Policy Options for Reducing Defensive Medicine Behaviors: A Multi-Method Study

Abstract

Background

Defensive medicine (DM) refers to taking or not taking clinical actions, mainly to prevent legal or reputational consequences. It increases patient and health system costs and threatens patient safety. This study aimed to provide policy options to reduce DM behaviors and was conducted in two phases.

Methods

First, a scoping review was conducted by searching the Web of Science, PubMed, ProQuest, and Scopus databases in 2000–2023, and interventions and strategies to control DM behaviors were identified. To recognize the advantages, disadvantages, and implementation considerations, one session of focus group discussion (FGD) with experts was designed. Finally, the policies, strategies, advantages, disadvantages, and implementation considerations were refined and categorized during two expert panel sessions.

Results

During the search, 1774 articles were retrieved. Finally, after the screening process, 58 articles were included in the study. Four main policy options were formulated: "evidence-based medicine," "legal reforms," "promotion of professional ethics and a supportive environment," and "improving the doctor-patient relationship." In the following, 13 interventions and strategies, 18 advantages, 18 disadvantages, and 21 implementation considerations were identified.

Conclusion

To manage and reduce the effects of DM behaviors, different interventions at macro, organizational, and individual levels are needed. At the micro and individual levels, the enhancement of knowledge and skills is valuable. Organizational interventions that create a supportive culture and promote ethical behavior are also important.

↑What is “already known” in this topic:

The problem of defensive medicine can lead to poor quality, limited access, higher costs, and negative results for patients and the health system. Several descriptive cross-sectional studies were performed to investigate the prevalence rate, reasons, and solutions to reduce defensive medicine in Iran.

→What this article adds:

For the first time, this study investigated the current policy approaches for reducing defensive medicine behaviors globally and provided an analysis of the advantages, disadvantages, and implementation issues in Iran.

Introduction

Medical science should be used to provide services and improve patients' health. Doctors are obliged to use their skills to advance the interests of patients' health instead of promoting personal interests. The doctor-patient relationship is often considered a fiduciary relationship; doctors should put the interests of patients above their own and provide services considering the patient's best interests. But defensive medicine (DM) is the opposite of these basic ethical obligations (1). DM refers to performing or not performing clinical actions, mainly to prevent legal or reputational consequences (2). These actions may be negative or positive. Negative actions refer to avoiding the admission of high-risk patients or not performing high-risk procedures, and positive actions include unnecessary referrals, unnecessary hospitalization, late discharge, unnecessary diagnostic tests, and prescribing unnecessary drugs (3).

The goal of the DM is to protect the physician from adverse outcomes that conflict with the physician's professional, ethical, and fiduciary obligations. While a doctor's decision-making should be based on the patient's best interests, a powerful set of doctors' interests influence their decision-making. Prioritizing doctors' interests over patients' interests, exposing patients to avoidable harm, and misallocating scarce healthcare resources is against medical ethics (1). In the professional code of ethics of the Medical Council of Iran, the priority of the patient's interests is emphasized over any other interest, and the unnecessary actions of the doctor to defend himself against the possible patient's complaint are not recognized as moral.

DM is widely practiced worldwide and is not limited to a specific country (4, 5). According to a systematic review, the overall prevalence of DM has been reported to range from 6.7 to 99.8% globally, with the highest percentage, 99.8%, belonging to Iran (6). Studies show that the prevalence of DM behaviors is high among general physicians (7), surgeons (3), and medical residents (8) in Iran, and almost all of them perform at least one of the DM behaviors.

Fear of litigation (1, 2, 5, 6, 9, 10), concern about the negative consequences of complaints (1, 6, 9, 10), increasing liability insurance premiums (3, 6), insufficient organizational protections for doctors in cases of malpractice (6, 11), organizational culture that blames medical errors (5, 9), low experience and confidence (5, 6, 10) and lack of commitment to medical ethics (1, 6) are important reasons for the prevalence of DM.

Among the adverse consequences of DM, we can mention the violation of independence, professional and fiduciary obligations of doctors, violation of patient safety (12, 13), weakening of public trust and justice in the use of resources (14), negative impact on the quality and access of health care (1) and most importantly imposing unnecessary costs on the health system and wasting financial and non-financial resources (12). In Italy, 10% of national health costs are attributed to DM (15), also 14% of total drug costs, 23% of total laboratory test costs, and 25% of total imaging costs per person are unnecessary and due to DM (16). The cost of DM in the United States was estimated at 55.6 billion dollars, equal to 2.4% of the total health expenditures (17).

