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Q. What types of doctors face the worst malpractice suits?Malpractice Risk, by Physician Specialty (rand.org)Data from 1991 through 2005 for nearly 41,000 physicians covered by a large nationwide liability insurer. At least 200 physicians in each of 24 specialties, allowing analysis of malpractice risk, by specialty. category.)Malpractice ClaimsAcross specialties, 7.4 percent of physicians annually had a claim, and 1.6 percent made an indemnity payment. Among physicians in neurosurgery, 19.1 percent annually faced a claim, but just 2.6 percent in psychiatry did (Figure 1). Physician age, year, and state of practice did not affect these estimates.Specialties with higher proportions of claims do not always incur higher proportions of payments. For example, gynecology had the 12th highest average annual share of physicians with a claim but the highest share with a payment.Indemnity PaymentsAcross specialties, the mean indemnity payment was $274,887, and the median was $111,749 (Figure 2). Specialties most likely to face indemnity claims were not always those with the highest average payments.The difference between mean and median reflects a skewed distribution toward large payments in some specialties. Obstetrics and gynecology accounted for the most payments of at least $1 million, followed by pathology, anesthesiology, and pediatrics.Career Malpractice RiskMost physicians can expect to face at least one malpractice claim over a 30 year career. By 45 years of age, 36 percent of physicians in low-risk specialties are likely to have had at least one malpractice claim, compared to 88 percent of those in high-risk categories. By this same age, just 5 percent in low-risk specialties and 33 percent in high-risk ones are likely to have made at least one indemnity payment. By 65 years of age, 75 percent of physicians in low-risk specialties and 99 percent of those in high-risk ones are likely to have had at least one malpractice claim, and 19 percent of those in low-risk specialties and 71 percent of those in high-risk ones are likely to have had at least one indemnity payment.Findings and ImplicationsThese results confirm malpractice rates in many high-risk specialties found in earlier research based on self-reporting. The results indicate higher malpractice rates than previously reported in low-risk specialties, possibly because of the stigma of a claim in these fields. The results also indicate that many will never have to make an indemnity payment. Nevertheless, the risk of a claim, the possibility of a claim leading to a payment, and the size of a payment contribute to high levels of perceived malpractice risk among U.S. physicians. ■Malpractice Risk According to Physician Specialty | NEJMTop 10 Specialties Sued: 2013 Malpractice ReportNearly 1,400 physicians who were sued for medical malpractice share their experience in Medscape’s recent Malpractice Report.According to the report, the top 10 medical specialties experiencing the most lawsuits were:Most malpractice claims against primary care physicians are a result of missed diagnoses, particularly of cancer and myocardial infarction in adults and meningitis in children, as well as medication errors.Other highlights from the malpractice report include:35% of lawsuits were “failure to diagnose” (17% “failure to treat”)74% of physicians were surprised to be sued24% of physicians sued were dismissed prior to deposition– 45% went to depositions– 21% went all the way to trial61% took up to 2 years to conclude57% of plaintiffs received no monetary award– 18% received up to $100,000– 16% received up to $500,000– 2% received over $2 million62% of responding physicians said the lawsuit result was fair.In almost all cases, the insurer paid the full payout amount.29% of physicians said they no longer trust patients and treat them differently.93% of sued physicians said saying “I’m sorry” would not have helped.Respondents to the malpractice survey advise other doctors to: follow up even when you don’t think you have to; practice more defensive medicine; document more often and more thoroughly; and get rid of rude, demanding, noncompliant patients.Click here to view the full Malpractice Report by Medscape.Medscape Malpractice Report 2015: Why Most Doctors Get SuedPaid Malpractice Claims Among US Physicians by Specialty, 1992-201410 Worst Medical Specialties with Highest Malpractice RatesOur list of 10 worst medical specialties with highest malpractice rates, should give you some insight into which medical jobs are probably the hardest to perform. Being sued can’t be a pleasant experience, and according to statistics by the age of 65 years, 99% of physicians in high-risk specialties are projected to face a malpractice claim. If you think that those belonging in low-risk specialties are in a