Navigating Risk Without Protection: Defensive Medicine Among General Practitioners in a Fragile Afghan Health System

Navigating Risk Without Protection: Defensive Medicine Among General Practitioners in a Fragile Afghan Health System | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Navigating Risk Without Protection: Defensive Medicine Among General Practitioners in a Fragile Afghan Health System Ali Vafaee Najar, Elaheh Hooshmand, Ahmad Bashir Darvishi, Marziyhe Meraji This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8837236/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Defensive medicine refers to clinical practices driven primarily by physicians’ concerns about potential complaints or accusations rather than patient benefit. While extensively studied in high-income countries, little is known about defensive medicine in fragile and low-resource health systems. This study aimed to examine the prevalence, perceived causes, and potential mitigation strategies of defensive medicine among general practitioners working in hospitals in Herat, Afghanistan. Methods: A cross-sectional survey was conducted in 2023 among general practitioners employed in four major hospitals in Herat. Of 318 eligible physicians, 104 completed a researcher-designed and validated questionnaire (response rate: 32.7%). Content validity was confirmed using the content validity ratio (0.56) and content validity index (0.79), and reliability was assessed through test–retest procedures (Cronbach’s α = 0.77). Descriptive statistics and Chi-square tests were used for data analysis. Results: Although only 35.3% of physicians reported full familiarity with defensive medicine, 46.2% indicated high levels of defensive practice. Common behaviors included unnecessary inpatient admissions (58.8%), avoidance of high-risk procedures (80.4%), and avoidance of high-risk patients (41.2%). Low clinical confidence and limited specialized knowledge were identified as the leading perceived causes. Legal protection for physicians was the most strongly supported mitigation strategy. Years of work experience were significantly associated with defensive practice (p = 0.02). Conclusion: Defensive medicine is prevalent among general practitioners in Herat despite limited conceptual awareness. These practices appear to be driven more by systemic vulnerabilities and clinical uncertainty than by litigation pressure. Strengthening legal protections, improving access to evidence-based guidelines, and enhancing professional training may help reduce unnecessary defensive behaviors in fragile health systems. Trial registration: Not applicable. Defensive medicine clinical decision-making patient safety general practitioners Afghanistan medico-legal environment fragile settings. Contributions to the Literature Provides the first empirical evidence on defensive medicine among general practitioners in Afghanistan, a fragile and under-researched health system. Demonstrates that defensive medical practices can be prevalent even in settings with limited medico-legal litigation, highlighting the role of systemic uncertainty. Identifies clinical confidence, training gaps, and lack of institutional support as key drivers of defensive behavior in low-resource contexts. Offers policy-relevant insights to support safer clinical decision-making and strengthen physician support in fragile health systems. Introduction Defensive medicine (DM) refers to diagnostic or therapeutic actions that are undertaken primarily to protect physicians from potential legal claims rather than to directly benefit the patient( 1 ). Over the past two decades, this phenomenon has gained substantial global attention due to its profound implications for patient safety, health-care costs, and the quality of clinical decision-making( 2 ). Numerous studies across high-income countries have shown that fear of litigation, regulatory sanctions, and patient complaints can significantly influence physicians’ clinical behavior, leading to unnecessary investigations, avoidant attitudes toward high-risk patients, and excessive documentation( 3 , 4 ). Such practices contribute to increased financial burden on health-care systems and may compromise patient-centered care( 5 ). Although defensive medicine is well explored in developed health systems such as the United States, United Kingdom, Italy, and Japan, evidence from low- and middle-income countries remains limited( 6 ). In these settings, the drivers of defensive medicine may differ substantially, as physicians often practice in environments characterized by limited legal protections, inconsistent regulatory frameworks, resource constraints, and high patient loads( 7 ). Furthermore, socio-cultural expectations, weak insurance coverage, and informal complaint systems may intensify physicians’ perceived vulnerability, potentially exacerbating defensive behaviors. Despite these contextual differences, the phenomenon of DM and its consequences in developing countries remain under-investigated( 8 ). Afghanistan presents a unique case. Its health-care system has faced decades of instability, shortages of medical personnel, inconsistent regulatory oversight, and limited malpractice governance( 9 ). Given the long-standing structural weaknesses and access barriers in Afghanistan’s health-care system, Afghan physicians are likely to experience heightened uncertainty and professional risk in their daily practice. Reports from Afghanistan describe major challenges related to insecurity, distance, costs and gaps in service performance, yet no empirical study has systematically examined how these conditions shape physicians’ clinical decision-making or drive defensive behaviors( 10 , 11 ). Importantly, no prior study has directly examined defensive medicine among general practitioners—who serve as the front line of health-care delivery and manage the majority of patient encounters. Given this substantial knowledge gap, exploring defensive medical practices in Afghanistan is both timely and essential. Understanding the extent of these behaviors, the contextual factors that drive them, and the strategies physicians perceive as effective for mitigation can provide valuable insights for policymakers, medical educators, and institutional leaders. Therefore, the present study aims to investigate the experience, perceived causes, and potential strategies to address defensive medicine among general practitioners working in hospitals in Herat, Afghanistan. By presenting the first empirical evidence from this context, the study contributes to the global understanding of defensive medicine in fragile and resource-limited health systems. Methods This study employed a cross-sectional analytical design and was conducted in 2024 in Herat, one of Afghanistan’s major urban centers with a diverse mix of public and private health facilities. General practitioners constitute a critical segment of the Afghan health-care workforce and deliver the majority of primary and emergency services. Because no empirical evidence has previously examined defensive medical practices in Afghanistan, the study sought to obtain a comprehensive snapshot of physicians’ experiences through a census approach. All 318 general practitioners employed across four major hospitals in Herat were considered eligible. Questionnaires were distributed to all eligible physicians, and 104 completed forms were returned, resulting in a response rate of 32.7%. Although the response rate was modest, it was acceptable given the challenging working conditions, time constraints, and sensitivity of the topic in the Afghan context. Data were collected using a structured questionnaire specifically developed for this study, drawing on concepts and items used in prior international research on defensive medicine, particularly the tool developed by Rezaei and colleagues in Iran( 12 ). The instrument included five sections: demographic information, familiarity with the concept of defensive medicine, experiences with defensive practices, perceived causes of such behaviors, and strategies that physicians believed could reduce their occurrence. Items addressing defensive practices were rated on a three-point scale (often, sometimes, never), while items related to causes and strategies were assessed using a five-point Likert scale ranging from strongly agree to strongly disagree. The questionnaire was initially drafted in English, reviewed by clinical practitioners and academic experts familiar with the Afghan health-care environment, and then adjusted for contextual and linguistic appropriateness. Minor revisions were made to ensure clarity and cultural relevance. The full English version of the researcher-developed questionnaire is provided as Supplementary File 1. To establish content validity, the questionnaire was evaluated by a panel of ten experts in medicine and health services management. Using Lawshe’s method, the Content Validity Ratio (CVR) for the instrument was calculated at 0.56, meeting the minimum required threshold for acceptance. In addition, the Content Validity Index (CVI), which reflects the relevance, clarity, and simplicity of the items, was found to be 0.79, indicating satisfactory content validity for a newly developed tool. Reliability was examined through a test–retest procedure in which 28 physicians completed the questionnaire twice with a 10-day interval. Cronbach’s alpha for the final version of the instrument was 0.77, demonstrating acceptable internal consistency for research purposes. Questionnaires were distributed in person during working hours. Before completing the survey, physicians were informed about the objectives of the study, assured that participation was voluntary, and guaranteed that no identifiable information would be collected. Given the sociopolitical conditions in Afghanistan and physicians’ concerns about workplace repercussions, anonymity and verbal informed consent were considered the most appropriate and least intrusive approaches. Completed questionnaires were returned in sealed envelopes to minimize the potential influence of social desirability or professional concerns. Data were analyzed using SPSS version 20. