- Email: [email protected]
Twenty-five years of professional liability in pediatric ophthalmology and strabismus: the OMIC experience
Twenty-five years of professional liability in pediatric ophthalmology and strabismus: the OMIC experience Robert E. Wiggins Jr, MD, MHA, Robert S. Gold, MD, and Anne M. Menke, RN, PhD PURPOSE METHODS
To summarize the claims statistics of the Ophthalmic Mutual Insurance Company (OMIC) in the field of pediatric ophthalmology and strabismus (POS). Internal OMIC case summaries and defense counsel case evaluations of all claims in the field of POS closed between December 1, 1988, and February 19, 2013 were retrospectively analyzed.
RESULTS
A total of 140 claims were closed over the 25-year study period, of which 44 were closed with an indemnity payment. Claims related to strabismus and retinopathy of prematurity (ROP) were most common, and claims related to ROP resulted in the highest indemnity and expense payments. Issues related to follow-up represented the most significant risk factor among system-related claims.
CONCLUSIONS
Claims in pediatric ophthalmology and strabismus were infrequent but associated with three times higher average indemnity payments relative to all claims paid by OMIC during the course of the study. ( J AAPOS 2015;19:535-540)
T
here has been renewed emphasis on improving quality while reducing the cost of health care in the United States. An understanding of the factors associated with professional liability claims offers one approach that may affect both. Claims in the field of pediatric ophthalmology and strabismus (POS) have not previously been the subject of comprehensive review.1-8 The Ophthalmic Mutual Insurance Company (OMIC) was founded in 1987 by the American Academy of Ophthalmology and currently is the major insurer of ophthalmologists in private practice. This study represents a retrospective analysis of the 140 claims closed in the field of POS over a 25-year period. Ophthalmologists can use the findings for risk management in their own practices, to improve the quality of care they provide their patients, and to reduce the personal and societal costs associated with professional liability litigation.
Materials and Methods This study conformed to requirements of the US Health Insurance Portability and Accountability Act of 1996. This retrospective study included all closed claims at OMIC against Author affiliations: Ophthalmic Mutual Insurance Company, San Francisco, California Financial disclosures: Robert E. Wiggins Jr, MD, MHA, is on the Board of OMIC, Robert S. Gold, MD, is an OMIC Committee member, and Anne M. Menke, RN, PhD, is the Risk Manager for OMIC. Submitted April 23, 2015. Revision accepted September 22, 2015. Correspondence: Robert E. Wiggins Jr, MD, MHA, Asheville Eye Associates, 8 Medical Park Drive, Asheville, NC 28803 (email: [email protected]). Copyright Ó 2015 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2015.09.007
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individuals (119) or entities (21) in the field of POS since the inception of the company and covers the period from December 1, 1988, through February 19, 2013. A claim was classified as pediatric if the plaintiff was 21 years of age or younger at the time of the incident.9 The authors reviewed data from OMIC claims summaries in each case and defense counsel case evaluations in 66 of 119 individual claims.
Results A total of 117 cases (unique plaintiffs) resulting in 140 closed claims against one or more physicians and/or entities (Table 1) over a 25-year period were reviewed (Figure 1). Clinical category of the cases (n 5 117) appears in Figure 2. Characteristics of Defendants and Plaintiffs The defendants were comprised of 119 ophthalmologists (100 males) of mean age 45 years at the time of the incident (range, 29-78 years). The most common practice designation/specialty was POS (56), although the majority of the defendants (61) were not subspecialists in this field. The latter group included comprehensive ophthalmologists (35), retinal specialists (10) and a broad range of other subspecialists with 5 or fewer each. Two were not designated. All ophthalmologists had claims-made insurance coverage (ie, policy effective on the date the claim was first made and reported to the insurer). The majority (67%) had coverage of $1/$3 million (single episode/annual aggregate). The plaintiff was most commonly less than 1 year of age (Figure 3). Most cases occurred in Texas (21), Illinois (14), Louisiana (13), and California (9).
