Doctors who call patients hypochondriacs are committing malpractice

By Zackary Berger
KevinMD.com
Originally posted on November 25, 2013

There’s one question I get asked a lot: “I research my health problems on the Internet. Am I a hypochondriac?”

First, we should ban that word when talking about ourselves. No one wants to be called that, and doctors who use that word are committing malpractice. Everyone has some range of complaints and worries in life, often physical and mental together, and this is our job as doctors: to hear them out. I firmly believe that no complaint is illegitimate.

The entire blog post is here.

Thanks to Ed Zuckerman for this information.

The Consequences of the Hindsight Bias in Medical Decision Making

By Hal Arkes
doi: 10.1177/0963721413489988
Current Directions in Psychological Science October 2013 vol. 22 no. 5 356-360

Abstract

The hindsight bias manifests in the tendency to exaggerate the extent to which a past event could have been predicted beforehand. This bias has particularly detrimental effects in the domain of medical decision making. I present a demonstration of the bias, its contribution to overconfidence, and its involvement in judgments of medical malpractice. Finally, I point out that physicians and psychologists can collaborate to the mutual benefit of both professions.

The hindsight bias manifests in the tendency to exaggerate the extent to which a past event could have been predicted beforehand. First systematically investigated by Fischhoff (1975), the bias is sometimes called “Monday morning quarterbacking” or the “I knew-it-all-along effect” (Wood, 1978). The hindsight bias has particularly detrimental effects in the domain of medical decision making. I begin with the classic study demonstrating how the bias diminishes the salutary impact of a medical education exercise.

The Hindsight Bias as an Impediment to Learning

A clinicopathologic conference (CPC) is a dramatic event at a hospital. A young physician, such as a resident, is given all of the documentation except the autopsy report that pertains to a deceased patient. After studying the material for a week or so, the physician presents the case to the assembled medical staff, going over the case and listing the differential diagnosis, which consists of the several possible diagnoses for this patient. Finally, the presenting physician announces the diagnosis that he or she thinks is the correct one. The presenter then sits down, sweating profusely, as the pathologist who did the autopsy takes the podium and announces the correct diagnosis. The cases are chosen because they are difficult, so the presenting physician’s hypothesis often is incorrect.

The entire article is here, behind a pay wall.  Hopefully you can obtain it through your university library.

Physicians and Malpractice Data

On Average, Physicians Spend Nearly 11 Percent Of Their 40-Year Careers With An Open, Unresolved Malpractice Claim

By Seth A. Seabury, Amitabh Chandra, Darius N. Lakdawalla, and Anupam B. Jena

Abstract

The US malpractice system is widely regarded as inefficient, in part because of the time required to resolve malpractice cases. Analyzing data from 40,916 physicians covered by a nationwide insurer, we found that the average physician spends 50.7 months—or almost 11 percent—of an assumed forty-year career with an unresolved, open malpractice claim. Although damages are a factor in how doctors perceive medical malpractice, even more distressing for the doctor and the patient may be the amount of time these claims take to be adjudicated. We conclude that this fact makes it important to assess malpractice reforms by how well they are able to reduce the time of malpractice litigation without undermining the needs of the affected patient.

The research can be found here.

Thanks to Ken Pope for this information.

Medical malpractice: Why is it so hard for doctors to apologize?

Fixing a system built on blame and revenge will require bold ways of analyzing mistakes and a radical embrace of openness.

By Dr. Darshak Sanghavi
The Boston Globe
Originally posted on January 27, 2013


DANIELLE BELLEROSE WENT THROUGH HELL for two years trying to conceive, undergoing nine rounds of fertility treatments before she finally got pregnant with twins in late 2003. Shortly thereafter, the then 28-year-old nurse and Massachusetts native developed a complication that required months of bed rest at home. Suddenly, on a June night nearly three months before her due date, Danielle’s uterus began bleeding profusely. At 4:56 a.m. she had an emergency caesarean section at Beth Israel Deaconess Medical Center. Her daughters, Katherine and Alexis, entered the world weighing only about 3 pounds each.

Everything seemed to go well until the end of the first week. When Danielle and her husband, John, visited the unit, Alexis looked fine, but Katherine appeared mottled and pale. Panicked, Danielle found a nurse, and testing confirmed that Katherine was in profound shock due to necrotizing enterocolitis, a devastating intestinal complication that affects premature babies. The infant’s blood had turned acidic. An X-ray indicated a tear in her bowel. Just after midnight, Katherine was taken by ambulance to Children’s Hospital Boston.

Extremely premature infants such as Katherine and Alexis are entirely unprepared to live outside their mother’s womb. After only 30 weeks of gestation, the newborn heart isn’t fully developed, and the intestines can’t easily digest breast milk or formula. At that age, a baby’s brain often doesn’t remember to breathe. In 1963, when President John F. Kennedy’s son, Patrick, was born prematurely, the only thing to do was “monitor the infant’s blood chemistry,” as a newspaper of the day put it. Patrick Kennedy died after two days. By the time Katherine Bellerose was being cared for in the same hospital, however, new treatments had increased survival rates in very low birth weight infants to 96 percent.

