Facing the malpractice crisis: academic physicians' willingness to accept quick fix solutions.

Background: We sought to determine the willingness of academic physicians to accept strategies to contain institutional malpractice costs.

Methods: We surveyed all 270 Department of Medicine physicians at a large academic center. Respondents were asked about their knowledge regarding malpractice premiums, willingness to reduce patient-care activities and accept decreases in compensation.

Results: The response rate was 80%. Respondents estimated the annual increase in malpractice premiums from 2004 to 2005 to be 29%. The true increase was 28% (P = 0.55). Almost all opposed eliminating patient care (95%) or providing patient care every other year at double effort and withdrawing from patient care on alternate years (97%). Seventy percent would limit their clinical procedures. Most physicians opposed salary reduction (97%) or decreases in fringe benefits (99%).

Conclusions: Few academic physicians are willing to limit patient care or accept decreases in compensation to recoup institutional malpractice costs.

Key Words: medical malpractice, academic medical centers, physician compensation

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Research, teaching, and patient care encompass the core mission of academic medical centers; however, increasing malpractice rates may threaten this mission. (1) Current efforts to address the crisis have focused primarily on tort reform. This involves complicated legal processes, multiple stakeholders, and will take time to result in meaningful change. (2-4) In the interim, academic medical centers are faced with the challenge of paying rapidly escalating malpractice premiums. Because of the unique setting in which academic medical centers provide care, creative ways to manage the malpractice crisis may be needed until more long-term solutions are developed. Consideration for the academic physician as clinician, teacher and investigator will need to be paramount. Possible quick fix solutions might involve eliminating patient care responsibilities for faculty who spend the majority of their time in nonclinical roles or reducing salaries and fringe benefits.

The purpose of this study was to determine the willingness of physicians at a large academic medical center to accept various strategies designed to rapidly contain institutional malpractice costs.

Methods

Study Administration

In May 2004 we surveyed all 270 clinically active physician faculty in the Department of Medicine at Johns Hopkins University School of Medicine (Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center). Up to two follow-up contacts were sent to encourage full participation. The study was approved by the Johns Hopkins Medicine Institutional Review Board.

Survey Content

We developed a 27-item questionnaire. The survey obtained information on participants' personal and professional characteristics, their estimates of current malpractice fees, attitudes about malpractice premiums and willingness to accept changes to their clinical practice and compensation (salary and benefits) in an effort to reduce institutional malpractice costs. Questions were formatted as multiple choice, short answer, yes/no and 5-point Likert scales.

Statistical Analysis

Descriptive statistics were used to characterize physician demographics and responses. Responses to 5-point Likert scales were dichotomized and analyzed as proportions. t tests were used to compare physician responses with actual malpractice premium values. Data were analyzed using Stata Statistical Software: 8.2 (Stata Corp., College Station, TX, 2004).

Results

Respondent Characteristics

Two-hundred and seventeen faculty completed the survey for an 80% response rate. Fifteen respondents were excluded from the analysis because they spent 0% of their time in patient care. The personal and professional characteristics of the respondents are presented in the Table. Thirty percent of the faculty spent 50% or more of their time on patient care. There were no significant differences between respondents and nonrespondents in terms of gender and rank (P > 0.05).

Knowledge and Attitudes About Current Malpractice Rates

Almost all respondents (99%) correctly reported that malpractice rates for the institution had increased in the last year. Respondents estimated the annual increase in malpractice premiums to be 29% from 2004 to 2005. The true premium increase was 28% (P = 0.55). Faculty estimated the mean rate per physician in the Department of Medicine in 2004 at $13,724.50: the actual mean rate was $10,453 (P < 0.001).

Most faculty believed that the following factors place academic medical centers at a greater risk for malpractice claims compared with nonacademic hospitals: higher expectations from patients and society (81%), sicker patients (81%) and the presence of trainees (62%). Forty-one percent of physicians in our sample thought that escalating malpractice premiums was the most important financial challenge facing academic medical centers.

Willingness to Accept Reductions In Patient Care Responsibility, Salary and Benefits

When asked if they would be willing to give up patient care responsibilities completely, almost all physicians opposed or strongly opposed this measure (95%), (Fig.). A similar number opposed or strongly opposed the option of providing patient care every other year at double the effort and withdrawing from patient care on alternate years (97%). Seventy percent of respondents were willing to limit their clinical procedures to only those that they regularly performed. Almost all physicians opposed or strongly opposed salary reductions (97%) and decreases in fringe benefits (99%) as ways to help the institution cover escalating malpractice costs.

Discussion

Academic physicians in our study appear to be aware of the magnitude of the current malpractice crisis. Almost all knew that costs were increasing. Many reported that increasing malpractice costs represent the most important financial challenge facing academic medical centers. Despite this knowledge, very few were willing to limit or eliminate patient care activities or accept a decrease in salary or benefits in an effort to help recoup institutional malpractice costs.