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were calculated to summarize demographic characteristics, levels of familiarity with defensive medicine, and patterns of defensive behavior. To explore associations between physicians’ defensive practices and demographic variables such as age, gender, marital status, and years of professional experience, Chi-square tests were conducted using a significance threshold of p < 0.05. Although more complex modeling approaches such as multivariable logistic regression could provide deeper insights into predictors of defensive behavior, the sample size and distribution of key variables limited the feasibility of such analyses; therefore, bivariate tests were considered appropriate for this initial exploratory study. This research was approved by the Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.REC.1400.103). Participation was voluntary, and all respondents provided verbal informed consent after being briefed on the purpose and confidentiality procedures of the study. No personal identifiers were collected, and all data were kept secure throughout the research process. Results A total of 104 general practitioners participated in the study, representing 32.7% of all eligible physicians working in the selected hospitals. Among respondents, 82.7% were male, and nearly three-quarters were married. More than half of the participants had fewer than 15 years of professional experience. The demographic characteristics of participants are presented in Table 1 . Table 1 Demographic Characteristics of Participants (n = 104) Variable Category Frequency (n) Percentage (%) Gender Male 86 82.7 Female 18 17.3 Age (years) < 50 57 54.8 ≥ 50 47 45.2 Marital Status Married 75 72.1 Single 29 27.9 Work Experience (years) < 15 57 54.9 ≥ 15 47 45.1 Familiarity With Defensive Medicine Of the respondents, 35.3% reported full familiarity with the concept of defensive medicine, while 37.3% were “somewhat familiar,” and 27.4% had no prior familiarity with the term. Experience with Defensive Medical Practices Nearly half of the physicians (46.2%) reported a high level of engagement in defensive medical behaviors. Another 27.4% reported moderate levels of defensive behavior, and 27.4% reported low involvement. Common Defensive Medical Practices Participants reported varying degrees of involvement in 13 types of defensive practices. As shown in Table 2 , the most frequently reported action was admitting patients who could be treated as outpatients, with 58.8% of participants indicating that they “often” performed this behavior. Avoiding high-risk procedures and avoiding high-risk patients ranked second and third, respectively. The least common defensive behaviors involved providing extra explanation about medication use and requesting follow-up visits. Table 2 Frequency of Defensive Medical Practices Among General Practitioners (n = 104) Defensive Practice Often n (%) Sometimes n (%) Never n (%) Mean Score* Rank Admitting outpatients unnecessarily 60 (58.8) 40 (39.2) 2 (2.0) 2.37 1 Avoiding high-risk procedures/prescriptions 82 (80.4) 16 (15.7) 4 (3.9) 2.10 2 Avoiding high-risk patients 42 (41.2) 46 (45.1) 14 (13.7) 2.02 3 Prescribing invasive diagnostics 60 (58.8) 40 (39.2) 2 (2.0) 1.98 4 Ordering imaging/tests to reduce risk 58 (56.9) 36 (35.3) 8 (7.8) 1.88 5 Ordering diagnostic laboratory tests 40 (40.0) 44 (44.0) 16 (16.0) 1.76 6 Excessive documentation 32 (31.4) 50 (49.0) 22 (19.6) 1.73 7 Prescribing low-risk medications 58 (56.9) 36 (35.3) 8 (7.8) 1.60 8 Providing extra details about treatment 20 (19.6) 64 (62.7) 18 (17.6) 1.51 9 Referring to higher specialty 16 (15.7) 32 (31.4) 54 (52.9) 1.51 10 Monitoring treatment outcomes 52 (50.0) 40 (40.0) 12 (10.0) 1.43 11 Requesting additional follow-ups 20 (19.6) 52 (51.0) 32 (29.4) 1.43 12 Giving detailed medication instructions 30 (29.4) 40 (39.2) 32 (31.4) 1.24 13 *Mean score based on "often"=3, "sometimes"=2, "never"=1. Causes of Defensive Medical Behavior Physicians rated 16 possible causes of defensive medicine. The factor with the highest level of agreement was low risk tolerance and low confidence among physicians (mean = 3.35), followed by limited specialized knowledge in some clinical areas (mean = 2.78). The lowest-rated cause was concern for personal safety and fear of violence (mean = 1.63). Physicians rated 16 possible causes of defensive medicine, as summarized in Table 3 . Table 3 Perceived Causes of Defensive Medicine (Likert Scale 1–5) Cause Mean Rank Low risk tolerance & low confidence 3.35 1 Limited specialized knowledge 2.78 2 Lack of clinical guidelines 2.67 3 Ensuring adherence to standards 2.47 4 Colleagues’ past lawsuit experiences 2.45 5 Defensive training during education 2.45 6 Prior malpractice concerns 2.42 7 Lack of liability insurance 2.34 8 Reassuring families fully 2.24 9 Lack of legal support 2.22 10 Protecting reputation 2.16 11 High cost of errors 2.10 12 Patient/family demand for certainty 2.06 13 Fear of lawsuits 1.98 14 DM as beneficial practice 1.94 15 Fear of violence 1.63 16 Strategies to Reduce Defensive Medicine Participants evaluated six strategies to reduce defensive practices. As shown in Table 4 , the most strongly endorsed strategy was implementing for legal protections physicians . Evidence-based practice, public awareness, and teamwork improvement were also supported. Table 4 Perceived Strategies to Reduce Defensive Medicine Strategy Mean Agreement SD Rank Legal protections for physicians 4.62 2.46 1 Evidence-based medicine 3.98 1.99 2 Public awareness of defensive medicine 3.65 2.39 3 Improving teamwork 3.32 2.72 4 Reforming complaint-handling processes 2.99 2.53 5 Establishing patient data registry 2.66 2.92 6 Association Between Defensive Medicine and Demographic Factors Chi-square analysis indicated a statistically significant relationship between defensive medical practice and years of work experience ( p = 0.02 ). Physicians with fewer years of experience were more likely to report engaging in defensive behaviors. No significant associations were observed with gender (p = 0.387), age group (p = 0.162), or marital status (p = 0.133). Discussion This study provides the first empirical evidence on defensive medical practices among general practitioners in Afghanistan, a country where research on clinical decision-making and medico-legal behaviors remains extremely scarce. The findings demonstrate that defensive medicine is both present and relatively common among physicians in Herat, even though a considerable proportion of respondents had limited prior familiarity with the term. This combination of low conceptual awareness and relatively high engagement in defensive actions highlights a significant gap in medical education, institutional governance, and regulatory protection in the Afghan health-care system. The prevalence of defensive practices observed in this study aligns with trends reported across a wide spectrum of countries( 13 ), although the exact patterns and underlying drivers differ substantially. For example, similar to findings from Iran( 14 ), Sudan( 15 ), Ethiopia( 16 ), and the United States( 17 ), participants in this study frequently reported unnecessary admissions, avoidance of high-risk patients, and overuse of diagnostic tests as common defensive behaviors. Studies in Japan ( 18 )and the United States( 19 ) have shown rates of defensive practice exceeding 90% among high-risk specialties, while research in Sudan reported defensive actions among approximately 72% of obstetricians and gynecologists( 15 ). Although the Afghan physicians surveyed in this study were general practitioners—rather than high-risk specialists—the pattern of frequent avoidance behavior and excessive diagnostic testing mirrors global findings, suggesting that defensive medicine is not limited to high-risk specialties and can arise in environments where medico-legal uncertainty is high( 20 ). Our finding of high rates of inpatient admission as a form of defensive medicine is consistent with evidence from European settings. In a UK study, 78% of hospital doctors reported practicing at least one form of defensive medicine, including unnecessary tests and referrals( 21 ); similar patterns have been documented among general practitioners in Denmark and other European countries( 22 ). Over-investigation, referrals, and even defensive hospitalization or delayed discharge have been repeatedly identified as common forms of defensive behavior in international reviews( 23 , 24 ). Nonetheless, in low-resource and fragile health-care systems — such as Afghanistan — the structural, organizational, and social drivers of defensive decisions may diverge from those in high-income settings, making defensive medicine not merely a response to malpractice risk but also a coping mechanism against systemic uncertainty and social pressures( 16 , 24 ). Another important finding relates to avoidance behaviors. Nearly half of the general practitioners indicated they often avoided high-risk procedures or high-risk patients. Avoidance behavior is consistently highlighted in international literature as one of the most harmful forms of defensive medicine, particularly because it compromises access to care( 25 ). Studies from South Africa, Turkey( 26 ), and Iran have documented similar patterns( 27 ), where physicians avoided high-risk patients or cases with uncertain prognosis due to fear of complications, complaints, or institutional blame( 28 ). Although no empirical research is available from Afghanistan, evidence from fragile and resource-limited systems suggests that limited referral pathways and scarce specialty services may amplify the consequences of avoidance behaviors, particularly in rural and underserved areas( 10 , 29 ). This finding underscores the need for targeted support for early-career physicians, who in several studies have been shown to engage more frequently in defensive practices ( 30 ). The analysis of perceived causes provides further insight into the mechanism of defensive medicine in Afghanistan. The most strongly endorsed reason—low risk tolerance and low clinical confidence—differs from findings in many high-income countries, where fear of litigation, media scrutiny, and malpractice costs are predominant( 17 , 21 ). In settings such as Japan( 31 ), Italy( 32 ), and the United States( 17 ), malpractice risk is directly tied to financial liability and legal repercussions. However, Afghan physicians identified lack of confidence, inadequate specialized knowledge, and absence of clinical guidelines as more influential. This suggests that defensive behaviors may, to some extent, reflect gaps in training and the limited availability of continuing medical education( 24 ). Limited clinical support structures, such as diagnostic algorithms, standard guidelines, and multidisciplinary teams, may further heighten uncertainty. This contrasts with studies from Denmark and the United Kingdom, where structured decision-support systems, well-established protocols, and