highly prevalent, with 96.7% of physicians reporting some form of DM: positive DM was observed in 94.8% and negative DM in 85.7% of participants. Although surgeons were significantly more likely to engage in specific positive DM behaviors like ordering additional tests, increasing imaging use, and emphasizing informed consent (P < 0.05). However, there was no statistically significant difference between surgical and non-surgical groups in overall DM prevalence.
High levels of DM practice were reported by 41.7% of surgical and 39.5% of non-surgical physicians, with no significant difference (P > 0.05). Regression analysis initially suggested that specialty type predicted positive DM, but this association lost significance after adjusting for demographic and occupational factors. Male gender, holding only a bachelor’s degree, and being a consultant were significant predictors of increased positive DM. In contrast, working in a university hospital and having medico-legal insurance coverage were associated with reduced positive DM practices. Concerns about financial consequences (β = 0.26) and negative patient reactions (β = 0.157) significantly increased the likelihood of positive DM (p < 0.05). No major predictors were detected for negative DM. Subgroup analysis showed that in surgical physicians, financial concerns were linked to increased positive DM (β = 0.299). Working in the private sector (β = 0.27) and experiencing more malpractice claims (β = 0.202) were linked to elevated negative DM practices in non-surgical physicians.
Overall, DM is highly prevalent among Egyptian physicians, regardless of specialty. It is influenced more by medico-legal concerns and systemic factors than by the nature of the specialty itself. Institutional support, such as employment in university hospitals and access to insurance coverage, appears to mitigate defensive practices, while financial concerns and fear of patient reactions drive them. Addressing these underlying issues through improved legal clarity, stronger insurance systems, and supportive healthcare environments could help reduce unnecessary defensive behaviors, enhance patient safety, and improve the efficiency and cost-effectiveness of healthcare delivery.
Reference: Tawfik AM, ElZoghby S, Elsherbiny NM, Salem MR. Comparison of accusations against physicians and the practice of defensive medicine between surgical and non-surgical specialties. PLoS One. 2026;21(3):e0343807. doi:10.1371/journal.pone.0343807
