Article Text

Download PDFPDF

Triggers of defensive medical behaviours: a cross-sectional study among physicians in the Netherlands
  1. Erik Renkema1,
  2. Kees Ahaus1,2,
  3. Manda Broekhuis1,
  4. Maria Tims3
  1. 1 Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
  2. 2 Department of Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
  3. 3 Department of Management and Organisation, School of Business and Economics, Amsterdam Business Research Institute, VU University Amsterdam, Amsterdam, The Netherlands
  1. Correspondence to Dr Erik Renkema; e.h.renkema{at}


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.

  • quality in health care
  • risk management
  • medical ethics

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

Statistics from


  • Contributors ER designed the study, collected, analysed and interpreted the data, and drafted the manuscript. KA co-designed the study, made significant contributions to the data acquisition and the interpretation of the data, and revised the manuscript. MB co-designed the study, made significant contributions to the analysis and interpretation of the data, and revised the manuscript. MT co-designed the study, contributed to the analysis and interpretation of the data, and revised the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional unpublished data from the study are available.

  • Patient consent for publication Not required.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.