robust professional protections reduce uncertainty and thereby limit defensive tendencies( 21 , 22 ). Interestingly, fear of violence or threats from patient families ranked lowest as a motivating factor for defensive practice in the present study, despite widespread anecdotal reports of hostility toward physicians in conflict-affected settings. This finding contrasts sharply with evidence from China, where fear of patient violence has been consistently identified as one of the strongest predictors of defensive medical behavior ( 33 ) ( 34 ).The observed difference may reflect underlying cultural and social dynamics in Afghanistan, where physicians traditionally retain relatively high social status and overt antagonistic behaviors toward them may be less common or less openly acknowledged. Alternatively, respondents may have been reluctant to disclose such fears explicitly due to social desirability bias or concerns about professional image. The findings regarding effective mitigation strategies closely parallel international recommendations. Physicians in this study identified legal protection as the most critical intervention, consistent with evidence from Jordan( 35 ), Iran( 27 ), and the United States( 17 ), where strengthening medico-legal frameworks and clarifying clinical accountability have been repeatedly emphasized as core strategies for reducing defensive practice. Strengthening medico-legal frameworks, clarifying standards for clinical practice, and improving institutional support may therefore help reduce uncertainty and discourage unnecessary defensive actions ( 17 , 25 ). Evidence-based medicine and clinical guidelines were also highly endorsed in the present study, indicating a strong demand for structured decision-making tools, a finding consistent with international evidence linking the absence of guidelines to higher defensive behavior ( 36 ). Although teamwork and communication were ranked lower by respondents, their importance remains well established, as strong interdisciplinary collaboration has been shown to reduce perceived professional risk and increase clinical confidence among physicians in several European health systems ( 8 , 25 ). Comparing these findings with the broader international literature suggests that defensive medicine in Afghanistan is shaped by a distinctive combination of contextual factors, including limited clinical resources, inconsistent regulatory structures, gaps in professional training, and strong social expectations from patients and families. Unlike high-income health systems, where defensive practices are largely driven by concerns about legal liability, Afghan physicians appear to engage in defensive behaviors primarily in response to clinical uncertainty, inadequate institutional support, and systemic vulnerabilities. This distinction is critical, as interventions shown to be effective in Europe or the United States—such as malpractice litigation reform—may not be directly transferable to the Afghan context. Instead, strengthening clinical education, expanding institutional support mechanisms, and developing standardized clinical practice guidelines may offer more feasible and immediate benefits. The significant association between defensive medicine and years of experience further highlights the role of training and mentorship. Less experienced physicians reported engaging in more defensive behaviors, a pattern that has also been documented in studies from Iran, Ethiopia, and Germany ( 16 , 30 , 37 ). Early-career physicians often lack the confidence and clinical judgment required to navigate ambiguous clinical cases, making them more prone to unnecessary testing or avoidance behaviors. Strengthening residency programs, enhancing supervised practice, and establishing structured mentorship systems could therefore play an important role in reducing defensive tendencies. Overall, this study contributes valuable and novel evidence to the global understanding of defensive medicine, particularly in fragile and resource-limited health systems. It highlights the importance of viewing defensive medicine not merely as a legal concern, but as a broader manifestation of systemic deficiencies in professional support, training, and governance. The findings underscore the urgent need for capacity building among Afghan physicians, investment in guideline development, strengthening of complaint-handling mechanisms, and creation of a more transparent and supportive medico-legal environment. Conclusion This study provides the first systematic evidence on defensive medical practices among general practitioners in Afghanistan and demonstrates that, despite limited familiarity with the concept, defensive behaviors are relatively common in routine clinical care. The findings highlight a constellation of contributing factors—ranging from low clinical confidence and insufficient specialized training to the absence of clear clinical guidelines and weak medico-legal protections—that collectively shape physicians’ decision-making in this fragile health system. These drivers differ in important ways from those reported in high-income countries, emphasizing the need for context-specific strategies. Strengthening legal protections for physicians, improving access to evidence-based guidelines, and enhancing professional support structures may help reduce unnecessary interventions and improve the quality of care. Additionally, targeted educational programs, mentorship for early-career practitioners, and reforms in complaint-handling mechanisms could further mitigate defensive tendencies. Because defensive medicine in Afghanistan appears closely tied to systemic vulnerabilities rather than litigation pressure alone, interventions must focus on building institutional capacity, clarifying clinical expectations, and reducing uncertainties in clinical practice. Future research should explore defensive behaviors in other regions and specialties, employ qualitative methods to capture deeper insights into decision-making processes, and assess the impact of targeted interventions on reducing defensive actions. By advancing understanding of defensive medicine in a resource-constrained setting, this study contributes to global discussions on patient safety, health system governance, and the development of supportive environments that enable physicians to provide optimal, patient-centered care. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.REC.1400.103). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. All participants were informed about the purpose of the study, assured of confidentiality, and provided verbal informed consent prior to participation. Participation was voluntary, and participants could withdraw at any time without consequence. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Authors’ information Not applicable. List of abbreviations Not applicable. Funding This research was conducted as part of a master’s thesis in health care management and was supported by Mashhad University of Medical Sciences (Grant No. 991779). Author Contribution AVN and EH contributed equally to the conception and design of the study and are considered co-first authors. AVN contributed to instrument development, data analysis, and interpretation of findings. EH contributed to methodological refinement and drafting and critical revision of the manuscript. ABD participated in data collection and field coordination. MM supervised the study and contributed to interpretation of results and critical revision of the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank all participating physicians for their cooperation despite the challenging conditions. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. References Eftekhari MH, Parsapoor A, Ahmadi A, Yavari N, Larijani B, Gooshki ES. Exploring defensive medicine: examples, underlying and contextual factors, and potential strategies - a qualitative study. BMC Med Ethics. 2023;24(1):82. Rajaie S, Azari S, Karimi F. Defensive Medicine and Healthcare Costs: A Scoping Review. Med J Islam Repub Iran. 1938;2024(15):119. Goetz K, Oldenburg D, Strobel CJ, Steinhäuser J. The influence of fears of perceived legal consequences on general practitioners' practice in relation to defensive medicine - a cross-sectional survey in Germany. BMC Prim Care. 2024;25(1):23. Miziara ID, Miziara CSMG. Medical errors, medical negligence and defensive medicine: A narrative review. Clinics. 2022;77:100053. Lykkegaard J, Andersen MKK, Nexøe J, Hvidt EA. Defensive medicine in primary health care. Taylor & Francis; 2018. pp. 225–6. Kakemam E, Arab-Zozani M, Raeissi P, Albelbeisi AH. The occurrence, types, reasons, and mitigation strategies of defensive medicine among physicians: a scoping review. BMC Health Serv Res. 2022;22(1):800. Agarwal R, Gupta A, Gupta S. The impact of tort reform on defensive medicine, quality of care, and physician supply: a systematic review. Health Serv Res. 2019;54(4):851–9. Pellino IM, Pellino G. Consequences of defensive medicine, second victims, and clinical-judicial syndrome on surgeons’ medical practice and on health service. Updates Surg. 2015;67(4):331–7. Yar FGM. Analysis of Challenges and Opportunities for Improving the Health System in Afghanistan: Innovative Approaches and Sustainable Solutions. Jurnal Sosial Teknologi. 2024;4(10):923–41. Acerra JR, Iskyan K, Qureshi ZA, Sharma RK. Rebuilding the health care system in Afghanistan: an overview of primary care and emergency services. Int J Emerg Med. 2009;2(2):77–82. Nic Carthaigh N, De Gryse B, Esmati AS, Nizar B, Van Overloop C, Fricke R, et al. Patients struggle to access effective health care due to ongoing violence, distance, costs and health service performance in Afghanistan. Int Health. 2015;7(3):169–75. Rezayi AA, Vafaee Najar A, Houshmand E, Esmaeli H, Kouhestani S. Experience and Etiology of Defensive Medicine in View of Residents in Mashhad University of Medical Sciences in 2016. J Paramedical Sci Rehabilitation. 2017;6(2):60–8. Pischedda G, Marinò L, Corsi K. Defensive medicine through the lens of the managerial perspective: a literature review. BMC Health Serv Res. 2023;23(1):1104. Rajaie S, Azari S, Karimi F. Defensive Medicine and Healthcare Costs: A Scoping Review. Med J Islamic Repub Iran. 2024;38(1):854–61. Ali AA, Hummeida ME, Elhassan YAM, Nabag M, Ahmed WO, Adam MAA. Concept of defensive medicine and litigation among Sudanese doctors working in obstetrics and gynecology. BMC Med Ethics. 2016;17(1):12. Assefa EA, Teferi YA, Alemu BN, Genetu A. Practice of defensive medicine among surgeons in Ethiopia: cross-sectional study. BMC Med Ethics. 