This study used a cross-sectional analytical research design. The study population included faculty members, specialists, and resident physicians working in gynecology and obstetrics clinics in Istanbul.

This cross-sectional analytical study included resident physicians, specialists, and faculty members working in the OB/GYN departments in Istanbul, Türkiye. Participants were recruited using a nonprobability convenience sampling strategy through on-site visits to participating institutions and the distribution of an online survey link. Physicians actively working in the OB/GYN department during the study period and who provided informed consent were eligible. Incomplete questionnaires and duplicate submissions were also excluded.

Because recruitment was based on on-site convenience sampling and distribution of an online survey link, the total number of eligible physicians who received or had access to the invitation could not be reliably determined; therefore, a formal response rate could not be calculated.

The study was conducted face-to-face between June 2023 and February 2024; however, owing to the workload of physicians, 11.6% of the surveys were conducted online and 88.4% were conducted face-to-face. The questionnaire consisted of 2 parts: the first consisted of questions about the demographic data and professional characteristics of the volunteers participating in the study.

In the second part, the Turkish Defensive Medical Practice Attitude Scale (TDMPAS), which consists of positive and negative defensive medical practice questions developed by Kolcu and Özceylan [4], was used as the data collection tool [6]. The TDMPAS consists of 14 items and 3 subdimensions [4]. A Likert scale was used to complete the questionnaires. There were no negative questions in the scale. The cost-increasing behavior subscale consists of 5 items, with possible scores ranging from 5 to 25. The defensive behavior subscale consists of 4 items, with a score range of 4 to 20. The avoidant behavior subscale also consists of 5 items, with scores ranging from 5 to 25. The total score on the scale ranged from 14 to 70. Higher scores on the scale and its subscales indicate a stronger tendency toward DM. Since there is no valid cutoff point for the scale, the scores should be interpreted dimensionally rather than categorically.

The data obtained were entered into SPSS software (version 22.0; IBM Corp) and statistically evaluated. Descriptive statistics and frequency distributions were calculated. Continuous variables were summarized using the mean (SD) and/or median (IQR), as appropriate. Normality was evaluated using graphical methods and the Shapiro-Wilk test. Because the total TDMPAS score was not normally distributed, unadjusted 2-group comparisons of the total score were performed using the Mann-Whitney U test, and comparisons involving more than 2 groups were performed using the Kruskal-Wallis test. Significant Kruskal-Wallis tests were followed by pairwise post hoc comparisons with Bonferroni adjustment. These unadjusted group comparisons were conducted for the total TDMPAS score only; subscale-specific unadjusted group comparisons were not performed. The 3 subscale outcomes were evaluated separately in the multivariable regression models and in the data collection modality sensitivity analysis.

In the confirmatory analyses, statistical significance was set at P<.05. Multivariable linear regression analyses were performed to identify factors independently associated with the total DM attitude score and each of its 3 subscale scores. Candidate predictors were selected a priori based on clinical relevance and the previous literature. Age, years in medical practice, and years in specialty practice were assessed for multicollinearity and were not entered simultaneously when strong correlations were observed. The categorical variables were dummy-coded. The regression assumptions were evaluated using residual plots, variance inflation factors, and influence diagnostics. Heteroscedasticity-consistent HC3 SEs were used when appropriate. The results are presented as unstandardized coefficients, SEs, standardized β coefficients, 95% CIs, and P values. Model fit was reported using R², adjusted R², and the F statistic. In the shift duration calculation, 125 physicians on call were excluded.

Ethics committee approval for the study was obtained from the Istanbul University, Istanbul Faculty of Medicine Clinical Research Ethics Committee (dated May 2, 2023, and numbered 1745917). This study was conducted in accordance with the Declaration of Helsinki. Informed consent and written permission to publish the data were obtained from all the individuals in the study.

In this large cross-sectional study of 1069 OB/GYN physicians, DM attitudes were common, with a mean total score of 48.12 (SD 10.59). Multivariable analysis showed that dissatisfaction with working conditions and a history of administrative investigation were independently associated with higher DM scores, whereas malpractice training, professor status, and longer specialty experience were associated with lower scores. In contrast, malpractice lawsuit history, sex, patient volume, on-call workload, and liability insurance status were not associated with the total score.

This pattern is consistent with recent evidence that DM reflects multilevel determinants spanning individual, relational, organizational, and environmental domains [7].

