Barbieri, Robert L. MD1
From the 1Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts.
Corresponding author: Robert Barbieri, MD, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts; e-mail: email@example.com.
OBJECTIVE: The purpose of this study was to test the hypothesis that the percentage of subspecialists in obstetrics and gynecology who made payments on professional liability claims was less than the percentage of general obstetrician–gynecologists who made payments.
METHODS: Professional liability payment data from the Massachusetts Board of Registration in Medicine was used.
RESULTS: During the 10 years preceding August 2005, 38.6% of obstetrician–gynecologists and 32.2% of gynecologists made at least 1 professional liability payment. During the same time period, the percentage of subspecialists who made a payment was significantly less than obstetrician–gynecologists: gynecologic oncologists 10.0% (P = .012), maternal–fetal medicine 3.7% (P = .002), and reproductive endocrinologists 11.9% (P = .016). Using aggregate payment data for the period 1994–2003, the average payment per claim for specialists in maternal–fetal medicine ($1,950,000) and gynecologic oncology ($1,014,006) were above the average payment per claim for obstetrician–gynecologists ($447,983) or gynecologists ($400,338). Reproductive endocrinologists had an average payment per claim of $454,047.
CONCLUSION: All specialists in the field of obstetrics and gynecology have major professional liability risks. Among subspecialists in obstetrics and gynecology, the favorable trend toward fewer physicians making payments is counterbalanced by greater payments per lost claim.
LEVEL OF EVIDENCE: II-2
Professional liability is an issue of paramount importance to all obstetrician–gynecologists.1 Many studies demonstrate that professional liability exposure has an important effect on recruitment of medical students to the field2 and retention of physicians within the field and within a particular state.3,4 Very little information is available concerning the professional liability experience of subspecialists in gynecologic oncology, maternal–fetal medicine, and reproductive endocrinology and infertility. The purpose of this report was to test the hypothesis that fewer subspecialists in obstetrics and gynecology make payments on professional liability claims than general obstetrician–gynecologists. Data from the Massachusetts Board of Registration in Medicine was used for the analysis.
Professional liability claims payment data were obtained from the Massachusetts Board of Registration in Medicine. The Board administers the initial licensing of physicians and requires license renewal every 2 years. In the licensing process physicians self-identify their practice specialty. Within the field of obstetrics and gynecology, physicians can identify themselves as practicing obstetrics and gynecology, gynecology only, gynecologic oncology, maternal–fetal medicine, or reproductive endocrinology and infertility. As part of the license renewal process, physicians are required to report their professional liability claims and payment history. The Board of Registration in Medicine also collects liability payment information from the court system, insurance carriers, hospitals, and other health care facilities.
Professional liability payments are summarized by the Board of Registration in Medicine in 2 different systems: the Physician Profile system5 and the Medical Malpractice Analysis report.6 Using the open-access Internet-based Physician Profile system, the professional liability payment experience for every licensed physician for the past 10 years can be obtained. For physicians with no payment history, the Physician Profile system indicates that the physician has not made a payment in the past 10 years. For a physician with a professional liability payment within the past 10 years, the Physician Profile system provides an updated count of the number of Massachusetts physicians licensed in the specialty or subspecialty and the number who made payments in the last 10 years. The Physician Profile system does not provide the dollar amount of the payments, but only indicates whether the payments were above average, average, or below average. This data set was queried in August 2005 to generate the data presented in Table 1. This data set is continuously changing as the active number of physicians practicing in the state and the number of payments made is continuously updated. In addition, when the Physician Profile is queried in 2005, payments made more than 10 years in the past are no longer available for viewing in the system.
A second data set generated by the Board of Registration in Medicine is the Medical Malpractice Analysis report. This report provides a summary of the total payments made by physicians within each major specialty and recognized subspecialty. The most recent Medical Malpractice Analysis report was released in November 2004 and covers the period 1994–2003. This report was used to generate the data presented in Table 2. Major differences between the Physician Profile system and the Medical Malpractice Analysis report are that the Physician Profile system provides information at a single point in time based on physicians who are currently licensed in the state in the practice category and does not include aggregate payment data. The Medical Malpractice Analysis report provides information on all physicians who were ever licensed to practice in the state during a 10-year period, which is a greater number of physicians than are actively practicing at any 1 point in time. The Board of Registration in Medicine collects but does not report to the public the number of claims made that did not result in a payment.
Statistical differences were tested with the Fisher exact test. The Partners Healthcare System Institutional Review Board provided an exemption for this research.
Table 1 presents the number of active specialists in each practice category in August 2005, the number of specialists making liability payments during the preceding 10-year interval (1996 to 2005), and the percentage of specialists making a liability payment as reported in the Physician Profile system. Among obstetrician–gynecologists, 38.6% made a liability payment from 1996 to 2005. Among gynecologists, 32.2% made a liability payment in the time interval. When subspecialists were compared with general obstetrician–gynecologists, fewer subspecialists in the fields of gynecologic oncology (10.0%, P = .012), maternal fetal medicine (3.7%, P = .002), and reproductive endocrinology (11.9%, P = .016) made payments. When compared with gynecologists, fewer subspecialists in maternal–fetal medicine made payments (P = .012). Differences between gynecologists and gynecologic oncologists (P = .067) and reproductive endocrinologists (P = .084) did not reach statistical significance. The relatively small number of physicians in the practice categories of gynecology, gynecologic oncology, and reproductive endocrinology limit the statistical power of the analysis. Because this analysis included all physicians licensed in Massachusetts in August 2005, the power problem can only be approached by adding physicians from other states or lengthening the interval of analysis beyond 10 years.
