PRACTICE PERSPECTIVES Attitudes AboutMedical Malpractice: An American Society of Neuroradiology Survey

SUMMARY: The concern over medicolegal liability is pervasive among physicians. We sought, through an email survey to the members of the ASNR, to assess the experiencewith and attitudes about themedicolegal environment among neuroradiologists. Of 4357 physicians surveyed, 904 answered at least 1 of the questions in the survey; 449 of 904 (49.7%) had been sued: 180 (44.9%) had been sued once, 114 (28.4%) twice, 60 (15.0%) 3 times, and 47 (11.7%) more than 3 times. The payouts for suits were most commonly in the $50,000 to $150,000 range, except for interventional neuroradiologists, in whom the most common value was $600,000 to $1,200,000. Only 9 of 481 (1.9%) of suits returned a plaintiff verdict. Despite reported outcomes that favored physicians with respect to cases being dropped (270/481 56.1%), settled without a payment (11/481 2.3%), or a defense verdict (46/481 9.6), most respondents (81.1%, 647/798) believed that the medicolegal system was weighted toward plaintiffs. More than half of the neuroradiologists (55.2%, 435/787) reported being mildly to moderately concerned, and 19.1% (150/787) were very or extremely concerned about being sued. ABBREVIATIONS: ASNR American Society of Neuroradiology; PIAA Physician Insurers Association of America Malpractice lawsuits are a significant source of concern for physicians. In one report of physicians covered by a large professional liability insurer, 7.4% of physicians had a claim made against them every year. There is a high variation of probability for facing a claim within medical specialties. Obstetricians/gynecologists, internists, family physicians, general surgeons, and orthopedists are more likely to be sued than radiologists. Of the top 10 specialties sued, plastic surgeons, anesthesiologists, cardiologists, and gastroenterologists are named less frequently than are radiologists as defendants in malpractice suits. Radiology also occupies the 6th position in terms of dollars paid per claim. Overall, approximately 30% of radiologists will be the subjects of at least 1 malpractice claim during their careers. The highest rates of claims of malpractice suits that include radiologists classified by organ system category are breast, followed by vertebral/musculoskeletal, pulmonary, and gastrointestinal systems. CNS-related claims ranked sixth among organ systems. Once a claim is made, the mean time between an injury claim being served and its resolution is 5 years, which means that the time taken to resolve the case can seem interminable to the parties involved. However, accordingly to the Physician Insurers Association of America (PIAA), 65% of claims are dropped, dismissed, or withdrawn; 25.7% are settled; and 5% are resolved by trial. Sixty percent of all radiologists’ claims that are resolved out of court result in a payment to a plaintiff. On the contrary, when a case goes to trial, 80% of verdicts are in favor of physicians. The mean legal costs associated with cases that go to trial, are settled, or are dropped/dismissed/withdrawn are $375,000, $200,000, and $40,000, respectively. Although there have been many studies published on medical malpractice in the United States, the experience and attitudes of neuroradiologists specifically have not been addressed. This study was designed to evaluate the opinions of neuroradiologists toward malpractice suits and the judicial system. On the basis of the experience in our own institution, in which less than 20% of the faculty have been named in a suit, we hypothesized that a minority of American Society of Neuroradiology (ASNR) members would have been named in malpractice suits. On the basis of the level of anxiety experienced within our own division, despite the low rate of suits, we hypothesized that the fear of being sued would outweigh the actual experience of ASNR members. MATERIALS AND METHODS Our data were based on an e-mail survey of 4357 ASNR members conducted in February 2013. The survey questions from which this report is based can be found in On-line Table 1. Received July 22, 2013; accepted July 24. From The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institution, Baltimore, Maryland. Please address correspondence to David M. Yousem, MD, MBA, Johns Hopkins Medical Institution, 600 NWolfe St, Phipps B100F, Baltimore, MD 21287; e-mail: [email protected] Indicates article with supplemental on-line table. http://dx.doi.org/10.3174/ajnr.A3730 AJNR Am J Neuroradiol ●:● ● 2014 www.ajnr.org 1 Published December 12, 2013 as 10.3174/ajnr.A3730 Copyright 2013 by American Society of Neuroradiology. The full results of the survey can be viewed at the following Web address: http://www.surveymonkey.com/sr.aspx?sm 4y1SduJ73pus EREHU34PyiMKMhry2RDb9LzA3P06UCM_3d. The survey was sent by means of a Web link. Through repeated e-mailing (2 reminders), a response rate of 20.7% (904/4357) was reached. The survey was conducted by an outside vendor (SurveyMonkey, http://www.surveymonkey.com) and administered by the ASNR. Data were sent to the ASNR SurveyMonkey Web site. The data were anonymized without individual respondent identification. Confidentiality was ensured to respondents. Open-question answers were grouped for trends in responses by the 2 reviewers in concert, for example, lawsuits were still pending judgment, people were named in suits for no apparent reason, the medicolegal system must be reconstructed, and so forth. These open-ended comments were analyzed by 2 radiologists independently, and, if disagreements arose in the categorization of the comments, they met to achieve consensus. RESULTS Nine hundred four of 4357 ASNR members (20.7%) answered at least 1 survey question, but as many as 117 (2.7%) skipped various mandatory questions. Of these, 455 of 904 (50.3%) said that they had never been sued during their career life and 449 of 904 (49.7%) had been sued. One hundred eighty (44.9%) of the 401 radiologists who