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Entries in New England Journal of Medicine (3)


Harvard Study: Most Physicians Will Be Sued

physician malpractice lawsuits

New England Journal of Medicine: Most doctors in America will be sued at some point during their career.

A Harvard study released yesterday in the New England Journal of Medicine has found that physicians who perform high-risk procedures, including neurosurgeons,  obstetricians, and thoracic surgeons, face a near certainty of being named in a malpractice case before they reach age 65.

Yet a relatively small number of claims, about 22 percent, result in payments to patients or their families.

Authors of the study, which examined 15 years of data, said it highlights the need for changes in malpractice law so that doctors and patients can resolve disputes before they resort to litigation, which often costs both parties money and heartache.

“Doctors get sued far more frequently than anyone would have thought, and in some specialties, it’s extremely high,’’ said Amitabh Chandra, an economist and professor of public policy at the Harvard Kennedy School and an author of the study. “In some sense, the payment is the least important part, because you can insure against it, but you can’t insure against the hassle cost.’’

The study looked at malpractice claims data for nearly 41,000 physicians from 1991 to 2005. The researchers found that 7.4% of physicians had a malpractice claim against them each year and that 1.6% had a claim that led to a payment each year.

Chandra and his coauthor, Dr. Anupam B. Jena of Mass. General, said they hope their study will dispel the fear that many doctors have of big payouts. Their study found just 66 claims that resulted in payments exceeding $1 million. Average claims by specialty ranged from $117,832 in dermatology to $520,923 in pediatrics.

So how can you lessen your chances of being sued by an unhappy patient even further?

Previous studies have shown that patients are less likely to sue when they receive an apology and explanation from their doctor.

Brian Rosman, research director of Health Care for All, said everyone will benefit if patient- doctor communication is divorced from legal proceedings and could actually inprove the quality of care. That would allow doctors and hospitals to deal more directly with the root cause of an error.

One medical society has been working with Beth Israel Deaconess Medical Center, using a $273,782 federal grant, to design a plan for a system that would encourage apologies and compensation, when justified, in Massachusetts. The plan is set to be released this fall.

It seems that nearly universal support exists for a system that encourages doctors to apologize and prevent the escalation of an unwanted outcome into a malpractice lawsuit.

Of course, this wall of scilence goes up on both sides. As soon as an unhappy patient contacts a lawyer they're instructed to have no further contact with the doctor to prevent anything that might mitigate damages or obstruct the lawsuit, like an admission to the doctor that they didn't follow instructions or a 'softening' of their stance as the identify with the physician as a person.

When I was running Surface Medical we ran in to this very problem many times.

Have you been in a lawsuit? Have you ever appologized to a patient?


Do You Regret Anything About Your Medical Training?

What do you regret about your medical training or specialty selection?


One thing I regret is not taking advantage of the Masters degree in Health Administration program at my medical school. At the time, I was focused solely on medicine and on being a doctor. I didn’t think the business side of medicine was all that important. In fact, I didn’t consider the business side of medicine at all. 

I regret that.

In a recent Medscape discussion physicians of different specialties discussed individual and collective regrets. 

More than a few doctors regretted their choice of specialty. Pathologists seemed very unhappy with their choice because of the job market and the future of healthcare. An ER doctor regretted not choosing a surgical career. Several General Practitioners regretted choosing Primary Care.

However, many doctors were more concerned with what they did or didn’t get during their training. Gastroenterologists and ophthalmologists cited the lack of training in the business side of medicine as a gap to be filled. 

Research has found that fewer than half of graduating medical students in the U.S. receives adequate training to understand healthcare system strategic approach and the economics of practicing medicine.

In a recent article in the New England Journal of Medicine two University of Michigan physicians recommended that healthcare policy be added to Medical School Curriculum.

“'Medical student and resident education has to include instruction on how healthcare systems function -- especially with the advent of complicated national healthcare reforms,’ University of Michigan physicians said.”

“Without education in health policy and the healthcare system, physicians are missing critical tools in their professional toolbox,” said co-author Matthew M. Davis, MD, associate professor at U-M in Pediatrics and Communicable Diseases, Internal Medicine and Public Policy.

The U-M Medical School has added an elective course in healthcare policy. Davis notes that it is enrolled to the maximum. 

But is there time for this information to be integrated into medical school and post-graduate training, each already overflowing with information? How can this curriculum be integrated with clinical instruction and permeate educational training without jeopardizing other topics?

Three years after I graduated from medical school I went back to school and got a business degree. However, going back to school requires a huge investment of time and resources that many of us are already short on. Most of the skills needed to succeed in the corporate world are already inherent in a doctor or cultivated by the discipline, dedication, drive and desire it takes to become a doctor. The business degree alone isn’t going to put you on the fast track to success.

What is the best way for doctors to appreciate and understand the business side of medicine? It’s important for the success of a clinical doctor who needs to market and oversee a practice. It’s important as we move into the realm of changes due to health reform and doctors must take leadership roles and be able to effectively negotiate their future employment situations. It’s important for the success of a doctor who is working in the non-clinical world in the financial sector or in a marketing, sales or management role.

What do you think?


The Value Proposition For Health Care: A Challenge For Physician Leadership

In health care there is nothing more complex than the simple.

In a recent New England Journal of Medicine article, What is Value in Health Care?,  Michael Porter, a Harvard trained PhD in business economics, makes a compelling case for defining, measuring and rewarding value in health care. By shifting our focus on value, simply defined as quality divided by cost, we can lower costs and improve quality.

The elegantly written article shows that value is what drives consumers.

Not quality. Most of us wouldn't shell out $100,000 for a  new automobile, regardless of its quality.

Not cost. We wouldn't buy a new car for $5,000 if we were convinced it would spend most of its time in the repair shop. Honda and Toyota have been kicking Detroit's butt because of value. Most of us see Honda or Toyota automobiles as providing high quality and low cost. It's time we move health care in the direction of value.

The value proposition is easy to understand, but its implementation will be complex.

There are three complexity challenges that will require effective physician leadership:  

  1. Defining and measuring quality outcomes
  2. Identifying and understanding the true costs involved in delivering care
  3. Shifting the paradigm of our health care culture from a physician-centric to a patient-centric one

Dr. Porter outlines some of the challenges in defining and measuring quality outcomes. These include the fragmented and insufficient state of medical informatics, the length of time needed to track outcomes, and the dynamic nature of quality outcomes.

He explores the difficulties in measuring costs (not charges) across a continuum of care. Dr. Porter also recognizes that to properly measure value, one needs to identify the proper consumer. In health care the proper consumer is the patient, not the physician. The culture therefore needs to be patient-centric.

As an economist, Dr. Porter presents a well nuanced analysis of the first two hurdles in achieving value in health care: measuring quality outcomes and tracking costs acurately. He may, however, have underestimated the challenge involved in the third: moving from a physician-centric to a patient-centric culture.

Our physician-centric health care culture has deep roots. It is planted in the elitist soil of medical school selection, fertilized by the academic docents of physician indoctrination, and nurtured by the competition skewed by a physician friendly supply-demand curve with further nutritional supplements supplied by a perverse payment incentive system.

The future culture of patient-centric healthcare will not take root in today's American health care soil unless the current physician-centric culture is uprooted. No one should underestimate this task's importance nor its challenges.

Uprooting the current physician-centric culture before it uproots the foundation of the American health care system is the biggest challenge facing our physician leaders. This task will require effective physician leadership in academic medical centers, in hospitals, in outpatient clinics, and in our medical societies. It's time to develop and support effective medical leaders by teaching them the leadership skills required for success.  

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