Table 4 Examples of positive and negative DM

Negative DM

Exaggerating about the seriousness of the patient’s health condition to encourage them to continue treatment with another physician

Exaggerating about the seriousness of the patient’s health condition reduces the patients’ and families’ expectations of the clinical outcomes and prevents the probability of future complaints, violence, or other negative consequences

Refusal to admit patients who are more likely to sue their physician due to their personality or other characteristics such as their occupation (such as a lawyer).

Avoiding risky and complex medical and surgical procedures

Dissuading patients from continuing treatment by providing false information such as treatment by unskilled students, the slowness of the treatment process, etc.

Unnecessary referral of patients to Tehran or provincial centers due to the lack of facilities

Absence of physicians at the bedside of critical patients

Refusal to admit high-risk, complicated, or referred patients

Exposing patients to unnecessary interventions and refusing to address underlying problems to discourage them from continuing treatment

Avoiding practicing medicine in unfamiliar regions due to lack of public trust and feeling of insecurity.

Avoiding practicing in areas where, based on previous experience or evidence, violence against medical professionals is more likely.

Avoiding practicing in areas where complaints from doctors are more likely.

Refusal to admit patients such as celebrities, politicians, and journalists whose news is subject to significant public attention due to their social position.

Wasting the patient’s time to transfer him/her to the next shift

Filling up ICU beds with low-risk patients instead of high-risk patients to reduce the likelihood of lawsuits against physicians.

Refraining from making explicit decisions for the patient and entrusting the decision to him with the justification of respecting the patient’s autonomy but with the aim of avoiding responsibilities and possible negative consequences.

Leaving medical activities and focusing on other activities such as research or medical equipment trading

Refusing to choose high-risk specialties to avoid complaints, stress or other types of challenges.

Shifting the field of practice from high-risk medical procedures to less risky activities such as cosmetic measures.

Positive DM

Asking for multiple consultations to involve other colleagues in the treatment process

Prescribing additional drugs to convince the patient about the importance of the actions taken.

Requesting multiple unnecessary paraclinical procedures for the patient

Obtaining acquittal from patients (in the hospital or even in the notary public office) in addition to informed consent

Over-documentation of performed procedures

Treatment of problems unrelated to the chief complaint of patients

Using invasive para clinical procedures when it is possible to diagnose with physical examination or simple para clinical procedures

Confusing patients with useless procedures when the physician is unable to make a correct diagnosis or treatment decision

Obtaining multiple and unnecessary informed consent forms from patients

Unnecessary ICU admissions

Entering patients with no indication into screening programs

Refusal of laboratories and para-clinical centers to provide a definitive answer and requesting rechecks due to fear of error

Multiple patient visits or consultations

Using medical interventions contrary to scientific standards to avoid complaints (like non-medically indicated C-sections due to the possibility of complications such as cerebral palsy)