It is well known that there is a high incidence of medical malpractice litigation in the field of obstetrics and gynecology. The 2003 American College of Obstetricians and Gynecologists (ACOG) Survey on Professional Liability1 reported that 76% of respondents experienced at least one claim against them and 57% reported two or more claims thus far in their career with the mean number of claims being 2.6. Obstetrics and gynecology residents are not exempt from these issues as almost 30% reported experiencing a claim against them during residency with 9% having two or more claims.1 Residents have growing concerns regarding medical liability, and a recent 2003 survey2 reports 62% of residents rated liability issues as their top concern in specialty choice and place of practice, which is up from 15% in 2001. This concern does not escape medical students either as a 2003 survey of medical students reports half of the respondents indicated medical liability as a factor in their specialty choice.3
Medical insurance premiums, rates of malpractice claims, and state of crisis or near crisis in most states, are also of utmost concern in the field of obstetrics and gynecology. Many practitioners are changing the way they practice (giving up obstetrics), moving their practice to different states, and even retiring earlier than originally planned due to this crisis.1 To what degree are these issues being addressed in training programs is unknown, and a literature search using Medline search engine (search terms: “Ob/Gyn, residents,” “legal education,” “medical legal education” without restrictions of year or language) did not reveal any publications on the topic of obstetrics and gynecology residency medical–legal education. To address this concern, we decided to survey the obstetrics and gynecology residency program directors to answer these questions.
We received approval from the University of California Davis Medical Center institutional review board for this project. A survey was created on www.freeonlinesurvey.com. (see Appendix 1). The survey included demographic data, inquiries into whether formal or informal education on medical–legal issues were available to residents, the number of sessions, the type of education, whether they were interested in providing this to residents, and a section for comments. There was also one question regarding education on these issues to medical students. This survey was then distributed via e-mail to all obstetrics and gynecology residency program directors as recorded in the Accreditation Council for Graduate Medical Education Residency Directory. For those who did not answer the survey initially, multiple repeat requests were sent via e-mail, and then a paper form of the survey was sent to the remaining directors. Responses were tracked by programs answering question 1, which asked for the program they were representing.
We had a 78% response rate of the 252 registered obstetrics and gynecology programs. Sixty-five percent of programs responded electronically; 13% responded to a mailed survey. Overall, 86% percent of responding programs provide formal and informal instruction on medical–legal teaching. The format that most institutions use are didactic lectures (38%) and grand rounds (30%). Other formats include case conferences (19%), mock trials (9%), and other (4%). The “other” category included joint course with law school, rotation through the legal department during ambulatory rotation (includes case discussions, witnessing depositions and trials, conferences related to on-going medical legal cases), simulator and note documentation, morbidity and mortality conferences, workshops by risk management lawyer, web-based education modules, during orientation, and daily rounds.
The information in these reported sessions included proper documentation (48%), giving a deposition (24%), testifying as a defendant (19%), testifying as an expert witness (6%), and other (2%). The “other” category included tort process, risk management, quality assurance issues (preventive measures versus litigation), what constitutes medical malpractice, common complaints, and how the medical malpractice coverage and process works, and legal process on how a suit is filed to settlement or denial. The average number of sessions per year was 4.1, with a range of 0 to 40, and the median was 3 sessions per year. Most responding programs (88%) are interested in providing more formal education on medical–legal issues to residents despite reporting already having some education programs. Most comments included at the end of the survey were that of the importance of this issue and need for more formal educational programs regarding these issues and tort reform. Other comments included how well mock trials worked, the importance of including legal personnel and law students into these discussions, the crisis that many states are in, and that web-based modules might be helpful.
Our initial hypothesis before starting this survey was that most residency programs did not have formal or informal sessions set up for medical–legal education for obstetrics and gynecology residents. Our hypothesis was incorrect, however, with 86% of program directors reporting some form of education in place. Despite this high percentage, 88% of the program directors felt that their residents needed additional education on this topic. Furthermore, the small number of sessions per year on the topic (4.1) could further limit the exposure of residents to this education. Finally, many of the comments at the end of the survey further confirmed that there is still a need for more extensive and formal teaching in this area. All of this suggests that, while present in the vast majority of programs, it appears that medical–legal education remains inadequate.
The average number of sessions per year was 4.1, which at first glance, may seem to be adequate. With the new work hour restrictions and the creation of a night float at many programs to comply with work hour requirements, it would clearly be possible for a resident to only attend a fraction of these educational programs. In addition to limitations on work time, vacation and off-service rotations could further limit education exposure. There is currently limited data on which method or forum is best for teaching medical–legal issues, but a prior publication using mock trials as one form of education stated that it was well received by the audience with a value score of 23.5 out of 25. This mock trial educational format had a multidisciplinary approach and included obstetricians, pediatricians, and medical students with forty percent of the comments stating the need for more sessions of this kind.4 In addition, many comments in our survey also stated how effective mock trials seemed.