answered the question said they had been sued once, 114 (28.4%) had been sued twice, 60 (15.0%) had been sued 3 times, and 47 (11.7%) had been sued more than 3 times. If one uses 4 suits for the value of “more than 3 suits,” these 401 respondents represent at least 776 claims in total (Fig 1). More than half of the 401 sued respondents had been sued 2 or more times. Of these 904 respondents, 806 – 808 answered demographic questions. Of those providing sex data, 86.6% (698/ 806) were men and 13.4% (108/806) were women. Of the 808 who responded to the question about their age, most were between 41– 60 years old (479/806; 59.4%). Use of the midpoint of the age ranges for the categories yielded a mean age of 48.1 years, a median age of 50 years, and a mode of 45 years (Fig 2). Whereas just 13.7% (30/219) of respondents less than 40 years old had been sued, the percentage of those aged 41–50 years who had been sued was 46.1% (111/241), and, for age group 51– 60 years, it rose to 72.9% (172/ 236). Above this age, the percentage remained relatively steady at 72.5% (79/ 109) (Fig 3). Thirty-eight and nine-tenths percent (42/108) of female neuroradiologists had been sued compared with 50.1% (348/695) of male neuroradiologists; 35.7% (15/42) of women had been sued more than once compared with 57.4% (198/345) of men. Among all radiologists answering survey questions, most practiced predominantly in diagnostic neuroradiology (657/771; 85.2%), with a small portion representing interventional neuroradiology (61/771; 7.9%) and “in training” (44/771; 5.7%); 49.7% (325/657) of diagnostic and 57.4% (35/61) of interventional neuroradiologists had been sued. The outcome for each lawsuit was available for 481 claims. Many lawsuits were noted to be still pending an outcome or no information was provided. Most of the lawsuits were dropped (270/481 cases; 56.1%). Many suits were settled with a payout to the plaintiff (145/481 cases, 30.1%). Although a minority of cases FIG 1. Distribution, in percentage, of lawsuits a radiologist has been named in (total of 776 lawsuits from 401 respondents who had been sued). FIG 2. Demographic information of radiologists enrolled in the survey who answered the question about sex (n 806) and age (n 808). 2 Pereira ● 2014 www.ajnr.org went to a trial, the verdict was mostly in favor of the defendant (46/55 cases with a verdict; 83.6%). Thus, between being dropped (270/481), settled without a payment (11/481), and a defense verdict in favor of the physician (46/481), a favorable outcome for physicians was noted in 68.0% (327/481) (Table 1). For diagnostic neuroradiologists, the rates of dropped, settled with a payment, settled without a payment, defense verdict, and plaintiff verdict were 57.4% (221/385), 29.4% (113/385), 2.1% (8/ 385), 1.3% (5/385), and 9.9% (38/385), respectively. For interventionalists, these same rates were 49.0% (25/51), 37.3% (19/51), 0%, 5.9% (3/51), and 7.8% (4/51). In terms of dollars paid to the plaintiff in settled or litigated cases, the most frequent amount paid for all the suits was less than $50,000. The percentage of suits that had a mean payout of less than $50,000 increased with increasing age [from 26% (6/23) of suits in the 41–50-year-old group to 75% (3/4) in those older than 70 years]. Regarding the most expensive payment for each lawsuit, the most frequently cited value was between $50,000 and $150,000 paid to the plaintiff (Fig 4). However, the most common average value of the suits cited was higher for interventional neuroradiologists ($600,000 to $1.2 million) than diagnostic neuroradiologists (less than $50,000). Among causes of the alleged negligence, nondetection of a lesion was the most common (31.0% 165/532), followed by complication of a procedure [17.3% (92/532) overall but 60% (24/40) for interventional neuroradiologists] and misinterpretation of a finding (16.0%, 85/532); 19.9% (106/532) of the respondents provided a comment regarding other reasons for being sued that were not mentioned as a survey choice. Of the comments provided, most said they were sued merely because they had their names on the radiology report (30 cases), there was a delay in treatment and/or diagnosis (20 cases), or there was a complication after a procedure (18 cases) (Table 2). Table 3 depicts the respondents’ fears and the main concerns about being sued. It shows that most neuroradiologists have mild (199/784, 25.4%) to moderately high (235/784, 30.0%) fear of being sued. Interestingly, with increasing age, the fear of being sued becomes progressively less, with 29.4% (5/17) of those older than 70 years, 22.5% (18/80) ages 61–70 years, 14.9% (34/228) ages 51– 60, 10.5% (24/231) ages 41–50, and 2.8% (6/210) of physicians younger than 40 years old never or rarely thinking about being sued. Women and men had similar ratings of their fears of being sued. The percentage of individuals expressing moderate to extreme fear of being sued was higher in those in training (60.4%, 26/43) and doing neurointerventional procedures (62.5%, 35/56) than for diagnostic neuroradiologists (48.0%, 302/629). Physicians were mainly concerned about the risk to their personal assets if they are sued (164/813, 20.2%). This was true for all age groups and either sex, except for the 41–50-year-old group, who were more concerned about losing their confidence leading to practicing defensive medicine. Women were also more concerned (25%, 22/88) than were men (15.4%, 91/592) about the impact of the malpractice on the injured plaintiff. Respondents (81.1%, 647/798) opined that the US judicial system is somewhat to heavily weighted in favor of the plaintiff (Table 4). As the age of the respondent increased, the degree to which they thought that the system favored the plaintiff decreased; 83% (87/ 105) of women and 80.7% (551/683) of men thought that the judicial system favored the plaintiff. A higher percentage of diagnostic (81.3%, 522/642) than neurointerventionalists (73.3%, 44/60) think the judicial system is biased