Table 4. The etiologic factors of unnecessary healthcare services.

Intrinsic

Extrinsic

Provider driven Induced demand Imbalance of knowledge and power between physician and patient Conflict of interest Financial incentives (self-referral, fee-splitting) Positional competition Fear of losing patients Desire for fame and reputation Personal and professional characteristics Desire to minimize regret Oversight failure Poor problem solving Ambition Mental illness Carelessness Substance abuse Stress Retaliation Achieve high patient satisfaction Reassurance Rely on investigations Poor communication skills Non-adherence to evidence-based medicine Limited knowledge Uncertainty of the diagnosis and management Absence, misuse, or misunderstanding of evidence-based medicine Prescribing without indication Defensive medicine: Fear of litigation Fear of malpractice Patient driven: Parents’ expectations or pressure Patients' “Jealousy” consumption behavior Patients vulnerability

Provider driven Induced demand Supplier-induced demand Patient insurance coverage Medical culture Payment mechanisms Fee-for-service Case-based Per diem payment systems Development of new technologies Overwhelmingly adopting new technology Inflationary increases in investment in technology Increasedavailability and access to the latest technologies Industries Increased utilization by industries Healthcare marketing Advertising by pharmaceutical companies Practice guidelines or norms Ambiguous practice guidelines or norms Unavoidable uncertainty and variations in practice Realization of the patients’ rights Medicalization Widening disease definitions Screening programs Corruption of moral and professional climate Documentation Difficulty in accessing prior medical records Incomplete healthcare documentation Increased demand for documentation Systems of practice Inadequate time Physicians' dual practice (public and private sectors) Competing organizational priorities Pressures from other healthcare professionals ·Medical culture Patient driven Patient's fascination for technological innovations (Public culture)