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To our knowledge, this is the first survey asking academic physicians what changes they would be willing to make in response to the malpractice crisis. One possible explanation for this unwillingness to limit or give up clinical roles may be that academic physicians recognize and are committed to their unique roles as clinicians, teachers and investigators. Another reason may be that academic physicians remain relatively cushioned from the pressure of increasing malpractice costs because they do not pay their own premiums. In contrast, many private physicians who must pay their own malpractice premiums, have responded to increases in malpractice costs by limiting or relocating their practices or retiring from clinical medicine. (5,6)

Physicians in our study were even less likely to accept decreases in salary or benefits in an effort to defray institutional malpractice costs. It is well documented that the salaries of academic physicians are lower than those of doctors in private practice. (7) Fringe benefits, including malpractice coverage, may reduce the magnitude of the discrepancy in salaries. Furthermore, the potential solutions proposed in our study are not without limitations. For example, faculty who conduct clinical research but who may not care for their own patients would still require malpractice coverage.

The academic physicians in our study believed that many factors place them at a greater risk for being sued than non-academic physicians, such as higher societal expectations, sicker patients and the presence of residents and fellows. The complex structure and multiple functions of academic medical centers create unique liability issues and the literature shows that litigation, including malpractice claims, has increased over the last half century. (8) Existing efforts to reduce the risk of litigation including systems approaches to enhance patient safety and reforms to graduate medical education may help control malpractice costs in the long term but are unlikely to have immediate effects. (9-11) However, if malpractice premiums continue to account for an increasing percentage of clinical income generated at academic institutions, academic physicians may no longer feel as sheltered from these costs. (1)

Several limitations of this study should be considered. First, our survey posed hypothetical questions. Faculty may have chosen different responses under more pressing real-life circumstances. Second, although we had a high response rate from faculty at a large institution, our findings may not be representative of the experiences of faculty in other departments or at other academic institutions. The Johns Hopkins Institutions are insured as part of an academic group consortium, and therefore, our malpractice premiums may not reflect national trends. Finally, we were unable to make comparisons based on amount of time spent in patient care due to the size of our sample. However, because of the high response rate, the percentage of faculty willing to accept the changes proposed in the survey would be unlikely to change even with a larger sample.

Conclusion

While academic physicians are aware of the magnitude of the current malpractice crisis, very few are willing to limit or eliminate patient care activities or accept a decrease in salary or benefits in an effort to help cover institutional malpractice costs at this time. Understanding physicians' perspectives will be important as academic medical centers consider potential quick fix solutions to address the rapidly rising costs of malpractice premiums.

Acknowledgments

Dr. Wright is an Arnold P. Gold Associate Professor of Medicine. Drs. Kravet and Wright receive support as Miller-Coulson Family Scholars through the Johns Hopkins Center for Innovative Medicine.

References

1. Brody WR. Dispelling Malpractice Myths. Washington, DC, The Washington Post, November 14, 2004.

2. Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. N Engl J Med 2003;348:2281-2284.

3. Studdert DM, Mello MM, Brennan TA. Medical malpractice. N Engl J Med 2004;350:283-292.

4. Kessler DP, Sage WM, Becker DJ. Impact of malpractice reforms on the supply of physician services. JAMA 2005;293:2618-2625.

5. Rice B. Hospitals feel the malpractice pain. Med Econ 2003;80:37-38.

6. Brehm J, Hannah K, Ruddick P, et al. Physician supply in key medical specialties in West Virginia hospitals, 2001-2004. W V Med J 2004; 100:132-135.

7. Academic Practice Compensation and Production Survey for Faculty and Management: 2004 Report Based on 2003 Data. Medical Group Management Association, 2004.

8. Helms LB, Helms CM. Litigation involving medical faculty and academic medical centers, 1950-1991. Acad Med 1993;68:7-19.

9. Brennan TA, Mello MM. Patient safety and medical malpractice: a case study. Ann Intern Med 2003;139:267-273.

10. Kachalia A, Studdert DM. Professional liability issues in graduate medical education. JAMA 2004;292:1051-1056.

11. Schoenbaum SC, Bovbjerg RR. Malpractice reform must include steps to prevent medical injury. Ann Intern Med 2004;140:51-53.

Rachel B. Levine, MD, MPH, Steven J. Kravet, MD, Darcy A. Reed, MD, MPH, Donna M. Windish, MD, MPH, Leah Wolfe, MD, and Scott M. Wright, MD

From the Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD; the Division of Primary Care Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN; and the Department of Internal Medicine, Yale University School of Medicine, New Haven, CT.

Reprint requests to Rachel B. Levine, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, B2N, Rom 235, 4940 Eastern Avenue, Baltimore, MD 21224. Email: [e-mail]

Accepted March 15, 2006.

RELATED ARTICLE: Key Points

* Increasing malpractice costs may limit the ability of academic medical centers to fulfill their commitment to research, teaching, and patient care.

* Academic physicians appear to be aware of the magnitude of the current malpractice crisis.

* Very few academic physicians are willing to significantly limit or eliminate patient care activities or accept decreases in salary or benefits in an effort to help contain institutional malpractice costs.

Table. Characteristics of the 202 Department of Medicine faculty
physician respondents

Characteristics

Mean age +/- SD, yr                            46.0 +/- 9.8
Women, n (%)                                   61 (30.0%)
Academic rank
  Instructor, n (%)                            19 (9.4%)
  Assistant Professor, n (%)                   81 (40.1%)
  Associate Professor, n (%)                   52 (25.7%)
  Professor, n (%)                             50 (24.7%)
Average percentage of time spent in research
    and patient care
  Research                                     39.5%
  Direct patient care (no learners present)    21.0%
  Supervising patient care (learners present)  18.3%