Still, at Children’s Hospital, Katherine struggled to survive. Surgeons made a last-ditch effort to save her life by removing her colon, in the hope that this would halt further damage. She failed to improve. Multiple rounds of CPR were performed.

The rest of the story is here.

Pa. Supreme Court rules general practitioners not held to sex prohibitions

Prohibitions stands for mental health care providers

By Zack Needles

The Legal Intelligencer

Originally published October 15, 2012

In a case of first impression, the state Supreme Court has ruled that general practitioner doctors are not barred from having consensual sex with a patient, even if they are also providing "incidental mental health treatment" to the patient.

In so doing, the court has refused to extend the prohibition that prevents mental health physicians from having consensual sex with their patients -- and makes those who do susceptible to medical malpractice suit -- to general practitioners and family doctors.

In Thierfelder v. Wolfert, the high court ruled 5-1 -- suspended Justice Joan Orie Melvin did not participate in the decision -- to reverse a divided May 2009 Superior Court ruling that both general practitioners and psychiatrists "need to maintain the same trust when rendering psychological care."

Chief Justice Ronald D. Castille, writing for the majority, said that even what might constitute an ethical violation does not necessarily amount to a legal violation.

"The question is not whether this court condones appellant's actions, nor even whether his actions amounted to a violation of medical ethics," Justice Castille said. "We hold here only that, as a general practitioner, appellant was under no specific or 'heightened' duty in tort to refrain from sexual relations with his patient under these circumstances."

The entire story is here.

Overtreatment as Myth

New York Times Letter to the Editor
Originally published September 3, 2012

To the Editor:

Re “Overtreatment Is Taking a Harmful Toll” (Well, Aug. 28): Undertreatment could be a much bigger problem than overtreatment. Studies by the RAND Institute, published in The New England Journal of Medicine, have found significant underuse of preventive testing and treatment for cervical, breast and colorectal cancer, as well as for H.I.V., heart disease and diabetes. RAND concluded that, on average, Americans receive only 55 percent of recommended preventive care and that underuse of such care was a bigger problem than overuse.

Alan Mertz

Washington

The writer is president, American Clinical Laboratory Association.

♦

To the Editor:

The overwhelming medical care in this country is actually appropriate. By emphasizing the bad experiences of a few, this article may end up suggesting to people that they should not trust their doctors.

Defensive medicine is sometimes practiced for fear of malpractice suits, but this should not be confused with the honest effort of the overwhelming majority of physicians to give their patients the best care possible.

Barry E. Rosenbloom, M.D.

Beverly Hills, Calif.

EHRs could mean fewer malpractice claims

By Mike Milard
IT Health News
Originally published August 3, 2012

A study by Harvard Medical School-affiliated researchers, published in June in the Archives of Internal Medicine, showed that Massachusetts physicians who used electronic health records saw a reduction in malpractice claims.

Correlation does not imply causation, of course. But the report's authors say their findings suggest, "implementation of EHRs may reduce malpractice claims and, at the least, appears not to increase claims as providers adapt to using EHRs."

(cut)

"We found that the rate of malpractice claims when EHRs were used was about one-sixth the rate when EHRs were not used," the researchers write. "This study adds to the literature suggesting that EHRs have the potential to improve patient safety and supports the conclusions of our prior work, which showed a lower risk of paid claims among physicians using EHRs. By examining all closed claims, rather than only those for which a payment was made, our findings suggest that a reduction in errors is likely responsible for at least a component of this association, since the absolute rate of claims was lower post-EHR adoption."

The entire article is here.

Sex with patients the biggest no-no for doctors

By Melissa Davey
Health Reporter - The Age
Originally published July 26, 2012

HAVING a sexual relationship with a patient is more likely to see a doctor banned from practising than if they give a patient the wrong operation, miss a diagnosis or breach patient confidentiality, according to new research.

(cut)

Of the 79 cases where doctors were guilty of a sexual relationship with a patient, 64 were removed from practice. Although it was far more common for doctors to be found guilty of inappropriate or inadequate treatment, writing inappropriate medical certificates and records, and illegal and unethical prescribing, they were much less likely to be removed.

The entire story is here.

Thanks to Gary Schoener for this article.

Can Doctors Learn Empathy?

By Pauline W. Chen, MD
The New York Times - Well
Originally published June 21, 2012

Empathy has always been considered an essential component of compassionate care, and recent research has shown that its benefits go far beyond the exam room. Greater physician empathy has been associated with fewer medical errors, better patient outcomes and more satisfied patients. It also results in fewer malpractice claims and happier doctors.

A growing number of professional accrediting and licensing agencies have taken these findings to heart, developing requirements that make empathy a core value and an absolute “learning objective” for all doctors. But even for the most enthusiastic supporters of such initiatives, the vexing question remains: Can people learn to be empathetic?

A new study reveals that they can.

