Demystifying malpractice risk


Dr. Gerald Hickson

Lack of information leaves physicians prone to misconceptions about their relative risk for malpractice suits, says Dr. Gerald Hickson, professor and vice chair of Pediatrics. In one study Hickson questioned a sampling of doctors who were all above the 94th percentile in terms of individual risk for malpractice suits.

“They all said their risk was average,” Hickson said.

Prone to suits year after year, these doctors thought it was simply the luck of the draw, that certain types of patients are more prone to sue and they happened to have more of these patients. These doctors were doubly mistaken, said Hickson, who has found that year in and year out the same doctors attract a disproportionate share of malpractice suits, and that six percent of doctors attract 40 percent of suits and generate 85 percent of malpractice losses.

Over the past 15 years Hickson has studied questions related to malpractice, including what motivates patients to bring suit, which types of patients are most apt to sue and which types of doctors are at greatest risk. He has found that 85 percent of malpractice claims are invalid, and that neither technical competence nor patient severity is a significant determinant of the risk of malpractice suit. “All doctors have patients who experience adverse events,” Hickson said. “What sends people to lawyers are perceptions, not necessarily medical facts.”

A central conclusion of Hickson’s research is that inability to establish rapport with the patient is a root cause of increased risk of malpractice suits. This finding resulted from Hickson’s identification of a surrogate identifier for malpractice suit risk. He recalls one day receiving a patient complaint forwarded to him by VUMC patient affairs. “I told myself Mrs. ‘Smith’ was having a bad day.”

But something in the language of the complaint gave him pause, reminding him of interviews he had done with Florida families who had brought malpractice suits against their doctors.

Hickson contacted patient affairs and learned they had five years of unsolicited patient complaints on file. Studying these files, he found that 10 percent of doctors generated 50 percent of patient complaints, and checking the distribution of complaints against the distribution of malpractice suits turned up obvious connections that have since been born out at other medical centers. (Hickson eventually arrived at three strong predictors for malpractice suits; these findings and a related editorial will appear in a June issue of the Journal of the American Medical Association.)

With malpractice insurance costs on a steep rise, Hickson and research partner Dr. Jim Pickert, associate professor of Medicine, were impelled by their findings to design a program to help medical centers lower risk for malpractice suits. They created a method to assign risk scores to doctors, and a program to educate high-risk doctors. The system involves software for coding patient complaints and running risk reports. The system is being used at 11 medical centers, ranging from a major academic health center to regional hospitals in rural Arkansas.

The system was recently adopted for use at VUMC by the Medical Center Medical Board, which has established the Patient Complaint Monitoring Committee. Risk scores will be calculated annually for all VMG clinicians and interventions undertaken with clinicians above the 94th percentile for individual risk.

• Well-regarded doctors are selected for training; they take the message about malpractice suit risk to their high-risk peers. The first intervention is strictly informative, with peers showing high-risk clinicians their risk for suit relative to VMG and to other clinicians in their specialty. Clinicians also receive a packet of the research on malpractice suit risk.

• If over the next two years the clinician’s complaint status does not improve, as a second-level intervention the department chair will be brought in to help tailor a program to identify and ameliorate the sources of patient dissatisfaction.

• As a third intervention, the institution’s leadership will have various options for corrective action as set out in the Vanderbilt faculty manual.

“Having high risk for malpractice suit doesn’t mean that you do not have outstanding medical skills,” Hickson said. “All of this in the end is about meeting patients’ needs. The better we are at collecting and using complaints, the better off we’ll be. The Chinese have a proverb: ‘In every complaint is a nugget of gold.’ Our culture isn’t always good at extracting the usefulness from complaints. We need to do better.”