Practice of Defensive Medicine Among Surgeons in Ethiopia: Cross Sectional Study

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Although the Federal Ethics Committee review in Ethiopia has shown that applications for medical/surgical error investigation claims are increasing at an alarming rate, there is no study to date done to estimate the degree of defensive practice done by the physicians with an intention of avoiding this increasing legal claim. This study assessed the practice of defensive medicine among highly litigious disciplines (surgery) and described factors associated with its practice. Methods Cross sectional quantitative study using online survey questionnaires was conducted to assess the degree of defensive practice and six factors (age, years of experience, specialty, monthly income, place of practice and previous medico legal history) associated with its practice were assessed among surgeons working in Ethiopia. Results A total of 430 surgeons directly received an online survey questionnaire and 236 of them successfully completed the questionnaire making the response rate 51.2%. Nearly half of the study participants (51.7%) were aware of the concept of defensive medicine and 174 (74%) reported performing one form of defensive practice. Twenty-nine (12.3%) of the participants have legal dispute history, though only 1.3% of them ended up in penalty. Avoiding high risk procedures was the commonest defensive act performed by 60% of the participants, followed by ordering tests unnecessarily (52.1%). Multinomial logistic regression model showed that there was no association between age of the participant, place of practice, year of experience and defensive practice. This model also showed that cardiothoracic and vascular surgeons perform less defensively than surgeons with other specialty with P value of 0.02. Conclusion The practice of defensive medicine is widespread among surveyed Ethiopian surgeons and further studies are required to objectively estimate the effect of defensive practice on the health care system of the country. Policy makers need to develop strategy towards decreasing this high rate of defensive practice. Defensive Ethiopia medicine practice surgeons Figures Figure 1 1 Background Defensive medicine refers to any deviation from sound medical care given by a physician with an intention of avoiding medico legal liability ( 1 – 3 ). It could be either positive defensive medicine (termed as assurance behavior) or negative defensive medicine (avoidance behavior). Positive defensive medicine involves extra tests or procedures performed with the primary intention of reducing malpractice liability. On the other hand, negative defensive medicine refers to avoiding high risk patients or procedures ( 4 , 5 ). Defensive medicine (DM) came into practice in the 1970s as the number of malpractice suits started rising geometrically, more frivolous lawsuits were being filed and as malpractice insurance premiums began rising. This was with anticipation that it will avoid or markedly reduce malpractice lawsuits ( 6 ). According to Wamisho et al. there are an alarmingly increasing number of applications filed for investigation of possible surgical/medical error in Ethiopia. Thus the Federal Ethics Committee for Health Professionals has made final decisions for a total of 125 medical error claims over a period of seven years from 2011 up to 2017 ( 7 ). This alarmingly increasing number of medical error claims inevitably brings the practice of DM into the region. Generally, there are various effects of DM and its practice on the health care system. It can supplement a care (performing an additional test or treatment), replace a care (referring the patient to another center or physician), or decrease care by avoiding high risk patients ( 4 ). Defensive medicine can also increase the cost of health care ( 2 ). According to most malpractice scholars, defensive medicine is highly prevalent but it is very difficult to estimate its cost ( 8 ). It is estimated that defensive medicine contributes to as much as $ 60.2 billion annual health care expenditure in the United States, therefore decreasing defensive medicine will reduce the health care cost ( 8 , 9 ). Defensive medicine also affects the patient physician relationship ( 4 ). The main challenge in studying DM is that not every practice with an intention of avoiding liability results in poor quality of medical care ( 2 ). It is also important to note that a physician can have more than one reason to order a test and it makes it difficult to draw a line between a desire to avoid lawsuit and a desire to make appropriate treatment to a patient ( 10 ). According to Studdert et al. some of the practices of DM were found to be beneficial ( 4 ). The emergence of defensive medicine in Africa is also described by different authors though the concept is not well understood by most physicians in the continent ( 9 , 11 – 13 ). A survey conducted among Sudanese doctors working in obstetrics and gynecology reported that around 71.8% respondents practice defensively ( 12 ). In Ethiopia there appears to be paucity of data on defensive medicine and medical malpractice issues. A Federal Ethics Committee showed that 80% of malpractice claims are related to some form of surgery or operation room activities however there is no study conducted in the country to depict defensive practice of physicians intended to avoid the increasing legal claims. This study was conducted with the objective of assessing the practice of defensive medicine among the highly litigious discipline in Ethiopia, surgery. The survey also tried to describe the factors associated with defensive acts of the physicians. The study is unique in the sense that no reports have been previously published from the country with similar objectives. Assessing the baseline level of awareness and practice of surgeons with regard to defensive medicine will give us the necessary data to pass recommendations for future preventive measures. 2 Methods 2.1 Study area and period The study was conducted among surgeons working in all government and private hospitals in Ethiopia over a period of 2 months from July 1, 2021 G.C up to August 31st 2021 G.C. All practicing surgeons in different subspecialties were conveniently included in the study because of the likelihood of variation in the type of defensive practices performed by the surgeons in different parts of the country 2.2 Study design, data collection and Sampling An observational type of cross-sectional study design was used to assess the practice of defensive medicine among physicians practicing surgery. Data was collected from eligible surgeons by using pre-tested structured online survey questionnaires. The online survey questionnaire was sent to each participant through social media networks directly and the responses were collected anonymously. The questionnaire had 34 in-depth questions divided into four important parts; socio demographic data, section assessing awareness towards defensive medicine, specific defensive practice, and factors that influence defensive behavior. The structured questionnaire was pretested initially using 10% of the sample size and necessary modifications were made. Surgeons who refused consent to participate in the survey and those who were not available or accessible during the study period were excluded from the study. Ethical clearance was obtained from AAU College of health science and school of medicine department of surgery research and ethics committee. Informed consent was included on the online survey questionnaire and a cover letter provided basic information about the study. The estimated minimum required sample size was calculated using a single population proportion formula with 95% confidence interval (CI) and 5% margin of error. During the calculation of sample size, we used population proportion value from a Sudanese study done in 2016 G.C which is 0.718. Based on this the sample size was calculated to be 229, but since this was an online survey, we considered non-response rate to be high and estimated it to be 50%. The final sample size became 460. From a total of 460 participants who were directly accessed through the online survey, 236 of them completely responded to the questionnaire making the response rate 51%. In this study physicians performing any of the stated assurance or avoidance behavior were considered as practicing defensive medicine. Assessed assurance behaviors were prescribing more medications than medically indicated, ordering more tests than necessary, writing overzealously/excessively in the patient's chart, admitting a patient unnecessarily and suggesting invasive procedures (like biopsy). Referring a patient unnecessarily, avoiding certain high-risk procedures, and refusing to treat high risk patients were the avoidance behaviors studied in the survey. 