The average payment for each practice category using the payment data provided in the Medical Malpractice Analysis report for the period 1994–2003 is presented in Table 2. It should be noted that the period in Table 1 (1996 to 2005) is different from the period used in Table 2 (1994–2003). The aggregate payment data for the period 1996 to 2005 is not yet available. The average payment per lost claim was similar for obstetrician–gynecologists, gynecologists, and reproductive endocrinologists. The average payment per lost claim was greater for gynecologic oncologists and maternal–fetal medicine specialists. Statistical testing between groups was not possible because the payment for each claim was not available, only the average payment for each subspecialty area.
Based on the data from the Massachusetts Board of Registration in Medicine, a significantly smaller percentage of subspecialists in the fields of gynecologic oncology, maternal–fetal medicine, and reproductive endocrinology and infertility made liability payments than general obstetrician–gynecologists during the period 1996 to 2005. However, for both gynecologic oncologists and maternal–fetal medicine subspecialists, the average payment per lost claim was greater than for obstetrician–gynecologists. The average payment per lost claim was similar for obstetrician–gynecologists, gynecologists, and reproductive endocrinologists. These data indicate that in obstetrics and gynecology both generalists and subspecialists have significant liability risks. Surprisingly, the risk profile for gynecologists was substantially similar to the risk profile for obstetricians.
This study did not gather data to identify directly the factors that result in fewer subspecialists making liability payments. Many potential factors could account for the observed difference, including level of clinical activity per physician, practice site (community compared with teaching hospital) and risk profile of the clinical activity of each physician. In many situations, subspecialists provide complex care to “high-risk” patients who have been told that they have an extraordinarily complex clinical problem. These patients who have been labeled “high-risk” may be more willing to accept adverse clinical outcomes without pursuing litigation. In contrast, patients who believe they are “low-risk” and then suffer an adverse clinical outcome may be more willing to pursue litigation against their general obstetrician-gynecologists.
The Massachusetts Board of Registration in Medicine data has many strengths. It is a comprehensive database of all liability payments for all physicians in 1 state over an extended period of time. The data set is likely to be accurate because of the multiple overlapping sources used to collect the information. This data set contains a large number of payment events (N = 554) that were made by a large number of physicians (N = 1,297). In addition, this data set provides information for subspecialists in obstetrics and gynecology that is not readily available from other sources.
The data used in this report have significant limitations that preclude a more detailed analysis of the liability experience of subspecialists. Although the Board of Registration in Medicine collects the total number of claims made against physicians, it currently reports to the public only the claims for which payments were made. This approach to reporting is intended to protect the reputation of physicians from frivolous liability claims. In the absence of data concerning the total claims filed it is not possible to analyze the number of claims filed against subspecialists compared with general obstetrician–gynecologists to determine whether subspecialists are less likely to be named in suits or are better able to defend claims successfully. In addition, the Board of Registration in Medicine only reports to the public the number of paid claims and the aggregate dollar value of all claims paid by practice category but not the dollar value of each individual paid claim. This reporting system permits the calculation of the dollar value of the average claim paid, but prevents a determination of the variance around the average. The data presented in this report are limited to the experience in a single state. Professional liability payment experience of subspecialists may be very different in other states.
Technical issues involving the aggregation of data in each of the practice categories affects the data quality and interpretation. Physicians in the gynecology-only category often practiced general obstetrics and gynecology before evolving their practice to gynecology-only. Some of the payments attributed to the physicians in the gynecology-only practice category are likely to have been obstetrics cases that took many years to settle, and once settled, were assigned to the physician who was then in the gynecology-only category. Detailed clinical data to help separate the obstetric cases from the gynecology cases for physicians in the gynecology-only category are not available to the author. Given the small number of subspecialists and the small number of payments made by subspecialists, a single major event that occurs outside of the interval used in the analysis could produce wide swings in the results. For example, the payment data reported in Table 2 is for the period 1994 to 2003 and is the most recent available data. However, in 2004 a reproductive endocrinologist in Massachusetts made an above-average multimillion dollar payment. This payment was not available for inclusion in the 1994 to 2003 data set, but it will cause the mean payment per claim for reproductive endocrinologists to rise significantly in the next Board of Registration in Medicine report. A single large payment can result in significant changes in the average payment per claim data. The nature of the professional liability system, with an occasional well above average payment, affects the statistical stability of many analyses. Consequently, it may be difficult to establish a stable individual risk pool for each group of subspecialists.
The data presented in this report indicate that all specialist areas within the field of obstetrics and gynecology have significant liability risks. Among subspecialists in obstetrics and gynecology, the favorable trend toward fewer physicians making payments is counterbalanced by greater payments per lost claim. The professional liability crisis is a growing, world-wide issue.7 It is likely that the problem can only be improved by a multidimensional approach that involves tort reform and clinical changes that reduce liability risk.
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