There are some studies regarding medical–legal instruction to residents in other specialties including pediatrics, internal medicine, family practice, and emergency medicine. Forty-four percent of family practice residents surveyed stated that they were not comfortable dealing with issues pertaining to law and medicine and that they thought their medical–legal education was poor or unacceptable.5 Another study of internal medicine chief residents found that only 28% reported that their residency program adequately addressed the medical–legal subject.6 These studies were surveys of residents assessing their education versus our study which is of program directors assessing what they report offering in their programs. Through our MEDLINE search mentioned earlier, we found no reports assessing obstetrics and gynecology resident’s perspectives of their medical–legal training. There are other reports of the usage of learning modules for medical–legal education in residency programs. One emergency medicine residency program implemented a one-week rotation through a medical liability insurance company while another reviewed cases and associated testimony of malpractice cases in which their faculty members had testified.7,8 Other programs created computer educational modules and formal medical–legal curriculums.9,10 All of these programs were successful in either increasing residents’ knowledge of the medical legal system or making them feel more prepared.
There are areas of bias that could affect the results of our survey. Although the response to our survey was high (78%), we do not know if the program directors accurately recalled their amount of education offered, lending to the possibility of recall bias. This bias could exist with the types or number of sessions. Furthermore, the 22% of programs that did not respond could be secondary to their lack of interest in the subject, among other reasons, leading to nonresponse bias.
We are unsure if increasing education on these medical–legal issues will decrease malpractice cases or rates or increase the number of obstetrics and gynecology providers entering or staying in the field. Regardless of this, we believe that exposure of obstetrics and gynecology residents to the medical–legal process in any and all forms will empower them when dealing with the entire process, one of which the vast majority of obstetrician–gynecologists will face. Residents would also be more educated and may be willing to get involved in tort reform issues to assist with changing the tides of the crisis most states are currently in. One possible solution would be that of forming a task force of experts from multiple disciplines to establish a more formal program to be integrated nationwide into obstetrics and gynecology residency curriculums. We conclude that there is a significant opportunity for enhancing the education of obstetrics and gynecology residents in the area of medical–legal education both with increasing frequency and types of these educational sessions.
1. The American College of Obstetricians and Gynecologists Department of Professional Liability/Risk Management. 2003 ACOG survey on professional liability: national ACOG statistics. Washington, DC: American College of Obstetricians and Gynecologists; 2004.
2. Summary report: 2003 survey of final year medical residents 5. Irving (TX): Merritt, Hawkins & Assoc; 2003.
3. Division of Market Research & Analysis, American Medical Association. AMA survey: medical students’ opinions of the current medical liability environment. Chicago (IL): American Medical Association; 2003.
4. Gilbert WM, Fadjo DE, Bills DJ, Morrison FK, Sherman MP. Teaching malpractice in a mock trial setting: a center for perinatal medicine and law. Obstet Gynecol 2003;101:589–93.
5. Saltstone SP, Saltstone R, Rowe BH. Knowledge of medical–legal issues: survey of Ontario family medicine residents. Can Fam Physician 1997;43:669–73.
6. Kollas CD. Chief residents’ medicolegal knowledge. Acad Med 1996;71:417–8.
7. Houry D, Shockley L. Evaluation of a residency program’s experience with a one-week emergency medicine resident rotation at a medical liability insurance company. Acad Emerg Med 2001;8:765–7.
8. Fish R, Ehrhardt M. Review of medical negligence cases: an essential part of residency programs. J Emerg Med 1992;10: 501–4.
9. Balcezak TJ, Lynch P, Jackson S, Richter J, Jaffe CC, Cadman EC. A web-based risk management and medical–legal curriculum for graduate medical education. J Biocommun 1998;25:2–5.
10. Kollas CD, Frey CM. A medicolegal curriculum for internal medicine residents. J Gen Intern Med 1999;14:441–3.
Survey Distributed to Obstetrics and Gynecology Program Directors
- 1) What residency program are you representing? (This is for response tracking purposes.)
- 2) Does your residency program provide FORMAL teaching sessions on medical–legal issues to the residents? (If no, skip to #5.)
- 3) If yes, in what format are these sessions (choose all that apply):
- ○ Didactic lectures
- ○ Grand rounds
- ○ Case conferences
- ○ Mock trials
- ○ Mock trials with local lawyers and/or judges
- Other (please specify):
- 4) If yes, what is the total number of sessions per year?
- 5) Does your residency provide any INFORMAL teaching of medical–legal issues to the residents?
- 6) Do these educational programs, either informal or formal, include information on (choose all that apply):
- ○ Giving a deposition?
- ○ Proper documentation in medical record?
- ○ Testifying as a defendant?
- ○ Testifying as an expert witness?
- Other (please specify):
- 7) Does your department have any programs for teaching MEDICAL STUDENTS medical–legal issues in obstetrics and gynecology?
- 8) Would you be interested in being able to provide some form of education to your residents and/or medical students concerning medical legal issues?
- 9) Any feedback, input, questions, or ideas?
Thank you, we appreciate your feedback and participation in this study.
William M. Gilbert, MD, and Carey Moreno-Hunt, MD