significantly better position, you are wrong because 75% chance of being sued is still a lot. Because of this, most physicians have a feeling that lawsuit is almost inevitable, and resort to defensive medicine. “Defensive medicine in simple words is departing from normal medical practice as a safeguard from litigation”. Ordering unnecessary tests, avoiding patients with complications, eliminating high risk procedures, are some forms of defensive medicine. The main problem with defensive medicine is that it raises the cost of healthcare, but it can also pose health risks to the patient.wavebreakmedia/Shutterstock.comWhile statistics are very interesting, they still can’t explain why male doctors have nearly 2.5 times the odds of being sued for malpractice than female doctors. Problems in physician – patient communication are claimed to be the biggest cause of malpractice claims, maybe that answers the question as to why female doctors face fewer claims.For our list, we are using data from a study published in the New England Journal of Medicine. We are ranking specialties by the annual probability of facing a malpractice claim, however the study presents data for all the specialties in the form of a graph, only giving exact numbers for some specialties – this is why we will mention only the percentages that are explicitly stated in the text of the study; but this poses no problem for correct ranking. Before we begin with our list of 10 worst medical specialties with highest malpractice rates, it is important to mention that while the specialties on our list have the highest rates of malpractice, they do not necessarily have the highest indemnity payments. For example, pediatrics have a rate of just 3.1% and are not on our list, while at the same time they have the highest average payment of $520,924, which is pretty high considering that average across specialties is $274,887, albeit if you think about it, it is quite logical, because jurors are more likely to be harsh towards a doctor whose mistake caused an injury of a child, than for example towards a doctor that messed up someone’s plastic surgery.10. Oncology (9.14%)Some claims against oncologists are delay in diagnosis of cancer, incorrect chemotherapy dosage, suboptimal pain management for a dying patient, negligence for informed consent.Romaset/Shutterstock.com9. Pulmonary medicine (9.32%)Failure to diagnose pulmonary embolism or lung cancer, premature extubation of a ventilated patient, injury of a patient during bronchoscopy are just some examples of pulmonary medicine malpractice claims.Photographee.eu/Shutterstock.com8. Urology (10.49%)When it comes to urology, the number 8 on our list of worst medical specialties with highest malpractice rates, surgical procedures with postoperative complications are the most common reason for malpractice claims, prostatectomy usually resulting in the most expansive claims. Taking into account that average rate of malpractice claims for all physician specialties is 7.4%, and that urology’s got rate above 10%, it’s not surprising that it is on our list of 10 worst medical specialties with the highest malpractice rates.Image Point Fr/Shutterstock.com7. Obstetrics and Gynecology (11.02%)Events during labor and delivery, missed diagnosis of fetal anomalies, shoulder entrapment with brachial plexus nerve injury, neurological impairment, wrongful birth or death are common claims against Obstetricians/Gynecologists.Africa Studio/Shutterstock.com6. Gastroenterology (11.64%)Medication errors relating to heartburn, errors in diagnosis associated with colonic malignancies are some of the most prevalent claims.Image Point Fr/Shutterstock.com5. Plastic Surgery (12.7%)Some plastic surgery malpractice injuries are: scarring, disfigurement, caving of the surgical site, infection, paralysis, and as with any major surgery – death.iconogenic/Shutterstock.com4. Orthopedic Surgery (14.16%)Total knee/hip replacement, knee arthroscopy, exploration and decompression of the spinal canal, shoulder arthroscopy, and rotator cuff repair, are some procedures that are associated with malpractice claims.Minerva Studio/Shutterstock.com3. General Surgery (15.31%)Annual probability of facing a malpractice claim for general surgery, the number three on our list of worst medical specialties with highest malpractice rates, is 15.3 percent. Surgery on the wrong body part or wrong patient, unnecessary disfigurement, nerve injuries, misdiagnosis, unsterilized equipment are some causes of general surgery malpractice claims.Stoyan Yotov/Shutterstock.com2. Thoracic-cardiovascular Surgery (18.9%)Common errors during Thoracic-cardiovascular surgery are accidental injury of neighboring organs, infection in the chest cavity, sponges or surgical instruments being left in the patient’s body, and of course in the worst cases