Myths About Medical Malpractice

Myths About Medical Malpractice

117
SHARE

A few days ago, I found myself involved in a debate over malpractice suits on The Heath Care Blog. One reader on the thread explained why, in his view, we need some type of tort reform: “What drives physicians to practice defensive medicine is the total lack of objectivity, fairness and consistency both across jurisdictions and even within a jurisdiction as to how medical disputes are decided. Juries of lay people who cannot understand the often conflicting scientific claims in these cases can be easily swayed by emotion and sympathy for injured plaintiffs.

“The inclination to practice defensively is especially prevalent in ER’s when the doctor and the patient often don’t know each other and there is time pressure to determine a diagnosis and send the patient on his or her way,” he added. “I’ve heard from plenty of doctors who work in inner city ER’s that even poor people are not shy about suing when there is a bad outcome if they can find a lawyer to take their case which they often can.”

This comment pretty well sums up the conventional wisdom about medical malpractice cases: Juries are not objective, don’t understand the evidence, and tend to sympathize with the patient. Meanwhile, doctors should be wary of those low-income patients in ERs. Americans are litigious by nature and if patients are not entirely happy with the outcome, they’ll jump at an opportunity to turn misfortune into a payday. Poor people, who need the money, are even more likely to try to “score.”

Those are the fictions.

Here are the facts, according to Drs. John Glasson, and David Orentlicher, writing in JAMA:

“Over the years, our understanding of medical malpractice has been plagued by a number of myths, many of which have been exposed by a remarkable series of reports.” ( Here, they footnote studies published in as number of peer-reviewed medical journals. ) “As a result of these reports, and contrary to popular belief,” they add, we know that “adverse events due to negligent practice rarely result in a lawsuit (only 2% of such events lead to malpractice claims), juries are not systematically biased against physicians (malpractice defendants win more than two thirds of cases, a better record than defendants in other kinds of personal injury cases), and juries decide cases on the basis of the physician’s quality of care rather than the patient’s severity of injury.”

The Difference between Malpractice and Other Personal Injury Cases

We have had this information for years. Glasson and Orentlicher published their piece in the early 1990s. Since then, newer research has only confirmed the critical difference between medical malpractice cases and other personal injury lawsuits. Writing in Emergency Medicine News, Dr. Jonathan Glauser, an ER physician at the Cleveland Clinic, points out that “While plaintiffs win an average of 50 percent of all personal injury cases, recent evidence reveals that Medical malpractice represents a consistent deviation from that average. In 2001 a large study showed plaintiffs winning only 27% of [malpractice] cases, while in 2006, a smaller study found them winning only 21 percent of the time.”

Glauser goes on to report that that “a more exhaustive investigation done in 2007, which looked at independent evaluations of cases by medical and legal experts, found that even when plaintiffs have “strong evidence of negligence,” they win only about half of the time. (Mich Law Rev 2007;105:1454.)

“Generally the assessment [of the evidence] was made by one or more physicians,” Glauser notes, and “the results are surprising but consistent.”) He then points to yet another study of malpractice cases, where the win rate was even lower –just 42 percent– even in cases where physicians assessing the claims concluded that “the quality of care was poor.” (Ann Intern Med 1992;117:780.)

It is difficult to explain the difference between malpractice cases and other personal injury claims. Why are plaintiffs more likely to prevail if they sue an automaker claiming that a defect in the design of the car caused an accident, than if they sue a hospital or a doctor? “Some experts say juries tend not to grasp complexities, which each side tends to introduce into a case, and therefore the juries side with the doctor,” Glauser explains. “In cases like these, the jury gives the physician the benefit of the doubt that his management was consistent with good medical practice when there is an appearance of legitimate conflict. Case complexity favors defendants, or so say some experts.”

I would add that most Americans trust their doctors. They also want to believe that our hospitals are safe. Few are eager to know how many hospital patients are killed or permanently injured by medical mistake. When it comes to the question of whether a large corporation will knowingly sell an unsafe product, consumers are far more cynical.

At Best, Perhaps Five Out of Six Plaintiffs Find Justice

In 2006, the NEJM published a review of malpractice claims sponsored by Harvard’s School of Public Health which has come to be seen as the gold standard for such research. The authors (who included Harvard surgeon Atul Gawande) argued that earlier studies had been flawed in various ways. Some “focused only on a small numbers of claims, a single hospital, insurer, specialty, or type of injury; others used very limited information in the determination of merit, or relied on the insurer’s view of the defensibility of the claim as a proxy for merit rather than on independent expert judgments.”

