You can’t deliver compassionate care from a defensive posture

The fear of litigation is affecting patient care, leading to over-investigation and damaging the doctor-patient relationship. Rohan Simon, CEO, Medical Defense Society, argues that it doesn’t need to be like this.

This is part of the Pulse Partners series. This article has been paid for by the Medical Defense Society, with editorial input by Pulse. The opinions in this article do not necessarily reflect the views of Pulse.

There is a truth that many doctors feel but few articulate: you cannot truly deliver compassionate care while practising from a place of fear. Yet for many GPs in today’s NHS, the fear of litigation, complaints, or regulatory scrutiny has become a constant undercurrent in their clinical decision-making. That fear may be quiet and rationalised, but it is there, shaping how consultations unfold, how risks are communicated, and how relationships with patients are formed.

The result? More tests, more referrals, more disengagement, more emotional exhaustion.

We need to remove this defensive culture in medicine and instead have the kind of clinical environment that fosters courage, clarity, and trust as the foundations of safe, human-centred care.

The consequences of defensive medicine

General practice has always involved complexity and uncertainty. No two patients present in the same way. And few consultations offer perfect clarity. What has changed is the cultural backdrop.

Today, doctors practise in an environment where the clinical consequences of a missed diagnosis are only part of the risk. The psychological weight of regulatory scrutiny and complaints procedures has a profound effect on behaviour. In a major 2015 BMJ Open UK study, 82–89% of doctors who had recently faced a complaint admitted to practising defensively.

As one GP recently told me: ‘You start doing what you think will be safest legally, not necessarily what you believe is best clinically.’ That shift, while understandable, is dangerous in its own right.

Defensive medicine takes many forms:

• Over-investigation and over-referral, often driven by anxiety rather than clinical necessity.
• Increased use of disclaimers or rigid scripts, which can reduce warmth and empathy.
• Avoidance of complex or emotionally charged cases, especially among newer or previously criticised doctors.
• Time-sapping documentation practices, done less for care continuity and more for legal protection.

Each of these responses might make sense in isolation. But together, they form a culture of detachment and depletion. Doctors feel they must protect themselves before they can support others. The result is a profession that is less confident, less connected, and more burned out.

In the same 2015 BMJ Open survey, it was found that 46-50% of GPs reported avoiding particular procedures and high-risk patients for fear of complaints, 16.9% experienced moderate to severe depression and 15% reported severe anxiety. These are not marginal effects. When care is delivered from a place of fear, compassion becomes a casualty.

Even more concerning: many admitted it was affecting their job satisfaction and emotional wellbeing.

This is not the practice of medicine as it should be. It is medicine under siege.

Rebuilding Confidence

Fear does not merely affect how doctors act; it affects how they relate. True compassion requires presence, attention, and emotional availability. When a GP is operating from a defensive posture, even subconsciously, they are often:

• Less attuned to non-verbal cues or emotional undertones.
• More transactional in communication style.
• More guarded in tone, which can lead patients to feel dismissed or mistrusted.

This can become a feedback loop. Detached care breeds patient dissatisfaction. Dissatisfaction increases the likelihood of complaints. And so the spiral continues.

Ironically, many GPs know that their best consultations the ones that avoided escalation, built rapport, or led to insight came when they were fully present, not guarded.

What is needed is not reckless certainty, but supported confidence. GPs must feel empowered to make decisions based on clinical reasoning and patient understanding, not legal anxiety.

This calls for cultural and structural change:

• Clearer guidance on acceptable risk, communicated from regulatory and legal bodies.
• Stronger early advisory support so that clinicians can sense-check judgement calls before issues escalate.
• Peer spaces for reflection, where doctors can discuss dilemmas without shame or fear.
• Training that addresses not just medical law, but psychological safety in decision-making.

There are models of professional support are starting to respond to the pressure faced by doctors. From access to immediate access to expert guidance during medico-legal uncertainty via medical defence organisations, to structured emotional wellbeing programmes provided by independent charities and NHS-affiliated schemes. These can offer peer support groups, mental health interventions, and spaces for reflection. These are positive steps, but if we want confident clinicians, we must build confident systems — systems that offer clarity, emotional safety, and timely support when it matters most, as Doctors in Distress, NHS Practitioner Health, and the BMA have argued.

A culture of psychological safety

One of the most promising concepts in modern clinical leadership is psychological safety. Originally described in high-performing teams in other industries, it refers to an environment in which individuals feel safe to speak up, admit uncertainty, and take thoughtful risks.

In medicine, psychological safety is often misunderstood. It does not mean avoiding accountability. It means holding ourselves to high standards without letting fear dominate the space where care is given.

Trust between colleagues. Respect for the pressures of frontline care. Space to reflect without immediate judgement. These are the hallmarks of psychologically safe practice. And they are antidotes to defensive postures.

Fear may be a short-term protector, but it is a long-term corrosive. It narrows judgement, erodes empathy, and wears down the very people we need at their most resilient.

As a profession, we must challenge the systems and mindsets that have normalised defensive medicine. Doctors did not enter medicine to protect themselves. They entered it to care.

Compassionate care demands that we support clinicians not just when complaints occur, but far earlier in how we train, advise, and structure the very environments they work in.

Let us commit to building a culture where doctors feel trusted to exercise sound judgement, supported in uncertainty, and free to connect with their patients not from fear, but from care.