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Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons
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Journal of the Formosan Medical Association (2017) xx, 1e8
Available online at www.sciencedirect.com
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ORIGINAL ARTICLE
Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons* Chiehfeng Chen a,b, Ching-Feng Lin c,d,e, Cha-Chun Chen f, Shih-Feng Chiu g, Fuh-Yuan Shih h, Shu-Yu Lyu c,i,*, Ming-Been Lee j,k,* a Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan b Department of Public Health, School of Medicine, College of Medicine, Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan c School of Public Health, Taipei Medical University, Taipei, Taiwan d Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan e Department of Public Health, Fu Jen Catholic University, New Taipei City, Taiwan f Department of Plastic Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan g Professional Master Program in Pharmaceutics and Biotechnology, Taipei Medical University, Taipei, Taiwan h Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan i Department of Leisure Industry and Health Promotion, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan j Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan k Department of Psychiatry, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
Received 26 July 2016; received in revised form 16 January 2017; accepted 17 January 2017
KEYWORDS media influence; medical dispute; physicianepatient communication; plastic surgeon
Abstract Purpose: The main purpose of this study is to investigate the prevalence of medical disputes among plastic surgeons in Taiwan and to elucidate their perspectives regarding the influence of medical litigation media coverage on the physicianepatient relationship. Methods: A self-administered questionnaire was distributed among plastic surgeons attending a series of continuing education training lectures organized by the Taiwan Society of Plastic Surgery in 2015.
*
Conflicts of interest: The authors have no conflicts of interest relevant to this article. * Corresponding authors. Shu-Yu Lyu, Department of Leisure Industry and Health Promotion, National Taipei University of Nursing and Health Sciences, No. 365, Ming-Te Rd., Taipei 11219, Taiwan. Ming-Been Lee, Department of Psychiatry, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wenchang Rd.,Taipei 11101, Taiwan. E-mail addresses: [email protected] (S.-Y. Lyu), [email protected] (M.-B. Lee). http://dx.doi.org/10.1016/j.jfma.2017.01.011 0929-6646/Copyright ª 2017, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Chen C, et al., Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.011
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C. Chen et al. Results: Of the 109 respondents, over a third (36.4%) had previously experienced a medical dispute. The vast majority of both physicians who had medical disputes (77.1%) and those who did not (72.1%) felt that the media tends to be supportive of patients in their reporting, and 37.1% of all plastic surgeons felt that the media always portrays the patient as a victim. Respondents who experienced medical disputes in this study felt that the top five leading causes of the high incidence of medical disputes were patient disappointment with procedure results (81.1%), insufficient patient psychological preparation or emotional instability (61.7%), inadequate risk communication on the part of the physician (64.9%), patient uneasiness with the procedure or perception of carelessness (60.6%), and insufficient physician training or incorrect medical evaluation (57.4%). Conclusion: Over a third of the respondents had previously experienced a medical dispute. This study highlights the perception among plastic surgeons that the media reporting of medical disputes and medical litigation is biased in favor of the patients, with 37.1% of the plastic surgeons surveyed opining that patients are always cast as victims. Copyright ª 2017, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/4.0/).
Introduction In Taiwan, the number of medical dispute cases has substantively increased between 1987 and 2006,1 with the highest medical dispute incident rate being observed among surgical specialties. This has affected specialty selection among residents. During the past 10 years, the overall number of physicians has increased by 12%, whereas the number of surgeons has decreased by 11%.2 At the same time, the ranks of practicing surgeons in Taiwan are increasingly made up of physicians of other specialties that have crossed over into aesthetic and plastic medicine to provide services outside the purview of the National Health Insurance, which began enforcing a government-mandated fee-for-service program some 20 years ago in 1996. This has made for a dangerous combination of high-risk medicine in an increasing litigious society, which is following trends in the United States and United Kingdom. The emergence of a newly “sue happy” culture and its associated growing pains are saliently visible in the substantial media coverage of medical disputes. While Taiwan’s medical malpractice insurance system remains immature, the central government is developing a medical error law. However, it has proven to be little protection for the physicians who appear in the news and whose medical education did little in the way of preparing them for confronting this changed medical landscape. Today’s physicians are moreover both reluctant and illequipped to even discuss less than ideal medical outcomes.3 The medical community in Taiwan has not successfully moved away from the deeply entrenched authoritarian hierarchies that have characterized it since its inception. To date, it retains the propensity to use punitive measures to deter physician error, thus curbing physician willingness to discuss medical errors and depriving them of opportunities to practice communicating outcomes to patients during their training and practice. Despite the massive influence the rise of litigation has had on the medical community and Taiwanese society as a whole, it remains a comparatively recent social phenomenon in Taiwan with little academic research having been
conducted to characterize either its prevalence or its etiology. Our prior work has indicted that surgeons are at the greatest risk for encountering a medical dispute, and other studies have underscored the high risk for malpractice claims to which plastic surgeons are exposed in particular.4 Another factor that is revolutionizing both health care and litigation is social media-informed media reporting. While the disclosure of such information during the litigation process may serve as an opportunity to reevaluate physician behavior, and thus work toward successful mediation,5 if media reporting is unjust, it may exacerbate the underlying dispute. Unfortunately, the latter seems to be the case more often, and most medical litigation regarding plastic surgery is resolved in favor of the plaintiff.6 While it is known that there is a certain degree of risk for poor cosmetic outcomes, such as disfigurement, scarring, and burns, such outcomes are nearly always ascribed to malpractice, despite less than half being the result of inappropriate procedures or lack of adequate informed consent.7,8 However, it is unknown whether there is any clear relationship between media reporting and medical litigation adjudication. Therefore, to elucidate the relationship between the media and recent trends in medical litigation, we set out to ascertain how plastic surgeons in Taiwan perceive the influence of media coverage on medical litigation and the physicianepatient relationship in light of recent trends in medical disputes.