death. Annual probability of facing a malpractice claim for thoracic-cardiovascular surgery is 18.9%.sudok1 / 123RF Stock Photo1. Neurosurgery (19.1%)If we were to take malpractice claims statistics as a measure of how difficult a surgeon’s job is, we’d come to the conclusion that neurosurgeons have the toughest job. However, it is significant to notice that the difference with thoracic-cardiovascular surgery is just 0.2%, which may be considered negligible and therefore a tie between the two specialties. With the annual probability of facing a malpractice claim of 19.1%, and average indemnity payment of $344,811 neurosurgery is on the top of our list of 10 worst medical specialties with highest malpractice rates.Herrndorff/Shutterstock.comWhen the Doctor Faces a LawsuitWithin months of completing my training, I received the call that every doctor dreads.“You’ve been named in a malpractice lawsuit,” said the hospital administrator on the other end of the line.The family of a patient I had seen briefly a year before believed that a colleague’s decision not to operate hastened her demise. Now their lawyers, combing through the medical records, believed that a single sentence in my note brought that doctor’s decision into question. As a second or maybe even third opinion, I had written that the woman was a “possible candidate” for surgery.The truth was that when I saw her she was a possible candidate, but only tenuously so. In fact, her health deteriorated so rapidly that by the time she finished seeing all the specialists and returned to her original surgeon, the chances of her surviving any treatment, no matter how heroic, were almost nil.Though I knew all that, in the weeks after that telephone call I couldn’t help questioning myself, going over the case in my mind as soon as I woke up, then again and again late into the night. I froze with fear every time I was asked for my opinion on a diagnosis or treatment plan and became a master at evasion, littering my assessments and write-ups with words like “maybe,” “perhaps” and “will await further work-up.” And I wondered if my colleagues knew, if the blot on my record had already soaked through the fabric of my professional reputation.In the end, the family dropped the case; I never met with any lawyers or went to court. But memories of the all-encompassing threat of a claim came flooding back when I read a recent study of how litigation affects doctors.Medical malpractice lawsuits have existed in the United States for more than 150 years, though today, most medical errors are never pursued in court, and a large majority of claims never result in any kind of payment to patients. And even though the direct and indirect costs of such suits account for only 2.4 percent of total health care costs, that’s still $55 billion yearly. To say nothing of the even more important social costs, an issue addressed last month in The Journal of the American College of Surgeons.Researchers surveyed more than 7,000 surgeons and found that nearly one in four were in the midst of litigation. Surgeons involved in a recent lawsuit were more likely to suffer from depression and burnout, including feelings of emotional exhaustion and detachment, a low sense of accomplishment and even thoughts of suicide.“Malpractice is at the top of the list of major stressors for most physicians,” said Dr. Charles M. Balch, the lead author and a professor of surgery at the University of Texas Southwestern Medical Center in Dallas. “It’s right up there with financial distress, serious work-home conflicts and life-and-death circumstances.”Other studies estimate that, depending on the specialty, anywhere from 75 percent to 99 percent of practicing doctors will over the course of a lifetime be threatened with a lawsuit. “We are not talking about some small subset of physicians who are vulnerable because they are weak,” said Dr. Tait D. Shanafelt, a co-author and associate professor of medicine at the Mayo Clinic in Rochester, Minn. “Malpractice affects a wide swath of our colleagues and their patients.”Doctors who have been sued may end up practicing defensive medicine, ordering unnecessary tests and medications or refusing to treat patients with more complex illnesses altogether as a safeguard against future litigation. Those same doctors can also become burned out, which can lead to even more errors, and more malpractice claims.