The explanatory power of the models also differed substantially across TDMPAS dimensions. The cost-increasing behavior and avoidance behavior models explained 17.7% and 15.8% of adjusted variance, respectively, whereas the defensive behavior model explained only 2%, despite reaching overall statistical significance (P=.03). This low explained variance suggests that the demographic, workload, professional, and organizational characteristics included in our models are less informative for generalized defensive behavior than for cost-increasing or avoidance-oriented responses. The defensive behavior subscale also had a relatively high mean score in relation to its possible range (16.07/20), which may limit between-participant variability. Other unmeasured factors, such as individual risk perception, previous adverse-event experiences, local institutional culture, patient expectations, specialty-specific clinical scenarios, and perceived litigation climate, may therefore account for a larger proportion of variation in this dimension.

Malpractice-related pressure should also be considered a psychological and occupational phenomenon rather than solely a legal or financial concern. Physicians involved in adverse clinical outcomes, malpractice allegations, or administrative investigations may experience anxiety, guilt, loss of professional confidence, sleep disturbances, fear of recurrent litigation, and changes in clinical decision-making. These responses have been described within the framework of medical malpractice stress syndrome and the second-victim phenomenon. Recent evidence from Türkiye has shown that medical malpractice stress syndrome and DM are closely related among obstetricians and gynecologists, highlighting the particular vulnerability of this high-risk specialty to malpractice-related psychological stress [14]. Similarly, recent research among obstetricians and gynecologists has demonstrated that surgical complications may negatively affect physicians’ mental well-being, sleep, professional confidence, and interpersonal functioning, supporting the relevance of the second-victim framework in this field [15]. Such psychological responses may contribute to both assurance-oriented defensive behaviors, including additional diagnostic testing or referrals, and avoidance-oriented behaviors, including reluctance to undertake high-risk procedures or manage high-risk patients. In the present study, the independent association between previous administrative investigations and higher DM scores may reflect not only medicolegal exposure but also the psychological and professional burdens associated with being formally investigated. These findings support the importance of institutional approaches that combine medicolegal education with peer support, structured debriefing, and psychological support for physicians involved in adverse events or malpractice-related processes.

In studies on DM among gynecologists and obstetricians, 38.7% to 90% of physicians were women, while this rate was 63.8% (682/1069) in our study [6,16]. In our study, the average working time of physicians in the specialty of OB/GYN was 11.66 (SD 11.28) years, while in another study, 14.5% of physicians worked for less than 5 years, 41.9% worked for 5 to 10 years, 43.6% worked for 10 years or more, 59.6% worked for 1 to 3 years, 21.1% worked for 4 to 9 years, and 19.3% worked for 10 years or more. In another study, the average working time in the specialty of OB/GYN was 8.3 (SD 3.1) years [6,12].

In our study, 42.9% (459/1069) of obstetricians and gynecologists were research assistants, whereas in similar studies, this rate was found to be 25% to 34.2%, and it was determined that the rate of research assistants in our study was higher than that reported in previous studies [7,12].

In our study, the average number of patients seen in outpatient clinics by OB/GYN physicians was 41.8 (SD 24.2), and the maximum number of patients seen was 120, while in another study, it was reported that OB/GYN physicians saw 50.25 (SD 9.5) patients per day in outpatient clinics, but the required number was 29.3 (SD 3.4). A research investigation across various departments revealed that physicians, on average, provided care to 47.28 patients daily [6]. Although the average number of patients seen in the outpatient clinic per day in our study was considered to be low compared to the literature, it was determined that the average number of patients seen in the outpatient clinic in our study was 42 patients per day, and the time allocated per patient in our study was 11 minutes at best. However, in clinics where 120 patients were seen in the outpatient clinic per day, the time allocated per patient was 4 minutes at best, which is insufficient.

According to a study in which 19,200 physicians from 26 different specialties participated in the United States, approximately 60% of physicians spend 13 to 20 minutes on outpatient diagnosis and treatment applications. Approximately 22% to 27% spend less than 13 minutes, and 5% spend less than 10 minutes. Approximately 23% of specialist physicians spend more than 20 minutes [17]. In our study, physicians examined an average of approximately 42 patients per outpatient clinic day, corresponding to a limited amount of time available for each patient. A review of national and international evidence concluded that outpatient visits should generally not be shorter than 10 minutes and that longer consultation times may be required for patients with complex medical conditions [18].

Medicolegal and financial liability concerns may also contribute to defensive medical practices. Çınarlı et al [19] examined defensive medical practices among health care professionals working in public institutions in Türkiye in the context of concerns about recourse compensation claims following medical errors.

