Summary of main results

Male doctors had nearly 2.5 times the odds (pooled OR, 2.45; 95 % CI, 2.05–2.93) of medico-legal action compared to female doctors. There was significant heterogeneity in the meta-analysis but this was not due to differences in the direction of the effects – no studies found that women were more likely than men to experience medico-legal action. The size of the effect of sex on experience of medico-legal action remained roughly constant in all subgroup analyses, suggesting that the effect of sex is not influenced by the study design, the country the doctor is in employed in, or the outcome definition, and the effect seems stable over time.

Overall completeness and applicability

Literature search

The literature searching was thorough, as demonstrated by the number of reports initially identified (>6,500). We did not extensively search grey literature sources due to limited resources and the vast number of reports obtained with the search methods used. It is possible that smaller studies, or studies that did not demonstrate a sex effect, may have been overlooked. Another limitation was the exclusion of studies whose abstract and/or full-text were not available in English or French – seven studies judged to be potentially eligible based on their titles were excluded for this reason [40–46]. The exclusion of studies not available in English may partly explain why the majority of the studies included in this report are from English-speaking, high-income countries. It is possible that literature from non-English speaking countries demonstrate a different size of effect of doctors’ sex on experience of medico-legal action, and as such the results of this report may not be applicable to non-English speaking countries.

Study selection

In our systematic review, we were able to capture >40,000 cases of medico-legal action against doctors, capturing >20,500 medico-legal action cases in the meta-analysis. These large numbers of cases allowed meaningful conclusions to be drawn from the results. The majority of the studies attempted to collect data applicable to the wider population (country-wide, state-wide, etc.), a likely reflection that a doctor experiencing a medico-legal action is a relatively rare outcome, and therefore large studies are required to attempt to capture as many cases as possible. Capturing data from the wider population does mean that the results are more likely to be generalizable. Our reported studies covered eight countries over four continents. We demonstrated that, when stratifying the data by continent, the pooled results for each stratum was relatively stable, with male doctors having approximately two times the odds of experiencing a medico-legal action. There was variability in the effect size within the North America stratum, though the direction of the effect remained consistent.

It is worth mentioning that, of the three studies included in the Asia and Australia stratum, two were from Australia and one was from Taiwan, and although the heterogeneity was small in this stratum, it did only include three studies. Within the Europe stratum, all three studies were from the UK, and therefore the stratum may not be an accurate reflection of Europe. The total number of studies and the limited range of countries from where the studies were from in both the Asia and Australia stratum and in the Europe stratum highlight the limitation of only including studies which were published in English or French.

The outcome definition used by the individual studies varied in severity. We chose to use a variety of terms to capture the outcome, with the aim of capturing as many relevant studies as possible. Because the different outcome types varied in severity, it may not be fair to include studies together. That said, the sub-analysis examining the data by outcome type showed that the overall effect of doctors’ sex was consistent, with male doctors having approximately 2–3 times the odds of experiencing a medico-legal action in each stratum. It is also interesting to note that the two largest strata were the outcomes ‘disciplinary action’ and ‘malpractice’, both of which have severe impact on a doctor’s professional career.

The demographics of doctors in the UK and USA have been changing, with increasing numbers of women choosing to follow medicine as a career [47, 48]. Our results suggest that the effect of male sex on experiencing medico-legal actions has remained fairly constant over the last 15 years (OR, 2.25–2.45), despite the increasing trend of women doctors (it is not possible to comment on the years prior to 2000 due to the small number of studies in the strata). We therefore feel one can no longer argue that male doctors are more likely to face medico-legal action because there are more male doctors practising. If this were the case, we would expect the effect size to diminish over time, to reflect the increasing number of female doctors.

Unfortunately, we were unable to explore further whether the sex difference in medico-legal action was impacted by specialty practised. Thirteen of the studies included in the meta-analysis examined whether the likelihood of medico-legal action differed between specialties [5, 6, 8, 9, 14, 16, 19, 28, 31, 35–37, 39]; however, the specialities most and least likely to face medico-legal action varied greatly between the studies. In the studies which controlled for the effect of specialty when examining the association between sex and medico-legal action, all but one [31] demonstrated that male doctors remained more likely to have had medico-legal experience even with specialty taken into account [6, 5, 16, 19, 35].

Other variables have been shown to be both associated with doctors’ sex and experience of medico-legal action, but have not been examined by this meta-analysis. These include the number of hours worked or the number of patient encounters. Studies included in this systematic review and meta-analysis have demonstrated that female doctors work less hours than male doctors [34, 35] and see less patients than their male colleagues [28]. The number of hours worked has been shown to be associated with increased likelihood of medico-legal action in three of these studies [23, 34, 35]. Exploring how the number of hours worked or number of patient encounters differ between the sexes and the effect on medico-legal action may be of interest for a future review of the literature to help towards understanding the sex difference in medico-legal action.

Other potential biases in the review process

One reviewer assessed the reports for eligibility, and this was not performed blind – this could have introduced bias; however, the reviewer did use previously agreed criteria to guide their decisions, with the aim of reducing bias. Another possible source of bias is that the outcome definitions used were not wide enough, and that there may be some culturally specific terms that the researchers, who are all from the UK, were unaware of. Finally, the assessment of the methodological quality of the studies is subjective. To reduce this source of bias, two researchers independently judged the methodological quality of the studies and the Newcastle-Ottawa scale checklist was used to guide and support our decisions. We also chose not to exclude any studies from the systematic review or meta-analysis based on the findings of the appraisal of methodological quality.