The extensive negative consequences of DM have caused it to be raised as an important concern in health policymaking, and policymakers are looking for effective strategies to manage it (18). Although DM is a recognized problem in the developed world and has been for several decades, developing countries, including Iran, are not as familiar with this phenomenon. Additionally, the prevalence of specific activities among Iranian doctors, like prescribing unnecessary medicines and referring patients to specialists, indicates that this issue occurs frequently (7). In Iran, Positive and negative DM among surgeons were reported by Ashtarnakhaee et al. to be 100% and 80%, respectively (19). Furthermore, among general practitioners, positive and negative DM were reported by Amiresmaili et al. to be 99 and 47 percent, respectively (20). It is required to reduce and manage this phenomenon as a result. The DM in Iran's health system has received little attention, and there need to be guidelines or comprehensive policies for management and control. Therefore, the present study is the first to identify policy strategies and interventions for DM management and reduction in Iran.

Methods

This study was conducted in two phases: (1) scoping review, (2) focus group discussion (FGD), and expert panel. The scoping review was conducted based on the Arksey and O'Malley framework (21). Also, the preferred reporting items for the systematic reviews and meta-analyses extension of the scoping review checklist (PRISMA-ScR) were used in the retrieval process.

Phase 1: Step 1. Identifying the research question

What are the strategies and interventions to reduce defensive medicine (DM) among physicians in Iran?

Step 2. Identifying relevant studies

The time frame of the search was considered to be from January 1st, 2000, to July 30th, 2023. Publications were searched in international databases, including Web of Sciences, PubMed, ProQuest, and Scopus. Using MeSH headings, we searched for the terms “defensive medicine”, “defensive practice”, solution, intervention, polic*, strateg*, legislat*, suggestion, recommendation, guideline, approach, and law (Appendix 1). The full search strategy in PubMed is highlighted in Table 1, which was adapted to other databases.

Table 1. Search strategy used in PubMed.

Database	Set	Search Strategy		Records (No)
PubMed	#1	MeSH	“Defensive medicine”	1,657
		Title & Abstract	“Defensive medicine” OR “Defensive practice”
	#2	Title & Abstract	“Solution” OR “Intervention” OR “Polic*” OR “Strateg*” OR “Legislat*” OR “Suggestion” OR “Recommendation” OR “Guideline” OR “Approach”	4,894,892
	#3		#1 AND #2	317
	#4		Filters: English, from 2000-2023	208

Step 3. Selecting studies

The following criteria were considered for the selection of articles: (1) first, DM was an important part of their purpose; and second, at least one policy, intervention, or strategy was proposed or discussed; (2) all types of articles, such as letters, reviews, and originals, except conference articles and book chapters; (3) in English; (4) studies whose target population was physicians; and (5) articles whose full text was available. All retrieved records were entered into EndNote X9 software. Duplicate articles were removed. For both abstract and full-text screening, two independent reviewers (EZ and IY) selected studies by title and abstract/full text, and the third reviewer (PF) resolved disagreements. The full text of the relevant articles for our study was prepared for data extraction.

Step 4. Charting the Data

Each article was read by two authors independently, and appropriate strategies/ interventions were extracted. It was then discussed by the team members and entered into the data form with an agreement. Additionally, the Critical Appraisal Skills Program (CASP) checklist was used to assess the quality of the qualitative and systematic review studies. There were ten questions on this checklist; the first two were screening questions, to which appropriate responses were "yes" and "no." After the first two questions, if the response was "yes," then the article will be assessed further. The evaluator chose one of the three answers—"yes," which received a score of 3, "no," which received a score of 1, or "cannot say" (a score of 2)—for each of the eight questions that followed. Article scores ranged from 8 to 24, with 24 being the maximum. Studies that had papers with scores less than 16 were not included (22, 23). The 22-item Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was also used to assess the quality of the cross-sectional studies. A score between 0 and 7 was considered low quality, 8 and 17 as moderate, and 18 and 22 as high quality (24). The characteristics of the studies, such as author, year of publication, source of publication, type of study, and quality appraisal score, were entered in a table (Appendix 2). Strategies/ interventions were also presented in another table (Table 2).

Table 2. Inclusion and exclusion criteria of the study.