“Burnout may be what reinforces the connections between malpractice, defensive medicine and poor-quality care,” said Amitabh Chandra, a professor of public policy at the Harvard Kennedy School of Government and an economist who has written extensively on medical malpractice.The study authors propose that one way to disrupt the negative cycle is to improve communication between patients and doctors, so that patients are aware of the risks that can occur despite a doctor’s best efforts. Another important step is instituting programs that continue those conversations even after an error occurs. “We need supportive work environments and more programs that allow doctors and patients to resolve issues directly,” Dr. Balch said.But change will require looking at malpractice reform in a new way, one that gives weight not just to the economic costs but to the ways reform might affect how patients and doctors interact.“Ultimately we are dealing with doctors who are working under enormous pressures,” Dr. Chandra said. “For them, the emotional costs are colossal.”Physicians React: Life After a LawsuitSandra LevyHow Does a Malpractice Lawsuit Change Doctors' Lives?Getting sued changes some physicians' lives and the way they view patients. When doctors are sued for malpractice, they often feel anxiety, anguish, depression, a sense of betrayal, and shame. The emotional distress they experience can last a lifetime.A lawsuit can drag on for months, or even years. When the case is pending, many physicians suffer. They don't eat well, they don't sleep well, and they are frequently depressed.After the lawsuit is settled or resolved, many doctors leave their practice, retire early, practice defensive medicine, and look at patients as potential adversaries for the remainder of their careers. Even when doctors win their court case, they may have lost substantial earnings in time away from their practices during court depositions and hearings. Physicians may also suffer in their personal lives.Spurred by a recent article in Medscape, in which five doctors described the emotional stress they went through during their malpractice trials, a lively discussion ensued."Three close college friends were never the same after their stupid lawsuits. It has to be a variant of post-traumatic stress disorder (PTSD), and while we're having a shortage of docs (especially primary care...), our legal system is removing good docs from the front line," said an internist.Sued More Than OnceAn ob/gyn who was sued three times expressed the emotional toil that ensued:All cases were settled, mainly because it was cheaper and because I was not sure that I could tolerate the emotional effects of a trial. I did continue to practice and didn't always see patients as adversaries, but I do think it took its toll. I retired at 60 after practicing for 30 years in ob/gyn with a main hospital that serviced an underprivileged community. I retired from exhaustion and burnout. I loved my work, and if it were possible to practice with shortened hours and without risk for lawsuits, I would still be working.Yet another physician who has experienced more than one lawsuit said:I was sued for something that was done by another medical provider without my knowledge. After over 3 years of stress, I was found not liable and dismissed. Two years later, I was just starting to feel like my life was getting back on track. Another suit was filed by the relatives of a deceased nursing home patient who had a court-appointed guardian. I cared for that patient for several years. Those relatives never once came to see him. The suit was dismissed, but my anger remains. Now it is no longer enough to provide good care and relate well with patients and families. Apparently, we are now supposed to relate well to family members we do not even know exist. I am actively planning for retirement and now work primarily on administration. If I had it to do over again, I would never have gone to medical school.A cardiologist who worries about lawsuits said:Now that I'm in private practice, I have fear of being sued, which does force me to spend extra hours every day to make sure I documented well. Between this and the pressure of sustaining productivity in private practice, it does affect other aspects of my life. I do ask myself whether I did the correct thing going into medicine...but my answer is "yes, I did"...the problem is, maybe I'm practicing in the wrong country. It's almost impossible to get sued in other countries, and it is based on true medical neglect. Unfortunately, it doesn't work that way in this country, and this is why we have sky-high medical costs, medical fraud, and sometimes a lack of trust in your own patients.A Call for Tort ReformSeveral respondents were adamant that tort reform is needed to protect physicians. An internist said:We desperately need tort reform. To paraphrase Atul Gawande, 'I do approximately the same number of surgeries a year as ground balls fielded by a major league third baseman. If that third baseman makes two errors, he wins the gold glove. If I make two errors, then patients end up injured, or worse.' Point being, we all make mistakes, and of course there needs to be a way to compensate those who experience bad outcomes. Unfortunately, our current system results in