The World Medical Association and the Turkish Medical Association state that the time allocated for each patient should be at least 20 minutes to provide quality health care. However, in our country, this time is below the European Union standards because of many problems in the provision of health services from beginning to end (personnel shortages, infrastructure problems, operational problems, etc). When the time allocated to patients coming without an appointment and for control is added, the time allocated per patient is reduced to 4 to 5 minutes. In fact, the recommendations of the Turkish Medical Association were not considered, and patient density was attempted to be solved by assigning 2 patients to physicians in 10 minutes through the central physician appointment system. Malpractice lawsuits for lack of diagnosis, treatment, and care have started to increase rapidly as the allocated time has decreased to 3 to 5 minutes [20].

Studies from Türkiye have reported high frequencies of defensive medical practices: among gynecologists, 64.6% (40/62) reported avoiding patients perceived as likely to litigate, while 93.5% (58/62) believed that malpractice lawsuits could affect their professional performance [3]; in Konya, 75.7% (131/173) of physicians reported increased use of imaging tests to protect themselves against malpractice allegations [21]; among resident physicians, positive and negative DM practices were reported by 98% (196/200) and 92% (184/200), respectively [22]; among physicians working in surgical disciplines, 94.2% (179/190) reported engaging in at least one positive or negative DM practice [23]; and among emergency medicine residents, 94.7% (145/153) believed that the number of malpractice lawsuits had increased, 83.7% (128/153) reported avoiding patients with a high likelihood of litigation or complex medical problems, and 100% (153/153) reported requesting additional laboratory or radiological tests to protect themselves against malpractice claims [24].

In a study conducted with OB/GYN physicians, it was reported that 8.1% to 51.4% of physicians were sued for malpractice, while this rate was 27.1% in our study, which is consistent with the literature [3,12].

It is estimated that 74.1% of OB/GYN specialists will face malpractice lawsuits by the age of 45 years and 97.2% by the age of 65 years [25]. Zhu et al [12] found that 60.8% of OB/GYN specialists had at least one medical dispute, 19% were sued, and 60.1% of those sued lost the case. In our study, 27.1% (290/1069) of OB/GYN physicians were sued, and 5.5% (16/290) of those who were sued received unfavorable results or were fined. In previous studies, 89.7% and 100% of OB/GYN physicians thought that malpractice lawsuits had increased, whereas in our study, 91.1% (974/1069) of physicians thought that malpractice lawsuits had increased in recent years, and 6.9% (74/1069) thought that they had partially increased. Our results are consistent with those of previous studies.

In a Turkish study carried out in Turkey involving 108 gynecologists and obstetricians, every participant reported an increase in malpractice lawsuits targeting their field, leading them to adopt more defensive practices [26]. A significant proportion of the participants (n=75, 69.4%) believed that informed consent forms would not provide protection in cases of medical errors. This perspective was shared by 75 individuals who doubted that such forms would shield them from potential medical malpractice claims [6]. In our study, 95.5% (1021/1069) of participating gynecologists and obstetricians expressed that malpractice lawsuits would hinder their medical practice.

In a study investigating DM among physicians in the United Arab Emirates, 54.6% were aware of PDM, 50.7% were afraid of patients and attendants, and 31.1% reported using a DM approach [23]. In 2023, another study of 1797 physicians in Egypt reported that a high proportion of participants had DM. Specifically, 89.6% reported avoiding high-risk procedures, 87.8% avoided treating high-risk patients, and 86.8% reported making unnecessary referrals to other specialists. Among the study participants, obstetricians and surgeons were most likely to have DM [27].

A study conducted among resident physicians in Turkey found that the frequencies of positive and negative DM practices were 98% and 92%, respectively, and that DM scores were significantly higher in those working in surgical sciences, those who had 8 or more shifts per month, and those who had medical malpractice lawsuits filed against them [22]. In a study of OB/GYN specialists conducted by Bourne et al [28], 13% (400/3073) of all OB/GYN specialists, 12% (239/2069) of women, and 16% (152/963) of men showed DM behavior. Regarding OB/GYN, DM was recorded in Sudan with 71.8% and in China with 62.9% [12,13].

Previous studies have reported high frequencies of DM practices among obstetricians and gynecologists in Türkiye, including avoidance of high-risk procedures and concerns about increasing medicolegal pressure [6]. Because the TDMPAS has no validated cutoff value, the present study does not estimate the prevalence of DM. Accordingly, our findings are interpreted using continuous total and subscale TDMPAS scores.