This study was designed to avoid those limitations. Independent physicians reviewed 1452 closed claims involving five malpractice insurance companies in four regions of the United States. The suits covered approximately 33,000 physicians, 61 acute care hospitals (35 of them academic and 26 nonacademic), and 428 outpatient facilities. In each case, physician-reviewers were examining cases in their own specialty.\

Reviewers followed the Institute of Medicine’s definition of error: “the failure of a planned action to be completed as intended (i.e. error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).”

The results of this larger, more carefully controlled study confirmed that juries seem to favor the defendant in a malpractice trial. When physician-reviewers were asked about the fairness of the verdicts, and whether medical error caused the poor outcomes, they concluded that “one in six claims involved errors but received no payment.” As a result, the authors point out: plaintiffs were forced to “shoulder the substantial economic and noneconomic burdens that flow from preventable injury.”

“One in six” (or 16 percent) is better than 50 percent. But it is worth noting that the physician-reviewers deemed 23 percent of the cases “too close to call.” After considering all of the details, they couldn’t decide whether a bad outcome was due to negligence. (Glauser also points out that when independent doctors evaluate the merits of malpractice suits, they disagree with each other about one-third of the time.)

Those “too close to call” claims were (rightly) excluded from the final tally. But assuming, for the sake of argument, that in one-third of those ambiguous cases, a medical error did cause injury, the percent of worthy, but unrequited claims might run as high as 24 percent. (Obviously “one-third” is an arbitrary shot-in-the-dark. We just don’t know. )

How Often Do Patients Win Awards When No Error Was Made?

When it comes to the fairness of financial awards, the physician-reviewers found “Plaintiffs were paid in cases where the reviewers found no error only 10 percent of the time. Plaintiffs were NOT PAID in cases where the reviewer found that there Was error 16 percent of the time. Thus, nonpayment of claims with merit occurred more frequently than did payment of claims that were not associated with errors or injuries. ”

It may be heartening to read that in cases where the reviewers found evidence of errors, plaintiffs were paid 84% of the time. But the fact plaintiffs won damages when the reviewers saw no evidence of malpractice in 10% of all case is extremely disturbing. Imagine the damage not only to a doctor’s reputation but to his psychic health when an award is made, even though he or she did not make a mistake. Just being sued is a hellish experience; being found guilty when you did no wrong is an injustice that could make a person want to give up the practice of medicine. (This is one reason why I would like to see our malpractice system focus on “How can we prevent this from happening again?” rather than “Who is to blame?”)

How could so many patients win awards in cases where there appears to have been no malpractice? Juries and even judges are human. A charismatic trial attorney may sway the jury; an unattractive, arrogant, or unrepentant defendant may prejudice his own case. More importantly, medicine is shot through with uncertainty.

Note that when the physicians who reviewed the cases in the Harvard study were asked to rate their judgments using a 6-point confidence scale, they reported that they had a “high level of confidence” in their assessment of the case only 44 percent of the cases. This signals that, in some cases where they found no error, they may have been wrong. Of course, when they found negligence, they also could have been mistaken. Though in cases where they genuinely were not sure, physician- reviewers might be more likely to see the case through the doctor’s eyes and err in his favor.

Finally, one might wonder, how could a case in which no mistake was made ever get to court? Here the problem is that when a doctor or hospital is sued, they usually stonewall the plaintiff and his or her attorneys. The defendant’s lawyers instruct them not to talk to the patient or her family. Nurses or others who witnessed the event are told to clam up. Often, the only way a patient or her relatives can find out “what happened” is by suing.

The authors of the Harvard School of Public Health Study explain that when they looked at the claims where reviewers found no error, these suits did not fit the popular profile of “frivolous” suits bought by “opportunistic trial lawyers pursuing questionable lawsuits . . . Rather, our findings underscore how difficult it may be for plaintiffs and their attorneys to discern what has happened before the initiation of a claim and the acquisition of knowledge that comes from the investigations, consultation with experts and sharing of information that litigation triggers. Previous research has described tort litigation as a process in which information is cumulatively acquired.”

Preparing for trial involves a process which lawyers call “discovery.” Typically, the plaintiff asks the defendant to open his files and computers to produce documents which may show what actually happened. If the plaintiff asks for 100 documents, the attorney for the defendant sends him 1000, maybe 2000. (This is what litigators call “burying the other guy in paper.”) Discovery can drag on for a year or two.