Methods Study sample and data collection In this study, we analyzed the results of a self-administered questionnaire distributed among plastic surgeons attending an annual meeting and one of a series of continuing education training lectures organized by the Taiwan Society of Plastic Surgery in 2015. In 2015, there were a total of 623 plastic surgeons registered in Taiwan. However, 25 had only recently passed their licensing exams and held their specialist certifications for < 6 months. We excluded these
Please cite this article in press as: Chen C, et al., Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.011
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Media influence on medical dispute incidence plastic surgeons from this study due to their lack of professional experience, thus leaving 598 plastic surgeons in our target population. Of these 598 plastic surgeons, 485 attended the annual meeting and continuing education course where this study was conducted. We randomly distributed the questionnaires to 220 of these 485 attendees and received 109 completed questionnaires, thus achieving a response rate of 49.5% and representing the opinions of 18% of all plastic surgeons in Taiwan. We feel that the data in this study are representative of all the plastic surgeons in Taiwan because the attendance of the annual meeting and continuing education training program, where the data acquisition phase of this study was conducted, is required for license renewal. This study was approved by the Taipei Medical University Joint Institutional Review Board (201407040).
Measures The principal tool used in this study was a structured questionnaire that consisted of four domains: (1) demographic information including sex, age, medical experience, location of practice by region, type of employment, and prior experience with medical disputes; (2) respondent perception of media reporting related to cosmetic medicine and related medical disputes; (3) physician opinions on the causes of the high incidence of medical disputes; and (4) respondent perception of ideal physicianepatient communication and suggestions for continuing education courses. Participants were prompted to indicate their degree of agreement to items regarding the following topics on a fivepoint Likert scale: the avoidability of medical disputes and medical litigation, the media’s support of either physicians or patients when reporting medical disputes, victimization of patients in medical dispute reporting, and the influence of the media on medical dispute proceedings. Respondents’ perception of ideal physicianepatient communication and suggestions for continuing education courses were ascertained through multiple response items.
Statistical analysis Descriptive statistics and subsequent analyses were performed using SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). We split participants into two groups: those who experienced a medical dispute and those who did not. We subsequently used Chi-square tests to investigate differences between these two groups in terms of their perspectives on items regarding media reporting and its influence on medical disputes. Next, we performed a similar analysis using Chi-square tests to investigate differences in the perceived causes of medical disputes between participants who experienced medical disputes and those who had not. We collapsed “don’t know”, “disagree”, and “strongly disagree” into a single “disagree” category for this analysis.
Results Table 1 presents the respondent demographics. Of the 109 respondents, the average age was 42.5 years and 77.1% were male. Over a third (36.4%) had previously experienced
3 Table 1
Demographic characteristics of respondents.
Variables Sex Male Female Age, y (mean SD) Medical experience, y (mean SD) Locations of practice region Northern Central Southern Eastern Type of employment Medical Center Clinic employee (not self-employed) Regional or district hospital Self-employed Prior experience with medical disputes Yes No
n
%
84 77.1 25 22.9 42.46 9.11 9.68 7.78 66 11 20 6
64.1 10.7 19.4 5.9
41 29 17 14
40.6 28.7 16.8 13.9
36 63
36.4 63.6
a medical dispute. The average respondent had 9.7 years of work experience. Most respondents (64%) worked in northern Taiwan, and 41% of respondents worked in a medical center. Only 10 plastic surgeons answered that they did not have prior experience with medical disputes. As seen in Table 2, the vast majority of both physicians who had medical disputes (77.1%) and those who did not (72.1%) felt that the media tends to be supportive of patients in their reporting, and 37.1% of all plastic surgeons felt that the media always portrays the patient as a victim. Over a quarter (26.8%) of the plastic surgeons felt that medical dispute reporting negatively influences cosmetic medical practices. There was no significant difference between respondents with medical dispute experience and those without medical dispute experience for any perception regarding the influence of media reporting on cosmetic medicine (p Z 0.875). Table 3 lists the reasons selected by respondents for the high incidence of medical disputes. Respondents who experienced medical disputes in this study felt that the top five leading causes of the high incidence of medical disputes were patient disappointment with procedure results (81.1%), insufficient patient psychological preparation or emotional instability (61.7%), inadequate risk communication on the part of the physician (64.9%), patient uneasiness with the procedure or perception of carelessness (60.6%), and insufficient physician training or incorrect medical evaluation (57.4%). Plastic surgeons with prior medical dispute experience had more agreement than those without prior experience that insufficient patient psychological preparation or emotional instability (p < 0.001) and patient uneasiness with the procedure or perception of carelessness (p Z 0.017) were contributory factors to medical litigation. Table 4 presents both the ideal physicianepatient communication characteristics as well as respondent suggestions for additional medical education courses. The largest proportion of respondents (37.4%) opined that the most important physicianepatient characteristic for ideal
Please cite this article in press as: Chen C, et al., Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.011
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C. Chen et al. Table 2
Respondent perception of cosmetic medicine- and medical dispute-related media reporting.
Variables
Prior experience with medical disputes Yes (n Z 36) %
Perception of the media’s attitude when reporting medical disputes Neutral Supportive of physicians Supportive of patients Not necessarily supportive of either physicians or patients Medical dispute reporting negatively influences cosmetic medical practices Strongly agree Agree Not sure Disagree/Strongly disagree Medical dispute reporting portrays the patient as a victim Always Often Seldom or never Avoidability of medical disputes and medical litigation Avoidable Cannot be avoided Not sure Referring to physicians of other specialties as plastic surgeons damages the professional reputation of plastic surgeons Strongly agree Agree Not sure Disagree/Strongly disagree
No (n Z 63) %
p
Total (n Z 99) % e
2.9 0.0 77.1 20.0
4.9 3.3 72.1 19.7
4.2 2.1 74.0 19.7 0.875
31.4 34.3 22.9 11.4
24.2 40.3 22.6 12.9
26.8 38.1 22.7 12.4 0.804
37.1 40.0 22.9
37.1 45.2 17.7
37.1 43.3 19.6 0.551
14.7 38.2 47.1
8.1 37.1 54.8
10.4 37.5 52.1 0.684
34.3 34.3 22.9 8.5
communication was the clear explanation of potential risks and side effects of surgical procedures and treatments, whereas the second-largest proportion (19.2%) felt that the most important characteristic was patients being informed of the course of treatment prior to beginning therapy. Based on multiple responses, 65.9% of respondents advised for the creation of courses teaching crisis management related to medical disputes to physicians, 55.7% advised for an introduction to civil and criminal litigation, and 48.9% advised for courses regarding patient communication. The only significant difference with regard to these perceptions and suggestions between respondents who had medical litigation experience and those who did not was a greater proportion of respondents without medical litigation experience suggesting a need for an introduction to civil and criminal litigation (64.3% vs. 40.6%).