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Table 1. Claim and case classification Type of claim
Number of claims
Individual Entitya Total Defendantb 1 physician 1 physician 1 entity Entity 2 physicians 2 physicians 1 entity 3 physicians Total
119 21 140 Number of cases 92 14 5 3 2 1 117
a
The practice corporation. In most cases only a single physician was involved in the care that was alleged to be negligent. Claims with multiple physician defendants occurred where physicians comanaged the patient. The physician’s entity may also have been named in the suit.
FIG 3. Plaintiff age at time of incident. Table 2. Standard of care Expert review
Individuals, n (%)
Entities, n (%)
Standard of care Met Not met Mixed reviews No expert review
62 (52) 33 (27) 11 (9) 13 (11)a
19 (90.5) 2 (9.5)
b
a
Claim dismissal before review.
emergency room physician in one case and a pediatrician in another). Most allegations related to treatment (44), surgery (37), or diagnosis (33). Standard of Care The standard of care in each case is determined by expert reviewers hired by both the plaintiff and defense attorneys. See Table 2 for how defense experts evaluated the claims. FIG 1. Claims by time period.
FIG 2. Clinical category of cases (n 5 117).
Location of Incident and Allegations The majority of cases originated in the office (55), surgical setting (26 total, including hospital outpatient surgery department [19], ambulatory surgery center [6], or office procedure room [1]), or inpatient hospital location (25). The remainder occurred in the emergency room (8). In 2 cases, the patient was never examined by the insured ophthalmologist; both were cases of trauma, where the physician had contact only with another physician (an
Claims Course and Costs The mean time from the incident to claim opening was 2.24 years (range, 18 days-18.39 years). The mean time from claim opening to closing was 2.58 years (range, 7 days-11.72 years). The mean nominal (actual or noninflation adjusted) indemnity payment in 44 claims closed with indemnity payment (CWIP) was $470,695 (median, $201,217). When adjusted for inflation (2012 dollars), the mean was $556,106 (median, $296,735). Of the 140 claims, 119 were individual claims; 21 were entity claims. In the individual claims group, 42 cases (35%) resulted in indemnity payments. In the entity claims group, 2 (9.5%) resulted in indemnity payments. In no case did the indemnity payment exceed the insured’s limit of liability. Of 117 cases, 105 had associated expenses (mostly attorney fees) for defense of the case. Mean expenses for all cases was $66,672 (range, $35-$489,061; adjusted for inflation, $79,459). Two indemnity payments were made on behalf of entities ($1 million, $75,000). In 5 claims the outcome was determined by mediation/arbitration; in 7, by jury trial. The remainder were settled with the consent of the insured ophthalmologist or dismissed. Frequency and Severity by Condition The frequency (number of claims) and severity (percentage of claims closed with indemnity payments and the
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Table 3A. Indemnity payments by clinical category Medical condition a
Strabismus ROP Trauma Neuro-ophthalmic Cornea Retina Cataract Refractive/surgical Oculoplastics Medication Nasolacrimal Amblyopia Refractive/glasses Total
% of % Cases cases CWIP CWIP 36 18 15 12 10 8 6 3 3 2 2 1 1 117
31% 15% 13% 10% 9% 7% 5% 3% 3% 2% 2% 1% 1%
13 9 5 4 3 3 2 2 2 0 1 0 0 44
Indemnity payments (2012)
Indemnity payments (nominal)
36% $2,157,707.12 50% $8,396,347.66 33% $1,442,759.60 33% $2,661,286.00 30% $1,300,000.00 38% $1,112,500.00 33% $1,990,000.00 67% $1,030,000.00 67% $600,000.00 0% 50% $20,000.00 0% 0% 38% $20,710,600.38
$2,831,669.57 $9,479,308.62 $1,763,532.75 $2,988,744.24 $1,764,775.00 $1,208,012.50 $2,586,070.00 $1,057,450.00 $763,600.00 $25,520.00
Risk Management Factors Each claim was reviewed by one of the authors (AM) to determine the main risk management factor involved. Claims were classified as primarily patient, physician, or system related. With patient and physician issues, the acts of the patient (eg, a condition/action of a patient over which the physician has no control) or physician (eg, problems with diagnosis, judgment, knowledge, or skill), respectively, were the weak point in the process of care. Systems issues, on the other hand, cannot be attributed to a single individual; instead, these involve processes in which multiple individuals and entities are involved.10 The results by frequency and severity of claims are shown in Table 4. Systems issues accounted for most claims. In lawsuits against individual physicians, the most frequent risk management factors were informed consent, follow-up (ie, tracking of missed patient appointments, referrals, handoffs, or test results), and the litigation process (see discussion). Most claims against entities were a consequence of the litigation process itself. Plaintiff attorneys may file suit against both physicians and their practices or institutions as defendants, because this often increases the amount of money available for a settlement. On review, most entities had no responsibility for the outcome and