Depositions also yield information. But if a case is complex and involves many actors, it could be at least two years before the plaintiff and his attorney begin to figure out what probably happened. (This goes a long way toward explaining why cases that involved no medical error wind up in the system.)

At that point, both parties have invested an enormous amount of time and money. Acrimony has built. One or both may refuse to settle. In cases where the doctor or hospital are quite certain that they are innocent, they are more likely to insist on going on to court. Insurers may press for a settlement, but reviewers have found that when the evidence against the health care provider is weak, the case is more likely to go to trial.

“Most of These Very Poor People Don’t Make Waves.”

Who brings malpractice claims? In the Harvard study of 1452 claims, sixty percent of the plaintiffs were female. The median age of the plaintiffs was 38 years; 19 percent were newborns, and just 12 percent were 65 years of age or older. Obstetrician-gynecologists were the most frequently sued (19 percent), followed by general surgeons (17 percent), and primary care physicians (16 percent).

As for the idea that poor patients are more likely to sue, a 2009 article published on ACP Internist , a blog sponsored by the American College of Physicians, notes that while “Many doctors think it is ‘poor patients on welfare’” who sue, “evidence shows that low income patients on Medicaid are actually less likely to sue than others.”

The research is consistent. Another study, published in JAMA looked at lawsuits at 51 hospitals in New York State: “Poor and uninsured patients are significantly less likely to sue for malpractice, even after controlling for the presence of medical injury,” the authors wrote. “Fear of malpractice risk should not be a significant factor in the decision to serve the poor. Tort reforms that would protect physicians who serve the medically indigent from malpractice suits may not be warranted.”

I cannot help but be reminded of what Dr. Liz Dreesen, a physician who had practiced in a small mill town in North Carolina, told me when I was writing Money-Driven Medicine: “Most of these very poor people don’t make waves.” The indigent are not demanding. In the game of life, they are accustomed to losing, and as a result, they are not as likely to be as shocked or indignant as you or I might be if we were injured because someone forgot to wash his hands.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

In Part 2 of this post, I will write about possible solutions to what Atul Gawande has called “the malpractice mess”: caps on awards (including a bill that is now in the House) and “health courts,” where an expert judge makes the decisions. I also will discuss the uncertainties of medicine which can make it so difficult, even for a physician, let alone a judge, to discern whether medical error caused a poor outcome. Finally, I’ll focus on the high cost of lawsuits, and explain why “apology and disclosure” makes far more sense than the bitter and costly adversarial system that we now use to try to sort out “what happened.”

Leave a Reply

117 Comments on "Myths About Medical Malpractice"


Guest
Carol Levy
Sep 18, 2014

This is a video synopsis of my medical malpractice case and how the doctor essentially got away with proven malpractice and perjury and the lawyer essentially worked for the defendant doctor.https://www.youtube.com/watch?v=R12rJd7BlvU

Guest

Hiii..,
This article is giving us the best idea and basic knowledge about nyc medical malpractice lawyer. I got impressed. Nice one. Thanks a lot.
nyc medical malpractice lawyer

Guest
Dec 19, 2013

My brother recommended I would possibly like this website.
He used to be entirely right. This post actually made my day.
You cann’t believe simply how so much time I had spent for this information!

Thank you!

Guest
Dec 16, 2013

Regarddlesѕ of the tyе of business that you own, as far as tax requiremеnts go most busineѕs are slotted in the same category.

Obvious examples of a breawch woulԁ inсlude trip hazards.o A child under the аge of 12 that is working on their parents’ farm, or on a small farm with theіr parents’ peгmissіon.

Look into my websіte :: website

Guest

The color of your blog is quite great. i would love to have those colors too on my blog.

Guest
Jul 23, 2011

Interesting I see immediately the post about cant tell if went thru but neither of my other replies so I will try again.
“How insensitive and thoughtless can someone be?! Why don’t you get sued and go through the uneventful process of discovery, depositions, accusations, and other unconsequential experiences of the process of going to court and then tell us how you didn’t panic.”

Try being a patient and going through it. Try having to pay out thousands of dollars that you don’t have to keep the lawsuit going. Try doing it while you are suffering the consequences of the malpractice, in my case diisfigurement and pain.