Discussion Regardless of having prior medical litigation experience, the majority of our 109 respondents felt that the media tends to be supportive of patients in their reporting, and 37.1% felt that the media always portrays the patient as a victim. The five most reported instigating factors for
43.5 24.2 21.0 11.3
40.2 27.8 21.6 10.4
medical disputes in this study included disappointment with the results of the procedure, insufficient patient psychological preparation or emotional instability, poor risk communication on the part of the physician, patient uneasiness with the procedure or perception of carelessness, and insufficient physician training or incorrect medical evaluation. The largest proportion of respondents opined that the most important characteristic for ideal physicianepatient communication was the clear explanation of postsurgical recovery and risk of side effects, whereas the second-largest proportion felt that it was the assurance that patients were informed of the course of treatment prior to beginning the treatment. This study highlights the perception among plastic surgeons that the media reporting of medical disputes and medical litigation is biased in favor of the patients, with 37.1% of the plastic surgeons surveyed opining that patients are always cast as victims. Cosmetic surgery and the use of social media have emerged contemporaneously during the last decade, and have come as a pair to the mainstream media. In our study, however, we did not find any “official” legal problems. The surgeons in this study opined that maintaining good communication and strong relationships between the treatment team and the patient can solve most problems.
Please cite this article in press as: Chen C, et al., Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.011
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Media influence on medical dispute incidence
Table 3
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Physician opinions on the causes of the high incidence of medical disputes.
Variables
Patient disappointment with procedure results Strongly agree Agree Not necessarily/Disagree/Strongly disagree Inadequate risk communication on the part of the physician Strongly agree Agree Not necessarily/Disagree/Strongly disagree Patient did not adhere to the prescribed medical regiment resulting in poor prognosis Strongly agree Agree Not necessarily/Disagree/Strongly disagree Insufficient physician training or incorrect medical evaluation Strongly agree Agree Not necessarily/Disagree/Strongly disagree Insufficient patient psychological preparation or emotional instability Strongly agree Agree Not necessarily/Disagree/Strongly disagree Physician failed to provide an adequate understanding of informed consent to the patient (including confidentiality and privacy) Strongly agree Agree Not necessarily/Disagree/Strongly disagree Patient uneasiness with the procedure or perception of carelessness Strongly agree Agree Not necessarily/Disagree/Strongly disagree Medical negligence Strongly agree Agree Not necessarily/Disagree/Strongly disagree Physician unfamiliar with the selected treatment Strongly agree Agree Not necessarily/Disagree/Strongly disagree Patient deliberately engaging in extortion Strongly agree Agree Not necessarily/Disagree/Strongly disagree Patient perceives a violation of personal privacy Strongly agree Agree Not necessarily/Disagree/Strongly disagree
Prior experience with medical disputes Yes (n Z 36) %
No (n Z 63) %
Total (n Z 99) %
51.5 36.4 12.1
32.2 45.2 22.6
38.9 42.2 18.9
p
0.158
0.511 18.2 48.5 33.3
9.8 54.1 36.1
12.8 52.1 35.1 0.253
24.2 36.4 39.4
14.5 53.2 32.3
17.9 47.4 34.7 0.066#
18.2 30.3 51.5
8.2 54.1 37.7
11.7 45.7 42.7 <0.001***
33.3 39.4 27.3
3.3 52.4 44.3
13.8 47.9 38.3 0.934
9.1 48.5 42.4
8.2 52.5 39.3
8.5 51.1 40.4 0.017*
30.3 33.3 36.4
8.2 50.8 41.0
16.0 44.6 39.4
15.2 36.4 48.4
8.3 46.7 45.0
10.8 43.0 46.2
12.1 39.4 48.5
4.9 44.3 50.8
7.4 42.6 50.0
21.2 30.3 48.5
8.3 26.7 65.0
12.9 28.0 59.1
15.2 21.2 63.6
3.3 34.4 62.3
7.4 29.8 62.8
0.472
0.442
0.148
0.070#
#p < 0.1; *p < 0.05; **p < 0.01; ***p < 0.001.
Please cite this article in press as: Chen C, et al., Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.011
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C. Chen et al. Table 4
Respondent perception of ideal physicianepatient communication and suggestions for continuing education courses.
Variables
Prior experience with medical disputes Yes (n Z 36) %
Ideal physicianepatient communication characteristics Clear explanation of the potential 44.4 risks and side effects of surgical procedures and treatments Informed of the course of 19.4 treatment prior to beginning therapy Physician eye contact and 13.9 attention to the patient during treatment or consultation Patience when responding to 5.6 patient questions Consideration of the patient’s 8.3 ability to understand the course of treatment Others 8.3 Suggestions for topics of future continuing medical educationa Crisis management related to 62.5 medical disputes Introduction to civil and criminal 40.6 litigation Introduction to copyright law 9.4 Medical professionals’ 40.6 communication with the media Medical marketing 18.8 Patient communication 50.0
p
No (n Z 63) %
Total (n Z 99) %
33.3
37.4
19.0
19.2
12.7
13.1
12.7
10.1
9.5
9.1
12.7
11.1
67.9
65.9
0.610
64.3
55.7
0.032*
7.1 25.0
8.1 30.7
e 0.126
16.1 48.2
17.0 48.9
0.748 0.872
0.796
*p < 0.05. a Based on multiple responses.