Mean (2012)
Median (nominal)
Median (2012)
$165,977.47 $217,820.74 $91,515.00 $142,398.83 $932,927.52 $1,053,256.51 $575,000.00 $841,225.00 $288,551.92 $352,706.55 $335,000.00 $176,052.73 $665,321.50 $747,186.06 $293,143.00 $372,697.12 $433,333.33 $588,258.33 $275,000.00 $386,775.00 $370,833.33 $402,670.83 $350,000.00 $355,387.50 $995,000.00 $1,293,035.00 $995,000.00 $1,293,035.00 $515,000.00 $528,725.00 $515,000.00 $528,725.00 $300,000.00 $381,800.00 $300,000.00 $381,800.00 $20,000.00 $25,520.00 $20,000.00 $25,520.00
$24,468,682.68 $470,695.46
amounts of these payments) are shown by clinical category in Table 3A-C. Strabismus accounted for the most individual cases (adults, 21; pediatric, 15). Of clinical categories with $6 cases, the highest percentage of cases closed with an indemnity payment (50%) was in retinopathy of prematurity (ROP), which was also associated with the highest mean indemnity payments and highest total dollars spent by OMIC when allocated defense expenses were included. ROP comprised 15% of all cases but accounted for 37% of the total dollars expended by OMIC in the field of POS over the course of this study.
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Mean (nominal)
$556,106.42
$201,217.00
$296,735.00
Table 3B. Defense expenses by clinical category Medical condition a
Strabismus ROP Trauma Neuro-ophthalmic Cornea Retina Cataract Refractive/surgical Oculoplastics Medication Nasolacrimal Amblyopia Refractive/glasses Total
Expenses (nominal)
Expenses (2012)
$969,935.52 $2,234,592.03 $1,038,822.35 $305,298.68 $401,412.20 $438,900.76 $848,149.55 $265,912.69 $536,052.25 $204,658.93 $530,444.80 $25,530.69 $866.01 $7,800,576.46
$1,247,634.32 $2,651,139.33 $1,152,282.75 $376,995.01 $535,591.80 $482,960.06 $1,024,703.29 $277,841.94 $756,651.09 $215,505.85 $541,698.51 $32,577.16 $1,122.35 $9,296,703.46
were dismissed (Table 5). The highest total indemnity payments among system issues were paid on behalf of insured individuals or entities in the category of “follow-up” (Table 6).
Discussion The 140 closed claims in the field of POS are lowfrequency events and represent only 4% of the entire OMIC closed claims in the 25-year history reported in this study. However, the severity of the claims, as measured by the percentage closed with an indemnity payment (31%), was relatively high compared to all claims (21%) at OMIC over this period (OMIC internal communication). Another measure of severity, the mean indemnity payment ($470,695), was also higher in the field of POS compared to that for all claims ($156,043) at OMIC (OMIC internal communication). A study from the United Kingdom evaluating clinical negligence in ophthalmology found that pediatric claims were low in frequency but had the second highest indemnity payments, second only to neuro-ophthalmology.5 Reasons cited for large payments involving children
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Table 3C. Total costs by clinical category Medical condition a
Strabismus ROP Trauma Neuro-ophthalmic Cornea Retina Cataract Refractive/surgical Oculoplastics Medication Nasolacrimal Amblyopia Refractive/glasses Total
Total (nominal)
Total (2012)
Cost/Case (nominal)
Cost/case (2012)
$3,127,642.64 $10,630,939.69 $2,481,581.95 $2,966,584.68 $1,701,412.20 $1,551,400.76 $2,838,149.55 $1,295,912.69 $1,136,052.25 $204,658.93 $550,444.80 $25,530.69 $866.01 $28,511,176.84
$4,079,303.89 $12,130,447.95 $2,915,815.50 $3,365,739.25 $2,300,366.80 $1,690,972.56 $3,610,773.29 $1,335,291.94 $1,520,251.09 $215,505.85 $567,218.51 $32,577.16 $1,122.35 $33,765,386.14
$86,878.96 $590,607.76 $165,438.80 $247,215.39 $170,141.22 $193,925.10 $473,024.93 $431,970.90 $378,684.08 $102,329.47 $275,222.40 $25,530.69 $866.01 $243,685.27
$113,314.00 $673,913.78 $194,387.70 $280,478.27 $230,036.68 $211,371.57 $601,795.55 $445,097.31 $506,750.36 $107,752.93 $283,609.26 $32,577.16 $1,122.35 $288,593.04
ROP, retinopathy of prematurity. a 21 adult, 15 pediatric.