unnecessary stress, loss of productivity, defensive medicine, and logjams in our judicial system.Another call for tort reform came from a dermatologist:All of these cases and replies are further evidence of how bad tort law is in this country. If, like most of civilization, a plaintiff MUST PAY damages to the winning defendant, it is highly probable that none of these suits would have taken place. The pathetic Band-Aids of tort reform would not change the fact that the doctor and all of his other patients and the whole of society, other than the plaintiff and his client, LOSE as soon as a suit is filed, even when the defending doctor "wins," the dermatologist added.Some physicians took an even stronger stand. An otolaryngologist commented:Doctors shouldn't complain about the high cost of malpractice insurance. They should threaten to withhold their precious lifesaving skills until unscrupulous patients and their predatory lawyers back off. The legal system is not set up to be fair to doctors, and the reason is that doctors have allowed it to evolve that way. We only have ourselves to blame, really.A family medicine doctor reported, "I know directly of at least one case where the case was lost, and the subsequent emotional toll on the physician was catastrophic. Another I know of indirectly where the loss of the malpractice suit was followed by massive clinical depression."Finally, an ophthalmologist whose lawsuit lasted 7 years said:I had seen a patient for ptosis of the upper eyelids who also complained of excessive tearing of his eyes. I had found that this was due to laxity of his lower eyelids and recommended repair at the same time. He declined. After the surgery, he sued me because I caused his eyes to tear even though my records documented that the problem was preexisting. Even his wife sued me separately for lack of consortium. He also alleged lack of informed consent. The charges stated that I coerced him into signing the consent on his gurney on the way into the operating room. The fact that the surgical consent was signed 7 days earlier in my office and was witnessed did not influence the judge who allowed the suit to go forward. Seven years of grief and heartache.Finally, the suit was dismissed the night before trial because the plaintiff's attorney admitted that they had tried all those years to get an expert witness to represent him and couldn't do so. He ultimately had gone to another hospital and had the lower lid laxity repaired (which I had recommended), and his tearing problem resolved.A wary physician had this advice for colleagues: "Don't give the plaintiff attorney any information. He/she may be fishing for discovery without the cost of discovery. In my case, it was a friendly phone call asking for my side of what happened. I took the call. Wrong. Call your malpractice carrier immediately. Follow the advice of the attorney assigned to you."Five Doctors Tell 'How I Survived After Being Sued'It's Easy To Predict Which Doctors Will Face Malpractice SuitsOJO_IMAGES VIA GETTY IMAGESA tiny fraction of doctors are responsible for a surprising number of malpractice claim settlements, according to new research published in The New England Journal of Medicine.Just one percent of doctors were linked to 32 percent of malpractice settlements paid out between 2005 to 2014, according to anonymized data collected from the U.S. National Practitioner Data Bank, which tracks nationwide information on all practicing physicians’ malpractice suits and their settlements.What’s more, the greater the number of claims a doctor settled, the chances they’d pay out another one in the future were exponential. Doctors who settled two malpractice suits had about twice the risk of being involved in a third settlement when compared to those with just one settlement. And doctors with three paid malpractice settlements were three times more likely to be accused of malpractice and pay out again.The highest risk doctors — those with six or more paid settlement claims — had more than 12 times the risk of a recurring settlement payment.While the study’s findings are meant as a wake-up call for hospitals and liability insurers, they are also an important reminder to patients that a minority of doctors may still be practicing despite disturbing track records.Who is most likely to face malpracticeCertain kinds of doctors are more likely to be involved in recurring malpractice settlements. Neurosurgeons, orthopedic surgeons, general surgeons, plastic surgeons and OB/GYNs were about twice as likely to have repeat malpractice settlements compared to internal medicine doctors, even after the researchers controlled for the inherent risk of things like surgery.Male doctors were also 40 percent more likely to have a recurring settlement compared to their female colleagues, while physicians younger than 35 