Inclusion criteria	Exclusion criteria
Scoping review
• Articles whose DM was an important part of their purpose. • At least one policy, intervention, or strategy was proposed or discussed. • All types of articles, such as letters, reviews, and originals, except conference articles and book chapters • In English • Studies whose target population was physicians • Articles whose full text was available • Published from 2000 to 2023		• Studies that did not mention any strategies, policies, or interventions to reduce DM. • Articles published in languages other than English. • Articles published before 2000 • Articles that were not available
FGD & Expert panels
• Having a work experience of at least 8 years. • Having two scientific articles in the field of medical ethics. • Having a certificate of specialization course.		• Work experience of less than 8 years • Not having two scientific articles in the field of medical ethics. • General practitioners • Unwillingness to participate

Step 5. Collate, summarize, and report results

The authors identified themes in the literature by reading and discussing each article included. Articles were then coded independently by two authors. All authors discussed each code and grouped codes into final themes. The content analysis method was applied to the data analysis. In this step, the main components of the examined articles were organized. Data were combined and interpreted by filtering, organizing, and categorizing components following the main research questions. The results were categorized into distinct extraction codes and a theme framework based on study codes.

Phase 2: FGD & Expert panels

According to the study by Nyumba et al., FGD comprises four main steps. These consist of the following: (1) research design, (2) data collection, (3) analysis and (4) reporting of results (25).

Step 1. Research design

The FGD was conducted with the aim of identifying appropriate policies and interventions to reduce the prevalence of DM behaviors in Iran's health system. The FGD session included two main questions: 1. What policies and regulations do you believe the health authorities should be focusing on to reduce DM behavior? 2. What interventions at the individual, organizational, and health system levels can reduce defensive medicine? Getting a consent form, obtaining permission to record the conversation, clarifying the goals of the study, and ensuring that the data will only be used for this study, as well as giving participants the right to withdraw at any time throughout the study, were ethical concerns of the research at this stage. By using a purposeful sampling method (26), experts in the field of medical ethics working in the hospital (6 people) and the Ministry of Health (one person) were selected. The participants were invited by telephone and in person. Including and excluding criteria for experts selecting included (1) having a work experience of at least 8 years, (2) having two scientific articles in the field of medical ethics and (3) having a certificate of specialization course (Table 2).

Step 2. Data collection

The FGD session was held in the Department of Health Service Management, School of Medical Education and Management, Shahid Beheshti University of Medical Sciences. The FGD was conducted in a room with adequate space, a round table, and working air conditioning. The researcher, who oversees the entire project (EZ), started interviewing and led the meeting (FGD duration was 120 min). After asking each participant to provide a brief introduction, the primary questions that had been prepared previously were asked. With the participant's consent, the entire session was recorded. One of the researchers who was knowledgeable about the subject and the outcomes from the earlier phase was in charge of taking notes during the recording (PF). There were follow-up questions after the primary ones. Ultimately, the facilitator clarified and double-checked the items provided throughout the meeting and then acknowledged the participants for participating in the research.

Step 3. Analysis

The content-analysis method was used for data analysis, which finds, analyzes, and reports patterns (themes) within the text. When there are few theories available on the subject, this type of analysis is employed. The following procedures were used for data analysis and coding: familiarizing the data text; finding and extracting the fundamental codes; identifying themes; completing and reviewing the themes; naming and defining themes; recoding and renaming some classes and themes; and verifying the validity of the codes (27, 28).

Step 4. Reporting of results

After analyzing the data, the results were shared with the participants (response validity). Response validity was employed to ensure the accuracy and rigor of the findings. Following each interview and FGD session, the participants' statements were summarized, and they were instructed to verify the validity of the findings (25).

After identifying advantages, disadvantages, and implementation considerations, factors based on strategies were refined and categorized through expert panels. To manage the conversation for 40-60 minutes, the expert panel was conducted in two face-to-face sessions with the meeting coordinator and leader. The opinions of experts were recorded and used by the research team to merge, add, and remove factors. Additionally, data transferability and reliability from expert checks, peer reviews, and immersion were used in this step to ensure rigor (29).

Results

Results of Phase 1: scoping review

As a result of the search, 1774 articles were retrieved; after removing duplicate titles (285 articles), two team members independently reviewed the title and abstract of the remaining articles, which resulted in the selection of 208 articles. After reviewing the full text, 58 articles suitable for the study topic were identified (Figure 1). Of the 58 articles, 45% (N= 26) were original, and 55% (N= 32) were reviewed (e.g., systematic reviews). Most of the articles were published between 2015 and 2023. Articles were imported from 18 countries; 43% were from the USA, and then 15% from Italy. Three articles from Iran were included in the review. Table S1 (Appendix 1) shows the included articles' characteristics. In this phase, all policies, strategies, interventions, actions, advantages, disadvantages, and implementation considerations were extracted from articles.

Figure 1.