Dr. Peter J. Jannetta paralyzed my face doing a Jannetta Procedure (for trigeminal neuralgia) He told me, in response to a direct question “I promise you your face cannot be injured.” I awakened with a 100% paralysis of the left side of my face. Defensive presurgical EMG showed injury to the facial nerve from a prior procedure – done 3 months before this dsurgery. That showed good chance of injuring the facial nerve completely. Only problem the facial nerve specialist wrote in chart the emg should have been evaluated before the Jannetta procedure.
Dr. Jannetta testified perjuriously re the risks, In 2 depositions he said, facial paralysis was a “major and common complication”. On the stand he said it was :”unknown.” The appeals court in retunring the case to the lower court stated “”We have little difficulty in concluding that Dr. Jannetta’s testimony at deposition was different than, or inconsistent with, the testimony at trial.” Levy v Jannetta, CCP Allegheny County, GD 81-7689; appeal -J. A370017/92 Levy v Jannetta et al, No. 00150 Pittsburgh, 1992. settled, 1995.” Nevertheless a juror, when asked later whom she believed said “I believed the doctor.” There was no point in asking her which time.
Doctors refused to testify ‘he is my friend’ or I won;t testify against Dr. Jannetta. It could cost me in the neurosurgical community.”
Nurses said “I could lose my job.”
My attorney forced me to settle for bupkis, the amount so low it is you the taxpayer who is helping to pay for my lifetime complications and medical care subsequent to the surgery.
The amount was to the limit of his insurance and the CAT fund picked up the rest. It did not cost him anything out of pocket.
Within the month after the forced settlement (I told my attorney 3 days later (at the start of the new week) that I did not accept the settlement and he told me I had no choice. I did not know at the time that was untrue.) Governor Tom Ridge nominated Dr., Jannetta to be sec’t of health for state of Pa. (Peter J. Jannetta 1995-1996)
I notified the local and state medical boards. They did not care. I notified the society of neurological surgeons. They did not care. I notified JAMA when they republished Dr. Jannetta’s seminal article about his history of doing MVD (Jannetta Procedure) which did not include me, although by virtue of their definition of the population studied I was definitely a member, that facial paralysis was not listed as a known risk despite Dr. Jannetta’s statement of major and common complication.
Until someone cares nothing will change.
The system is broken.
Carol Jay Levy
author A PAINED LIFE, a chronic pain journey
womeninpainawareness.ning.com/
apainedlife.blogspot.com/

Guest
Jul 23, 2011

I posted a reply but cannot tell if it went through or not. I do not want to rewrite it if it was taken.

Guest
Lucky Seven
Jul 12, 2011

Vicodin is a painkiller that brings relief to those in need. Analgesics are recommended by doctors as the remedy for treating pain globally; which is the most common ailment today! Vicodin is one of the highly available and accepted medicines for curing pains. It is very effective in reducing modest to chronic pains and also relaxes the mind, creating a sense of well being. This medicine is one of the most commonly used in United States for the health care of people suffering from chronic pain as mentioned Findrxonline in your web.

Guest
allen ethan
Jul 11, 2011

i just love your post… i am pleased to be here…

http://goo.gl/GFqVu

Guest
Jul 10, 2011

Hey guys I found this awesome site about Medical Marijuana, You all
need to check this out. They have a lot of information about growing
some hydro Medical Marijuana. This site is all about
Growing Marijuana

Guest
Jul 9, 2011

Reality–

I’m not at all anti-doctor.

Many of my best sources are M.D.s (See my book, Money-Driven Medicine).

If I were anti-doctor why would:

State medical societies from Massachusetts to Texas have asked me to speak at their annual conferences.?

Kevin M.D., the most widely read physician blogger, continue to post pieces from my blog on http://www.KevinMD.com?

Medical schools, hospitals and medical groups around the country have asked me to introduce screenings of the documentary based on my book
“Money-Driven Medicne” ?. (For info on the documentary from the distributor, see http://www. moneydrivenmedicine.org.)

The National Physicians Alliance, a group that represents the many (often younger) doctors who do not identify with the AMA asked me speak at their nationall conference? (The NPA also has endorsed my work).
(You can Google any of these facts.)

Perhaps you are out of step with where doctor are going today.

Kevin M.D. often cross-posts pieces from by blog.

Guest
Reality
Jul 9, 2011

Why do people like Ms Mahar gain from their anti-doctor rhetoric? (this is more for Mahar to contemplate. I think a bit of soul-searching on her part may do her well, but again, as a fanatic, she’s just following her herd)

You know people, as long as we have people like her disseminating their misinformed view on healthcare, we can expect things to continue to get worse. I wish doctors were more united and vocal about the realities of things on the ground.

It’s a sad state of affairs.

