BackgroundPracticing safe behavior regarding patients is an intrinsic part of a physician’s ethical and professional standards. Despite this, physicians practice behaviors that run counter to patient safety, including practicing defensive medicine, failing to report incidents, and hesitating to disclose incidents to patients. Physicians’ risk of malpractice litigation seems to be a relevant factor affecting these behaviors. The objective of this study was to identify conditions that influence the relationship between malpractice litigation risk and physicians’ behaviors.MethodsWe carried out an exploratory field study, consisting of 22 in-depth interviews with stakeholders in the malpractice litigation process: five physicians, two hospital board members, five patient safety staff members from hospitals, three representatives from governmental healthcare bodies, three healthcare law specialists, two managing directors from insurance companies, one representative from a patient organization, and one representative from a physician organization. We analyzed the comments of the participants to find conditions that influence the relationship by developing codes and themes using a grounded approach.ResultsWe identified four factors that could affect the relationship between malpractice litigation risk and physicians’ behaviors that run counter to patient safety: complexity of care, discussing incidents with colleagues, personalized responsibility, and hospitals’ response to physicians following incidents.ConclusionIn complex care settings procedures should be put in place for how incidents will be discussed, reported and disclosed. The lack of such procedures can lead to the shift and off-loading of responsibilities, and the failure to report and disclose incidents. Hospital managers and healthcare professionals should take these implications of complexity into account, to create a supportive and blame-free environment. Physicians need to know that they can rely on the hospital management after reporting an incident. To create realistic care expectations, patients and the general public also need to be better informed about the complexity and risks of providing health care.

ObjectivesThis study investigated whether the attitudes of physicians towards justified and unjustified litigation, and their perception of patient pressure in demanding care, influence their use of defensive medical behaviours.DesignCross-sectional survey using exploratory factor analysis was conducted to determine litigation attitude and perceived patient pressure factors. Regression analyses were used to regress these factors on to the ordering of extra tests or procedures (defensive assurance behaviour) or the avoidance of high-risk patients or procedures (defensive avoidance behaviour).SettingData were collected from eight Dutch hospitals.ParticipantsRespondents were 160 physicians and 54 residents (response rate 25%) of the hospital departments of (1) anaesthesiology, (2) colon, stomach and liver diseases, (3) gynaecology, (4) internal medicine, (5) neurology and (6) surgery.Primary outcome measuresRespondents’ application of defensive assurance and avoidance behaviours.Results‘Disapproval of justified litigation’ and ‘Concerns about unjustified litigation’ were positively related to both assurance (β=0.21, p<0.01, and β=0.28, p<0.001, respectively) and avoidance (β=0.16, p<0.05, and β=0.18, p<0.05, respectively) behaviours. ‘Self-blame for justified litigation’ was not significantly related to both defensive behaviours. Perceived patient pressures to refer (β=0.18, p<0.05) and to prescribe medicine (β=0.23, p<0.01) had direct positive relationships with assurance behaviour, whereas perceived patient pressure to prescribe medicine was also positively related to avoidance behaviour (β=0.14, p<0.05). No difference was found between physicians and residents in their defensive medical behaviour.ConclusionsPhysicians adopted more defensive medical behaviours if they had stronger thoughts and emotions towards (un)justified litigation. Further, physicians should be aware that perceived patient pressure for care can lead to them adopting defensive behaviours that negatively affects the quality and safety of patient care.

Due to the variation among physicians in their litigation attitude and behaviour in terms of incident disclosure the oft-heard call for 'openness' about medical incidents will not be easy to achieve. A coaching system in which physicians can share and discuss their differing attitudes and disclosure principles, teaching medical students and junior physicians about disclosure, and explaining how to organize emotional and legal support for oneself in case of litigation could decrease stress feelings and support open disclosure behaviour.

Professionals are expected to justify their actions to clients, disciplinary committees and courts in multiple accountability systems. Although developed to reflect professional standards, is it possible that these systems induce proactive behaviours that counteract their goals and instead serve to protect the professional? This article examines the types of stimuli professionals acquire from the public and professional accountability contexts and how these stimuli motivate engagement in specific proactive behaviours. An interpretive grounded theory study was conducted; it included 31 in-depth interviews with physicians from eight hospitals. The study revealed that accountability systems trigger and motivate professionals to engage in self-serving, proactive job-crafting behaviours. Professionals simultaneously manage their perceived accountability pressures and their personal interests. Context-specific factors that motivate individuals to craft their jobs are identified, and we reveal four distinct stimuli–motivation–job-crafting patterns that are linked to specific performance episodes (i.e., work stages). Our findings emphasize the importance of taking specific work contexts (i.e., accountability) and work stages into account when studying job-crafting behaviours. This study contributes to understanding professionals’ motivations and behaviours in the context of accountability, which is essential, as the quality and safety of their work are matters of public concern.