2.3 Data analysis Data was analyzed using Statistical Package for Social Sciences (SPSS) version 25.0 software package. Six important predictors of defensive medicine were analyzed using Chi-square (fisher’s exact whenever necessary) probability tests. The six independent variables were; age, years of experience, place of practice, specialty, monthly income and previous legal dispute history. Associated predictors were further analyzed using binomial and multinomial logistic regression model. During the analysis, P-value of < 0.05 with 95% confidence interval was used in judging the significance of the association. Finally, results were displayed using text, frequency tables and charts. 3 Result 3.1 Socio demographic data A total of 460 surgeons directly received the online survey questionnaire and 236 of them completely responded to the questionnaire during the of survey administration period making the response rate 51%. The majority of the participants were male 205 (86.9%) and age of the participants range from 29 years to 66 years. General surgeons are most represented specialty in the survey 109 (46.2%) and none of the physicians involved in the survey mentioned having health insurance coverage. Table 1 shows details of the socio demographic characteristics of participants involved in the survey. Table 1 Socio demographic characteristics of participants Socio demographic characteristics Number (n) Percentage (%) Gender Male 205 86.9 Female 31 13.1 Age of participants 50 years 17 7.2 Place of practice Addis Ababa 123 52.1 Regional capital city 54 22.9 Other city or rural part of Ethiopia 59 25.0 Institution Government hospital 138 58.5 Both government and private hospital 92 39.0 Private hospital 6 2.5 Specialty General surgery 109 46.2 Orthopedics 34 14.4 Gynecology and obstetrics 29 12.3 Urology 14 5.9 Cardiothoracic/Vascular surgery 13 5.5 Other specialty/subspecialty* 37 Years of experience Number (n) Percentage (%) = 20 years 11 4.7 Monthly income in ETB > 15000 50 21.2 15000–29999 87 36.9 30000–49999 64 27.1 >= 50000 35 14.8 Total 236 100.0 * Other specialty includes: - Pediatric surgery, Hepatobiliary surgery, Colorectal surgery, Endocrine surgery, Plastic and reconstructive surgery. From a total of 236 surveyed doctors 29 (12.3%) of them had directly experienced legal dispute and majority won the dispute while 3 (10%) of them lost the dispute. 3.2 Awareness towards defensive medicine and its impact Nearly half (51.7%) of the surgeons participated in the survey are aware of the concept of DM while the remaining 114 (48.3%) of them reported to have never come across the concept. Figure 1 shows the details of awareness of respondents towards DM and its impact. 3.3 Defensive Practice Nearly three fourth 175 (74.2%) of surveyed physicians reported that they have performed one or another form of defensive medicine. Of these respondents 60 (34.4%) of them admitted to being involved either sometimes or often, while the remaining 114 (65.5%) rarely act defensively. From a total of 236 participants 174 (73.7%) of them detailed their most recent defensive practice and the majority 109 (62.6%) did not actually remember the time of their most recent defensive act. Table 2 shows the details of recent and specific defensive act. Table 2 Specific most recent defensive act/s by surgeons Type of most recent defensive act Number (n) Percentage (%) Ordered CT, MRI, or x-ray 65 37.8 Admitted a patient unnecessarily 14 8.1 Obtained cardiac workup 16 9.3 Ordered another test 17 9.9 Referred a patient to another Physician 23 13.4 Refused to treat critical patient 8 4.7 Other 29 16.9 Time of most recent defensive act In the past 1 month 16 9.2 In the past 1 year 49 28.2 Don't remember the time 109 62.6 3.3.1 Negative (Avoidance behavior) and positive (Assurance Behavior) defensive practice Avoiding high risk procedures was the commonest of all types of defensive behavior reported by 132 (60.2%) of the surveyed surgeon; being performed either sometimes or rarely. On the other hand, ordering more tests than indicated was the commonest assurance behavior practiced by most of investigated surgeons (see Table 3 ) Table 3 Specific most recent defensive act/s by surgeons Specific defensive practice Often (%) Rarely (%) Never (%) Ordering more tests than indicated 15 (6.4%) 108 (45.8%) 113 (47.9%) Prescribed more medications than medically indicated 20 (8.5%) 94 (39.8%) 122 (51.7%) Written in patient’s chart overzealously/excessively 39 (16.5%) 80 (33.9%) 117 (49.6%) Referred a patient unnecessarily 7 (3%) 71 (30.1%) 158 (66.9%) Admitted a patient unnecessarily 2 (0.8%) 102 (43.2%) 132 (55.9%) Suggested invasive procedures (like biopsy) 10 (4.2%) 75 (31.8%) 151 (64%) Avoided certain high-risk procedures 26 (11%) 116 (49.2%) 94 (39.8%) Avoided caring for high-risk patient 8 (3.4%) 78 (33%) 150 (63.6%) 3.4 Factors associated with defensive practice Respondents were asked for the factors that commonly lead them to act defensively and majority of them 229 (97.1%) of them agree or strongly agree that fear of medico legal litigation was the commonest reason. Additionally, significant proportions of participants stated that, experience of medico legal litigation 206 (87.3%), fear of negative publicity 203 (86%), fear of disciplinary sanction 197 (84.3%), and fear for compensation 193 (81.8%) were all contributors for defensive practice. 3.5 Correlates of practice of Defensive Medicine Six important predictors of defensive practice were identified and analyzed. Age and years of experience were found to have association with defensive practice with p-value of < 0.0001 (using Chi-square and fisher’s exact probability testing). Surgeon’s specialty and place of practice were also found to have correlation with defensive acts with p-value of 0.001 and 0.004 respectively. Further analysis was carried out using binomial and multinomial logistic regression model and there was no statistically significant association between age of the participant, place of practice, years of experience and defensive practice among surgeons. Logistic regression model also showed that cardiothoracic and vascular surgeons perform by 90% (AOR:0.10; 95% CI: 014,0.705) less defensively compared to other specialties included in the survey. Table 4 shows association between defensive practice and its correlates. Table 4 Factors associated with practice of defensive medicine (n = 236) Variables Category N COR (95% CI) AOR (95% CI) P-value Age of participants < 30 years 7 0.053(0.006–0.484) 6.40(0.167–245.35) 0.318 30–35 years 165 0.022(0.005–0.101) 19.21(0.80-460.35) 0.068 36–40 years 29 0.051(0.009–0.274) 21.32(0.867–524.23) 0.061 41–45 years 11 0.233(0.034–1.591) 9.90(0.30-326.41) 0.198 46–50 years 7 0.800(0.061–10.562) 0.93(0.03–28.77) 0.968 > 50 years 17 Ref. Ref. Place of practice Addis Ababa 123 1.835(0.893–3.768) 1.911(0.619–5.899) 0.26 Regional capital city 54 0.442(0.155–1.262) 1.873(0.733–4.876) 0.19 Other city or rural part of Ethiopia 59 Ref. Ref. Specialty General surgery 109 0.588(0.258–1.34) 0.725(0.218–2.412) 0.6 Orthopedic surgery 34 0.359(0.111–1.16) 1.189(0.241–5.854) 0.832 Gynaecology and obstetrics surgery 29 0.543(0.175–1.686) 0.843(0.195–3.651) 0.819 Urology 14 0.833(0.216–3.21) 1.771(0.192–16.348) 0.614 Cardiothoracic/Vascular surgery 13 6.944(1.609–29.972) 0.1(0.014–0.705) 0.021 Other specialty (subspecialty)* 37 Ref. Ref. Years of experience < 5 years 171 0.017(0.002–0.140) 4.936(0.126–193.92) 0.394 5–9 years 40 0.054(0.006–0.465) 1.989(0.056–70.586) 0.706 10–14 years 7 0.600(0.031–11.473) 0.370(0.03–28.77) 0.641 15–19 years 7 0.600(0.031–11.473) 2.135(0.055–83.52) 0.685 >= 20 years 11 Ref. Ref. *Other specialty includes: - Pediatric surgery, Hepatobiliary surgery, Colorectal surgery, Endocrine surgery, Plastic and reconstructive surgery. 