Although the media’s dissemination of information during the litigation process provides the opportunity to reevaluate physician behavior and change patient attitudes,5 most media sources in Taiwan focus on the patient’s opinion rather than striving to achieve a neutral standpoint when reporting on medical mediation. One recent medical dispute serves to illustrate this point. After suffering a miscarriage due to adenomyosis, a Taiwanese news anchor denounced her physician across several social media platforms. The story’s online presence encouraged formal media agencies to take notice and begin reporting on it from the anchor’s perspective, much to the injustice of her physician. The medical community came out in defense of the attending physician; however, the anchor refused to accept the physician’s diagnosis and instead filed for a medical dispute. While this case was clearly not based on malpractice or negligence, and the outcome was an unavoidable medical risk, most people exposed to the media alone would likely condemn the physician. This phenomenon might not be unique to Taiwan. Moses et al.9 cautioned against the role of social media in the medical community in general, and suggested that its use brings with it the possibility to further complicate legal action by increasing the difficulty of balancing patients’ needs while complying with current laws and not exposing physicians to additional legal risks.9 Thus, additional policy
work will be needed to protect physicians from lawsuits and warrants further investigation. Our results are in line with those of previous studies regarding the reasons underlying medical disputes.10 The greatest proportion of respondents in our study opined that medical disputes are the result of treatments not meeting patient expectations. This was followed by a lack of patients’ psychological readiness or emotional disturbance prior to treatment. This demonstrates that most physicians whether they have experienced a medical dispute or not can recognize an important truth: most medical disputes might not be caused by physicians but rather arise from patient-related psychological factors.10 Thus, good informed consent might be the best form of protection for both plastic surgeons and their patients,11 followed by wellmaintained medical records.12 These opinions were equally shared by respondents who were previously embroiled in medical disputes of their own and those who were not, thus giving credence to these results being representative of an unbiased view of the plastic surgery community. However, we did find some discrepancies between the agreement of physicians who had experienced medical disputes and those who did not regarding the causes of the high incidence of medical disputes. A greater proportion of physicians with medical litigation experience opined that insufficient patient psychological preparation or emotional
Please cite this article in press as: Chen C, et al., Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.011
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Media influence on medical dispute incidence instability and patient uneasiness with the procedure or perception of carelessness were the causal factors for medical litigation. This indicates that physicians without medical dispute experience may take lightly the importance of informed consent and patient education. As over a third of the respondents reported that the high incidence of medical litigation is unavoidable, we can conclude that most physicians working in aesthetic medicine and plastic surgery have some degree of vigilance to medical disputes. However, medical training needs to be commensurate with the changing medical landscape and better educate physicians to prevent and handle medical disputes and litigation. These educational needs may be met with continuing medical education in jurisprudence, civil and criminal litigation, and communication. More physicians without medical dispute experience thought that medical education should provide an introduction to civil and criminal litigation rather than patient communication. This finding may indicate two important things: (1) after experiencing a medical dispute, physicians might place less trust in medical education classes; (2) most physicians might think that patient communication does not help avoid medical disputes. Thus, we might infer that “defensive medicine” has already had profound effects on plastic surgery. Our report demonstrates that Taiwanese plastic surgeons pay little attention to the effects of social media. However, we did not compare between those with and without legal judgments. This situation is similar to that in Korea where the media may hold a strong negative attitude toward cosmetic surgeons.13 Therefore, in the future, we plan to explore the associations between cosmetic medicine, legal judgments, and the media. Our study has several strengths. First, it is the first study to investigate physician opinions regarding medical disputes and the influence of the media. Although there are many medical disputes and medical litigation events each year, we still lack a good evidence base to inform our medical education system. Second, the items in our questionnaire were all created from qualitative interviews, so they can be considered to represent the current situation in Taiwan. However, these strengths and the results of our study need to be seen in light of several limitations. First, this study was cross-sectional in nature and cannot be used to explain the causal relationship between medical disputes, patient attitudes and opinions, and the influence of the media. Second, although we captured a robust sample size considering its specificity, the agreement between some variables is highly skewed. To overcome this limitation, we suggest that future studies investigate medical disputes using a larger sample to corroborate our findings. Third, while the annual meeting and continuing education training program, where the data acquisition phase of this study was conducted, is important for the professional development of all plastic surgeons in Taiwan, as they are unable to renew their licenses without attending continuing education, and the vast majority of doctors did attend (81.1%), there are likely to be intrinsic differences between the attendees and those who did not choose, or were unable, to participate. One such notable difference can be observed by comparing the percentage of the population who had experienced a medical dispute. In this study, 36.4%
7 of the respondents had experienced a prior dispute, which approximates the 44.1% and 36.0% rates found amongst all Taiwanese physicians in 199314 and 2005,15 respectively. However, among Taiwanese surgeons overall, 63.3% and 56.5% had been involved in malpractice claims in 1991 and 2005, respectively.16 Thus, the plastic surgeons in this study seemed to have substantially fewer malpractice claims than the gamut of surgical specialties. Therefore, while our selection may have engendered a slight bias in our results, it is far more likely that the surgeons in this study would have borne a more agreeable attitude toward medical litigation than the general population of surgeons given their comparatively fewer forays into medical disputes. Thus, our results are likely conservative estimates regarding the perception that the media is biased in favor of the patients.
Conclusions This study highlights the perception among plastic surgeons that the media reporting of medical disputes and medical litigation is biased in favor of the patients who are routinely cast as victims. These opinions were equally shared by respondents who were and were not previously embroiled in medical disputes of their own, thus giving credence to these results being representative of an unbiased view of the plastic surgery community. Moreover, this community commonly perceived that media reporting engenders a strong negative effect on both private practices as well as the overall reputation of plastic surgery as a discipline. Over a third of respondents reported feeling that the high incidence of medical litigation is unavoidable. However, they feel that the causes underlying this high incidence stem from both patients and physicians, who they suggested should engage in continuing medical education in jurisprudence, civil and criminal litigation, and communication. In addition to underscoring the importance of continuing medical education, these results also indicate the need for courses on medical litigation in medical school, so that young physicians are well informed when making career choices, and medical insurance, which will balance the risks now inherent in the medical community. The gravity of the societal implications surrounding these issues and their resolution warrants future research efforts directed at disentangling the underlying factors predisposing to medical disputes and determining how to best avoid and contend with them.
Acknowledgments We would like to thank the Ministry of Science and Technology (grant number: NSC102-2511-S-038-002-MY2(2-2)) and Taipei Municipal Wanfang Hospital (Managed by Taipei Medical University) (grant number: 105TMU-WFH-03) for supporting this investigation.