PRISMA-ScR flowchart of literature review

Results of Phase 2: FGD & Expert panels

FGD was done with the seven eligible experts. According to the demographic characteristics, two of the specialists were female, with an average age of 58.8 and work experience of 10.7 years. In this phase, 45 items were identified. Eventually, after eliminating and merging similar items, factors were reduced to 41 items. Additionally, finalized items in the scoping review and FGD stages, after removing duplicates and merging similar items in round table discussion, were checked. Finally, during two face-to-face sessions, 7 items were repetitive (based on a literature review), and 34 items remained, including 7 advantages, 9 disadvantages, and 18 implementation considerations. Based on the viewpoint of experts, four main policies (dimensions) were selected and strategies and interventions were divided among them; “evidence-based medicine” (3, 8, 9, 11, 14, 30-40), “legal reforms” (3, 8, 9, 12, 15, 18, 35, 37, 41-57), “promotion of professional ethics and supportive environment” (3-5, 8, 9, 13, 33, 39, 58-68), and “improving the doctor-patient relationship” (4, 8, 9, 16, 32, 62, 66, 69-71) (Figure 2). A total of 18 advantages, 18 disadvantages and 21 implementation considerations for the policies were found. The lowest number of advantages (n= 3) and the highest number of disadvantages (n= 6) were related to the “legal reform” policy (Table 3).

Figure 2.

Policies and interventions/ strategies to control and manage DM behaviors

Table 3. Policies, advantages, disadvantages, and implementation considerations.

Policies	Advantages (n= 18)	Disadvantages (n= 18)	Implementation considerations (n= 21)
Evidence-based medicine	✔ Improving the efficiency, availability, and affordability of healthcare services (34) ✔ Regular access and recording of patient clinical information (8) ✔ Standardization of treatments and reducing the risk of complaints from doctors (14, 38 ) ✔ The most effective method to reduce DM (39) ✔ Preventive approach	✔ The impossibility of developing the same guidelines for all cases of the disease (34) ✔ Requires multiple updates ✔ Unclear distinction between appropriate and inappropriate care in many clinical situations (15) ✔ Doctors' lack of trust in the protective effect of guidelines (36) ✔ Lack of awareness, sense of responsibility, and low acceptance and compliance of guidelines by doctors (31, 37)	✔ Developing policies for the development, publication, and implementation of guidelines ✔ Drawing a road map, developing the infrastructure, and implementing the clinical information registration system ✔ User-friendly, physician-oriented, and simple design of decision support systems ✔ Computer training in the curriculum and continuing education programs ✔ Creating non-financial incentives to increase the compliance of doctors ✔ Evidence-based medical education
Legal reforms	✔ Reducing unnecessary prescriptions and health system costs (9, 53) ✔ Successful experience in other countries (39) ✔ Sustainable effect	✔ Politically challenging (32) ✔ Time-consuming and requires the coordination of many organizations ✔ Uncertainty of complications and long-term consequences (42) ✔ Lack of influence on unnecessary prescriptions due to patient preferences (53) ✔ Increasing the willingness of doctors to perform fearless treatments ✔ Reluctance of insurance companies to increase the liabilities and reduce the premium (41)	✔ Development of policies for the management of frivolous complaints, quick handling, transparency, and impartiality in the processes of handling complaints (36, 45) ✔ Creation of specialized courts ✔ Attracting opinions and extensive lobbies with influential institutions such as the Parliament and the Judiciary ✔ Negotiating with insurance companies to increase liability obligations
Promotion of professional ethics & supportive environment	✔ Preventive approach ✔ Low costs ✔ Institutionalization of professional ethics ✔ Sustainability and long-term effect ✔ Increasing the knowledge of doctors and familiarity with low-cost alternative measures (33, 67)	✔ Time-consuming (55) ✔ No effect on lawsuits caused by possible unavoidable consequences in the treatment process (55) ✔ Influenced by the conditions and socio-cultural context of the environment	✔ Creating a supportive environment and institutionalizing a culture of learning from mistakes instead of blaming and warning (14, 33) ✔ Supporting doctors in lawsuits (for example, providing a lawyer) ✔ Academic and continuing education programs ✔ Developing ethical codes and guidelines ✔ Changing organizational culture
Improving the doctor-patient relationship	✔ Increasing patient and doctor satisfaction (72, 73) ✔ Improving disease management, more appropriate and efficient use of health services, and patient compliance with the treatment plan (74) ✔ Increasing patient safety (70, 72) ✔ Increasing empathy between doctor and patient (72) ✔ Improving trust and better interaction between doctor and patient	✔ Needs various measures to influence the doctor and the patient ✔ Patient confusion caused by increased information and interaction with the doctor ✔ Time-consuming ✔ Influenced by socio-cultural conditions	✔ Determining and observing the standard visit time ✔ Improving the hospital environment and patient privacy ✔ Education on patients' rights ✔ Creating a doctor's standard working environment ✔ Improving patient and doctor communication skills (69 ) ✔ Launching patient education campaigns

Discussion

This study aimed to provide policy options to reduce DM behaviors in Iran's health system, and four policy options were proposed. In this section, we have discussed policy options, emphasizing their implementation considerations.