Table 4. Frequency and severity (percentage of indemnity payments per category) of risk issues Type
No. individual No. No. % eye MD entities paid paid
Physician
40
0
System
72
21
Patient
7
0
Examples from this study
23/40 58 Telephone treatment of postoperative strabismus patient despite 4 phone calls who on subsequent office evaluation proved to have endophthalmitis 20/93 22 Surgery on the incorrect eye after nurse prepped and draped the incorrect eye 1/7 14 Patient aspirated during strabismus surgery and died; found on autopsy not to have fasted
include the accumulated lifetime expenses of lost earnings and caring for a child with a permanent disability, sympathy for children with disabilities, and use of malpractice payments as a form of “social insurance” to help care for a child with devastating disabilities, regardless of whether the injury was caused by malpractice or not.11 The decreased frequency in claims in the most recent years parallels that of OMIC as a whole, where the average frequency of claims between 2004 and 2013 was nearly 40% lower than the average between 1996 and 2003 (OMIC internal communication). The causes for this may include factors such as improved quality of care, risk management education (eg, the ROP “safety net” program introduced by OMIC in 2006 and wrong site initiatives), and tort reform.12,13 The mean time from the incident to filing of claim was just over 2 years but ranged to as long as 18 years. The long duration in some cases, relative to claims for the
Table 5. Frequency analysis of systems issue Risk/defendant
Physician
Entities
Total
Litigation Informed consent Follow-up Identification of surgical site Telephone care Evolving standard of care Payment issues Equipment (cautery fire)
16 24 19 4 3 2 1 1
13 2 3 1 1 0 1 0
29 26 21 5 4 2 2 1
entire field of ophthalmology, related to the lengthy statute of limitations (SOL) in some states in which claims may be filed in pediatric cases. There was an additional 2.5 years mean duration from time of filing a claim to time of settlement. Whereas the costs of indemnity payments and expenses to insure a claim are readily available, it is difficult to calculate the costs of physician time spent defending a claim or to assign a value to nonmonetary factors such as anxiety and lack of closure on both the part of the physician and patients and their families during the lengthy litigation process.11,14 Resources are available to manage litigation stress.15
Clinical Conditions We found that plaintiffs were most commonly \1 year of age at the time of the incident. Five clinical categories had 10 or more claims. Strabismus was the most frequent medical condition resulting in claims, with those in adults more frequent than in children. The most common reasons for the claims in this category were lack of timely referral to a strabismus specialist, poor documentation of the decision-making process, inadequate management of patient expectations about the surgical procedure, and not performing the planned surgery. The informed consent process was a major driver in strabismus claims. Although claims related to strabismus were most common in terms
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Table 6. Severity analysis of systems issues Amount aid Type
No. paid
Nominal
2012 inflation adjusted
Follow-up Evolving standard of care Telephone care Equipment (cautery fire) Identification of surgical site Informed consent Litigation Payment issues
9/21 2/2 1/4 1/1 4/5 3/26 0/29 0/2
$5,630,967 $376,666 $337,500 $200,000 $185,265 $67,500 $0 $0
$6,712,168 $399,910 $355,387 $200,000 $250,326 $86,825 $0 $0
of frequency, the mean indemnity payment of $165,977 was among the lowest. The second most common number of claims related to ROP, which was associated with the greatest severity both in terms of percentage of CWIP claims (50%) and mean indemnity payment ($932,928). Systems errors are discussed below. The third most common category was claims related to trauma. The treatment window is often narrow in these patients, and claims of patients presenting emergently were typically associated with allegations of delays in diagnosis or treatment. Telephone care played a role in 4 cases. Contact form checklists help mitigate the risk of professional liability, prompting ophthalmologists to ask patients and referring physicians questions about traumatic ocular