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Please cite this article in press as: Chen C, et al., Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.011
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Journal of the Formosan Medical Association (2017) xx, 1e8
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jfma-online.com
ORIGINAL ARTICLE
Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons* Chiehfeng Chen a,b, Ching-Feng Lin c,d,e, Cha-Chun Chen f, Shih-Feng Chiu g, Fuh-Yuan Shih h, Shu-Yu Lyu c,i,*, Ming-Been Lee j,k,* a Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan b Department of Public Health, School of Medicine, College of Medicine, Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan c School of Public Health, Taipei Medical University, Taipei, Taiwan d Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan e Department of Public Health, Fu Jen Catholic University, New Taipei City, Taiwan f Department of Plastic Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan g Professional Master Program in Pharmaceutics and Biotechnology, Taipei Medical University, Taipei, Taiwan h Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan i Department of Leisure Industry and Health Promotion, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan j Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan k Department of Psychiatry, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
Received 26 July 2016; received in revised form 16 January 2017; accepted 17 January 2017
KEYWORDS media influence; medical dispute; physicianepatient communication; plastic surgeon
Abstract Purpose: The main purpose of this study is to investigate the prevalence of medical disputes among plastic surgeons in Taiwan and to elucidate their perspectives regarding the influence of medical litigation media coverage on the physicianepatient relationship. Methods: A self-administered questionnaire was distributed among plastic surgeons attending a series of continuing education training lectures organized by the Taiwan Society of Plastic Surgery in 2015.
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Conflicts of interest: The authors have no conflicts of interest relevant to this article. * Corresponding authors. Shu-Yu Lyu, Department of Leisure Industry and Health Promotion, National Taipei University of Nursing and Health Sciences, No. 365, Ming-Te Rd., Taipei 11219, Taiwan. Ming-Been Lee, Department of Psychiatry, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wenchang Rd.,Taipei 11101, Taiwan. E-mail addresses: [email protected] (S.-Y. Lyu), [email protected] (M.-B. Lee). http://dx.doi.org/10.1016/j.jfma.2017.01.011 0929-6646/Copyright ª 2017, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Chen C, et al., Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.011
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C. Chen et al. Results: Of the 109 respondents, over a third (36.4%) had previously experienced a medical dispute. The vast majority of both physicians who had medical disputes (77.1%) and those who did not (72.1%) felt that the media tends to be supportive of patients in their reporting, and 37.1% of all plastic surgeons felt that the media always portrays the patient as a victim. Respondents who experienced medical disputes in this study felt that the top five leading causes of the high incidence of medical disputes were patient disappointment with procedure results (81.1%), insufficient patient psychological preparation or emotional instability (61.7%), inadequate risk communication on the part of the physician (64.9%), patient uneasiness with the procedure or perception of carelessness (60.6%), and insufficient physician training or incorrect medical evaluation (57.4%). Conclusion: Over a third of the respondents had previously experienced a medical dispute. This study highlights the perception among plastic surgeons that the media reporting of medical disputes and medical litigation is biased in favor of the patients, with 37.1% of the plastic surgeons surveyed opining that patients are always cast as victims. Copyright ª 2017, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/4.0/).
Introduction In Taiwan, the number of medical dispute cases has substantively increased between 1987 and 2006,1 with the highest medical dispute incident rate being observed among surgical specialties. This has affected specialty selection among residents. During the past 10 years, the overall number of physicians has increased by 12%, whereas the number of surgeons has decreased by 11%.2 At the same time, the ranks of practicing surgeons in Taiwan are increasingly made up of physicians of other specialties that have crossed over into aesthetic and plastic medicine to provide services outside the purview of the National Health Insurance, which began enforcing a government-mandated fee-for-service program some 20 years ago in 1996. This has made for a dangerous combination of high-risk medicine in an increasing litigious society, which is following trends in the United States and United Kingdom. The emergence of a newly “sue happy” culture and its associated growing pains are saliently visible in the substantial media coverage of medical disputes. While Taiwan’s medical malpractice insurance system remains immature, the central government is developing a medical error law. However, it has proven to be little protection for the physicians who appear in the news and whose medical education did little in the way of preparing them for confronting this changed medical landscape. Today’s physicians are moreover both reluctant and illequipped to even discuss less than ideal medical outcomes.3 The medical community in Taiwan has not successfully moved away from the deeply entrenched authoritarian hierarchies that have characterized it since its inception. To date, it retains the propensity to use punitive measures to deter physician error, thus curbing physician willingness to discuss medical errors and depriving them of opportunities to practice communicating outcomes to patients during their training and practice. Despite the massive influence the rise of litigation has had on the medical community and Taiwanese society as a whole, it remains a comparatively recent social phenomenon in Taiwan with little academic research having been
conducted to characterize either its prevalence or its etiology. Our prior work has indicted that surgeons are at the greatest risk for encountering a medical dispute, and other studies have underscored the high risk for malpractice claims to which plastic surgeons are exposed in particular.4 Another factor that is revolutionizing both health care and litigation is social media-informed media reporting. While the disclosure of such information during the litigation process may serve as an opportunity to reevaluate physician behavior, and thus work toward successful mediation,5 if media reporting is unjust, it may exacerbate the underlying dispute. Unfortunately, the latter seems to be the case more often, and most medical litigation regarding plastic surgery is resolved in favor of the plaintiff.6 While it is known that there is a certain degree of risk for poor cosmetic outcomes, such as disfigurement, scarring, and burns, such outcomes are nearly always ascribed to malpractice, despite less than half being the result of inappropriate procedures or lack of adequate informed consent.7,8 However, it is unknown whether there is any clear relationship between media reporting and medical litigation adjudication. Therefore, to elucidate the relationship between the media and recent trends in medical litigation, we set out to ascertain how plastic surgeons in Taiwan perceive the influence of media coverage on medical litigation and the physicianepatient relationship in light of recent trends in medical disputes.
