IntroductionThe term defensive medicine, referring to actions motivated primarily by litigious concerns, originates from the USA and has been used in medical research literature since the late 1960s. Differences in medical legal systems between the US and most European countries with no tort legislation raise the question whether the US definition of defensive medicine holds true in Europe.AimTo present the protocol of a systematic review investigating variations in definitions and understandings of the term ‘defensive medicine’ in European research articles.Methods and analysisIn concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of all medical research literature that investigate defensive medicine will be performed by two independent reviewers. The databases PubMed, Embase and Cochrane will be systematically searched on the basis of predetermined criteria. Data from all included European studies will systematically be extracted including the studies’ definitions and understandings of defensive medicine, especially the motives for doing medical actions that the study regards as ‘defensive’.Ethics and disseminationNo ethics clearance is required as no primary data will be collected. The results of the systematic review will be published in a peer-reviewed, international journal.PROSPERO registration numberThis review has been submitted to International Prospective Register of Systematic Reviews (PROSPERO) and is awaiting registration.

ObjectivesDefensive medicine has originally been defined as motivated by fear of malpractice litigation. However, the term is frequently used in Europe where most countries have a no-fault malpractice system. The objectives of this systematic review were to explore the definition of the term ‘defensive medicine’ in European original medical literature and to identify the motives stated therein.DesignSystematic review.Data sourcesPubMed, Embase and Cochrane, 3 February 2020, with an updated search on 6 March 2021.MethodsFollowing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we reviewed all European original peer-reviewed studies fully or partially investigating ‘defensive medicine’.ResultsWe identified a total of 50 studies. First, we divided these into two categories: the first category consisting of studies defining defensive medicine by using a narrow definition and the second category comprising studies in which defensive medicine was defined using a broad definition. In 23 of the studies(46%), defensive medicine was defined narrowly as: health professionals’ deviation from sound medical practice motivated by a wish to reduce exposure to malpractice litigation. In 27 studies (54%), a broad definition was applied adding … or other self-protective motives. These self-protective motives, different from fear of malpractice litigation, were grouped into four categories: fear of patient dissatisfaction, fear of overlooking a severe diagnosis, fear of negative publicity and unconscious defensive medicine. Studies applying the narrow and broad definitions of defensive medicine did not differ regarding publication year, country, medical specialty, research quality or number of citations.ConclusionsIn European research, the narrow definition of defensive medicine as exclusively motivated by fear of litigation is often broadened to include other self-protective motives. In order to compare results pertaining to defensive medicine across countries, future studies are recommended to specify whether they are using the narrow or broad definition of defensive medicine.PROSPERO registration numberCRD42020167215.