1- Use of evidence-based medicine (EBM)

In some studies, physicians' informed use of the best available evidence for clinical decision-making has been stated as the best policy to reduce DM (15, 39). Clinical practice guidelines (CPG) are a tool to improve the effectiveness and quality of health care (34), reduce variation in clinical practices, and prevent side effects, medical malpractice claims, and DM behaviors (11, 38). The use of CPGs in many countries, including the United States and Italy (11), has positively reduced DM. However, there are challenges in developing and monitoring their implementation and success rate. Their successful implementation requires a correct understanding of the executive obstacles of supervision and its correct implementation; otherwise, it will lead to low compliance of doctors and, as a result, a lack of desired effect (75). The development and use of CPGs have been emphasized in Iran's general health policies, but studies show that the number of developed CPGs in Iran is limited (76).

Along with the development of CPGs, there should also be a plan for their implementation (77). With the help of electronic health records, rules can be set so that providers behave according to CPG. In a study, medical residents believed that the patient's clinical information recording system could prevent the occurrence of DM to a great extent (8). In Iran, scattered activities have been carried out in the field of patient clinical information recording systems. Still, studies show there have always been obstacles to achieving its goals (77). Also, studies show that the use of clinical decision support systems (CDSS) has a positive effect on compliance with CPGs (33, 38). The use of reminder and warning systems can help to reduce medical errors and consequently reduce DM.

Improving the legal status of clinical guidelines as a safe harbor can lead doctors to comply with them. Compliance with CPG should protect the doctor from legal claims and thus reduce DM (32, 36, 37). Legislators in Iran have expressed their support for doctors under certain circumstances and exempted them from responsibility, but there is no direct reference to using clinical guidelines. Priorities appear to be making sure that clinical guidelines are followed, reinforcing the systems for recording and analyzing patient data in Iran.

2- Legal reforms

Studies in most countries, including Iran, show that "fear of lawsuits" is the most important reason for DM actions by doctors (8). Changing the legal responsibility systems of doctors and moving towards "enterprise liability" and "no-fault liability" can be an effective way to reduce DM. The characteristic of the enterprise liability system is that the doctor will no longer be responsible alone, and this responsibility will be transferred to the institution/hospital where the doctor works. As a result, the mental pressure will be removed from the doctor and reduce DM (37). "No-fault liability system" in Norway, Finland, Sweden, and the USA has had successful experience in reducing DM (32, 42). To reduce DM, it may be necessary to amend the laws regarding doctors' liability, the complaint investigation system, and regulations that shift from being individual-oriented to organization-oriented.

Modifying complaint investigation processes (alternative dispute resolution) can reduce DM effectively. In a study with the participation of 11,000 doctors in the United Kingdom, modifying the complaints investigation processes to become more transparent, impartial, and efficient was recognized as an effective solution to reduce DM (45). Using alternative dispute resolution leads to informality and lower costs. This method uses volunteers instead of a jury to judge medical malpractice (37). Doctors think this method is fairer than the traditional method, and because of its informality, they do not worry about damaging their image. However, the definitive effects of this method still need to be completely clear. Another measure is to deal with medical malpractice lawsuits in specialized medical courts (18, 36). Apology laws have also been enacted in several US states, allowing doctors to apologize for mistakes or poor results without going to court. An apology reduces the patient's anger, maintains his trust, and thus reduces complaints (36).

Tort reform in different countries was an important step toward managing DM and reducing its consequences (12, 35, 41, 43, 48, 50-52). “Non-economic and punitive damage caps” (49), “Capping attorney fees” (36), and “Collateral source rule” (47), were among the measures that should be approved and implemented after adapting to the structure of the country's legal system.

Liability insurance plays an important role in protecting doctors and reducing their fear. Various studies have stated the positive effect of liability insurance in reducing DM (18, 55). The existence of liability insurance only partially prevents DM, but evidence shows its impact on reducing referrals to specialists, hospitalization, surgery, and imaging (41). In a study on Iranian surgeons, weak support and high premiums as one of the main reasons for taking DM measures were stated by doctors (3). One of the solutions is to pay the insurance premium to the organization or the government. For example, doctors in England are covered by insurance by the NHS and do not need to pay insurance premiums (78), so they are much less exposed to lawsuits (79). With liability insurance in place, physicians can focus on providing appropriate care without the constant fear of being sued for every decision. This allows them to avoid ordering excessive tests or treatments that are not medically necessary.