Methods Study sample and data collection In this study, we analyzed the results of a self-administered questionnaire distributed among plastic surgeons attending an annual meeting and one of a series of continuing education training lectures organized by the Taiwan Society of Plastic Surgery in 2015. In 2015, there were a total of 623 plastic surgeons registered in Taiwan. However, 25 had only recently passed their licensing exams and held their specialist certifications for < 6 months. We excluded these
Please cite this article in press as: Chen C, et al., Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.011
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Media influence on medical dispute incidence plastic surgeons from this study due to their lack of professional experience, thus leaving 598 plastic surgeons in our target population. Of these 598 plastic surgeons, 485 attended the annual meeting and continuing education course where this study was conducted. We randomly distributed the questionnaires to 220 of these 485 attendees and received 109 completed questionnaires, thus achieving a response rate of 49.5% and representing the opinions of 18% of all plastic surgeons in Taiwan. We feel that the data in this study are representative of all the plastic surgeons in Taiwan because the attendance of the annual meeting and continuing education training program, where the data acquisition phase of this study was conducted, is required for license renewal. This study was approved by the Taipei Medical University Joint Institutional Review Board (201407040).
Measures The principal tool used in this study was a structured questionnaire that consisted of four domains: (1) demographic information including sex, age, medical experience, location of practice by region, type of employment, and prior experience with medical disputes; (2) respondent perception of media reporting related to cosmetic medicine and related medical disputes; (3) physician opinions on the causes of the high incidence of medical disputes; and (4) respondent perception of ideal physicianepatient communication and suggestions for continuing education courses. Participants were prompted to indicate their degree of agreement to items regarding the following topics on a fivepoint Likert scale: the avoidability of medical disputes and medical litigation, the media’s support of either physicians or patients when reporting medical disputes, victimization of patients in medical dispute reporting, and the influence of the media on medical dispute proceedings. Respondents’ perception of ideal physicianepatient communication and suggestions for continuing education courses were ascertained through multiple response items.
Statistical analysis Descriptive statistics and subsequent analyses were performed using SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). We split participants into two groups: those who experienced a medical dispute and those who did not. We subsequently used Chi-square tests to investigate differences between these two groups in terms of their perspectives on items regarding media reporting and its influence on medical disputes. Next, we performed a similar analysis using Chi-square tests to investigate differences in the perceived causes of medical disputes between participants who experienced medical disputes and those who had not. We collapsed “don’t know”, “disagree”, and “strongly disagree” into a single “disagree” category for this analysis.
Results Table 1 presents the respondent demographics. Of the 109 respondents, the average age was 42.5 years and 77.1% were male. Over a third (36.4%) had previously experienced
3 Table 1
Demographic characteristics of respondents.
Variables Sex Male Female Age, y (mean SD) Medical experience, y (mean SD) Locations of practice region Northern Central Southern Eastern Type of employment Medical Center Clinic employee (not self-employed) Regional or district hospital Self-employed Prior experience with medical disputes Yes No
n
%
84 77.1 25 22.9 42.46 9.11 9.68 7.78 66 11 20 6
64.1 10.7 19.4 5.9
41 29 17 14
40.6 28.7 16.8 13.9
36 63
36.4 63.6
a medical dispute. The average respondent had 9.7 years of work experience. Most respondents (64%) worked in northern Taiwan, and 41% of respondents worked in a medical center. Only 10 plastic surgeons answered that they did not have prior experience with medical disputes. As seen in Table 2, the vast majority of both physicians who had medical disputes (77.1%) and those who did not (72.1%) felt that the media tends to be supportive of patients in their reporting, and 37.1% of all plastic surgeons felt that the media always portrays the patient as a victim. Over a quarter (26.8%) of the plastic surgeons felt that medical dispute reporting negatively influences cosmetic medical practices. There was no significant difference between respondents with medical dispute experience and those without medical dispute experience for any perception regarding the influence of media reporting on cosmetic medicine (p Z 0.875). Table 3 lists the reasons selected by respondents for the high incidence of medical disputes. Respondents who experienced medical disputes in this study felt that the top five leading causes of the high incidence of medical disputes were patient disappointment with procedure results (81.1%), insufficient patient psychological preparation or emotional instability (61.7%), inadequate risk communication on the part of the physician (64.9%), patient uneasiness with the procedure or perception of carelessness (60.6%), and insufficient physician training or incorrect medical evaluation (57.4%). Plastic surgeons with prior medical dispute experience had more agreement than those without prior experience that insufficient patient psychological preparation or emotional instability (p < 0.001) and patient uneasiness with the procedure or perception of carelessness (p Z 0.017) were contributory factors to medical litigation. Table 4 presents both the ideal physicianepatient communication characteristics as well as respondent suggestions for additional medical education courses. The largest proportion of respondents (37.4%) opined that the most important physicianepatient characteristic for ideal
Please cite this article in press as: Chen C, et al., Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.011
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C. Chen et al. Table 2
Respondent perception of cosmetic medicine- and medical dispute-related media reporting.
Variables
Prior experience with medical disputes Yes (n Z 36) %
Perception of the media’s attitude when reporting medical disputes Neutral Supportive of physicians Supportive of patients Not necessarily supportive of either physicians or patients Medical dispute reporting negatively influences cosmetic medical practices Strongly agree Agree Not sure Disagree/Strongly disagree Medical dispute reporting portrays the patient as a victim Always Often Seldom or never Avoidability of medical disputes and medical litigation Avoidable Cannot be avoided Not sure Referring to physicians of other specialties as plastic surgeons damages the professional reputation of plastic surgeons Strongly agree Agree Not sure Disagree/Strongly disagree
No (n Z 63) %
p
Total (n Z 99) % e
2.9 0.0 77.1 20.0
4.9 3.3 72.1 19.7
4.2 2.1 74.0 19.7 0.875
31.4 34.3 22.9 11.4
24.2 40.3 22.6 12.9
26.8 38.1 22.7 12.4 0.804
37.1 40.0 22.9
37.1 45.2 17.7
37.1 43.3 19.6 0.551
14.7 38.2 47.1
8.1 37.1 54.8
10.4 37.5 52.1 0.684
34.3 34.3 22.9 8.5
communication was the clear explanation of potential risks and side effects of surgical procedures and treatments, whereas the second-largest proportion (19.2%) felt that the most important characteristic was patients being informed of the course of treatment prior to beginning therapy. Based on multiple responses, 65.9% of respondents advised for the creation of courses teaching crisis management related to medical disputes to physicians, 55.7% advised for an introduction to civil and criminal litigation, and 48.9% advised for courses regarding patient communication. The only significant difference with regard to these perceptions and suggestions between respondents who had medical litigation experience and those who did not was a greater proportion of respondents without medical litigation experience suggesting a need for an introduction to civil and criminal litigation (64.3% vs. 40.6%).