4 Discussion This is the very first study conducted about the practice of defensive medicine among Ethiopian physicians. The survey showed that only half (51.7%) of the participants were aware of the concept of defensive medicine. This is far less than the awareness of physicians in the United Kingdom (UK) where 98% of them were aware of defensive medical practice, but it was higher than awareness of Sudanese physicians working in Obstetrics and Gynaecology where only 42.7% were found to have awareness ( 5 , 12 ). However, it can be seen that the notion of defensive medicine in Ethiopia is at its conception. The practice of defensive medicine is prevalent worldwide; where the rate is 93% among high risk physicians in the USA, 84.8% among neurosurgeons in South Africa, and 71.8% among Sudanese doctors working in obstetrics and gynecology ( 4 , 9 , 12 ). Defensive act is also significantly practiced among the surveyed surgeons in Ethiopia, where 74% of them reported performing one or another form of defensive practice. This figure is comparable with the rate of practice among Italian surgeons where 75% of them practice defensively but it is relatively lower than the study done among doctors in UK where the prevalence is about 78% and a survey conducted among Japanese gastroenterologists where almost all (98%) of them reported performing some form of defensive practice ( 5 , 14 , 15 ). Almost all 223 (94.5%) of the sampled surgeons believe that legal claims against doctors are increasing and 29 (12.3%) of them directly experienced legal claims of which only 3 (1.3%) actually lost the legal dispute. This number is by far less than the rate of litigation among high risk specialists in the USA where 88% of them have one or another form of legal dispute and it is also lower than the rate of legal dispute among Chinese obstetric and gynecologic surgeons (61%) ( 4 , 16 ). This widespread practice of defensive medicine despite low rate of legal dispute might be due to the physicians' self-perceived threats rather than actual or existing litigation. On the other hand, the prevalent defensive practice in the country can be due to fear of negative publicity, fear of compensation or fear of disciplinary sanction which makes them to consider a patient as a risky subject than someone who needs help. Our study showed that both avoidance and assurance behaviors are significantly performed by the surgeons who responded to the survey. Sixty percent of the participants mentioned avoiding high risk procedure; a figure three times higher than physicians in the UK and significantly higher than Sudanese physician where only 20.5% of them reported avoiding high risk procedures ( 5 , 12 ). Nearly half of the study participants reported ordering a test more than indicated, which is a higher figure compared to the rate among Japanese gastroenterologists (36%) but relatively lower than the rate observed in the USA (59%) ( 4 , 15 ). Many literatures in the world showed age and year of experience were strongly associated with defensive practice ( 5 , 15 ). But our study didn’t show any correlation between age, year of experience and rate of defensive practice. In this study logistic regression model also showed cardiothoracic and vascular surgeons perform less defensively compared to other specialties. But this might not be true figure since physicians in this specialty represented less in the survey. On the other hand, income was found not to have association with defensive acts. This was a finding in contrary to the study done by He et al . where the rate of defensive act was relatively higher among low-income physicians ( 17 ). This difference can be due to lack of awareness of the surveyed doctors in this study where ordering unnecessary tests with an intension to get additional fee is considered as a continuum of standard medical care than a defensive act. Unlike many studies, this survey didn’t show any correlation between defensive practice and previous medical dispute history ( 4 , 16 ). This could be due to the fact that most of the participants who experienced legal disputes actually won their cases and are confident enough in differentiating clinical decisions with legal consequences from unnecessary defensive acts. 5 Conclusion The practice of DM is widespread among surveyed Ethiopian surgeons. Avoiding high risk procedures and ordering tests more than indicated were the most common types of defensives practiced by the surveyed physicians. The vast majority of Ethiopian surgeons believe that legal dispute among doctors is increasing, but only minority actually got penalized due to malpractice. There was no statistically significant association between ages, year of experience, place of practice, previous legal dispute history and income of a surgeon with defensive practice. The widespread practice of DM despite low rate of legal dispute might be due to the physicians’ self-perceived threats rather than actual legal danger. Educating surgeons about the possible impact of defensive practice on the health care system and awareness creation about the existing high level of self-believed threat of legal suit than actual legal consequences can reduce defensive act and mitigate the negative impact of defensive medicine. Policy makers and other responsible bodies should design strategy towards decreasing defensive practice by surgeons and its negative impact on the health care system. Further studies are required to objectively estimate the effect of defensive practice on the health care system of the country. Abbreviations AA Addis Ababa AAU Addis Ababa University CI Confidence Interval DM Defensive Medicine ETB Ethiopian Birr G.C Gregorian Calendar SSE Surgical Society of Ethiopia SD Standard Deviation UK United Kingdom USA United State of America Declarations Ethical clearance and consent to participate Ethical clearance was obtained from AAU College of health science and school of medicine department of surgery research and ethics committee from a letter written with a reference number of RC/DOS/CHS/AAU/019/2021. Informed consent was included on the online survey questionnaire and a cover letter provided basic information about the study. Informed consent was obtained from all participants included in the survey and the study complied with the Declaration of Helsinki. All data are collected anonymously and it will not be used for other purpose than the study question. Participants who failed to give consent, the online survey questioner allowed them to automatically leave the survey. Regarding physicians who decided to leave the survey after initial consent, the survey questionnaire allowed them to decline submission. Competing interest There is no competing interest Consent for publication Not applicable Availability of data and materials All necessary data are available at the hands of corresponding author upon reasonable request. Funding Nil Acknowledgement Our deepest gratitude goes to all physicians who kindly participated in this survey. Authors gratitude also goes to AAU, college of health science and school of medicine for the technical support and approval of the study. Authors contribution EAA: Initiated the research, wrote the research proposal, conducted the study, study analysis, and wrote the manuscript. YAT: Involved in research proposal writing, statistical analysis and drafting of manuscript. BNA: Coordinated the research, involved in study design and statistical analysis AGT: Involved in in statistical analysis and drafting of manuscript. 