3- Promoting professional ethics and a supportive environment

The medical profession has traditionally relied on self-regulatory tools such as codes of ethics to enforce ethical standards and protect patient interests. Organizations should also support doctors who prioritize the patient's interests and refrain from providing low-value care and taking DM actions (5). Combating DM requires strengthening the moral values of doctors (39). Developing ethical codes and systemic reforms in medical culture to reduce DM measures (9) through strengthening moral values are two important approaches in this field. In Iran, the Medical Council has tried to develop professional ethics codes, but there is a need for a more complete guide.

Improving legal knowledge is useful to increase doctors' confidence in their decision-making and to ensure that the law operates based on rational criteria and that any negative result does not mean medical malpractice (5). Education can also give clinicians a realistic awareness of legal risks and counter exaggerated fears that cause DM (5, 9). Strengthening professionalism and understanding of legal and ethical responsibilities, such as obtaining patient consent, which includes adequate patient information about treatment options, risks, and benefits, should be strengthened through education (9). Evidence shows that the use of persuasive educational messages has been effective in reducing unnecessary diagnostic procedures (80). Studies have shown that increasing students' knowledge and training regarding the value of prescription, diagnostic tests, and evidence-based medicine has reduced unnecessary services (62). Also, many doctors need more information about DM and appropriate briefing and training sessions in continuing education programs and professional meetings (59).

Studies show that environments that promote ethical behavior and a supportive culture play an important role in controlling DM. Physicians should be able to seek colleagues' opinions, especially in difficult clinical cases, and make collaborative decision-making (8). They need opportunities to discuss issues with colleagues when problems arise (5). Organizations should also support doctors through their actions. If a hospital takes initiatives to reduce low-value care, it should also support physicians who face lawsuits. Evidence shows that the fear of colleagues' blame is a more important factor than the fear of patients' complaints in the occurrence of DM. The existence of macro and organizational policies that reduce peer criticism is necessary to reduce DM by physicians (5). In the "Just culture," there is no fear of doctors being blamed by colleagues, and instead, collective learning and safe and valuable care are promoted (5). Therefore, it is necessary to move from the punitive approach to identifying and correcting structural errors and promoting a supportive culture (4, 9). Organizations should also take timely and fair mechanisms to support doctors when patients complain (15). It can be stated that medical professionals are more inclined to concentrate on delivering high-quality care rather than engaging in DM when they feel valued and supported in their workplace. The reason for this change is that a supportive culture encourages honest dialogue, mutual trust, and teamwork among healthcare professionals, which can improve decision-making and reduce lawsuit concerns.

4- Improving the doctor-patient relationship

One of the approaches to reduce DM is the patient's active participation and interaction with the doctor to make decisions about unnecessary care (81). Various studies have emphasized improving the doctor-patient relationship as one of the ways to reduce lawsuits and consequently reduce DM (4, 5, 9, 39, 69, 81). These are often indirect interventions that can affect the doctor, the patient, or both (71). Appropriate workload, improving teamwork, strengthening doctor's communication skills, increasing examination duration, continuity of care, patient participation in the treatment process, and improving the service delivery environment are among the interventions that can lead to the improvement of the doctor-patient relationship (5, 8, 39, 70, 72).

Patient pressure on doctors to prescribe unnecessary services can lead to the adoption of the DM approach in doctors. Studies have shown that community education regarding unnecessary diagnostic procedures has positively affected doctors' behavior and better patient communication (16). A successful example of these campaigns under the title "Choosing Wisely," which deals with the simultaneous awareness of patients and doctors, has been implemented in 13 countries so far and, in cooperation with professional medical associations, publishes resources to inform patients and doctors on various issues (9, 16, 82). In summary, improving the doctor-patient relationship through increased trust, communication, shared decision-making, and reduced fear of litigation can help reduce the practice of DM and lead to more efficient and cost-effective healthcare.

Limitations

One of the limitations of the present study was the participation of only Iranian experts and also the literature review, which was limited to English language articles, which could reduce the generalizability of the results. Moreover, it is possible that the meeting facilitator unintentionally caused limited opinions during the FGD or that the majority's viewpoint overwhelmed the minority's. As a result, some items may not have been mentioned in the meeting.

