Defensive medicine as a systemic response: a cross-sectional study among physicians in Italy

Background

Defensive medicine is increasingly recognized as a systemic response to medico-legal, organizational and reputational pressures rather than an individual professional behavior, with implications for care quality and system sustainability. This study aimed to assess its prevalence and determinants among physicians in Italy.

Methods

A cross-sectional study was conducted between April and July 2024 using an anonymous web-based questionnaire. The instrument, adapted from a previously validated survey, underwent pre-testing and psychometric evaluation: after initial deployment items were selected based on face and content validity, theoretical coherence with the construct of interest, response distribution and informativeness, and factor loadings from exploratory factor analysis. Descriptive analyses and multivariable logistic regression models were performed.

Results

262 healthcare professionals participated. About 75% reported practicing defensive medicine during the previous year, while over 90% had observed such behaviors among colleagues. Fear of malpractice litigation was the strongest predictor of both practicing and witnessing defensive medicine. Younger professionals were more likely to adopt defensive behaviors. The most frequently reported practices included unnecessary diagnostic tests and laboratory investigations. Psychometric evaluation of the retained items indicated a coherent multidimensional structure and good internal consistency (Cronbach’s α = 0.86).

Conclusions

Defensive medicine appears to be a structural feature of the healthcare system rather than an isolated professional behaviour. Its high prevalence and strong link to medico-legal pressures highlight a misalignment between clinical decision-making and system-level incentives. Addressing defensive medicine requires coordinated policy actions, including legal reform and institutional support to improve system functioning and trust.

Key messages

• Addressing defensive practices requires coordinated policy interventions, including legal reform and strengthened institutional support to improve system efficiency and trust.

• Defensive medicine is common among physicians in Italy and is influenced by medico-legal, organisational and reputational pressures.