2023;24(1):95. Studdert 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. JAMA. 2005;293(21):2609–17. Hiyama T, Yoshihara M, Tanaka S, Urabe Y, Ikegami Y, Fukuhara T, et al. Defensive medicine practices among gastroenterologists in Japan. World J Gastroenterol. 2006;12(47):7671–5. Studdert 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. JAMA. 2005;293(21):2609–17. Garattini L, Padula A. Defensive medicine in Europe: a ‘full circle’? Eur J Health Econ. 2020;21(4):477–82. Ortashi O, Virdee J, Hassan R, Mutrynowski T, Abu-Zidan F. The practice of defensive medicine among hospital doctors in the United Kingdom. BMC Med Ethics. 2013;14(1):42. Andersen MK, Hvidt EA, Pedersen KM, Lykkegaard J, Waldorff FB, Munck AP, et al. Defensive medicine in Danish general practice. Types of defensive actions and reasons for practicing defensively. Scand J Prim Health Care. 2021;39(4):413–8. Al Awar S, Sallam G, Elbiss H. Factors associated with defensive medicine practice in United Arab Emirates: A cross-sectional study with multivariate analysis. Medicine. 2024;103(47):e40619. Ries NM, Jansen J. Physicians’ views and experiences of defensive medicine: an international review of empirical research. Health Policy. 2021;125(5):634–42. Baungaard N, Skovvang PL, Hvidt EA, Gerbild H, Andersen MK, Lykkegaard J. How defensive medicine is defined in European medical literature: a systematic review. BMJ open. 2022;12(1):e057169. Delice O, Tekin E, Yılmaz S. Defensive medicine in the emergency department: a cross-sectional study from the perspective of emergency medical specialists. Eurasian J Emerg Med. 2019. Fahimi M, Sayad S, Noroozi M, Gooshki ES, Zarghami SY, Shahrezaei A et al. Defensive medicine in surgical disciplines: attitudes and practices among faculty and residents at Iran University of Medical Sciences. J Med Ethics History Med. 2025;18. Summerton N. Positive and negative factors in defensive medicine: a questionnaire study of general practitioners. BMJ. 1995;310(6971):27–9. Nic Carthaigh N, De Gryse B, Esmati AS, Nizar B, Van Overloop C, Fricke R, et al. Patients struggle to access effective health care due to ongoing violence, distance, costs and health service performance in Afghanistan. Int Health. 2015;7(3):169–75. Daneshkohan A, Ashtar-Nakhaei F, Zali A, Kakemam E, Zarei E. Defensive medicine and its related risk factors: evidence from a sample of Iranian surgeons. Hosp Pract. 2023;51(2):101–6. Hiyama T, Yoshihara M, Tanaka S, Urabe Y, Ikegami Y, Fukuhara T, et al. Defensive medicine practices among gastroenterologists in Japan. World J gastroenterology: WJG. 2006;12(47):7671. Fineschi V, Arcangeli M, Di Fazio N, Del Fante Z, Fineschi B, Santoro P, et al. editors. Defensive medicine in the management of cesarean delivery: a survey among Italian Physicians. Healthcare: MDPI; 2021. Lu L, Dong M, Wang S-B, Zhang L, Ng CH, Ungvari GS, et al. Prevalence of workplace violence against health-care professionals in China: a comprehensive meta-analysis of observational surveys. Trauma Violence Abuse. 2020;21(3):498–509. Duan X, Ni X, Shi L, Zhang L, Ye Y, Mu H, et al. The impact of workplace violence on job satisfaction, job burnout, and turnover intention: the mediating role of social support. Health Qual Life Outcomes. 2019;17(1):93. Al-Balas Q, Altawalbeh S, Rinaldi C, Ibrahim I. The practice of defensive medicine among Jordanian physicians: A cross sectional study. PLoS ONE. 2023;18(11):e0289360. Raposo VL. Defensive medicine and the imposition of a more demanding standard of care. J Leg Med. 2019;39(4):401–16. Goetz K, Oldenburg D, Strobel CJ, Steinhäuser J. The influence of fears of perceived legal consequences on general practitioners’ practice in relation to defensive medicine–a cross-sectional survey in Germany. BMC Prim care. 2024;25(1):23. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1DefensiveMedicineQuestionnaire.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 21 Mar, 2026 Reviewers agreed at journal 15 Mar, 2026 Reviewers invited by journal 06 Mar, 2026 Editor invited by journal 12 Feb, 2026 Editor assigned by journal 10 Feb, 2026 Submission checks completed at journal 10 Feb, 2026 First submitted to journal 10 Feb, 2026 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8837236","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":602627746,"identity":"3a18feab-1066-4a28-8ad1-5e6124b5e015","order_by":0,"name":"Ali Vafaee Najar","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"Vafaee","lastName":"Najar","suffix":""},{"id":602627748,"identity":"ce6f9d7e-d220-4c66-8e4c-a0a029ad9bc1","order_by":1,"name":"Elaheh Hooshmand","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Elaheh","middleName":"","lastName":"Hooshmand","suffix":""},{"id":602627750,"identity":"936ef07c-abed-4fa4-a298-3bccf251959b","order_by":2,"name":"Ahmad Bashir Darvishi","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ahmad","middleName":"Bashir","lastName":"Darvishi","suffix":""},{"id":602627756,"identity":"8c7145e2-b3b5-4184-95ad-473db83a7750","order_by":3,"name":"Marziyhe Meraji","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYLACCQMGHn44j5lILTKSDSRpAQIbgwPEukm3vffhB4uCbTzG186YbvzBYCfPwM77AK8WszPHjSUkDG7zmN3OMbvNw5Bs2MDMboBfy400BoQWoEcSGJjZ8DvM7P4z5h8gLcazc8xu/mCoJ0LLDTY2sC0G0jlmN3gYDhOh5UwamwVIi8TttDKgxuOGbQS1HD/GfFviz217/tnJ227+qKiW5+c/hl8LCDBLwJnAsCJgBwQwfiBG1SgYBaNgFIxcAABiwzl8e4X1LQAAAABJRU5ErkJggg==","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Marziyhe","middleName":"","lastName":"Meraji","suffix":""}],"badges":[],"createdAt":"2026-02-10 06:38:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8837236/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8837236/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104808390,"identity":"e6282da1-dc3e-40f6-a35b-c5dc1695c3f1","added_by":"auto","created_at":"2026-03-17 12:37:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":737224,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8837236/v1/8ad55d58-0041-4506-8a64-13d93592aa29.pdf"},{"id":104431656,"identity":"c2321e5a-8ddc-4850-9a9c-1f89f8c0b5d3","added_by":"auto","created_at":"2026-03-11 15:44:37","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":38028,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1DefensiveMedicineQuestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-8837236/v1/c894dc3e657003ed5b5bad4a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Navigating Risk Without Protection: Defensive Medicine Among General Practitioners in a Fragile Afghan Health System","fulltext":[{"header":"Contributions to the Literature","content":"\u003cul\u003e\n \u003cli\u003eProvides the first empirical evidence on defensive medicine among general practitioners in Afghanistan, a fragile and under-researched health system.\u003c/li\u003e\n \u003cli\u003eDemonstrates that defensive medical practices can be prevalent even in settings with limited medico-legal litigation, highlighting the role of systemic uncertainty.\u003c/li\u003e\n \u003cli\u003eIdentifies clinical confidence, training gaps, and lack of institutional support as key drivers of defensive behavior in low-resource contexts.\u003c/li\u003e\n \u003cli\u003eOffers policy-relevant insights to support safer clinical decision-making and strengthen physician support in fragile health systems.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eDefensive medicine (DM) refers to diagnostic or therapeutic actions that are undertaken primarily to protect physicians from potential legal claims rather than to directly benefit the patient(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Over the past two decades, this phenomenon has gained substantial global attention due to its profound implications for patient safety, health-care costs, and the quality of clinical decision-making(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Numerous studies across high-income countries have shown that fear of litigation, regulatory sanctions, and patient complaints can significantly influence physicians\u0026rsquo; clinical behavior, leading to unnecessary investigations, avoidant attitudes toward high-risk patients, and excessive documentation(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Such practices contribute to increased financial burden on health-care systems and may compromise patient-centered care(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough defensive medicine is well explored in developed health systems such as the United States, United Kingdom, Italy, and Japan, evidence from low- and middle-income countries remains limited(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In these settings, the drivers of defensive medicine may differ substantially, as physicians often practice in environments characterized by limited legal protections, inconsistent regulatory frameworks, resource constraints, and high patient loads(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Furthermore, socio-cultural expectations, weak insurance coverage, and informal complaint systems may intensify physicians\u0026rsquo; perceived vulnerability, potentially exacerbating defensive behaviors. Despite these contextual differences, the phenomenon of DM and its consequences in developing countries remain under-investigated(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAfghanistan presents a unique case. Its health-care system has faced decades of instability, shortages of medical personnel, inconsistent regulatory oversight, and limited malpractice governance(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the long-standing structural weaknesses and access barriers in Afghanistan\u0026rsquo;s health-care system, Afghan physicians are likely to experience heightened uncertainty and professional risk in their daily practice. Reports from Afghanistan describe major challenges related to insecurity, distance, costs and gaps in service performance, yet no empirical study has systematically examined how these conditions shape physicians\u0026rsquo; clinical decision-making or drive defensive behaviors(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Importantly, no prior study has directly examined defensive medicine among general practitioners\u0026mdash;who serve as the front line of health-care delivery and manage the majority of patient encounters.\u003c/p\u003e \u003cp\u003eGiven this substantial knowledge gap, exploring defensive medical practices in Afghanistan is both timely and essential. Understanding the extent of these behaviors, the contextual factors that drive them, and the strategies physicians perceive as effective for mitigation can provide valuable insights for policymakers, medical educators, and institutional leaders.