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Cite Share Download PDF Status: Published Journal Publication published 08 Nov, 2023 Read the published version in BMC Medical Ethics → Version 1 posted Editorial decision: Major revision 15 Sep, 2023 Reviews received at journal 15 Sep, 2023 Reviewers agreed at journal 29 Aug, 2023 Reviews received at journal 26 Aug, 2023 Reviewers agreed at journal 21 Jul, 2023 Reviewers agreed at journal 19 May, 2023 Reviewers invited by journal 19 May, 2023 Editor assigned by journal 05 Apr, 2023 Editor invited by journal 14 Dec, 2022 Submission checks completed at journal 13 Dec, 2022 First submitted to journal 02 Dec, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2338521","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":159932258,"identity":"d314de14-16af-438c-b5bc-39dd89eb8492","order_by":0,"name":"Eskinder Amare Assefa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIiWNgGAWjYBAC+wY2hgMMbHC+DYTiwaPFgAFVSxpCCy5tBmDlCC2HidDCfyzxcEGZTT4D++nEzxUV5+X5ZyQwPnjbxiBnj8svEmkHDs84l2bZwJO7WfLMmduGM24kMBvObWMwxmmLBHvDYd62wwYMDLkbJBvbbjM23Ehgk+ZtY0jswemw4yAt/w0Y+N9u/tn475z9/BsJ7L+BWupxamEAOoy37YABg0TuNsnGhgOJG4C2MAO1JOB2WFrCYZ5zyQZsEm+3WTYcS07eeOZhs+SccxKGPQdweL//mPFnnjI7A37+3M03G2rsbOcdTz744U2ZjTx7Aw5rYAARNQyMILUSBNSPglEwCkbBKMAHAOpAWAJs1hATAAAAAElFTkSuQmCC","orcid":"","institution":"Debre Berhan University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Eskinder","middleName":"Amare","lastName":"Assefa","suffix":""},{"id":159932259,"identity":"89bf2d9c-bcf3-4f33-9792-a3a083e6a860","order_by":1,"name":"Yonas Ademe Teferi","email":"","orcid":"","institution":"Addis Ababa University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yonas","middleName":"Ademe","lastName":"Teferi","suffix":""},{"id":159932261,"identity":"09c9e90c-ffe7-499c-b095-abcea3fbe0f4","order_by":2,"name":"Birhanu Nega Alemu","email":"","orcid":"","institution":"Addis Ababa University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Birhanu","middleName":"Nega","lastName":"Alemu","suffix":""},{"id":159932263,"identity":"81fd839d-b095-4b15-9ca3-f73a6524d83f","order_by":3,"name":"Abraham Genetu Tiruneh","email":"","orcid":"","institution":"Addis Ababa University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Abraham","middleName":"Genetu","lastName":"Tiruneh","suffix":""}],"badges":[],"createdAt":"2022-12-02 17:59:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2338521/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2338521/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12910-023-00979-w","type":"published","date":"2023-11-08T15:01:19+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":30385794,"identity":"d025485a-9714-465a-822a-ffe48ebf823c","added_by":"auto","created_at":"2022-12-15 16:30:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47746,"visible":true,"origin":"","legend":"\u003cp\u003eAwareness of surgeons towards defensive medicine\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-2338521/v1/04584c9f33dd52daa25634c3.png"},{"id":46349316,"identity":"74af0650-536e-4a13-9469-ce5a9d2ccbe7","added_by":"auto","created_at":"2023-11-13 15:10:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":465643,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2338521/v1/4c64cdce-0559-4d20-bb3a-25bf8eee53b0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePractice of Defensive Medicine Among Surgeons in Ethiopia: Cross Sectional Study\u003c/p\u003e","fulltext":[{"header":"1 Background","content":"\u003cp\u003eDefensive medicine refers to any deviation from sound medical care given by a physician with an intention of avoiding medico legal liability (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). It could be either positive defensive medicine (termed as assurance behavior) or negative defensive medicine (avoidance behavior). Positive defensive medicine involves extra tests or procedures performed with the primary intention of reducing malpractice liability. On the other hand, negative defensive medicine refers to avoiding high risk patients or procedures (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDefensive medicine (DM) came into practice in the 1970s as the number of malpractice suits started rising geometrically, more frivolous lawsuits were being filed and as malpractice insurance premiums began rising. This was with anticipation that it will avoid or markedly reduce malpractice lawsuits (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). According to Wamisho et al. there are an alarmingly increasing number of applications filed for investigation of possible surgical/medical error in Ethiopia. Thus the Federal Ethics Committee for Health Professionals has made final decisions for a total of 125 medical error claims over a period of seven years from 2011 up to 2017 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This alarmingly increasing number of medical error claims inevitably brings the practice of DM into the region.\u003c/p\u003e \u003cp\u003eGenerally, there are various effects of DM and its practice on the health care system. It can supplement a care (performing an additional test or treatment), replace a care (referring the patient to another center or physician), or decrease care by avoiding high risk patients (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Defensive medicine can also increase the cost of health care (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). According to most malpractice scholars, defensive medicine is highly prevalent but it is very difficult to estimate its cost (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). It is estimated that defensive medicine contributes to as much as \u003cspan\u003e$\u003c/span\u003e60.2\u0026nbsp;billion annual health care expenditure in the United States, therefore decreasing defensive medicine will reduce the health care cost (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Defensive medicine also affects the patient physician relationship (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe main challenge in studying DM is that not every practice with an intention of avoiding liability results in poor quality of medical care (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). It is also important to note that a physician can have more than one reason to order a test and it makes it difficult to draw a line between a desire to avoid lawsuit and a desire to make appropriate treatment to a patient (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). According to Studdert et al. some of the practices of DM were found to be beneficial (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe emergence of defensive medicine in Africa is also described by different authors though the concept is not well understood by most physicians in the continent (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). A survey conducted among Sudanese doctors working in obstetrics and gynecology reported that around 71.8% respondents practice defensively (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Ethiopia there appears to be paucity of data on defensive medicine and medical malpractice issues. A Federal Ethics Committee showed that 80% of malpractice claims are related to some form of surgery or operation room activities however there is no study conducted in the country to depict defensive practice of physicians intended to avoid the increasing legal claims. This study was conducted with the objective of assessing the practice of defensive medicine among the highly litigious discipline in Ethiopia, surgery. The survey also tried to describe the factors associated with defensive acts of the physicians. The study is unique in the sense that no reports have been previously published from the country with similar objectives. Assessing the baseline level of awareness and practice of surgeons with regard to defensive medicine will give us the necessary data to pass recommendations for future preventive measures.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study area and period\u003c/h2\u003e \u003cp\u003eThe study was conducted among surgeons working in all government and private hospitals in Ethiopia over a period of 2 months from July 1, 2021 G.C up to August 31st 2021 G.C. All practicing surgeons in different subspecialties were conveniently included in the study because of the likelihood of variation in the type of defensive practices performed by the surgeons in different parts of the country\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Study design, data collection and Sampling\u003c/h2\u003e \u003cp\u003eAn observational type of cross-sectional study design was used to assess the practice of defensive medicine among physicians practicing surgery. Data was collected from eligible surgeons by using pre-tested structured online survey questionnaires. The online survey questionnaire was sent to each participant through social media networks directly and the responses were collected anonymously. The questionnaire had 34 in-depth questions divided into four important parts; socio demographic data, section assessing awareness towards defensive medicine, specific defensive practice, and factors that influence defensive behavior. The structured questionnaire was pretested initially using 10% of the sample size and necessary modifications were made. Surgeons who refused consent to participate in the survey and those who were not available or accessible during the study period were excluded from the study. Ethical clearance was obtained from AAU College of health science and school of medicine department of surgery research and ethics committee. Informed consent was included on the online survey questionnaire and a cover letter provided basic information about the study.