Wednesday, January 27, 2016

A canary in the coal mine?

How should we think about medical malpractice claims against doctors?  Are they indicative of something about those doctors who've been sued? Are they a symptom of underlying quality and safety issues in a hospital, a kind of canary in the coal mine that suggests there might be deeper problems?  These are long-standing questions.

Perhaps part of the answer is provided in a new article in the New England Journal of Medicine, "Prevalence and Characteristics of Physicians Prone to Malpractice Claims," by David Studdert and colleagues.  (The article has a theme that is somewhat consistent to one I discussed a few days ago, which reported that a small group of doctors in Australia accounted for many patient complaints.)

The authors conducted an extensive review of US National Practitioner Data Bank information, analyzing 66,426 claims paid against 54,099 physicians from 2005 through 2014. They found that, over this 10-year period, "a small number of physicians with distinctive characteristics accounted for a disproportionately large number of paid malpractice claims."

Approximately 1% of all physicians accounted for 32% of paid claims. Among physicians with paid claims, 84% incurred only one during the study period (accounting for 68% of all paid claims), 16% had at least two paid claims (accounting for 32% of the claims), and 4% had at least three paid claims (accounting for 12% of the claims). In adjusted analyses, the risk of recurrence increased with the number of previous paid claims. For example, as compared with physicians who had one previous paid claim, the 2160 physicians who had three paid claims had three times the risk of incurring another.

Risks also varied widely according to specialty. As compared with the risk of recurrence among internal medicine physicians, the risk of recurrence was approximately double among neurosurgeons, orthopedic surgeons, general surgeons, plastic surgeons, and obstetrician–gynecologists. The lowest risks of recurrence were seen among psychiatrists and pediatricians.

Male physicians had a 38% higher risk of recurrence than female physicians. The risk of recurrence among physicians younger than 35 years of age was approximately one third the risk among their older colleagues. Residents had a lower risk of recurrence than nonresidents, and M.D.s had a lower risk than D.O.s. 

We could stop right there and conclude that the problem lies solely with the high-risk doctors.  But, as the authors point out, these doctors practice in health systems, and those systems have the potential to intervene.

All institutions that handle large numbers of patient complaints and claims should understand the distribution of these events within their own “at risk” populations. In our experience, few do. With notable exceptions, fewer still systematically identify and intervene with practitioners who are at high risk for future claims. Rather, the risk-mitigation initiatives that are in place — such as the educational and premium-discount programs that some malpractice-insurance companies offer — are generally offered en masse. Otherwise, insurers tackle the problem of claim-prone physicians primarily by raising premiums or terminating coverage. These strategies do not directly address the underlying problems that lead to many claims.

In an environment in which a small minority of physicians with multiple claims accounts for a substantial share of all claims, an ability to reliably predict who is at high risk for further claims could be very useful. . . . If reliable prediction proves to be feasible, our hope is that liability insurers and health care organizations would use the information constructively, by collaborating on interventions to address risks posed by claim-prone physicians (e.g., peer counseling, training, and supervision). It could present an exciting opportunity for the liability and risk-management enterprises to join the mainstream of efforts to improve quality.


BenK said...

We could also remark that one paid claim could be 'blood in the water' and lead to further claims, even providing evidence to support them and attracting lawyers to higher than average rates of return on their time... in short, a paid claim might turn a regular doctor into 'high risk' for claims against work he had already done, which may have been not particularly poor.

Retired doctor said...

Rather than be drawn in by the metaphor of the canary in a mine as a way of understanding how a minority of doctors are responsible for the preponderance of malpractice suits, perhaps we might ask why the majority of doctors operating in the very same institutions and environments manages to function without a single lawsuit. Even correcting for the often touted "sicker patient" excuse, it would seem that a particular number of doctors are responsible for more than their statistical share of lawsuits. There is no argument that a large amount of morbidity and mortality in the patient population is the result of medical error. Why is it that excuse upon excuse is made to avoid ascribing responsibility for what has come to be described as an "unexpected outcome." Terribly sorry, but your mother died because the doctor did not note she was allergic to x, or sorry, but somehow the wrong breast was marked and a mastectomy was performed on a healthy breast and so a repeat surgery is now needed, or sorry, you brother died and we can find no reason based on procedures, but the entire staff knows that this surgeon is known for rough and overly long surgeries. The systems have turned themselves inside out requiring time outs, double and triple checks on information and interminable paperwork as testimony to the safety of a system which can be no safer than the individuals who interact within that system. It is no shock that nothing changes, but little recognition that the system is averse to ascribing individual fault and thus blame. We're this kindergarten in which every child should get a trophy to avoid blows to fragile self esteem, it might be seen appropriate.

We might better ask why all but this small percentage of doctors are able to function just fine within the system and then follow the probable evidence to explore what about the practice of the smaller sued group leads to so many unhappy results. We all have sympathy for a good doctor being unfairly targeted, but make no mistake; the blood in the water is not the doctors, it is the patients and the patient is also the dead canary killed by something within the system deemed too precious to be blamed.

if one were to review the license information at Mass aboard of entire medical staffs as I have, one would discover that what the report that Paul referred to was pretty accurate. Most of the doctors (even some whom I would have expected to be among the sued or censured) were clean as a whistle. There were a very small number of doctors who had reports of settled malpractice cases and among those there seemed to be a few who had more than one or two. Since as soon as a doctor is served notice of a pending suit, a gag order by his attorney is made and during and after the suit or settlement, An agreement not to discuss the facts or possible settlement is made. The argument of blood in the water attracting more cases for work which was "not particularly poor" (as though that were a reason able expectation of care ) does not fall credibly on my ears. There should be more than a few ears listening and voices calling BS on the old defenses.

It woul