\u003c/p\u003e \u003cp\u003eTherefore, the present study aims to investigate the experience, perceived causes, and potential strategies to address defensive medicine among general practitioners working in hospitals in Herat, Afghanistan. By presenting the first empirical evidence from this context, the study contributes to the global understanding of defensive medicine in fragile and resource-limited health systems.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study employed a cross-sectional analytical design and was conducted in 2024 in Herat, one of Afghanistan\u0026rsquo;s major urban centers with a diverse mix of public and private health facilities. General practitioners constitute a critical segment of the Afghan health-care workforce and deliver the majority of primary and emergency services. Because no empirical evidence has previously examined defensive medical practices in Afghanistan, the study sought to obtain a comprehensive snapshot of physicians\u0026rsquo; experiences through a census approach. All 318 general practitioners employed across four major hospitals in Herat were considered eligible. Questionnaires were distributed to all eligible physicians, and 104 completed forms were returned, resulting in a response rate of 32.7%. Although the response rate was modest, it was acceptable given the challenging working conditions, time constraints, and sensitivity of the topic in the Afghan context.\u003c/p\u003e \u003cp\u003eData were collected using a structured questionnaire specifically developed for this study, drawing on concepts and items used in prior international research on defensive medicine, particularly the tool developed by Rezaei and colleagues in Iran(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The instrument included five sections: demographic information, familiarity with the concept of defensive medicine, experiences with defensive practices, perceived causes of such behaviors, and strategies that physicians believed could reduce their occurrence. Items addressing defensive practices were rated on a three-point scale (often, sometimes, never), while items related to causes and strategies were assessed using a five-point Likert scale ranging from strongly agree to strongly disagree. The questionnaire was initially drafted in English, reviewed by clinical practitioners and academic experts familiar with the Afghan health-care environment, and then adjusted for contextual and linguistic appropriateness. Minor revisions were made to ensure clarity and cultural relevance. The full English version of the researcher-developed questionnaire is provided as Supplementary File 1.\u003c/p\u003e \u003cp\u003eTo establish content validity, the questionnaire was evaluated by a panel of ten experts in medicine and health services management. Using Lawshe\u0026rsquo;s method, the Content Validity Ratio (CVR) for the instrument was calculated at 0.56, meeting the minimum required threshold for acceptance. In addition, the Content Validity Index (CVI), which reflects the relevance, clarity, and simplicity of the items, was found to be 0.79, indicating satisfactory content validity for a newly developed tool. Reliability was examined through a test\u0026ndash;retest procedure in which 28 physicians completed the questionnaire twice with a 10-day interval. Cronbach\u0026rsquo;s alpha for the final version of the instrument was 0.77, demonstrating acceptable internal consistency for research purposes.\u003c/p\u003e \u003cp\u003eQuestionnaires were distributed in person during working hours. Before completing the survey, physicians were informed about the objectives of the study, assured that participation was voluntary, and guaranteed that no identifiable information would be collected. Given the sociopolitical conditions in Afghanistan and physicians\u0026rsquo; concerns about workplace repercussions, anonymity and verbal informed consent were considered the most appropriate and least intrusive approaches. Completed questionnaires were returned in sealed envelopes to minimize the potential influence of social desirability or professional concerns.\u003c/p\u003e \u003cp\u003eData were analyzed using SPSS version 20. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were calculated to summarize demographic characteristics, levels of familiarity with defensive medicine, and patterns of defensive behavior. To explore associations between physicians\u0026rsquo; defensive practices and demographic variables such as age, gender, marital status, and years of professional experience, Chi-square tests were conducted using a significance threshold of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Although more complex modeling approaches such as multivariable logistic regression could provide deeper insights into predictors of defensive behavior, the sample size and distribution of key variables limited the feasibility of such analyses; therefore, bivariate tests were considered appropriate for this initial exploratory study.\u003c/p\u003e \u003cp\u003e This research was approved by the Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.REC.1400.103). Participation was voluntary, and all respondents provided verbal informed consent after being briefed on the purpose and confidentiality procedures of the study. No personal identifiers were collected, and all data were kept secure throughout the research process.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 104 general practitioners participated in the study, representing 32.7% of all eligible physicians working in the selected hospitals. Among respondents, 82.7% were male, and nearly three-quarters were married. More than half of the participants had fewer than 15 years of professional experience. The demographic characteristics of participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\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\u003eDemographic Characteristics of Participants (n\u0026thinsp;=\u0026thinsp;104)\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\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\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\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\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e82.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e72.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWork Experience (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.1\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\u003eFamiliarity With Defensive Medicine\u003c/p\u003e \u003cp\u003eOf the respondents, 35.3% reported full familiarity with the concept of defensive medicine, while 37.3% were \u0026ldquo;somewhat familiar,\u0026rdquo; and 27.4% had no prior familiarity with the term.\u003c/p\u003e \u003cp\u003eExperience with Defensive Medical Practices\u003c/p\u003e \u003cp\u003eNearly half of the physicians (46.2%) reported a high level of engagement in defensive medical behaviors. Another 27.4% reported moderate levels of defensive behavior, and 27.4% reported low involvement.\u003c/p\u003e \u003cp\u003eCommon Defensive Medical Practices\u003c/p\u003e \u003cp\u003eParticipants reported varying degrees of involvement in 13 types of defensive practices. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the most frequently reported action was admitting patients who could be treated as outpatients, with 58.8% of participants indicating that they \u0026ldquo;often\u0026rdquo; performed this behavior. Avoiding high-risk procedures and avoiding high-risk patients ranked second and third, respectively. The least common defensive behaviors involved providing extra explanation about medication use and requesting follow-up visits.\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\u003eFrequency of Defensive Medical Practices Among General Practitioners (n\u0026thinsp;=\u0026thinsp;104)\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=\"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 \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" 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\u003eDefensive Practice\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOften n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSometimes n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNever n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean Score*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRank\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmitting outpatients unnecessarily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60 (58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (39.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvoiding high-risk procedures/prescriptions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e82 (80.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvoiding high-risk patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (41.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46 (45.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14 (13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrescribing invasive diagnostics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60 (58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (39.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrdering imaging/tests to reduce risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58 (56.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36 (35.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrdering diagnostic laboratory tests\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44 (44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcessive documentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (31.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50 (49.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrescribing low-risk medications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58 (56.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36 (35.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProviding extra details about treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64 (62.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReferring to higher specialty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (31.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54 (52.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonitoring treatment outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRequesting additional follow-ups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52 (51.