Discussion Regardless of having prior medical litigation experience, the majority of our 109 respondents felt that the media tends to be supportive of patients in their reporting, and 37.1% felt that the media always portrays the patient as a victim. The five most reported instigating factors for
43.5 24.2 21.0 11.3
40.2 27.8 21.6 10.4
medical disputes in this study included disappointment with the results of the procedure, insufficient patient psychological preparation or emotional instability, poor risk communication on the part of the physician, patient uneasiness with the procedure or perception of carelessness, and insufficient physician training or incorrect medical evaluation. The largest proportion of respondents opined that the most important characteristic for ideal physicianepatient communication was the clear explanation of postsurgical recovery and risk of side effects, whereas the second-largest proportion felt that it was the assurance that patients were informed of the course of treatment prior to beginning the treatment. This study highlights the perception among plastic surgeons that the media reporting of medical disputes and medical litigation is biased in favor of the patients, with 37.1% of the plastic surgeons surveyed opining that patients are always cast as victims. Cosmetic surgery and the use of social media have emerged contemporaneously during the last decade, and have come as a pair to the mainstream media. In our study, however, we did not find any “official” legal problems. The surgeons in this study opined that maintaining good communication and strong relationships between the treatment team and the patient can solve most problems.
Please cite this article in press as: Chen C, et al., Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.011
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Media influence on medical dispute incidence
Table 3
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Physician opinions on the causes of the high incidence of medical disputes.
Variables
Patient disappointment with procedure results Strongly agree Agree Not necessarily/Disagree/Strongly disagree Inadequate risk communication on the part of the physician Strongly agree Agree Not necessarily/Disagree/Strongly disagree Patient did not adhere to the prescribed medical regiment resulting in poor prognosis Strongly agree Agree Not necessarily/Disagree/Strongly disagree Insufficient physician training or incorrect medical evaluation Strongly agree Agree Not necessarily/Disagree/Strongly disagree Insufficient patient psychological preparation or emotional instability Strongly agree Agree Not necessarily/Disagree/Strongly disagree Physician failed to provide an adequate understanding of informed consent to the patient (including confidentiality and privacy) Strongly agree Agree Not necessarily/Disagree/Strongly disagree Patient uneasiness with the procedure or perception of carelessness Strongly agree Agree Not necessarily/Disagree/Strongly disagree Medical negligence Strongly agree Agree Not necessarily/Disagree/Strongly disagree Physician unfamiliar with the selected treatment Strongly agree Agree Not necessarily/Disagree/Strongly disagree Patient deliberately engaging in extortion Strongly agree Agree Not necessarily/Disagree/Strongly disagree Patient perceives a violation of personal privacy Strongly agree Agree Not necessarily/Disagree/Strongly disagree
Prior experience with medical disputes Yes (n Z 36) %
No (n Z 63) %
Total (n Z 99) %
51.5 36.4 12.1
32.2 45.2 22.6
38.9 42.2 18.9
p
0.158
0.511 18.2 48.5 33.3
9.8 54.1 36.1
12.8 52.1 35.1 0.253
24.2 36.4 39.4
14.5 53.2 32.3
17.9 47.4 34.7 0.066#
18.2 30.3 51.5
8.2 54.1 37.7
11.7 45.7 42.7 <0.001***
33.3 39.4 27.3
3.3 52.4 44.3
13.8 47.9 38.3 0.934
9.1 48.5 42.4
8.2 52.5 39.3
8.5 51.1 40.4 0.017*
30.3 33.3 36.4
8.2 50.8 41.0
16.0 44.6 39.4
15.2 36.4 48.4
8.3 46.7 45.0
10.8 43.0 46.2
12.1 39.4 48.5
4.9 44.3 50.8
7.4 42.6 50.0
21.2 30.3 48.5
8.3 26.7 65.0
12.9 28.0 59.1
15.2 21.2 63.6
3.3 34.4 62.3
7.4 29.8 62.8
0.472
0.442
0.148
0.070#
#p < 0.1; *p < 0.05; **p < 0.01; ***p < 0.001.
Please cite this article in press as: Chen C, et al., Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.011
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C. Chen et al. Table 4
Respondent perception of ideal physicianepatient communication and suggestions for continuing education courses.
Variables
Prior experience with medical disputes Yes (n Z 36) %
Ideal physicianepatient communication characteristics Clear explanation of the potential 44.4 risks and side effects of surgical procedures and treatments Informed of the course of 19.4 treatment prior to beginning therapy Physician eye contact and 13.9 attention to the patient during treatment or consultation Patience when responding to 5.6 patient questions Consideration of the patient’s 8.3 ability to understand the course of treatment Others 8.3 Suggestions for topics of future continuing medical educationa Crisis management related to 62.5 medical disputes Introduction to civil and criminal 40.6 litigation Introduction to copyright law 9.4 Medical professionals’ 40.6 communication with the media Medical marketing 18.8 Patient communication 50.0
p
No (n Z 63) %
Total (n Z 99) %
33.3
37.4
19.0
19.2
12.7
13.1
12.7
10.1
9.5
9.1
12.7
11.1
67.9
65.9
0.610
64.3
55.7
0.032*
7.1 25.0
8.1 30.7
e 0.126
16.1 48.2
17.0 48.9
0.748 0.872
0.796
*p < 0.05. a Based on multiple responses.
