Hospital Culture: Defensive Medicine as Perceived by Medical Students - A Qualitative Study

There are numerous reasons for overtreatment. One of them, defensive medicine (DM), refers to a mode of medical practice that is generally understood to be motivated by fear of litigation. The phenomenon is widespread and can lead to poorer medical care, thereby harming not only patients but also the healthcare system (1). It is as yet unknown whether this defensive behavior develops as early as during training. Given that contextual factors relating to the curriculum itself—such as observing the clinical practice of others—influence subsequent medical behavior (2), it is possible that trainee physicians already begin to adopt DM during clinical rotations. Therefore, the aim of this study was to investigate whether students encounter DM during their rotations and how they perceive and evaluate this behavior.

Methods

Since, to our knowledge, there is no literature on this research question to date, we chose the exploratory approach of a qualitative study based on to the grounded theory methodology of Corbin and Strauss. Medical students at the University of Erlangen, Germany, were recruited (snowball sampling, starting with direct personal contact) along theoretical sampling lines. Using a semi-structured interview guide, the survey was conducted as individual interviews and focus group discussions. The interview guide covered the topics of DM, error culture, and medical law. Respondents were first asked about their own understanding of DM, and this was then compared with the standard definition (fear of legal consequences). Building on this, stimuli such as case studies relating to these topics were provided. Following transcription, the recorded data were subsequently coded and analyzed using the programs f4transcript and MAXQDA2022.

Results

A total of 14 students (three male and 11 female) took part in the study (mean number of semesters: 10.2). The interviews lasted between 57 and 98 min. Although DM during medical training was not explicitly addressed, it was found that students were, in principle, familiar with DM and had observed it during their clinical rotations. However, when reflecting on these observations and projecting them onto their future practice, they were less likely to attribute DM to fear of legal consequences. Rather, our data revealed two key phenomena as preconditions for DM from the students’ perspective: The “hospital system” and “medical culture” (Table). They perceived the “hospital system”—their future workplace, characterized by steep hierarchies and a lack of support—as intimidating. The students felt inadequately prepared for this environment. More specifically, students expressed this feeling as a fear of being left on their own in future decision-making situations. These experiences led to a decline in their motivation for the medical profession as their insight into the hospital system increased.

The other contextual factor, the “medical culture,” referred to the medical profession and the prevailing norms and values of this field from the students’ perspective. This medical culture was shaped by the pressure of anticipated high levels of responsibility, perfectionism, and an intolerance of the uncertainty or ambiguity inherent in medical decisions. Students reported having high expectations of themselves and a fear of making mistakes, which they often equated with “failure” and whose potential consequences they considered catastrophic, resulting in a marked intolerance of errors. It was also notable that students held the view that there is a clear right or wrong in medicine, with little gray area in between.

Students reported that they could understand why physicians engaged in the observed DM—which they perceived as an excessive form of self-protective behavior—and, in view of the structures of the “hospital system” and “medical culture,” expressed a strong desire for greater security in their future professional lives.

Table

Discussion

Our data suggest that fear of litigation plays only a minor role as a motivation for DM among students. This finding adds to individual findings from recent research (3). Thus, it appears that “hospital culture” is a far more significant factor than the fear of legal consequences: The structures of the “hospital system” and the prevailing “medical culture” may create an environment that promotes defensive behavior. Uncertainty is an inherent part of the medical profession, given that diagnoses and treatment decisions are virtually never entirely clear-cut. However, students reported that they believed this type of uncertainty would be difficult to tolerate in their future clinical work. This has also been described in the literature and has been linked to reduced psychological well-being and an increased need for defensive measures (4). Thus, merely the fact of observing DM in clinical practice may have a lasting influence on students’ future clinical behavior.

Limitations of our study included the small sample size and a possible selection bias due to theoretical sampling. Nevertheless, our findings based on students’ perspectives point to directions for future research into the causes of DM and provide impetus for such work.

Our findings underscore the need to consider additional motives for DM beyond fear of litigation. They suggest that not only the framework conditions of medical training but also the structures of the “hospital system” and the “medical culture” should be critically reflected upon. In our view, a more realistic approach to the possibility of error, as well as greater tolerance of the described uncertainty, is crucial to reducing the incentive for DM.

This research was carried out as part of Ms Lara Kube’s doctoral studies.

Lara Kube, Thomas Kühlein, Maria Sebastiao, Constantin Unger

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript submitted on 25 September 2025, revised version accepted
on 9 February 2026.

Translated from the original German by Christine Rye.

Cite this as: Kube L, Kühlein T, Sebastiao M, Unger C: Hospital culture: Defensive medicine as perceived by medical students. A qualitative study. Dtsch Arztebl Int 2026; 123: 231–2. DOI: 10.3238/arztebl.m2026.0024

References

1. Lorenc T, Khouja C, Harden M, Fulbright H, Thomas J: Defensive ­healthcare practice: Systematic review of qualitative evidence. BMJ Open 2024; 14: e085673

2. Muller D, Ornstein K: Perceptions of and attitudes towards medical errors among medical trainees. Med Educ 2007; 41: 645–52

3. Baungaard N, Skovvang PL, Assing Hvidt E, Gerbild H, Kirstine Andersen M, Lykkegaard J: How defensive medicine is defined in European ­medical literature: A systematic review. BMJ Open 2022; 12: e057169

4. Patel P, Hancock J, Rogers M, Pollard SR: Improving uncertainty ­tolerance in medical students: A scoping review. Med Educ 2022; 56: 1163–73