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32 (29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGiving detailed medication instructions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30 (29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (39.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32 (31.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13\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*Mean score based on \"often\"=3, \"sometimes\"=2, \"never\"=1.\u003c/p\u003e \u003cp\u003eCauses of Defensive Medical Behavior\u003c/p\u003e \u003cp\u003ePhysicians rated 16 possible causes of defensive medicine. The factor with the highest level of agreement was \u003cb\u003elow risk tolerance and low confidence among physicians\u003c/b\u003e (mean\u0026thinsp;=\u0026thinsp;3.35), followed by limited specialized knowledge in some clinical areas (mean\u0026thinsp;=\u0026thinsp;2.78). The lowest-rated cause was concern for personal safety and fear of violence (mean\u0026thinsp;=\u0026thinsp;1.63).\u003c/p\u003e \u003cp\u003ePhysicians rated 16 possible causes of defensive medicine, as summarized in Table\u0026nbsp;\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\u003ePerceived Causes of Defensive Medicine (Likert Scale 1\u0026ndash;5)\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\u003eCause\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRank\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow risk tolerance \u0026amp; low confidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLimited specialized knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of clinical guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnsuring adherence to standards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColleagues\u0026rsquo; past lawsuit experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDefensive training during education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior malpractice concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of liability insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReassuring families fully\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of legal support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProtecting reputation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh cost of errors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient/family demand for certainty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFear of lawsuits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDM as beneficial practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFear of violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\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\u003eStrategies to Reduce Defensive Medicine\u003c/p\u003e \u003cp\u003eParticipants evaluated six strategies to reduce defensive practices. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the most strongly endorsed strategy was \u003cb\u003eimplementing for legal protections physicians\u003c/b\u003e. Evidence-based practice, public awareness, and teamwork improvement were also supported.\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\u003ePerceived Strategies to Reduce Defensive Medicine\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=\"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 \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrategy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean Agreement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRank\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLegal protections for physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvidence-based medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic awareness of defensive medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImproving teamwork\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReforming complaint-handling processes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstablishing patient data registry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\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\u003eAssociation Between Defensive Medicine and Demographic Factors\u003c/p\u003e \u003cp\u003eChi-square analysis indicated a statistically significant relationship between defensive medical practice and years of work experience (\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.02\u003c/b\u003e). Physicians with fewer years of experience were more likely to report engaging in defensive behaviors. No significant associations were observed with gender (p\u0026thinsp;=\u0026thinsp;0.387), age group (p\u0026thinsp;=\u0026thinsp;0.162), or marital status (p\u0026thinsp;=\u0026thinsp;0.133).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides the first empirical evidence on defensive medical practices among general practitioners in Afghanistan, a country where research on clinical decision-making and medico-legal behaviors remains extremely scarce. The findings demonstrate that defensive medicine is both present and relatively common among physicians in Herat, even though a considerable proportion of respondents had limited prior familiarity with the term. This combination of low conceptual awareness and relatively high engagement in defensive actions highlights a significant gap in medical education, institutional governance, and regulatory protection in the Afghan health-care system.\u003c/p\u003e \u003cp\u003eThe prevalence of defensive practices observed in this study aligns with trends reported across a wide spectrum of countries(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), although the exact patterns and underlying drivers differ substantially. For example, similar to findings from Iran(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), Sudan(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), Ethiopia(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), and the United States(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), participants in this study frequently reported unnecessary admissions, avoidance of high-risk patients, and overuse of diagnostic tests as common defensive behaviors. Studies in Japan (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)and the United States(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) have shown rates of defensive practice exceeding 90% among high-risk specialties, while research in Sudan reported defensive actions among approximately 72% of obstetricians and gynecologists(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Although the Afghan physicians surveyed in this study were general practitioners\u0026mdash;rather than high-risk specialists\u0026mdash;the pattern of frequent avoidance behavior and excessive diagnostic testing mirrors global findings, suggesting that defensive medicine is not limited to high-risk specialties and can arise in environments where medico-legal uncertainty is high(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur finding of high rates of inpatient admission as a form of defensive medicine is consistent with evidence from European settings. In a UK study, 78% of hospital doctors reported practicing at least one form of defensive medicine, including unnecessary tests and referrals(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e); similar patterns have been documented among general practitioners in Denmark and other European countries(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Over-investigation, referrals, and even defensive hospitalization or delayed discharge have been repeatedly identified as common forms of defensive behavior in international reviews(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Nonetheless, in low-resource and fragile health-care systems \u0026mdash; such as Afghanistan \u0026mdash; the structural, organizational, and social drivers of defensive decisions may diverge from those in high-income settings, making defensive medicine not merely a response to malpractice risk but also a coping mechanism against systemic uncertainty and social pressures(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother important finding relates to avoidance behaviors. Nearly half of the general practitioners indicated they often avoided high-risk procedures or high-risk patients. Avoidance behavior is consistently highlighted in international literature as one of the most harmful forms of defensive medicine, particularly because it compromises access to care(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Studies from South Africa, Turkey(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), and Iran have documented similar patterns(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), where physicians avoided high-risk patients or cases with uncertain prognosis due to fear of complications, complaints, or institutional blame(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Although no empirical research is available from Afghanistan, evidence from fragile and resource-limited systems suggests that limited referral pathways and scarce specialty services may amplify the consequences of avoidance behaviors, particularly in rural and underserved areas(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). This finding underscores the need for targeted support for early-career physicians, who in several studies have been shown to engage more frequently in defensive practices (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe analysis of perceived causes provides further insight into the mechanism of defensive medicine in Afghanistan. The most strongly endorsed reason\u0026mdash;low risk tolerance and low clinical confidence\u0026mdash;differs from findings in many high-income countries, where fear of litigation, media scrutiny, and malpractice costs are predominant(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In settings such as Japan(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), Italy(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), and the United States(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), malpractice risk is directly tied to financial liability and legal repercussions. However, Afghan physicians identified lack of confidence, inadequate specialized knowledge, and absence of clinical guidelines as more influential. This suggests that defensive behaviors may, to some extent, reflect gaps in training and the limited availability of continuing medical education(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Limited clinical support structures, such as diagnostic algorithms, standard guidelines, and multidisciplinary teams, may further heighten uncertainty. This contrasts with studies from Denmark and the United Kingdom, where structured decision-support systems, well-established protocols, and robust professional protections reduce uncertainty and thereby limit defensive tendencies(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInterestingly, fear of violence or threats from patient families ranked lowest as a motivating factor for defensive practice in the present study, despite widespread anecdotal reports of hostility toward physicians in conflict-affected settings. This finding contrasts sharply with evidence from China, where fear of patient violence has been consistently identified as one of the strongest predictors of defensive medical behavior (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).The observed difference may reflect underlying cultural and social dynamics in Afghanistan, where physicians traditionally retain relatively high social status and overt antagonistic behaviors toward them may be less common or less openly acknowledged. Alternatively, respondents may have been reluctant to disclose such fears explicitly due to social desirability bias or concerns about professional image.