#KeyLIMEPodcast 215: A Question of Dyscompetence

Reference

Studdert et al.,Changes in Practice among Physicians with Malpractice Claims N Engl J Med.2019 Mar 28;380(13):1247-1255

Reviewer

Jason Frank (@drjfrank)

Background

Thinking about the concept of “dyscompetence”, or the possession of less competence, some questions for the health professions come to mind…

1. Are there members of health professions who have passed through their training and emerged into practice with a level of competence that harms patients?

2. Do these practitioners get identified in terms of complaints, peer reviews, revalidation processes, or malpractice findings?

3. If they do, what happens to them?

4. What are the obligations of a health profession to police its own members in order to protect the public? Thinking of a just culture and growth mindset, are these clinicians just “not yet competent”?

If we are stewards of our own profession (one of the privileges afforded to professions in their “contract with society”), how should we think about colleagues who have been identified as having such extreme dyscompetence that they have multiple malpractice rulings against them? What happens to these people today?

Purpose

Enter the study by Studdert et al in the NEJM this month: Changes in Practice among Physicians with Malpractice Claims. The authors set out to describe the practice patterns of American doctors with multiple malpractice rulings against them.

Key Points on the Methods

The study compared the number of medicolegal rulings against doctors to 4 changes in practice outcomes found in the dataset:

1. Leaving medical practice in the US
2. Moving a practice
3. Moving a practice to a smaller group (e.g. solo practice), and
4. Changes in clinical volume

The authors created a database of US physicians from 2008-2015 using Medicare data and compared it to a national repository of all paid malpractice claims and other adverse professional actions taken against clinicians since 2003. The authors took steps to preserve anonymity of individuals in the data set. They excluded physicians younger <35 and >65 years old in order to control for practice changes unrelated to malpractice incidents. They also excluded doctors who billed for <100 services in the first year of their cohort, as a marker of not working in medicine full-time.

Malpractice exposure was operationalized as the cumulative number of paid claims since 2003 in the database. The authors used logistic and linear regression for each cohort of physicians by year. They conducted four sensitivity analyses to test their results.

Key Outcomes

The cohort of physicians was made up of 480,894 who had 68,956 malpractice claims. Some interesting stats about the claims:

• Internal Med, Family Med, EM, Radiology, and Anesthesiology made up 50%
• 8% were solo practitioners
• 33% of claims were for patient deaths, nearly half were for “major” nonfatal injury
• Only 2.6% were court rulings. >97% were settlements
• Mean payment was $355,631 USD in 2015 dollars

With respect to patterns of who accounted for the claims:

• 89% of physicians had none
• 3% accounted for ~40% of all claims
• This group were usually male surgeons over 50

Main practice outcomes:

• Physicians who have >1 claim are more likely to have another in practice
• Physicians odds of leaving practice increased with each medicolegal claim. Odds ratio of 1.09 higher for one claim, 1.45 for those with five or more claims.
• 8% of physicians with 5 or more claims continued to practice (0.1% of the total doc population).
• Physicians with more claims tended to change to see fewer patients
• Physicians with 4 or more claims were more likely to move to smaller or solo practices
• Geographic moves were not associated with claims

Key Conclusions

The authors conclude that there is a clear dose-response relationship between claims and exits from practice, but those with the most claims were largely still working. They found it reassuring that high-claim physicians did not move geographically to “escape” but note that many continued in other risky practices. Group and hospital policies may drive high-risk physicians to other practices.

Spare Keys – other take home points for clinician educators

This is a fascinating study from an emerging body of literature about physicians with risk practices. Many of our colleagues who work in regulatory or medicolegal defense organizations have deep understandings of these practice patterns, but little has entered policy and medical education design.

This is yet another example of a clever use of existing medical databases for meded and health policy decision-making as well as scholarship.

Leaving practice and other practice decisions are complex, contextual, and multi-factorial.

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