Physicians and Malpractice

We have always been fascinated with understanding medical malpractice, largely because although the research evidence is skimpy, we strongly suspect that malpractice suit fears are a factor leading doctors to deliver potentially unnecessary care.  No one likes to be accused of doing a bad job.  The New England Journal of Medicine carries research analyzing which physicians seem most likely to experience malpractice claims.  (NEJM Article)   The authors were primarily interested in understanding the distribution of actual paid malpractice claims (so claims that had at least some likely merit) among physicians nationwide and in seeing if they could identify characteristics that seemed correlated with a doctor having more claims.  The National Practitioner Data Bank was the primary data source.  There were 66,426 paid claims over the ten-year study period, involving 54,099 doctors, 82% of whom were men.  Four specialties accounted for over half the claims–internal medicine (15%); OB/GYN (13%); general surgery (12%) and family medicine (11%).  In one-third of the claims the patient died and 54% related to major harms.  Only 3% were as a result of a court verdict, the rest were settlements.  Looking at the total population of doctors, only 6% had even one paid claim, and about 1% accounted for 32% of all paid claims.  2160 doctors had at least three claims and 722 physicians had at least four.  It appears that having even one paid claim is a somewhat good predictor of having another one and that having two becomes a better predictor of having a third and so on as the number of paid claims rises.  Neurosurgeons, other surgeons and OB/GYN doctors were particularly at risk of having multiple additional claims if they had one.  Men had a higher risk of recurrence than did females and older doctors had a higher recurrence risk as well (this may just reflect more years of practice).  While this suggests that a small number of doctors could be focused on to ensure that they are practicing quality medicine, looking at the specialties which account for most of the multiple paid claims indicates that there may be intrinsic risk which can’t be eliminated here, both because the care being delivered is very complex and risky and the harm if something goes wrong is quite large.  The underlying debate really should be around what is poor care in these specialties.  Someone who is doing brain surgery should be highly skilled and trained, but the expectation that bad outcomes can be avoided is unreasonable.  High rates of malpractice in these specialties drive up premiums and drive qualified people out of the specialties, making access to care harder, especially for poorer populations.  While there may be some physicians who bear monitoring to ensure that they are doing their jobs well, the study actually suggests that the problem is more one of use of unreasonable standards for good outcomes when delivering very complex care.