\u003c/p\u003e \u003cp\u003eThe findings regarding effective mitigation strategies closely parallel international recommendations. Physicians in this study identified legal protection as the most critical intervention, consistent with evidence from Jordan(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), Iran(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), and the United States(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), where strengthening medico-legal frameworks and clarifying clinical accountability have been repeatedly emphasized as core strategies for reducing defensive practice. Strengthening medico-legal frameworks, clarifying standards for clinical practice, and improving institutional support may therefore help reduce uncertainty and discourage unnecessary defensive actions (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Evidence-based medicine and clinical guidelines were also highly endorsed in the present study, indicating a strong demand for structured decision-making tools, a finding consistent with international evidence linking the absence of guidelines to higher defensive behavior (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Although teamwork and communication were ranked lower by respondents, their importance remains well established, as strong interdisciplinary collaboration has been shown to reduce perceived professional risk and increase clinical confidence among physicians in several European health systems (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eComparing these findings with the broader international literature suggests that defensive medicine in Afghanistan is shaped by a distinctive combination of contextual factors, including limited clinical resources, inconsistent regulatory structures, gaps in professional training, and strong social expectations from patients and families. Unlike high-income health systems, where defensive practices are largely driven by concerns about legal liability, Afghan physicians appear to engage in defensive behaviors primarily in response to clinical uncertainty, inadequate institutional support, and systemic vulnerabilities. This distinction is critical, as interventions shown to be effective in Europe or the United States\u0026mdash;such as malpractice litigation reform\u0026mdash;may not be directly transferable to the Afghan context. Instead, strengthening clinical education, expanding institutional support mechanisms, and developing standardized clinical practice guidelines may offer more feasible and immediate benefits.\u003c/p\u003e \u003cp\u003eThe significant association between defensive medicine and years of experience further highlights the role of training and mentorship. Less experienced physicians reported engaging in more defensive behaviors, a pattern that has also been documented in studies from Iran, Ethiopia, and Germany (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Early-career physicians often lack the confidence and clinical judgment required to navigate ambiguous clinical cases, making them more prone to unnecessary testing or avoidance behaviors. Strengthening residency programs, enhancing supervised practice, and establishing structured mentorship systems could therefore play an important role in reducing defensive tendencies.\u003c/p\u003e \u003cp\u003eOverall, this study contributes valuable and novel evidence to the global understanding of defensive medicine, particularly in fragile and resource-limited health systems. It highlights the importance of viewing defensive medicine not merely as a legal concern, but as a broader manifestation of systemic deficiencies in professional support, training, and governance. The findings underscore the urgent need for capacity building among Afghan physicians, investment in guideline development, strengthening of complaint-handling mechanisms, and creation of a more transparent and supportive medico-legal environment.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides the first systematic evidence on defensive medical practices among general practitioners in Afghanistan and demonstrates that, despite limited familiarity with the concept, defensive behaviors are relatively common in routine clinical care. The findings highlight a constellation of contributing factors\u0026mdash;ranging from low clinical confidence and insufficient specialized training to the absence of clear clinical guidelines and weak medico-legal protections\u0026mdash;that collectively shape physicians\u0026rsquo; decision-making in this fragile health system. These drivers differ in important ways from those reported in high-income countries, emphasizing the need for context-specific strategies.\u003c/p\u003e \u003cp\u003e Strengthening legal protections for physicians, improving access to evidence-based guidelines, and enhancing professional support structures may help reduce unnecessary interventions and improve the quality of care. Additionally, targeted educational programs, mentorship for early-career practitioners, and reforms in complaint-handling mechanisms could further mitigate defensive tendencies. Because defensive medicine in Afghanistan appears closely tied to systemic vulnerabilities rather than litigation pressure alone, interventions must focus on building institutional capacity, clarifying clinical expectations, and reducing uncertainties in clinical practice.\u003c/p\u003e \u003cp\u003eFuture research should explore defensive behaviors in other regions and specialties, employ qualitative methods to capture deeper insights into decision-making processes, and assess the impact of targeted interventions on reducing defensive actions. By advancing understanding of defensive medicine in a resource-constrained setting, this study contributes to global discussions on patient safety, health system governance, and the development of supportive environments that enable physicians to provide optimal, patient-centered care.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study was approved by the Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.REC.1400.103). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. All participants were informed about the purpose of the study, assured of confidentiality, and provided verbal informed consent prior to participation. Participation was voluntary, and participants could withdraw at any time without consequence.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eAuthors\u0026rsquo; information\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eList of abbreviations\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e This research was conducted as part of a master\u0026rsquo;s thesis in health care management and was supported by Mashhad University of Medical Sciences (Grant No. 991779).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAVN and EH contributed equally to the conception and design of the study and are considered co-first authors. AVN contributed to instrument development, data analysis, and interpretation of findings. EH contributed to methodological refinement and drafting and critical revision of the manuscript. ABD participated in data collection and field coordination. MM supervised the study and contributed to interpretation of results and critical revision of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe authors would like to thank all participating physicians for their cooperation despite the challenging conditions.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEftekhari MH, Parsapoor A, Ahmadi A, Yavari N, Larijani B, Gooshki ES. Exploring defensive medicine: examples, underlying and contextual factors, and potential strategies - a qualitative study. BMC Med Ethics. 2023;24(1):82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajaie S, Azari S, Karimi F. Defensive Medicine and Healthcare Costs: A Scoping Review. Med J Islam Repub Iran. 1938;2024(15):119.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoetz K, Oldenburg D, Strobel CJ, Steinh\u0026auml;user J. The influence of fears of perceived legal consequences on general practitioners' practice in relation to defensive medicine - a cross-sectional survey in Germany. BMC Prim Care. 2024;25(1):23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiziara ID, Miziara CSMG. Medical errors, medical negligence and defensive medicine: A narrative review. Clinics. 2022;77:100053.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLykkegaard J, Andersen MKK, Nex\u0026oslash;e J, Hvidt EA. Defensive medicine in primary health care. Taylor \u0026amp; Francis; 2018. pp. 225\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKakemam E, Arab-Zozani M, Raeissi P, Albelbeisi AH. The occurrence, types, reasons, and mitigation strategies of defensive medicine among physicians: a scoping review. BMC Health Serv Res. 2022;22(1):800.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgarwal R, Gupta A, Gupta S. The impact of tort reform on defensive medicine, quality of care, and physician supply: a systematic review. Health Serv Res. 2019;54(4):851\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePellino IM, Pellino G. Consequences of defensive medicine, second victims, and clinical-judicial syndrome on surgeons\u0026rsquo; medical practice and on health service. Updates Surg. 2015;67(4):331\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYar FGM. Analysis of Challenges and Opportunities for Improving the Health System in Afghanistan: Innovative Approaches and Sustainable Solutions. Jurnal Sosial Teknologi. 