Defensive medicine practices and workplace violence among physicians in tertiary healthcare settings in Zagazig, Egypt: a cross-sectional study

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Abstract Background Defensive medicine involves clinical practices—either through overuse of interventions (positive) or avoidance of high-risk procedures (negative)—driven by liability concerns rather than patient care. In Egypt, rising medico-legal issues and workplace violence may exacerbate these behaviors. This study assessed the prevalence and drivers of defensive medicine among physicians at a tertiary academic hospital, comparing medical and surgical specialties and examining the impact of prior litigation experience. Methods A cross-sectional study was conducted at Zagazig University Hospitals using a two-stage sampling design, involving stratified random selection of departments followed by voluntary response sampling of physicians through an online questionnaire. Data were collected between 1 November 2024 and 30 April 2025 through a self-administered questionnaire covering: (1) socio-demographic and occupational characteristics; (2) positive and negative defensive medicine practices during physicians’ entire career; and (3) perceived causes of defensive practices and involvement in medical litigation. Data were analyzed using Chi-square and Fisher’s exact tests. Binary logistic regression analysis was performed to detect the associations of age, sex, years in profession, working hours/day, and exposure to workplace violence with defensive medicine practice. Statistical significance was set at p < 0.05. Results The study included 340 physicians, of whom 323 (95%) reported performing at least one defensive medicine practice. Exposure to workplace violence was reported by 261 participants (76.8%) over the past 12 months. The most frequently cited reasons for defensive medicine were fear of medical litigation (234, 68.8%) and fear of disciplinary sanctions (169, 49.7%), whereas prior personal involvement in litigation was less commonly reported (87, 25.6%). Significant specialty-based differences were observed. Surgeons (47.9% of the sample) were more likely than medical specialists to perform unnecessary procedures ( p = 0.04), avoid high-risk patients ( p = 0.03), and avoid high-risk procedures ( p = 0.004). Conversely, medical specialists showed greater willingness to accept litigation-involved patients ( p = 0.005). Conclusion Defensive medicine practices were highly prevalent among physicians in this tertiary academic setting. The findings reflect associations between exposure to workplace violence and defensive behaviors, highlighting the potential influence of medico-legal pressures and unsafe working conditions on clinical decision-making.