Development of a scale for defensive medicine practices in primary care

Defensive medicine, characterized by the avoidance of high-risk patients or the overuse of diagnostic and therapeutic interventions due to fear of litigation or complaints, poses significant challenges in primary care. Existing scales primarily focus on hospital settings, limiting their applicability to family physicians. This study aimed to develop and validate a scale tailored to measure defensive medicine behaviors in primary care contexts.

Scale development involved reviewing the literature, conducting focus group discussions with family physicians, and consulting with experts. An initial 37-item draft was pilot-tested for clarity, resulting in a refined instrument. Data were collected from family physicians in two phases: exploratory factor analysis (EFA) with 252 participants and confirmatory factor analysis with 266 participants. Criterion validity was assessed by correlating the new scale with a previously validated defensive medicine scale. Reliability was evaluated using Cronbach's alpha and McDonald's omega.

EFA supported a five-factor structure: referral, complaint, e-report, verbal/physical violence, and interventional procedure dimensions. After item removal, the final 21-item scale demonstrated acceptable goodness-of-fit indices (χ²/df = 2.43, root mean square error of approximation (RMSEA) = 0.07, comparative-fit index (CFI) = 0.93). Criterion validity was evidenced by a moderate positive correlation (r = 0.350, P < .01) with an existing scale. Internal consistency was high, with both Cronbach's alpha and McDonald's omega at 0.92 for the total scale.

The Primary Care Defensive Medicine Practices Scale is a valid and reliable instrument specifically tailored for primary care settings. It offers a more nuanced understanding of defensive behaviors, guiding targeted interventions to enhance care quality, patient safety, and resource utilization.