Conclusion

DM has received less attention in Iran, while its effects are significant due to increased costs and the threat to patient safety. The proposed policies from this study and their advantages, disadvantages, and implementation considerations are evidence-based and up-to-date, which can help policymakers use them to reduce DM-related behaviors. There is a need for intervention at different macro, organizational, and micro levels to manage and reduce the effects of DM. Interventions at the micro and individual levels to enhance knowledge and skills are valuable. Still, organizational interventions and environments that create a supportive culture and promote ethical behavior are also important. Legal interventions should also be done at the macro level. A combination of the following actions has better effectiveness in reducing the negative effects of DM: first, focusing on informing patients and doctors and promoting professional ethics guidelines, and then, in the long term, making legal reforms and focusing on promoting evidence-based medicine.

Ethical Considerations

Not applicable.

Conflict of Interests

The authors declare that they have no competing interests.

Appendix 1.

Table S1. Characteristics of included articles.

No	Author (Year)	Country	Article type	Publication source	Quality appraisal score
1	Daneshkohan et al. (2023)	Iran	Original	Hospital Practice	STROBE= 20
2	Ries et al. (2022)	Australia	Original	BMC Medical Ethics	CASP= 24
3	Vento et al. (2018)	Kazakhstan	Review	World Journal of Clinical Cases	CASP= 20
4	Moosazadeh et al. (2014)	Iran	Original	International Journal of Health Policy and Management	STROBE= 20
5	Vafaee Najar et al. (2016)	Iran	Original	Journal of Healthcare Management	STROBE= 18
6	Ries & Jansen (2022)	Australia	Review	Health Policy	CASP= 24
7	Zerbo et al. (2020)	Italy	Review	Risk Management and Healthcare Policy	CASP= 22
8	Antoci et al. (2022)	Italy	Review	Socio-Economic Planning Sciences	CASP= 20
9	Cervellin & Cavazza (2016)	Italy	Review	Emergency Care Journal	CASP= 22
10	Tuers (2013)	USA	Review	Nursing administration quarterly	CASP= 20
11	Panella et al. (2016)	Italy	Original	Revista de Calidad Asistencial	CASP= 18
12	Pellino & Pellino (2015)	Italy	Review	Updates in Surgery	CASP= 22
13	Kucuk (2018)	Turkey	Original	Journal of Obstetrics and Gynaecology	CASP= 20
14	Reis et al. (2018)	Australia	Review	Journal of Medical Radiation Sciences	CASP= 22
15	Chawla &Gunderman (2008)	USA	Review	Academic Radiology	CASP= 20
16	Oliveira et al. (2012)	Portugal	Review	Advances in Distributed Computing and Artificial Intelligence Journal	CASP= 20
17	Austad et al. (2016)	Norway	Original	BMC Family Practice	CASP= 24
18	Toker et al. (2004)	Israel	Original	American Journal of Otolaryngology	STROBE= 22
19	Katz (2019)	USA	Review	Clinical Practice and cases in emergency medicine	CASP= 22
20	Panella et al. (2017)	Italy	Original	JournalHealth Services Research & Policy	STROBE= 20
21	Kessler (2011)	USA	Review	Journal of Economic Perspectives	CASP= 20
22	Blume et al. (2017)	Netherlands	Original	Journal of Evaluation in Clinical Practice	CASP= 18
23	Dove et al. (2010)	USA	Review	Journal of the American College of Cardiology	CASP= 22
24	Carrier et al. (2013)	USA	Original	Health Affairs	CASP= 22
25	Segal (2016)	USA	Review	World Neurosurgery	CASP= 22
26	Reschovsky &Saiontz-Martinez (2018)	USA	Original	Health services research	STROBE= 20
27	Antoci et al. (2016)	Italy	Review	Plos One	CASP= 22
28	Bourne et al. (2016)	UK	Original	BMJ Open	CASP= 22
29	Frakes & Gruber (2020)	UK	Review	Journal of Empirical Legal Studies	CASP= 22
30	Hermer & Brody (2010)	USA	Review	Journal of General Internal Medicine	CASP= 23
31	Moghtaderi et al. (2019)	USA	Original	Journal of Empirical Legal Studies	CASP= 21
32	Agarwal et al. (2019)	USA	Review	Health Services Research	CASP= 22
33	Avraham et al. (2012)	USA	Review	Journal of Law Economics & Organization	CASP= 22
34	Li et al. (2017)	USA	Original	Journal of the American College of Radiology	STROBE= 18
35	Solomon (2006)	USA	Original	Emergency Medicine Clinics of North America,	CASP= 20
36	Currie & MacLeod (2008)	USA	Original	Quarterly Journal of Economics	CASP= 22
37	Fronczak (2016)	USA	Review	World Neurosurgery	CASP= 22
38	Paik et al. (2017)	USA	Review	Journal of health economics	CASP= 21
39	Frakes (2012)	USA	Review	Journal of Empirical Legal Studies	CASP= 20
40	Sataloff (2008)	USA	Review	Ear, Nose & Throat Journal	CASP= 22
41	Bean (2016)	USA	Review	World Neurosurgery	CASP= 22
42	Kherad et al. (2020)	Switzerland	Review	European Journal of Internal Medicine	CASP= 22
43	Calikoglu & Aras (2020)	Turkey	Original	Journal of Forensic and Legal Medicine	STROBE= 20
44	Montagnan & Lippi (2016)	Italy	Review	Emergency Care Journal	CASP= 22
45	Renkema at al. (2019)	Netherlands	Original	BMJ Open	STROBE= 20
46	Simianu et al. (2016)	USA	Original	BMC Medical Informatics and Decision-Making	STROBE= 20
47	Donner-Banzhoff et al. (2020)	Germany	Original	Diagnosis	CASP= 22
48	Catino & Celotti (2009)	Italy	Original	Studies in health technology and informatics	CASP= 20
49	Askren & Leslie (2019)	USA	Review	Seminars in speech and language	CASP= 19
50	Prabhu (2016)	USA	Review	World Neurosurgery	CASP= 22
51	Al-Balas & Al-Balas (2021)	Jordan	Review	BMCMedical Ethics	CASP= 23
52	Bae (2017)	South Korea	Review	Journal of preventive medicine and public health	CASP= 21
53	Bell ae al. (2017)	USA	Original	BMJ quality & safety	STROBE= 20
54	Qiao et al. (2019)	China	Original	Patient preference and adherence	STROBE= 20
55	Boissy et al. (2016)	USA	Original	Journal of General Internal Medicine	STROBE= 20
56	Godillot et al. (2021)	France	Review	Dermatologic therapy	CASP= 20
57	Tofan et al. (2013)	Moldova	Review	Health expectations	CASP= 21
58	Nafradi et al. (2017)	Switzerland	Review	PLoS One	CASP= 24

