Malpractice-Related Stress Among Physicians in Emergency and Acute Care: A Scoping Review

Introduction: Medical malpractice claims and litigation represent potentially relevant occupational stressors for physicians, particularly in high-intensity clinical environments such as emergency medicine and acute care. Epidemiological evidence indicates that malpractice litigation is highly prevalent among physicians. Studies have estimated that by the age of 65 years, approximately 75% of physicians in low-risk specialties have faced at least one malpractice claim, whereas the percentage rises to approximately 99% among physicians in high-risk specialties. This is due to the complexity of clinical decision-making, time pressure, and diagnostic uncertainty, which contribute substantially to medico-legal exposure. In this context, malpractice-related stress has been conceptualized within the framework of Medical Malpractice Stress Syndrome (MMSS), encompassing a descriptive construct of psychological and somatic manifestations that may impair professional performance and well-being. However, MMSS does not currently represent a uniformly defined clinical entity supported by standardized diagnostic criteria. The present review aims to examine the current evidence on malpractice-related stress among physicians in these high-intensity clinical environments, with particular focus on psychological outcomes, behavioral adaptations, and occupational consequences. The available evidence was heterogeneous and was concentrated primarily in emergency and acute-care settings, with limited trauma-specific evidence. Materials and Methods: This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The bibliographic search was carried out in April 2026 using databases including PubMed and Google Scholar, applying the following search strings: “malpractice AND physician stress AND emergency”, “malpractice stress AND ER”, and “malpractice stress AND trauma care”. Inclusion criteria included English-language studies focusing on physicians in acute care settings and evaluating psychological, behavioral, or occupational outcomes related to malpractice exposure. Exclusion criteria included absence of full text, lack of primary empirical data, or a focus limited to legal aspects without assessment of physician well-being. A two-stage screening process was applied. Results: The search strategy identified 1901 records, of which 7 studies met the predefined eligibility criteria. The available evidence indicated associations between malpractice-related exposure or fear of litigation and adverse psychological and occupational outcomes, including burnout, reduced job satisfaction, procedural anxiety, and changes in clinical behavior. Defensive medical practices and changes in clinical decision-making, including increased diagnostic testing and more conservative decision-making in some studies, were also reported. Evidence regarding supportive interventions was limited, with one pilot study providing preliminary information on the feasibility and potential value of structured peer support rather than evidence of effectiveness. Discussion: The findings of this review suggest that malpractice-related stress may represent a multidimensional occupational phenomenon associated with psychological and behavioural outcomes. Beyond its legal dimension, malpractice exposure has been associated with burnout and changes in clinical decision-making. The contextual literature has discussed broader implications of defensive medicine, although these system-level effects were not directly established by the included studies. Overall, the findings support further investigation of malpractice-related stress and of potential approaches to physician well-being and healthcare quality. Conclusions: Malpractice-related stress is increasingly recognized as an occupational factor associated with physician burnout, psychological distress, reduced job satisfaction, and defensive medicine in acute care and emergency settings, potentially affecting healthcare quality and patient safety. Further investigation of malpractice-related stress within the proposed MMSS descriptive framework may help inform the development of preventive psychological and organizational interventions. Despite limited and heterogeneous evidence, current findings highlight the need for greater institutional awareness and further longitudinal, multicenter research to better define causal relationships and evaluate targeted support strategies for physicians in high-risk clinical environments.