injuries and help to document the conversation. When the patient is referred by another physician, the ophthalmologist cannot assume that physician has the requisite knowledge and skill to identify serious ocular injuries and should have a low threshold for personally evaluating the patient. Neuro-ophthalmic pediatric claims represented the fourth most common source of claims and, following ROP, were associated with the second highest total indemnity payments. These claims were frequently associated with allegations of delays in diagnosis or treatment. Developing and documenting a differential diagnosis, meticulous follow-up of patients and laboratory results, and obtaining consultations may help reduce risk in these low-frequency, high-severity cases.16 The fifth most common disease category, corneal disorders, commonly resulted from a delay in diagnosis and management of infection. Ruling out infection, particularly prior to beginning corticosteroids, careful followup, and early referral to a corneal specialist when the patient is not responding to treatment are important risk management strategies for this population.
Patients and Physicians These few claims highlight the fact that while ophthalmologists may be sued for poor outcomes, they are generally not held liable for the conditions or actions of patients over which they have no control. Careful, repeated, well-
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documented instructions and educational efforts facilitate the defense of such claims. Claims involving physician factors were associated with high severity in terms of total indemnity payments and percentage of claims closed with indemnity payments. Diagnostic errors led this category. Analysis of diagnostic failures highlight the cognitive problems inherent in the way physicians reason, formulate judgments, and make decisions.17 Strategies that encourage physicians to examine their thinking process may help. Two key safety steps are to consider what else could produce the same signs and symptoms and to consider, even briefly, the worst-case scenario.16 For example, a retinal specialist diagnosed a child with Coats disease. The child had several intraocular surgeries and was eventually diagnosed with retinoblastoma, which had never been ruled out. The case was settled after the child died from the disease. The majority of ophthalmologists in this series were not POS specialists and encompassed a broad range of comprehensive and other subspecialty providers. Physician factors were more common in claims against ophthalmologists who were not POS specialists (61% vs 40%); thus, subspecialty training in POS may decrease the risk of claims in this category. For example, expert reviewers opined that complex strabismus surgery should have been performed by strabismus specialists and that nonspecialists often did not refer the patient in a timely manner. Systems Issues Systems issues involve care processes in which multiple individuals and entities are involved and accounted for the majority of claims in this series. The three most common issues are follow-up, informed consent, and the litigation process. Follow-up issues led the severity list both in amount of money paid and the number of claims settled, and ranked second in frequency in claims against physicians. It is therefore a key area of loss prevention to emerge from this study. Ophthalmologists must develop robust follow-up systems to track appointments, referrals to specialists, hand-offs of patients transitioning from the hospital to outpatient setting, and test results. Lawsuits alleging failure to follow-up included those related to ROP, amblyopia, emergent care, and neurological conditions. The clear message from the number of claims, settlements, and jury verdicts related to follow-up is that physicians are expected to notice when prescribed care has not been obtained and take steps to address it by having appointment, referral, and test tracking mechanisms in place. Sample tracking protocols for ROP care in the hospital and office setting, as well as sample appointment, test, and referral tracking for all practices are available.12,18 Physicians are urged to review these documents and to contact the risk manager of their professional liability company for assistance in customizing and implementing these crucial loss prevention measures.