\u003c/p\u003e \u003cp\u003eThe estimated minimum required sample size was calculated using a single population proportion formula with 95% confidence interval (CI) and 5% margin of error. During the calculation of sample size, we used population proportion value from a Sudanese study done in 2016 G.C which is 0.718. Based on this the sample size was calculated to be 229, but since this was an online survey, we considered non-response rate to be high and estimated it to be 50%. The final sample size became 460. From a total of 460 participants who were directly accessed through the online survey, 236 of them completely responded to the questionnaire making the response rate 51%.\u003c/p\u003e \u003cp\u003eIn this study physicians performing any of the stated assurance or avoidance behavior were considered as practicing defensive medicine. Assessed assurance behaviors were prescribing more medications than medically indicated, ordering more tests than necessary, writing overzealously/excessively in the patient's chart, admitting a patient unnecessarily and suggesting invasive procedures (like biopsy). Referring a patient unnecessarily, avoiding certain high-risk procedures, and refusing to treat high risk patients were the avoidance behaviors studied in the survey.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data analysis\u003c/h2\u003e \u003cp\u003eData was analyzed using Statistical Package for Social Sciences (SPSS) version 25.0 software package. Six important predictors of defensive medicine were analyzed using Chi-square (fisher\u0026rsquo;s exact whenever necessary) probability tests. The six independent variables were; age, years of experience, place of practice, specialty, monthly income and previous legal dispute history. Associated predictors were further analyzed using binomial and multinomial logistic regression model. During the analysis, P-value of \u0026lt;\u0026thinsp;0.05 with 95% confidence interval was used in judging the significance of the association. Finally, results were displayed using text, frequency tables and charts.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Result","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Socio demographic data\u003c/h2\u003e \u003cp\u003eA total of 460 surgeons directly received the online survey questionnaire and 236 of them completely responded to the questionnaire during the of survey administration period making the response rate 51%. The majority of the participants were male 205 (86.9%) and age of the participants range from 29 years to 66 years. General surgeons are most represented specialty in the survey 109 (46.2%) and none of the physicians involved in the survey mentioned having health insurance coverage. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows details of the socio demographic characteristics of participants involved in the survey.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio demographic characteristics of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocio demographic characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge of participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;35 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36\u0026ndash;40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e41\u0026ndash;45 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e46\u0026ndash;50 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;50 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlace of practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAddis Ababa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegional capital city\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther city or rural part of Ethiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGovernment hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth government and private hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopedics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGynecology and obstetrics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiothoracic/Vascular surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther specialty/subspecialty*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;9 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;14 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u0026ndash;19 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;= 20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonthly income in ETB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;15000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15000\u0026ndash;29999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30000\u0026ndash;49999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;= 50000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* Other specialty includes: - Pediatric surgery, Hepatobiliary surgery, Colorectal surgery, Endocrine surgery, Plastic and reconstructive surgery.\u003c/p\u003e \u003cp\u003eFrom a total of 236 surveyed doctors 29 (12.3%) of them had directly experienced legal dispute and majority won the dispute while 3 (10%) of them lost the dispute.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Awareness towards defensive medicine and its impact\u003c/h2\u003e \u003cp\u003eNearly half (51.7%) of the surgeons participated in the survey are aware of the concept of DM while the remaining 114 (48.3%) of them reported to have never come across the concept. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the details of awareness of respondents towards DM and its impact.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Defensive Practice\u003c/h2\u003e \u003cp\u003eNearly three fourth 175 (74.2%) of surveyed physicians reported that they have performed one or another form of defensive medicine. Of these respondents 60 (34.4%) of them admitted to being involved either sometimes or often, while the remaining 114 (65.5%) rarely act defensively. From a total of 236 participants 174 (73.7%) of them detailed their most recent defensive practice and the majority 109 (62.6%) did not actually remember the time of their most recent defensive act. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the details of recent and specific defensive act.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSpecific most recent defensive act/s by surgeons\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of most recent defensive act\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrdered CT, MRI, or x-ray\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmitted a patient unnecessarily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObtained cardiac workup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrdered another test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReferred a patient to another Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRefused to treat critical patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime of most recent defensive act\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn the past 1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn the past 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDon't remember the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Negative (Avoidance behavior) and positive (Assurance Behavior) defensive practice\u003c/h2\u003e \u003cp\u003eAvoiding high risk procedures was the commonest of all types of defensive behavior reported by 132 (60.2%) of the surveyed surgeon; being performed either sometimes or rarely. On the other hand, ordering more tests than indicated was the commonest assurance behavior practiced by most of investigated surgeons (see Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSpecific most recent defensive act/s by surgeons\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecific defensive practice\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOften (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRarely (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNever (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrdering more tests than indicated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (6.