Review: Evidence of greater medical knowledge was associated with increased malpractice claims
Ely JW, Dawson JD, Young PR, Doebbeling BN, Goerdt CJ, Elder NC, et al. Malpractice claims against family physicians. Are the best doctors sued more? J Fam Pract 1999;48:23-30.
Question
Among family doctors, what is the relation between medical
knowledge and the incidence of malpractice claims?
Design
Cohort study linking data from medical directories and family
practice certification examination scores with medical malpractice
insurance claims.
Setting
Florida, United States.
Participants
Two overlapping samples of Florida family doctors were gathered:
3686 doctors were listed in the American Medical Association (AMA)
Directory of Physicians in the United States, held a
Florida medical licence, and were licensed before 1994; 1406 doctors
were board certified family doctors listed in the 1997 American
Board of Family Practice Directory. Doctors' mean age was 54.6
years. Doctors from both samples were excluded if their primary
practice activity was administration, education, research or other
non-patient care.
Assessment of risk factors
Proxy measures of medical knowledge included AMA physician's
recognition award status (50 hours of continuing education per year),
quality of US medical schools (Gourman report rankings, medical college
admission test scores, and grade point averages for first year medical
school classes), completion of a family practice residency,
certification by the American Board of Family Practice certification,
membership in the Alpha Omega Alpha Honor Society, and board
certification examination scores. Medical malpractice claims were
obtained from the database at the Florida Department of Insurance.
 |
| Risk factors associated with malpractice claims in Florida family doctors | <
|
| Risk factors |
Incidence rate ratio (95% CI) |
|
| Male sex |
1.7 (1.4 to 2.1) |
| Graduation from US or Canadian medicalschool |
1.5 (1.3 to 1.7) |
| Family Practice Board certification |
1.6 (1.4 to 1.8) |
| AMA physician's recognition award |
1.4 (1.2 to 1.7) |
| Non-urban practice location |
1.3 (1.1 to 1.5) |
|
Main outcome measure
Incidence rate of malpractice claims.
Main results
In a univariate analysis, the risk factors associated with
malpractice claims were male sex, graduation from a US or Canadian
medical school, certification by the Family Practice Board, AMA
physician's recognition award, membership in the Alpha Omega Alpha
Honor Society, and non-urban practice location. These risk factors
remained significant in a multivariate analysis (P<0.001) (see table);
membership in the Alpha Omega Alpha Honor Society was not included in
the multivariate analysis because of small numbers. Among board
certified doctors, frequency of claims was not associated with
certification examination scores.
Conclusion
Among family doctors in Florida, markers of greater medical
knowledge were associated with increased incidence of malpractice
claims.
Funding: American Academy of Family Physicians Foundation.
EBM-Commentary
What if it is true? Might our health maintenance organisations
fire us to avoid a malpractice claim because we did so well on our
board exams? Will medical schools begin to pretest candidates and
reject the ones with the higher scores?
What if it is not true? Is the evidence flawed? Perhaps. Being better
educated and getting sued may be linked by some unidentified factor.
For example, does including older doctors, practising before AMA
awards, the pressure to be board certified, and the pressure of
escalating lawsuits cause a spurious association between lawsuits and
young, awarded, certified physicians? Or are physicians in Florida who
are sued sent for continuing education courses? Do better doctors
practise more?
On the basis of this observational study, our jury cannot come to
a firm conclusion. We also have no evidence that greater medical
knowledge, although it may improve outcomes, leads to fewer malpractice
claims. A tantalising case-control study of doctors being sued compared
with those not being sued suggested that better communication skills
were important in reducing claims.1 This study had serious
limitations, however. Although we should strive to improve our medical
knowledge better to help our patients, we may need to look elsewhere to
reduce the escalating rate of claims.
Robert McNutt Cook County Hospital, Chicago, Illinois, USA
- Levinson W, Roter DL, Mullooly
JP, Dull VT, Frankel RM. Physician-patient communication. The
relationship with malpractice claims among primary care physicians and
surgeons. JAMA 1997;277:553-9.
Ely JW, Dawson JD, Young PR, Doebbeling BN, Goerdt CJ, Elder NC, et al.
Correspondence to: J W Ely, University of Iowa Hospitals and Clinics, Department of Family Medicine, 200 Hawkins Drive, 01291-D PFP, Iowa City, IA 52242, USA.
Fax: 319-384-7822.
studentBMJ 2000;08:175-216 June ISSN 0966-6494