Guest
rbaer
Jul 9, 2011

Peter, maybe it is clearer that way: our exams (boards and specialty boards) consist, like many exams, of diagnostic questions (or, increasingly of PC simulated clinical situations/case scenarios). (For completeness sake, let me mention that most but not all questions are directly practice relevant diagnostic problems – other questions test e.g. genetic or pathophysiologic concepts that you cannot directly apply to patientcare, at least not as of yet, and other questions are from neighboring specialties) .

It’s a fact of life that almost noone will not get 100% right (otherwise the test is too easy) … you know about the Bell curve, right? So let’s say the cutoff of the test is 60% (i.e. you fail with less) …. and keep in mind that almost all docs will get at least 1 in 10 questions wrong (the median is probably 2-3 out of 10 for most exams). However, there is almost never a reasonable question that everyone fails (the questions everyone gets wrong are often taken out of exams because they are usually useless). Therefore, most future docs err, say, in 1-3 out of 10 diagnostic problems … while the same problem may have been correctly solved by a majority of the other testtakers.
Does that sound familiar and makes sense? Does it now sound like a fact of life that doctors make mistakes? (or do you want only the upper 2% of testtakers to practice, so you barely have any error? But where do you want to get a sufficient number of doctors from? How will you even attract people do go into medicine if only 2/100 are accepted to practice)

That is why there are many clinical situations where many physicians, esp in retrospect, may say: every (insert specialist here) knows that, nearly everyone would have done better here- by which they mean 80-90%, forgetting that 1. they themselves may and will err at another problem that 90% of their colleagues will get right 2. there may be situational factors that make the situation in real time much more challenging then their monday morning quarterbacking. But that’s the reason why you get medical experts to testify for almost all “standards of care” (that and the money).

Yes, there are compensatory mechanisms that you can use during real life but not during exams: you can open up a book (nowadays rather looking into knowledge data bases), you can ask a colleague … but there are also a lot of things running against you in real life. Patients give inconsistent histories, and most importantly, in many complex patients, you may have such a huge set of data (symptoms, exam findings, treatment effects) that it is very hard to filter out the relevant ones.

“the body shows a limited number of symptoms for many different problems” – no, that’s a huge oversimplification, although not wrong given the weasel words (“limited” – yes, the number of possible symptoms and their combination is finite, “many”). Read what I wrote about specific and nonspecific symptoms. Wonder why there isn’t a workable software where the doc (or you) just enters the symptoms and with the stroke of a key, there is the right Dx (or differential Dx). And read a book about medical decision making – your wife presumably knows a lot about health care, but probably little about the diagnostic process. You apparently know even less, and that’s entirely OK, but then try not to have so strong, reinforced opinions about medical decision making. Sorry for being blunt or sounding arrogant.

I tried to make the difference between negligence (e.g. not examining a patient) and honest diagnostic errors (that I suggested could be a)”normal” errors and b) errors due to incompetence). I would have no problems to keep the current system for true negligence; re. compensation for honest diagnostic errors, I think that every human being who is sick or injured should be taken care of by society (yes, even if it is their fault). But I don’t think that it is helpful at all to make doctors fearful re the a) errors because it causes costly defensive medicine. However, I do think that docs doing more than one clear b) mistake should loose their license or at least go into a less risky field (insurance review, administration etc.). And I agree that we can and should do much more re. incompetence.

Guest
Peter
Jul 9, 2011

“(and never ever believe Hollywood fiction,”

rbaer, don’t imply I’m stupid enough to get my opinions about real life from TV shows, my wife (nurse) gives me plenty of grounding opinions about what to take for real life. But the show actually gives you guys plenty of good PR and shows how difficult diagnosis can be given the body shows a limited number of symptoms for many different problems. Most of the show centers around opposing personality conflicts. My point was that there has to be some structured method of diagnosis, and that as far as “errors & omissions”, there must be the possibility of both occurring in diagnosis – which you seem to want to exclude from any malpractice claim possibility.

Guest
Barry Carol
Jul 9, 2011

“Since THCB changed their page presentation, NOT USER FRIENDLY, that is for sure!!!”

Determined MD –

I agree. After about 50 comments, the earlier comments start to disappear and some of the more recent ones appear either out of sequence or don’t appear at all on the blog but they do show up in my e-mail in the correct order that they were posted.

Matthew – Can’t something be done to fix this?

Admin
Jul 10, 2011

Barry–we’re looking into it. Thanks for pointing it out