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108 (45.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e113 (47.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrescribed more medications than medically indicated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (8.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (39.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e122 (51.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWritten in patient\u0026rsquo;s chart overzealously/excessively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (16.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80 (33.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e117 (49.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReferred a patient unnecessarily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (30.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e158 (66.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmitted a patient unnecessarily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (43.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e132 (55.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuggested invasive procedures (like biopsy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (4.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (31.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e151 (64%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvoided certain high-risk procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116 (49.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94 (39.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvoided caring for high-risk patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e150 (63.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Factors associated with defensive practice\u003c/h2\u003e \u003cp\u003eRespondents were asked for the factors that commonly lead them to act defensively and majority of them 229 (97.1%) of them agree or strongly agree that fear of medico legal litigation was the commonest reason. Additionally, significant proportions of participants stated that, experience of medico legal litigation 206 (87.3%), fear of negative publicity 203 (86%), fear of disciplinary sanction 197 (84.3%), and fear for compensation 193 (81.8%) were all contributors for defensive practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Correlates of practice of Defensive Medicine\u003c/h2\u003e \u003cp\u003eSix important predictors of defensive practice were identified and analyzed. Age and years of experience were found to have association with defensive practice with \u003cem\u003ep-value\u003c/em\u003e of \u0026lt;\u0026thinsp;0.0001 (using Chi-square and fisher\u0026rsquo;s exact probability testing). Surgeon\u0026rsquo;s specialty and place of practice were also found to have correlation with defensive acts with \u003cem\u003ep-value\u003c/em\u003e of 0.001 and 0.004 respectively. Further analysis was carried out using binomial and multinomial logistic regression model and there was no statistically significant association between age of the participant, place of practice, years of experience and defensive practice among surgeons. Logistic regression model also showed that cardiothoracic and vascular surgeons perform by 90% (AOR:0.10; 95% CI: 014,0.705) less defensively compared to other specialties included in the survey. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows association between defensive practice and its correlates.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with practice of defensive medicine (n\u0026thinsp;=\u0026thinsp;236)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eAge of participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.053(0.006\u0026ndash;0.484)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.40(0.167\u0026ndash;245.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.318\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;35 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.022(0.005\u0026ndash;0.101)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.21(0.80-460.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u0026ndash;40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.051(0.009\u0026ndash;0.274)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.32(0.867\u0026ndash;524.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u0026ndash;45 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.233(0.034\u0026ndash;1.591)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.90(0.30-326.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.198\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u0026ndash;50 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.800(0.061\u0026ndash;10.562)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.93(0.03\u0026ndash;28.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.968\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;50 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePlace of practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAddis Ababa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.835(0.893\u0026ndash;3.768)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.911(0.619\u0026ndash;5.899)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegional capital city\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.442(0.155\u0026ndash;1.262)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.873(0.733\u0026ndash;4.876)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther city or rural part of Ethiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eSpecialty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.588(0.258\u0026ndash;1.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.725(0.218\u0026ndash;2.412)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrthopedic surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.359(0.111\u0026ndash;1.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.189(0.241\u0026ndash;5.854)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.832\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGynaecology and obstetrics surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.543(0.175\u0026ndash;1.686)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.843(0.195\u0026ndash;3.651)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.819\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.833(0.216\u0026ndash;3.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.771(0.192\u0026ndash;16.348)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.614\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCardiothoracic/Vascular surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.944(1.609\u0026ndash;29.972)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1(0.014\u0026ndash;0.705)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther specialty (subspecialty)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eYears of experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.017(0.002\u0026ndash;0.140)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.936(0.126\u0026ndash;193.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.394\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;9 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.054(0.006\u0026ndash;0.465)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.989(0.056\u0026ndash;70.586)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.706\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026ndash;14 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.600(0.031\u0026ndash;11.473)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.370(0.03\u0026ndash;28.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.641\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026ndash;19 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.600(0.031\u0026ndash;11.473)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.135(0.055\u0026ndash;83.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.685\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;= 20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Other specialty includes: - Pediatric surgery, Hepatobiliary surgery, Colorectal surgery, Endocrine surgery, Plastic and reconstructive surgery.