In a particular study, 71.8% (84/117) of gyn-obstetricians engaged in defensive medical practices, 41% (48/117) employed positive defensive strategies, and 30.8% (36/117) used negative strategies. Additionally, 23.1% (27/117) of the practitioners made unnecessary patient referrals, 20.5% (24/117) steered clear of high-risk procedures, 12% (14/117) ordered unnecessary tests, and 6% (7/117) prescribed unnecessary drugs. The most commonly observed actions included physicians declining to treat high-risk patients and 5.1% (6/117) of them performing off-label surgeries, such as cesarean sections, to prevent legal actions and complaints [13].

A study conducted in Iran in 2017 revealed that the occurrence of both positive and negative DM behaviors was 100% (160/160) and 80% (128/160), respectively [29]. The most frequent PDM behavior involved ordering unnecessary biopsies, imaging studies, and laboratory tests. In contrast, the most prevalent negative DM behaviors included avoiding the care of high-risk patients and declining to accept them based on their social status. The primary reasons for engaging in DM were that physicians felt unsupported and feared being complained against [29].

In 94.2% (179/190) of the cases, practitioners employed at least one form of DM, whether positive or negative [30].

In a study conducted in Turkey, it was shown that assistant physicians ordered more tests than specialist physicians did [31].

In a particular study, obstetricians and gynecologists had an average score of 48.22 (SD 10.24) on a questionnaire about DM practices, with scores ranging from 29 to 66. The attending physicians recorded an average score of 44.16 (SD 10.31), with a minimum of 29 and a maximum of 60, whereas the resident physicians had an average score of 52.29 (SD 8.52), with scores ranging from 34 to 66 [3]. In a study conducted by Kolcu and Özceylan [4] with family physicians, the DM score was found to be 40.55 (SD 8.30). In our research, the average scores from the attitude questionnaire concerning DM practices were 48.12 (SD 10.59), aligning with existing literature [3,4,6].

Our research revealed that individuals who faced malpractice lawsuits had an average score of 47.36 (SD 11.81), whereas those who did not have a mean score of 48.40 (SD 10.10). Similarly, another study found that physicians with a history of malpractice litigation exhibited lower DM scores [30]. Physicians who had faced malpractice lawsuits exhibited significantly lower DM scores, with a statistical significance level of P<.05 [27].

Our research revealed notable differences between research assistants and professors, associate professors and assistant professors, specialists and professors, and professors and associate professors and subdivision assistants (P<.05). Although no significant differences were observed among the other titles, Çalıkoğlu identified a significant variation in DTU scores across academic titles [30].

Three primary factors affected the DM scores: academic position, field of medical practice, and prior involvement in malpractice cases. Other characteristics, such as sex, age, total professional time, and length of experience in a particular area of expertise, showed no effect on DM scores [27].

In studies conducted in our country, 82.3% to 84.2% of CHD physicians stated that they had heard of the concept of DM practices before, while this rate was 86.6% (926/1069) in our study, which is consistent with the literature [3].

In previous studies, 29% to 42.7% of physicians reported that they had sufficient knowledge about DM practices, while this rate was 38.8% (415/1069) in our study, which is consistent with the literature [3,12].

Medical malpractice insurance is compulsory for all physicians in Turkey. OB/GYNs pay the highest fees for malpractice insurance premiums and are considered the highest-risk group.

Hiyama et al [10] reported that 96% of the physicians surveyed in their study had insurance to protect themselves from malpractice lawsuits. In a 2009 study conducted among physicians working in Tokat provincial center, it was reported that only 1.7% of physicians had insurance. A 2020 study conducted among emergency medicine residents reported that 87.6% of physicians had insurance at the time of the study [24]. Our research revealed that 69.5% (319/459) of resident physicians and 96.1% (586/610) of specialist and academic staff physicians, 84.7% (905/1069) overall, had CFLI at the time of the survey and maintained it continuously, which is consistent with the existing literature. Furthermore, assistant doctors have lower CFLI than specialists and academic staff doctors because they perform their daily medical duties under the guidance of specialists and academic staff. They do not face the same level of responsibility pressure as specialists and academic staff, which may lead them to believe that insurance is unnecessary during their assistance. In a study conducted by Kumtepe et al [24], 29.4% of participants believed that CFLI would facilitate their medical practice, whereas 46.4% felt that CFLI would not make their medical practice easier.

Furthermore, the reason assistant doctors have less CFLI coverage than specialist and academic staff doctors is attributed to the fact that assistant doctors carry out their daily medical duties under the guidance of specialist and academic staff doctors. Consequently, they do not face the same level of responsibility pressure as their senior counterparts, which may lead them to believe that insurance is unnecessary [11]. In our study, 24.9% (266/1069) of participants who had previously and consistently maintained CFLI felt at ease, 32.1% (343/1069) did not feel at ease, and 43% (460/1069) felt somewhat at ease while practicing their profession, which aligns with the existing literature. The low sense of security provided by CFLI, observed in our study and other studies, is attributed to CFLI’s lack of protection under criminal law.