only had about one-third the risk of recurrence compared to older ones. As these young physicians grew older, their risk of recurrence increased.In all, the study analyzed 66,426 paid malpractice claims for 54,099 doctors over ten years. Almost one-third of the claims centered around patient deaths. Fifty-four percent were suits about serious physical injury. Most malpractice lawsuits ended in settlements and averaged $371,054; only three percent resulted in verdicts.How patients are protectedBy federal law, when a hospital is thinking about giving a doctor admitting privileges in their institution, they have to look up his or her malpractice and disciplinary history in the Data Bank. Only hospitals, medical boards and federal investigators are allowed to query the databank in full, so patients don’t have access to this information.In one sense, patients can feel assured that the hospital has already vetted a doctor and knows their full history, good or bad. But the law doesn’t stipulate what hospitals do with that information, or how it should inform their decision-making process, which explains why some high-risk doctors are still working.The study’s lead researcher David Studdert, a medicine and law professor at Stanford University School of Medicine, says he intended his findings to be a call to hospitals, liability insurance companies and other institutions about this minority of high-risk doctors. Studdert calls his work an important step in developing a predictive, national tool that could one day identify high-risk physicians before they start accumulating malpractice claims.“Can you identify high risk physicians early on?” Studdert said. “If the answer is yes, then [institutions] want to hook into some kind of intervention program that can get in and reduce those risks.”If our study provokes a debate about what the right level of transparency is for multi-claim physicians, I think that’s a good thingDavid Studdert, senior researcherWhat malpractice actually meansOverall, very few doctors are sued for malpractice. Over the 10-year period Studdert analyzed, only six percent of all practicing American doctors were linked to a paid malpractice settlement. And just because a doctor chose to settle a malpractice suit, it doesn’t necessarily mean he or she is admitting to malpractice, he pointed out. It could be a strategic move to avoid the costs of a lengthy lawsuit. It also could be that an investigation revealed he or she delivered substandard — but not negligent — care, and the settlement is an acknowledgment of that.“It may be that the physician is delivering substandard care, it may be that physician has poor conversational skills or some combination of those things,” Studdert said about recurring claim settlements. “But either way it’s a little bit of a warning sign and suggests at the very least that someone should be looking into the quality of care that clinician is delivering.”Some states make data malpractice settlements and disciplinary action for doctors available through the state medical board, either on a website or by submitting a formal request, according to The Washington Post. Consumer sites like docinfo.org or healthgrades.com, which spit out reports on disciplinary actions and settled lawsuits, are also avenues for research, notes the Post. But the information probably won’t give you much insight into why that claim was settled, or for what.Say you’ve got an upcoming breast cancer surgery and you want to research your surgeon. You may not know if the claim settled against your doctor was for breast surgery or something else completely unrelated to the type of procedure you’re getting, says Studdert, which makes this kind of data imperfect.Arthur Caplan, founding director of the division of medical ethics at NYU’s Langone Medical Center, pointed out that another problem with the available public databases is that they show only settled claims — not ongoing lawsuits. Patients could try to ask the doctor or surgeon face-to-face how many malpractice suits they’ve settled or how many are ongoing, he added, but while they should expect an honest answer, there are “no guarantees.”“I don’t think the potential patient can do much except get second opinions,” said Caplan.While Studdert’s findings are aimed at hospitals and other medical institutions, he understands the curiosity and worry it might arouse in patients. But he hopes his analysis demonstrates that malpractice lawsuits are a highly concentrated phenomenon among a small percentage of practicing doctors, and that the claims are skewed even more toward a few physicians who are sued again and again.“If our study provokes a debate about what the right level of transparency is for multi-claim physicians, I think that’s a good thing,” he concluded.5 of the worst medical malpractice cases (today.mims.com)