2024;4(10):923\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcerra JR, Iskyan K, Qureshi ZA, Sharma RK. Rebuilding the health care system in Afghanistan: an overview of primary care and emergency services. Int J Emerg Med. 2009;2(2):77\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNic Carthaigh N, De Gryse B, Esmati AS, Nizar B, Van Overloop C, Fricke R, et al. Patients struggle to access effective health care due to ongoing violence, distance, costs and health service performance in Afghanistan. Int Health. 2015;7(3):169\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRezayi AA, Vafaee Najar A, Houshmand E, Esmaeli H, Kouhestani S. Experience and Etiology of Defensive Medicine in View of Residents in Mashhad University of Medical Sciences in 2016. J Paramedical Sci Rehabilitation. 2017;6(2):60\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePischedda G, Marin\u0026ograve; L, Corsi K. Defensive medicine through the lens of the managerial perspective: a literature review. BMC Health Serv Res. 2023;23(1):1104.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajaie S, Azari S, Karimi F. Defensive Medicine and Healthcare Costs: A Scoping Review. Med J Islamic Repub Iran. 2024;38(1):854\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAli AA, Hummeida ME, Elhassan YAM, Nabag M, Ahmed WO, Adam MAA. Concept of defensive medicine and litigation among Sudanese doctors working in obstetrics and gynecology. BMC Med Ethics. 2016;17(1):12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssefa EA, Teferi YA, Alemu BN, Genetu A. Practice of defensive medicine among surgeons in Ethiopia: cross-sectional study. BMC Med Ethics. 2023;24(1):95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\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. JAMA. 2005;293(21):2609\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiyama T, Yoshihara M, Tanaka S, Urabe Y, Ikegami Y, Fukuhara T, et al. Defensive medicine practices among gastroenterologists in Japan. World J Gastroenterol. 2006;12(47):7671\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\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. JAMA. 2005;293(21):2609\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarattini L, Padula A. Defensive medicine in Europe: a \u0026lsquo;full circle\u0026rsquo;? Eur J Health Econ. 2020;21(4):477\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrtashi O, Virdee J, Hassan R, Mutrynowski T, Abu-Zidan F. The practice of defensive medicine among hospital doctors in the United Kingdom. BMC Med Ethics. 2013;14(1):42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndersen MK, Hvidt EA, Pedersen KM, Lykkegaard J, Waldorff FB, Munck AP, et al. Defensive medicine in Danish general practice. Types of defensive actions and reasons for practicing defensively. Scand J Prim Health Care. 2021;39(4):413\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl Awar S, Sallam G, Elbiss H. Factors associated with defensive medicine practice in United Arab Emirates: A cross-sectional study with multivariate analysis. Medicine. 2024;103(47):e40619.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRies NM, Jansen J. Physicians\u0026rsquo; views and experiences of defensive medicine: an international review of empirical research. Health Policy. 2021;125(5):634\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaungaard N, Skovvang PL, Hvidt EA, Gerbild H, Andersen MK, Lykkegaard J. How defensive medicine is defined in European medical literature: a systematic review. BMJ open. 2022;12(1):e057169.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelice O, Tekin E, Yılmaz S. Defensive medicine in the emergency department: a cross-sectional study from the perspective of emergency medical specialists. Eurasian J Emerg Med. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFahimi M, Sayad S, Noroozi M, Gooshki ES, Zarghami SY, Shahrezaei A et al. Defensive medicine in surgical disciplines: attitudes and practices among faculty and residents at Iran University of Medical Sciences. J Med Ethics History Med. 2025;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSummerton N. Positive and negative factors in defensive medicine: a questionnaire study of general practitioners. BMJ. 1995;310(6971):27\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNic Carthaigh N, De Gryse B, Esmati AS, Nizar B, Van Overloop C, Fricke R, et al. Patients struggle to access effective health care due to ongoing violence, distance, costs and health service performance in Afghanistan. Int Health. 2015;7(3):169\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaneshkohan A, Ashtar-Nakhaei F, Zali A, Kakemam E, Zarei E. Defensive medicine and its related risk factors: evidence from a sample of Iranian surgeons. Hosp Pract. 2023;51(2):101\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiyama T, Yoshihara M, Tanaka S, Urabe Y, Ikegami Y, Fukuhara T, et al. Defensive medicine practices among gastroenterologists in Japan. World J gastroenterology: WJG. 2006;12(47):7671.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFineschi V, Arcangeli M, Di Fazio N, Del Fante Z, Fineschi B, Santoro P, et al. editors. Defensive medicine in the management of cesarean delivery: a survey among Italian Physicians. Healthcare: MDPI; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu L, Dong M, Wang S-B, Zhang L, Ng CH, Ungvari GS, et al. Prevalence of workplace violence against health-care professionals in China: a comprehensive meta-analysis of observational surveys. Trauma Violence Abuse. 2020;21(3):498\u0026ndash;509.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuan X, Ni X, Shi L, Zhang L, Ye Y, Mu H, et al. The impact of workplace violence on job satisfaction, job burnout, and turnover intention: the mediating role of social support. Health Qual Life Outcomes. 2019;17(1):93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Balas Q, Altawalbeh S, Rinaldi C, Ibrahim I. The practice of defensive medicine among Jordanian physicians: A cross sectional study. PLoS ONE. 2023;18(11):e0289360.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaposo VL. Defensive medicine and the imposition of a more demanding standard of care. J Leg Med. 2019;39(4):401\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoetz K, Oldenburg D, Strobel CJ, Steinh\u0026auml;user J. The influence of fears of perceived legal consequences on general practitioners\u0026rsquo; practice in relation to defensive medicine\u0026ndash;a cross-sectional survey in Germany. BMC Prim care. 2024;25(1):23.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Defensive medicine, clinical decision-making, patient safety, general practitioners, Afghanistan, medico-legal environment, fragile settings.","lastPublishedDoi":"10.21203/rs.3.rs-8837236/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8837236/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eDefensive medicine refers to clinical practices driven primarily by physicians\u0026rsquo; concerns about potential complaints or accusations rather than patient benefit. While extensively studied in high-income countries, little is known about defensive medicine in fragile and low-resource health systems. This study aimed to examine the prevalence, perceived causes, and potential mitigation strategies of defensive medicine among general practitioners working in hospitals in Herat, Afghanistan.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA cross-sectional survey was conducted in 2023 among general practitioners employed in four major hospitals in Herat. Of 318 eligible physicians, 104 completed a researcher-designed and validated questionnaire (response rate: 32.7%). Content validity was confirmed using the content validity ratio (0.56) and content validity index (0.79), and reliability was assessed through test\u0026ndash;retest procedures (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.77). Descriptive statistics and Chi-square tests were used for data analysis.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eAlthough only 35.3% of physicians reported full familiarity with defensive medicine, 46.2% indicated high levels of defensive practice. Common behaviors included unnecessary inpatient admissions (58.8%), avoidance of high-risk procedures (80.4%), and avoidance of high-risk patients (41.2%). Low clinical confidence and limited specialized knowledge were identified as the leading perceived causes. Legal protection for physicians was the most strongly supported mitigation strategy. Years of work experience were significantly associated with defensive practice (p\u0026thinsp;=\u0026thinsp;0.02).\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eDefensive medicine is prevalent among general practitioners in Herat despite limited conceptual awareness. These practices appear to be driven more by systemic vulnerabilities and clinical uncertainty than by litigation pressure. Strengthening legal protections, improving access to evidence-based guidelines, and enhancing professional training may help reduce unnecessary defensive behaviors in fragile health systems.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Navigating Risk Without Protection: Defensive Medicine Among General Practitioners in a Fragile Afghan Health System","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-11 15:44:32","doi":"10.21203/rs.3.rs-8837236/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-21T13:20:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"41898569298823140986772143537009959474","date":"2026-03-16T02:17:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-06T07:58:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-12T08:02:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-10T22:19:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-10T22:19:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2026-02-10T06:17:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f5865a6c-cba7-440d-85c5-687068b3b7dd","owner":[],"postedDate":"March 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-11T15:44:32+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-11 15:44:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8837236","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8837236","identity":"rs-8837236","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}