There is a strong disincentive to going to trial for both sides. Costs are high for plaintiffs to try a case – $200,000 to $300,000 in complex cases. Stress and risk of a loss are always a disincentive for the physician. Keep in mind that some insurance companies have a “consent-to-settle” clause in their contracts. This means your carrier may not need your approval to settle your legal case. You should know whether your carrier has such an “against-your-will” clause in your agreement.
Actions that Lower Malpractice Risk
- Building good doctor-patient relationships;
- Being alert in high-risk situations (cardiovascular, neurological, infectious disease);
- Keeping good documentation;
- Obtaining written and verbal informed consent; and
- Paying attention to drug toxicities.
Heads, Hearts, and Bugs
Let’s look at IM issues. The majority of rheumatologists are board certified in IM and, as such, can be held to the standard of care for IM physicians. As practitioners of a specialty that deals with the whole person, rheumatologists often find themselves on the front line, seeing rheumatic patients with chest pain, neurological symptoms, or infections – just as internists do.
The IM experience can be looked at in two ways. One approach is to look at error types. COPIC data suggest that 60% of IM lawsuits arise from failure to diagnose illnesses, 20% from improper care of a known illness, 10% medication errors, and 10% improper procedures. The other way to analyze these findings is to look at the largest category, the failure-to-diagnose group. Here, I find that lawsuits cluster around chest pain (missed pulmonary emboli and myocardial infarctions), neurological problems (missed cerebral vascular accidents and meningitis), underappreciated or missed infections, and failure to diagnose cancer. The mnemonic device I preach is this: Beware of heads, hearts, and bugs. That’s what will get you sued.
For Rheumatology, Medication Issues Are Key
Rheumatology data have some similarities but also some significant differences from those in IM. COPIC malpractice insurance covers about 80% of the private practitioners in Colorado. Between 1999-2005 we covered between 35 and 40 rheumatologists per year. The rheumatology claim rate averaged 5.64 claims per 100 doctor-years. The IM claim rate in comparable years is similar, at 6.26 claims per 100 doctor-years. In rheumatology, 40% of claims were for medicine side effects, including infections on TNF inhibitors and several relating to steroid complications (injection atrophy, avascular necrosis, osteoporosis, and psychosis). The other 60% were for failure to diagnose medical problems or complications of known medical conditions. Prominent were systemic lupus erythematosus (SLE) complications with either clotting events, cardiovascular, or neurological issues. There was also a recent settlement (on behalf of an emergency room physician, not a rheumatologist) in a case of temporal arteritis and associated blindness with normal sedimentation rates – rare according to the literature.4