According to one study involving 108 participants, 102 (94.4%) respondents believed that the increased involvement of lawyers in medicolegal matters contributed to the rise in litigation [26]. The high potential for financial compensation was also identified as a factor contributing to increased litigation. Furthermore, 78.7% (85/108) respondents reported inadequate equipment, in terms of both quantity and quality, at their institutions, which could potentially contribute to medicolegal problems. In addition, 38.9% (42/108) participants reported an insufficient number of support staff, including midwives and nurses, and 50% (54/108) indicated that they occasionally had to perform procedures with an anesthesia technician rather than an anesthesiologist. In our study, 820/1069 (76.7%) obstetricians and gynecologists identified an increased patient-to-physician ratio, 819/1069 (76.6%) identified the role of media coverage, and 626/1069 (58.6%) identified the physical conditions of hospitals and clinics as factors contributing to the increase in malpractice lawsuits.

The fear of being sued for malpractice has also affected physicians’ specialty preferences over the years. The specialty of gynecology and obstetrics, which was previously preferred, with high scores in national exams in our country, has fallen to the background in the ranking of physicians’ preferences in recent years, and some quotas have become research assistant positions that cannot be filled by those who are not preferred. Similarly, in the branches of general surgery and emergency medicine, many national exam quotas have remained vacant in recent years. In addition to the heavy workload during residency training and specialization in the field, physicians’ anxiety about being complained about medical malpractice reduces the rate of preference in the relevant departments. Studies have also shown that physicians consider these factors when choosing their specialty [32]. However, while 85.4% (913/1069) of the participants in our study stated that they chose the profession of medicine voluntarily, this rate was reported to be 54.7% to 77.5% in different studies conducted in our country. The physicians in our study were more likely to voluntarily choose the medical profession than those in the literature.

This study had several limitations. Its cross-sectional design precludes the establishment of temporal or causal relationships between the identified factors and DM attitudes. For example, although dissatisfaction with working conditions and previous administrative investigations were associated with higher DM scores, the direction of these relationships could not be determined from the present data. The study relied on self-reported attitudes and experiences and may therefore be subject to recall and social desirability biases. Reported DM attitudes may not necessarily correspond directly to physicians’ actual clinical behaviors. The participants were recruited using nonprobability convenience sampling. Consequently, physicians who agreed to participate may have differed systematically from those who did not participate, introducing potential selection and nonresponse bias. Moreover, the study was conducted exclusively among physicians working in OB/GYN departments in Istanbul; therefore, the findings may not be generalizable to physicians practicing in other regions of Türkiye, other health care systems, or other medical specialties. Data were collected using both face-to-face and online approaches, which could have influenced response patterns. Although unadjusted analyses indicated a small difference in avoidance behavior scores between the 2 collection modalities, sensitivity analyses demonstrated that the data collection modality was not independently associated with the total TDMPAS score or any of its subscales after adjustment for relevant covariates and did not materially alter the primary regression findings. However, the unequal distribution of participants between the 2 data collection modalities should be considered when interpreting these findings. The multivariable analyses involving monthly on-call duration were based on 944 participants with available numeric data, rather than the entire study sample, and complete case analysis may have introduced additional bias if the missing data were not completely random. Finally, this study assessed physicians’ self-reported medicolegal experiences and attitudes but did not incorporate independently verified malpractice claims, administrative records, patient outcomes, or direct measures of unnecessary investigations, procedures, or health care expenditures. Therefore, the clinical and economic consequences of DM cannot be objectively quantified. Future prospective multicenter studies incorporating objective medicolegal, clinical, and health economic outcomes are needed to confirm these findings and assess whether organizational or educational interventions can reduce defensive medical practices.

DM attitudes were common among OB/GYN physicians in Istanbul and were independently associated with several professional and organizational characteristics. In particular, dissatisfaction with working conditions and previous administrative investigations were associated with higher DM scores, whereas malpractice training and greater professional seniority showed inverse associations with DM scores. These findings suggest that interventions aimed solely at financial liability protection may be insufficient and that organizational working conditions, medicolegal education, and physician support mechanisms should also be considered. Because of the cross-sectional and nonprobability sampling design, causal interpretations should be avoided. Multicenter prospective studies are needed to determine whether modifying these factors can reduce DM attitudes and practices.