\u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis is the very first study conducted about the practice of defensive medicine among Ethiopian physicians. The survey showed that only half (51.7%) of the participants were aware of the concept of defensive medicine. This is far less than the awareness of physicians in the United Kingdom (UK) where 98% of them were aware of defensive medical practice, but it was higher than awareness of Sudanese physicians working in Obstetrics and Gynaecology where only 42.7% were found to have awareness (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, it can be seen that the notion of defensive medicine in Ethiopia is at its conception.\u003c/p\u003e \u003cp\u003eThe practice of defensive medicine is prevalent worldwide; where the rate is 93% among high risk physicians in the USA, 84.8% among neurosurgeons in South Africa, and 71.8% among Sudanese doctors working in obstetrics and gynecology (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Defensive act is also significantly practiced among the surveyed surgeons in Ethiopia, where 74% of them reported performing one or another form of defensive practice. This figure is comparable with the rate of practice among Italian surgeons where 75% of them practice defensively but it is relatively lower than the study done among doctors in UK where the prevalence is about 78% and a survey conducted among Japanese gastroenterologists where almost all (98%) of them reported performing some form of defensive practice (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlmost all 223 (94.5%) of the sampled surgeons believe that legal claims against doctors are increasing and 29 (12.3%) of them directly experienced legal claims of which only 3 (1.3%) actually lost the legal dispute. This number is by far less than the rate of litigation among high risk specialists in the USA where 88% of them have one or another form of legal dispute and it is also lower than the rate of legal dispute among Chinese obstetric and gynecologic surgeons (61%) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This widespread practice of defensive medicine despite low rate of legal dispute might be due to the physicians' self-perceived threats rather than actual or existing litigation. On the other hand, the prevalent defensive practice in the country can be due to fear of negative publicity, fear of compensation or fear of disciplinary sanction which makes them to consider a patient as a risky subject than someone who needs help.\u003c/p\u003e \u003cp\u003eOur study showed that both avoidance and assurance behaviors are significantly performed by the surgeons who responded to the survey. Sixty percent of the participants mentioned avoiding high risk procedure; a figure three times higher than physicians in the UK and significantly higher than Sudanese physician where only 20.5% of them reported avoiding high risk procedures (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Nearly half of the study participants reported ordering a test more than indicated, which is a higher figure compared to the rate among Japanese gastroenterologists (36%) but relatively lower than the rate observed in the USA (59%) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMany literatures in the world showed age and year of experience were strongly associated with defensive practice (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). But our study didn\u0026rsquo;t show any correlation between age, year of experience and rate of defensive practice. In this study logistic regression model also showed cardiothoracic and vascular surgeons perform less defensively compared to other specialties. But this might not be true figure since physicians in this specialty represented less in the survey. On the other hand, income was found not to have association with defensive acts. This was a finding in contrary to the study done by \u003cem\u003eHe et al\u003c/em\u003e. where the rate of defensive act was relatively higher among low-income physicians (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). This difference can be due to lack of awareness of the surveyed doctors in this study where ordering unnecessary tests with an intension to get additional fee is considered as a continuum of standard medical care than a defensive act. Unlike many studies, this survey didn\u0026rsquo;t show any correlation between defensive practice and previous medical dispute history (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This could be due to the fact that most of the participants who experienced legal disputes actually won their cases and are confident enough in differentiating clinical decisions with legal consequences from unnecessary defensive acts.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eThe practice of DM is widespread among surveyed Ethiopian surgeons. Avoiding high risk procedures and ordering tests more than indicated were the most common types of defensives practiced by the surveyed physicians. The vast majority of Ethiopian surgeons believe that legal dispute among doctors is increasing, but only minority actually got penalized due to malpractice. There was no statistically significant association between ages, year of experience, place of practice, previous legal dispute history and income of a surgeon with defensive practice. The widespread practice of DM despite low rate of legal dispute might be due to the physicians\u0026rsquo; self-perceived threats rather than actual legal danger. Educating surgeons about the possible impact of defensive practice on the health care system and awareness creation about the existing high level of self-believed threat of legal suit than actual legal consequences can reduce defensive act and mitigate the negative impact of defensive medicine. Policy makers and other responsible bodies should design strategy towards decreasing defensive practice by surgeons and its negative impact on the health care system. Further studies are required to objectively estimate the effect of defensive practice on the health care system of the country.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAA\u0026nbsp; \u0026nbsp;Addis\u0026nbsp;Ababa\u003c/p\u003e\n\u003cp\u003eAAU\u0026nbsp;Addis\u0026nbsp;Ababa\u0026nbsp;University\u003c/p\u003e\n\u003cp\u003eCI\u0026nbsp; \u0026nbsp;Confidence\u0026nbsp;Interval\u003c/p\u003e\n\u003cp\u003eDM\u0026nbsp; \u0026nbsp;Defensive\u0026nbsp;Medicine\u003c/p\u003e\n\u003cp\u003eETB\u0026nbsp;Ethiopian\u0026nbsp;Birr\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eG.C\u0026nbsp; \u0026nbsp;Gregorian\u0026nbsp;Calendar\u003c/p\u003e\n\u003cp\u003eSSE\u0026nbsp; \u0026nbsp;Surgical\u0026nbsp;Society\u0026nbsp;of\u0026nbsp;Ethiopia\u003c/p\u003e\n\u003cp\u003eSD\u0026nbsp;Standard\u0026nbsp;Deviation\u003c/p\u003e\n\u003cp\u003eUK\u0026nbsp; \u0026nbsp;United\u0026nbsp;Kingdom\u003c/p\u003e\n\u003cp\u003eUSA United State of America\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical clearance and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from AAU College of health science and school of medicine department of surgery research and ethics committee from a letter written with a reference number of RC/DOS/CHS/AAU/019/2021. Informed consent was\u0026nbsp;included on the online survey questionnaire and a cover letter provided basic information about the study. Informed consent was obtained from all participants included in the survey and the study complied with the Declaration of Helsinki. All data are collected anonymously and it will not be used for other purpose than the study question. Participants who failed to give consent, the online survey questioner allowed them to automatically leave the survey. Regarding physicians who decided to leave the survey after initial consent, the survey questionnaire allowed them to decline submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;There is no competing interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll necessary data are available at the hands of corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur deepest gratitude goes to all physicians who kindly participated in this survey. Authors gratitude also goes to AAU, college of health science and school of medicine for the technical support and approval of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEAA:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eInitiated the research, wrote the research proposal, conducted the study, study analysis, and wrote the manuscript. YAT: Involved in research proposal writing, statistical analysis and drafting of manuscript. BNA: Coordinated the research, involved in study design and statistical analysis AGT: Involved in in statistical analysis and drafting of manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eU.S. Congress, Office of Technology Assessment, Defensive Medicine and Medical Malpractice, OTA-H--6O2 (Washington, DC: U.S. Government Printing Office, July 1994).