Appendix 2. Search Strategy

WOS= 1278

#1 (TS=(defensive medicine)) OR TS=(defensive practice)

#2 (((((((((TS=(solution*)) OR TS=(intervention*)) OR TS=(polic*)) OR TS=(strateg*)) OR TS=(suggestion*)) OR TS=(recommendation*)) OR TS=(guidelin*)) OR TS=(approach*)) OR

TS=(law)) OR TS=(legislat*)

#3: #1 AND #2

PubMed= 235

((defensive medicine [Title/Abstract]) OR (defensive practice [Title/Abstract]) AND (english[Filter])) AND ((((((((((solution*[Title/Abstract]) OR (intervention*[Title/Abstract])) OR (polic*[Title/Abstract])) OR (strateg*[Title/Abstract])) OR (suggestion*[Title/Abstract])) OR (recommenda-tion*[Title/Abstract])) OR (guidelin*[Title/Abstract])) OR (approach*[Title/Abstract])) OR (law[Title/Abstract])) OR (legislat*[Title/Abstract]) AND (english[Filter]))

Filters: English

ProQuest= 112

(ab(defensive medicine) OR ab(defensive practice)) AND (ab(solution*) OR ab(intervention*) OR ab(polic*) OR ab(strateg*) OR ab(suggestion*) OR ab(recommendation*) OR ab(guidelin*) OR ab(approach*) OR ab(law) OR ab(legislat*))

SCOPUS= 149

#1 ( TITLE ( defensive AND medicine ) OR TITLE ( defensive AND practice ) )

#2 ( TITLE-ABS-KEY ( solution* ) OR TITLE-ABS-KEY ( intervention* ) OR TITLE-ABS-KEY ( polic* ) OR TITLE-ABS-KEY ( strateg* ) OR TITLE-ABS-KEY ( suggestion* ) OR TITLE-ABS-KEY ( recommendation* ) OR TITLE-ABS-KEY ( guidelin* ) OR TITLE-ABS-KEY ( approach* ) OR TITLE-ABS-KEY ( law ) OR TITLE-ABS-KEY ( legislat* ) )

#3 ( LIMIT-TO ( LANGUAGE, "English" ) )

#4: #1 AND #2 AND #3

Cite this article as : Zarei E, Yousefi I, Shiranirad S, Poursaki T, Zahmatkesh MM, Farrokhi P. Policy Options for Reducing Defensive Medicine Behaviors: A Multi-Method Study. Med J Islam Repub Iran. 2024 (29 Jul);38:86. https://doi.org/10.47176/mjiri.38.86