The entire story is here.

Providers to Test Power of Apology in Malpractice Claims

By Robert Lowes

Medscape Medical News

Originally published April 27, 2012

The Massachusetts Medical Society (MMS) wants to prove that clinicians and hospitals can keep medical malpractice out of the courtroom by owning up to their mistakes with apologies — and sometimes cash as well.

The result, says the MMS, will be not only fewer lawsuits but also improved patient safety, less defensive medicine, and lower costs.

Earlier this month, the MMS and 5 other state healthcare organizations announced the start of a pilot program to promote a process called Disclosure, Apology, and Offer, or DA&O. It's a kinder and gentler approach to medical liability reform compared with measures such as caps on noneconomic (pain and suffering) and punitive damages, which are viewed in some quarters as abridging the legal rights of patients.

Like most of organized medicine, MMS supports these traditional liability reforms, but it also sees merit in avoiding the courts.

"The current liability system impedes open communication," says Alan Woodward, MD, a past MMS president and chair of its professional liability committee. "It creates a culture of blame, finger-pointing, and secrecy. We're trying to turn that around into an advocacy system that supports both patients and providers."

The entire article is here.

Thanks to Gary Schoener for this lead.

Malpractice Risk According to Physician Specialty

Blog Editor Note:

According to this study, only 1 in 5 malpractice claims against doctors leads to a settlement or other payout. While doctors and their insurers may be winning most of these lawsuits, there still remains a high amount of legal actions in medicine. This study indicates that, each year, about 1 in 14 doctors is the target of a claim, and most physicians and virtually every surgeon will face at least one in their careers. While these numbers may support those who believe there are a high number of frivolous lawsuits, the authors seek to understand the complexity of these issues.  Also, psychiatrists have one of the lowest lawsuit rates of the medical specialities and one of the lowest number of payouts.

------------------------------

Anupam B. Jena, M.D., Ph.D., Seth Seabury, Ph.D., Darius Lakdawalla, Ph.D., and Amitabh Chandra, Ph.D.

The New England Journal of Medicine

Abstract


Despite tremendous interest in medical malpractice and its reform, data are lacking on the proportion of physicians who face malpractice claims according to physician specialty, the size of payments according to specialty, and the cumulative incidence of being sued during the course of a physician's career. A recent American Medical Association (AMA) survey of physicians showed that 5% of respondents had faced a malpractice claim during the previous year. Studies estimating specialty-specific malpractice risk from actual claims are much less recent, including a Florida study from 1975 through 1980 showing that 15% of medical specialists, 34% of obstetricians and anesthesiologists, and 48% of surgical specialists faced at least one claim that resulted in an associated defense cost or payment to a claimant (an indemnity payment) during the 6-year study period.

Each of these earlier studies has limitations, including the use of older data with limited geographic coverage, reliance on self-reports with limited sample size and low response rates, limited information on physician specialty, and a lack of information on the size of payments. Although the National Practitioner Data Bank includes most cases in the United States in which a plaintiff was paid on behalf of a licensed health care provider, it does not report the specialties of physicians and does not record information on cases that do not result in a payment.

Using physician-level malpractice claims obtained from a large professional liability insurer, we characterized three aspects of malpractice risk among physicians in 25 specialties: the proportion of physicians facing a malpractice claim in a given year, the proportion of physicians making an indemnity payment, and the size of this payment. In addition, we estimated the cumulative career risk of facing a malpractice claim for physicians in high- and low-risk specialties.

Part of the Discussion Section

Our results may speak to why physicians consistently report concern over malpractice and the intense pressure to practice defensive medicine, despite evidence that the scope of defensive medicine is modest. Concern among physicians over malpractice risk varies far less considerably across states than do objective measures of malpractice risk according to state (e.g., rates of paid claims, average payment sizes, malpractice premiums, and state tort reforms). For example, 65% of physicians practicing in states in the bottom third of rates for paid malpractice claims (5.5 paid claims per 1000 physicians) express substantial concern over malpractice, as compared with 67% of physicians in the top third (14.6 claims per 1000 physicians). Although these annual rates of paid claims are low, the annual and career risks of any malpractice claim are high, suggesting that the risk of being sued alone may create a tangible fear among physicians.

The perceived threat of malpractice among physicians may boil down to three factors: the risk of a claim, the probability of a claim leading to a payment, and the size of payment. Although the frequency and average size of paid claims may not fully explain perceptions among physicians, one may speculate that the large number of claims that do not lead to payment may shape perceived malpractice risk. Physicians can insure against indemnity payments through malpractice insurance, but they cannot insure against the indirect costs of litigation, such as time, stress, added work, and reputational damage.  Although there is no evidence on the size of these indirect costs, direct costs are large. For example, a Harvard study of medical malpractice suggested that nearly 40% of claims were not associated with medical errors and that although a low percentage of such claims led to payment of compensation (28%, as compared with 73% of claims with documented medical errors), they accounted for 16% of total liability costs in the system.

The entire article can be read here.