Abstract
Abstract
Background
Defensive medicine (DM) is particularly relevant in obstetrics and gynecology (OB/GYN), where physicians face substantial medicolegal risks and malpractice-related pressures. Defensive practices may involve cost-increasing diagnostic or therapeutic behaviors and avoidance of high-risk patients or procedures. Identifying factors independently associated with DM may help inform organizational and medicolegal interventions.
Objective
This study aimed to evaluate DM attitudes among physicians working in OB/GYN clinics in Istanbul, Türkiye, and to identify professional, organizational, and medicolegal factors independently associated with these attitudes.
Methods
A cross-sectional analytical study was conducted among resident physicians, specialists, and faculty members working in OB/GYN departments in Istanbul between June 2023 and February 2024. Participants were recruited using nonprobability convenience sampling through on-site visits and an online survey. DM attitudes were assessed using the 14-item Turkish Defensive Medical Practice Attitude Scale (TDMPAS). Multivariable linear regression models with heteroscedasticity-consistent HC3 SEs were used to identify factors independently associated with the total and subscale scores. Sensitivity analyses were used to assess the potential influence of the data collection modality.
Results
A total of 1069 physicians participated in the study. The mean total TDMPAS score was 48.12 (SD 10.59), with mean scores of 15.65 (SD 5.21) for cost-increasing behavior, 16.07 (SD 3.24) for defensive behavior, and 16.40 (SD 5.22) for avoidance behavior. Internal consistency was good for the total TDMPAS (Cronbach α=0.880), cost-increasing behavior (α=0.879), and avoidance behavior (α=0.879) and acceptable for defensive behavior (α=0.780). In the multivariable model, dissatisfaction with working conditions (B=6.62, 95% CI 4.19 to 9.05;
P
P
P
=.001) were independently associated with higher total DM scores. Malpractice training (B=−2.18, 95% CI −3.54 to −0.82;
P
=.002), professor status compared with resident physician status (B=−7.53, 95% CI −12.22 to −2.83;
P
=.002), and longer experience in OB/GYN (B=−0.15 per y, 95% CI −0.29 to −0.01;
P
=.03) were associated with lower mean scores. The total-score model explained 17.6% of the variance (
R
²=0.176; adjusted
R
²=0.154). The data collection modality was not independently associated with the total TDMPAS score or any subscale score and did not materially alter the primary findings.
Conclusions
DM attitudes were prominent among physicians working in OB/GYN and were independently associated with professional and organizational factors. Dissatisfaction with working conditions and previous administrative investigations were associated with stronger DM attitudes, whereas malpractice training and greater professional seniority showed inverse associations with these attitudes. These findings suggest that interventions addressing working conditions, medicolegal education, and institutional support for physicians may complement financial liability protection strategies. Prospective multicenter studies are required to clarify the causal relationships and evaluate the effectiveness of such interventions.