Although the media’s dissemination of information during the litigation process provides the opportunity to reevaluate physician behavior and change patient attitudes,5 most media sources in Taiwan focus on the patient’s opinion rather than striving to achieve a neutral standpoint when reporting on medical mediation. One recent medical dispute serves to illustrate this point. After suffering a miscarriage due to adenomyosis, a Taiwanese news anchor denounced her physician across several social media platforms. The story’s online presence encouraged formal media agencies to take notice and begin reporting on it from the anchor’s perspective, much to the injustice of her physician. The medical community came out in defense of the attending physician; however, the anchor refused to accept the physician’s diagnosis and instead filed for a medical dispute. While this case was clearly not based on malpractice or negligence, and the outcome was an unavoidable medical risk, most people exposed to the media alone would likely condemn the physician. This phenomenon might not be unique to Taiwan. Moses et al.9 cautioned against the role of social media in the medical community in general, and suggested that its use brings with it the possibility to further complicate legal action by increasing the difficulty of balancing patients’ needs while complying with current laws and not exposing physicians to additional legal risks.9 Thus, additional policy
work will be needed to protect physicians from lawsuits and warrants further investigation. Our results are in line with those of previous studies regarding the reasons underlying medical disputes.10 The greatest proportion of respondents in our study opined that medical disputes are the result of treatments not meeting patient expectations. This was followed by a lack of patients’ psychological readiness or emotional disturbance prior to treatment. This demonstrates that most physicians whether they have experienced a medical dispute or not can recognize an important truth: most medical disputes might not be caused by physicians but rather arise from patient-related psychological factors.10 Thus, good informed consent might be the best form of protection for both plastic surgeons and their patients,11 followed by wellmaintained medical records.12 These opinions were equally shared by respondents who were previously embroiled in medical disputes of their own and those who were not, thus giving credence to these results being representative of an unbiased view of the plastic surgery community. However, we did find some discrepancies between the agreement of physicians who had experienced medical disputes and those who did not regarding the causes of the high incidence of medical disputes. A greater proportion of physicians with medical litigation experience opined that insufficient patient psychological preparation or emotional
Please cite this article in press as: Chen C, et al., Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.011
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Media influence on medical dispute incidence instability and patient uneasiness with the procedure or perception of carelessness were the causal factors for medical litigation. This indicates that physicians without medical dispute experience may take lightly the importance of informed consent and patient education. As over a third of the respondents reported that the high incidence of medical litigation is unavoidable, we can conclude that most physicians working in aesthetic medicine and plastic surgery have some degree of vigilance to medical disputes. However, medical training needs to be commensurate with the changing medical landscape and better educate physicians to prevent and handle medical disputes and litigation. These educational needs may be met with continuing medical education in jurisprudence, civil and criminal litigation, and communication. More physicians without medical dispute experience thought that medical education should provide an introduction to civil and criminal litigation rather than patient communication. This finding may indicate two important things: (1) after experiencing a medical dispute, physicians might place less trust in medical education classes; (2) most physicians might think that patient communication does not help avoid medical disputes. Thus, we might infer that “defensive medicine” has already had profound effects on plastic surgery. Our report demonstrates that Taiwanese plastic surgeons pay little attention to the effects of social media. However, we did not compare between those with and without legal judgments. This situation is similar to that in Korea where the media may hold a strong negative attitude toward cosmetic surgeons.13 Therefore, in the future, we plan to explore the associations between cosmetic medicine, legal judgments, and the media. Our study has several strengths. First, it is the first study to investigate physician opinions regarding medical disputes and the influence of the media. Although there are many medical disputes and medical litigation events each year, we still lack a good evidence base to inform our medical education system. Second, the items in our questionnaire were all created from qualitative interviews, so they can be considered to represent the current situation in Taiwan. However, these strengths and the results of our study need to be seen in light of several limitations. First, this study was cross-sectional in nature and cannot be used to explain the causal relationship between medical disputes, patient attitudes and opinions, and the influence of the media. Second, although we captured a robust sample size considering its specificity, the agreement between some variables is highly skewed. To overcome this limitation, we suggest that future studies investigate medical disputes using a larger sample to corroborate our findings. Third, while the annual meeting and continuing education training program, where the data acquisition phase of this study was conducted, is important for the professional development of all plastic surgeons in Taiwan, as they are unable to renew their licenses without attending continuing education, and the vast majority of doctors did attend (81.1%), there are likely to be intrinsic differences between the attendees and those who did not choose, or were unable, to participate. One such notable difference can be observed by comparing the percentage of the population who had experienced a medical dispute. In this study, 36.4%
7 of the respondents had experienced a prior dispute, which approximates the 44.1% and 36.0% rates found amongst all Taiwanese physicians in 199314 and 2005,15 respectively. However, among Taiwanese surgeons overall, 63.3% and 56.5% had been involved in malpractice claims in 1991 and 2005, respectively.16 Thus, the plastic surgeons in this study seemed to have substantially fewer malpractice claims than the gamut of surgical specialties. Therefore, while our selection may have engendered a slight bias in our results, it is far more likely that the surgeons in this study would have borne a more agreeable attitude toward medical litigation than the general population of surgeons given their comparatively fewer forays into medical disputes. Thus, our results are likely conservative estimates regarding the perception that the media is biased in favor of the patients.
Conclusions This study highlights the perception among plastic surgeons that the media reporting of medical disputes and medical litigation is biased in favor of the patients who are routinely cast as victims. These opinions were equally shared by respondents who were and were not previously embroiled in medical disputes of their own, thus giving credence to these results being representative of an unbiased view of the plastic surgery community. Moreover, this community commonly perceived that media reporting engenders a strong negative effect on both private practices as well as the overall reputation of plastic surgery as a discipline. Over a third of respondents reported feeling that the high incidence of medical litigation is unavoidable. However, they feel that the causes underlying this high incidence stem from both patients and physicians, who they suggested should engage in continuing medical education in jurisprudence, civil and criminal litigation, and communication. In addition to underscoring the importance of continuing medical education, these results also indicate the need for courses on medical litigation in medical school, so that young physicians are well informed when making career choices, and medical insurance, which will balance the risks now inherent in the medical community. The gravity of the societal implications surrounding these issues and their resolution warrants future research efforts directed at disentangling the underlying factors predisposing to medical disputes and determining how to best avoid and contend with them.
Acknowledgments We would like to thank the Ministry of Science and Technology (grant number: NSC102-2511-S-038-002-MY2(2-2)) and Taipei Municipal Wanfang Hospital (Managed by Taipei Medical University) (grant number: 105TMU-WFH-03) for supporting this investigation.
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Please cite this article in press as: Chen C, et al., Potential media influence on the high incidence of medical disputes from the perspective of plastic surgeons, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.011