\u003c/li\u003e\n\u003cli\u003eHershey N. The Defensive Practice of Medicine: Myth or Reality. Milbank Mem Fund Q. 1972 Jan; 50(1):69. \u003c/li\u003e\n\u003cli\u003eKlingman D, Localio AR, Sugarman J, Wagner JL, Polishuk PT, Wolfe L, et al. Measuring Defensive Medicine Using Clinical Scenario Surveys. J. Health Policy Law. 1996; 21(2):185\u0026ndash;220. \u003c/li\u003e\n\u003cli\u003eStuddert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, et al. Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment. :9. \u003c/li\u003e\n\u003cli\u003eOrtashi O, Virdee J, Hassan R, Mutrynowski T, Abu-Zidan F. The practice of defensive medicine among hospital doctors in the United Kingdom. BMC Medical Ethics. 2013 Dec; 14(1):42. \u003c/li\u003e\n\u003cli\u003eBerlin L. Medical errors, malpractice, and defensive medicine: an ill-fated triad. Diagnosis. 2017 Sep 26;4(3):133\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eWamisho B, Abeje Tiruneh M, Enkubahiry Teklemariam L. Surgical and Medical Error Claims in Ethiopia: Trends Observed From 125 Decisions Made by The Federal Ethics Committee for Health Professionals Ethics Review. Medicolegal Bioeth. 2019 Oct;Volume 9:23\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eMello MM, Chandra A, Gawande AA, Studdert DM. National Costs of The Medical Liability System. Health Aff (Millwood). 2010 Sep;29(9):1569\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eYan SC, Hulou MM, Cote DJ, Roytowski D, Rutka JT, Gormley WB, et al. International Defensive Medicine in Neurosurgery: Comparison of Canada, South Africa, and the United States. World Neurosurg. 2016 Nov; 95:53\u0026ndash;61. \u003c/li\u003e\n\u003cli\u003eFloyd TK. Medical Malpractice: Trends in Litigation. Gastroenterology. 2008 Jun;134(7):1822-1825.e1. \u003c/li\u003e\n\u003cli\u003eOgunbanjo G, Bogaert KD. Ethics in health care: The practice of defensive medicine. South Afr Fam Pract. 2014 Jan 1;56: S6\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eAli AA, Hummeida ME, Elhassan YAM, M.Nabag WO, Ahmed MAA, Adam GK. Concept of defensive medicine and litigation among Sudanese doctors working in obstetrics and gynecology. BMC Med Ethics. 2016 Dec; 17(1):12. \u003c/li\u003e\n\u003cli\u003eAdwok J, Kearns EH. Defensive Medicine: Effect on Costs, Quality, and Access to Healthcare. J Biol. 2013;7. \u003c/li\u003e\n\u003cli\u003eCatino M, Celotti S. The Problem of Defensive Medicine: Two Italian Surveys. Detect Prev Adverse Drug Events. 2009; 206\u0026ndash;21. \u003c/li\u003e\n\u003cli\u003eHiyama T. Defensive medicine practices among gastroenterologists in Japan World J Gastroenterology. 2006; 12(47):7671. \u003c/li\u003e\n\u003cli\u003eZhu L, Li L, Lang J. The attitudes towards defensive medicine among physicians of obstetrics and gynaecology in China: a questionnaire survey in a national congress. BMJ Open. 2018 Feb;8 (2): e019752. \u003c/li\u003e\n\u003cli\u003eHe AJ. The doctor\u0026ndash;patient relationship, defensive medicine and over-prescription in Chinese public hospitals: Evidence from a cross-sectional survey in Shenzhen city. Soc Sci Med. 2014 Dec; 123:64\u0026ndash;71.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Defensive, Ethiopia, medicine, practice, surgeons","lastPublishedDoi":"10.21203/rs.3.rs-2338521/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2338521/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDefensive medicine is physicians\u0026rsquo; deviation from standard medical care which is primarily intended either to reduce or avoid medico legal litigation. Although the Federal Ethics Committee review in Ethiopia has shown that applications for medical/surgical error investigation claims are increasing at an alarming rate, there is no study to date done to estimate the degree of defensive practice done by the physicians with an intention of avoiding this increasing legal claim. This study assessed the practice of defensive medicine among highly litigious disciplines (surgery) and described factors associated with its practice.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eCross sectional quantitative study using online survey questionnaires was conducted to assess the degree of defensive practice and six factors (age, years of experience, specialty, monthly income, place of practice and previous medico legal history) associated with its practice were assessed among surgeons working in Ethiopia.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 430 surgeons directly received an online survey questionnaire and 236 of them successfully completed the questionnaire making the response rate 51.2%. Nearly half of the study participants (51.7%) were aware of the concept of defensive medicine and 174 (74%) reported performing one form of defensive practice. Twenty-nine (12.3%) of the participants have legal dispute history, though only 1.3% of them ended up in penalty. Avoiding high risk procedures was the commonest defensive act performed by 60% of the participants, followed by ordering tests unnecessarily (52.1%). Multinomial logistic regression model showed that there was no association between age of the participant, place of practice, year of experience and defensive practice. This model also showed that cardiothoracic and vascular surgeons perform less defensively than surgeons with other specialty with \u003cem\u003eP value\u003c/em\u003e of 0.02.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe practice of defensive medicine is widespread among surveyed Ethiopian surgeons and further studies are required to objectively estimate the effect of defensive practice on the health care system of the country. Policy makers need to develop strategy towards decreasing this high rate of defensive practice.\u003c/p\u003e","manuscriptTitle":"Practice of Defensive Medicine Among Surgeons in Ethiopia: Cross Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-12-15 16:30:21","doi":"10.21203/rs.3.rs-2338521/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-09-15T10:25:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-09-15T07:45:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4aa6d0da-7642-418f-9e91-faf4885e32e3","date":"2023-08-29T10:50:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-08-26T17:29:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"f345ba58-eeb8-4383-b1b1-0def6d82a38a","date":"2023-07-21T10:49:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"0e75d23e-8de2-47d2-99b4-0fcab8a57fbd","date":"2023-05-19T15:22:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-05-19T15:00:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-04-05T17:58:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-12-14T09:20:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-12-14T04:34:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Ethics","date":"2022-12-02T17:57:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"31399025-cfc8-430b-a05b-261b4ce08733","owner":[],"postedDate":"December 15th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-11-13T15:07:08+00:00","versionOfRecord":{"articleIdentity":"rs-2338521","link":"https://doi.org/10.1186/s12910-023-00979-w","journal":{"identity":"bmc-medical-ethics","isVorOnly":false,"title":"BMC Medical Ethics"},"publishedOn":"2023-11-08 15:01:19","publishedOnDateReadable":"November 8th, 2023"},"versionCreatedAt":"2022-12-15 16:30:21","video":"","vorDoi":"10.1186/s12910-023-00979-w","vorDoiUrl":"https://doi.org/10.1186/s12910-023-00979-w","workflowStages":[]},"version":"v1","identity":"rs-2338521","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2338521","identity":"rs-2338521","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}