Table 3 Underlying and contextual factors of DM

Organizational-managerial factors

Factors related to medical education and training.

Lack of sufficient scientific and practical skills which would end in using several Para clinical interventions to prevent error

Lack of officially approved national guidelines for disease diagnosis and treatment

Insufficient training of physicians in evidence-based medicine, critical appraisal, and clinical reasoning

Fading of ethical-oriented clinical relationship and bureaucratization and legalization of the physician-patient relationship

The presence of some defensive considerations even in educational material and medical textbooks (e.g. recommendations of some emergency medicine textbooks for CT scans upon parents’ insistence despite lack of medical indications)

Not allocating enough time to patient examination and clinical judgment, and using multiple Para clinical interventions to avoid error

Performing defensive interventions as learned from superiors and professors

Factors Related to the Management of health centers and health system policymaking

The dominance of a technology-centered attitude over medical practices has led to physicians’ concerns about malpractice in case of not using technology

Physicians’ feeling of lack of sufficient legal and professional support from responsible organizations including professional organizations.

A poor referral system and the inability of physicians to refer patients properly when they find themselves unqualified to treat them.

Presence of defensive interventions as routine medical practice including diagnostic and treatment procedures in health care centers

Lack of transparency in medical liability laws, regulations, and procedures

Limitations of liability insurance coverage packages in forms such as setting time limits for coverage after each medical intervention.

Insufficient sensitivity of public and private insurance companies about unnecessary prescriptions and practices including those with defensive motivations

Facilitating filing complaints against physicians by related regulatory and supervising institutions

Force and demand of Health facilities’ managers - (who could be liable as well as physicians in case of complaints and lawsuits) for using defensive measures.

Lack of balance between the expectations of society and patients (which is high) on one hand and available resources and infrastructures (which are always limited)

Lack of enough equipment and infrastructure in small health facilities, for management of possible adverse complications of medical practice such as single-specialty facilities or remote and rural health centers.

High-demanding conditions for junior physicians and residents, beyond their practical and scientific capabilities

Physicians’ lack of trust in the documentation system in healthcare centers

Overcrowding of public health care facilities and inability to concentrate properly on diagnosis and treatment

Equal diagnostic and therapeutic tariffs of high-risk and critically ill patients and normal patients which decreases the risk-taking

The level of available equipment, resources, and support is higher in well-equipped referral university hospitals where physicians are trained and usually lower in smaller and less affluent centers where physicians would work after graduation.

Reprimanding and blaming attitudes and presence of a culture of blame in clinical environments and fear of blame from colleagues

Factors related to the medical complaints system

The strict approach of judicial authorities and supervising agencies regarding refraining from some procedures that are not indicated medically, and the indifference of courts and other complaint-handling organizations toward excess and unnecessary procedures

Sharing the experience of being summoned to court with other colleagues, and physicians’ concerns arising from previous unpleasant experiences of colleagues about the process of trial in courts or other complaint-handling organizations

Lack of uniform practice in handling medical complaints in different courts and other complaint-handling organizations which makes such organizations unpredictable for

A multiplicity of medical complaint-managing organizations, including courts, the Medical Council, the Ministry of Health, and the Governmental Discretionary Punishments Organization (GDPO)

Arbitrary judgment of complaint-handling authorities

Concerns about criminal liability in medical malpractice cases

Judicial authorities’ inattention to the systemic nature of medical errors while managing medical complaints and imposing most of the liabilities on physicians

Lack of a system for primary assessment of complaints and summoning doctors for baseless, unjustified, and non-scientific complaints

Concerns about the lack of enough respect for medical professionals and the human dignity of physicians whose cases are being investigated in complaint-handling organizations

Physicians’ lack of knowledge about judicial proceedings and laws in courts and other complaint-handling organizations

Social factors

Factors related to the patient-physician relationship

Insufficient communication skills of physicians to interact with patients

Presence of a paternalistic approach in the patient-physician relationship and a feeling that it is not necessary to obtain informed consent for every medical procedure (if informed consent is obtained, defensive interventions would be reduced ).

Patients’ demands for and satisfaction with multiple Para clinical procedures

Personality traits of some patients like being demanding, having hostile behavior, and being obsessive

Concerns about being accused of scientific incompetence

Factors related to the general culture of society

Increased public expectations from physicians due to a relative increase in health literacy and awareness of medical advances

Dissemination of misinformation and pseudoscience, through cyberspace, and its effects on public expectations

Encouraging patients to file complaints to lawyers

The reduced general level of social capital in society

Gradual familiarity of patients with their rights including their right for filing complaints from physicians

Change of public religious beliefs and attitudes toward the role of medical interventions in the treatment of patients; In the past healing was seen more as something from God and the physician was merely a tool for healing, while increasingly physicians have a more significant role in this regard according to public beliefs.

Increasing financial motives for filing a complaint against physicians to receive indemnity.

Concerns about people’s hostile, threatening, or insulting confrontations with medical complications or malpractice, especially in small cities and rural and marginal areas.

The increasing number of reports of social harassment against medical professionals. In the news and social media.

Physicians are concerned about the negative consequences of medical complications in certain well-known and famous patients like politicians, celebrities, etc.

Physicians’ personal factors

The poor motivation of physicians for risk-taking

Believing in the unfairness of medical tariffs

A feeling of weakening of mutual trust between patient and physician in society

Lack of trust in the impartiality of the system of handling medical complaints

Physician’s Personality Traits and psychological condition

Poor self-confidence due to a feeling of scientific or practical incompetence

Personal traits such as conservative, obsessive, or histrionic personality which increase their need to receive assurance through involving colleagues in the treatment process by requesting a consultation, par clinical services, etc.

Involving other physicians to share the responsibility and liability.

Lack of mental preparedness of some physicians to cope with the stress of working in new circumstances

Insufficient cultural competence of physicians when they start practice in diverse cultural contexts.

Factors related to the nature of medicine and medical interventions.

Factors related to the nature of medicine

Increasing trend of specialization and sub-specialization of medicine

High-risk nature of some specialties like surgery or gynecology

Uncertainty about the prognosis of the disease of individual patients

Higher risk of admitting complicated patients referred from other centers.

Factors related to the nature of the medical intervention

Uncertainties about some para-clinical test results

Uncertainty about the outcomes of medical interventions.