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The physician and the patient play obvious roles in informed consent. However, linguistic and cultural differences, educational material, consent forms, and education provided by staff also affect the informed consent process. Problems in this area were the most common source of systems claims against physicians and resulted in 2 entity claims. Although not as costly as claims related to followup, 3 of 26 claims were settled. Failure to properly obtain informed consent is a common allegation in medical malpractice lawsuits. One study that attempted to determine why patients sue their physicians found that doctors who were perceived as “hurried, uninterested, and unwilling to listen and answer questions” were much more likely to be sued.19 Another study found that communication breakdowns occurred in 70% of malpractice claims.20 Some of the communication problems can be avoided by engaging the patient and family in a constructive, ongoing informed consent dialogue designed to invite participation in their care, clarify misconceptions, and minimize unrealistic expectations.21 Rather than being a purely legal function performed prior to invasive procedures, consent becomes an opportunity to establish a therapeutic alliance between the ophthalmologist and the patient wherein each recognizes the clinical uncertainties that exist to some degree with each medical or surgical intervention. All but 1 of the 16 surgical informed consent claims involved strabismus surgery; the vast majority were for adult strabismus surgery. In particular, the patients/parents did not “hear” that a second surgery might be needed, that surgery might be complicated by prior surgery or the underlying disease, that surgery might not correct all symptoms, and that diplopia might not resolve. The use of a procedure-specific consent form is recommended. It is best to provide the patient with a copy to review at home. Finally, ophthalmologists should decline to perform the surgery if unrealistic expectations cannot be successfully managed. The most frequent vulnerability identified in suits against entities and the third most frequent system issue against individual ophthalmologists is the litigation process. Admittedly, in the early days of a lawsuit, it may be difficult for the plaintiff attorney to determine who, if anyone, may be negligent, and defendants may be named with limited investigation as the statute of limitations approaches. The claims in this category were, however, deemed to be without merit by claims department staff, defense attorneys, and expert witnesses, and all these defendants were dismissed without indemnity payments. Physicians should cooperate fully during the litigation process, regardless of the perceived merit of the case, as failure to meet legal deadlines can have serious consequences.
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Literature Search PubMed was last searched July 23, 2015 for Englishlanguage results using the following terms: professional liability, malpractice claims, pediatric ophthalmology, and strabismus. References 1. Bettman JW. Seven hundred medicolegal claims in ophthalmology. Ophthalmology 1990;97:1379-84. 2. Craven ER. Risk management issues in glaucoma: diagnosis and management. Surv Ophthalmol 1996;40:459-62. 3. Ellis JH, Abbott RL, Brick DC, Weber P. Liability issues associated with PRK and the excimer laser. Surv Ophthalmol 1997;42:279-82. 4. Abbott RL, Ou RJ, Bird M. Medical malpractice predictors and risk factors for ophthalmologists performing LASIK and photorefractive keratectomy surgery. Ophthalmology 2003;110:2137-46. 5. Rashmi RG, Ferguson V, Hingorani M. Clinical negligence in ophthalmology: fifteen years of National Health Service litigation authority data. Ophthalmology 2013;120:859-64. 6. Demorest BH. Retinopathy of prematurity requires diligent followup care. Surv Ophthalmol 1996;41:175-8. 7. Reynolds JD. Malpractice and the quality of care in retinopathy of prematurity. Trans Am Ophthalmol SOC 2007;125: 1515-22. 8. Day S, Menke AM, Abbott RL. Retinopathy of prematurity claims: the Ophthalmic Mutual Insurance Company experience. Arch Ophthalmol 2009;127:794-8. 9. American Academy of Pediatrics. Policy Statement: AAP Publications Reaffirmed. Pediatrics 2012;129:2.e561. 10. Smetzer JL, Cohen MR. Lesson from the Denver medication error/ criminal negligence case: look beyond blaming individuals. Hospital Pharmacy 1998;33:640-57. 11. Jena AB, Chandra A, Seabury SA. Malpractice risk among US pediatricians. Pediatrics 2013;131:1148-54. 12. Menke AM. ROP: materials for creating a hospital safety net. Available at http://www.omic.com/rop-creating-a-safety-net/. Accessed December 4, 2014. 13. AAO Wrong Site Task Force. Recommendations of the American Academy of Ophthalmology Wrong-Site-Task Force. Available at http://one.aao.org/patient-safety-statement/recommendations-ofamerican-academy-ophthalmology-. Accessed December 4, 2014. 14. Charles S. Surviving the aftershocks of malpractice litigation. OMIC Digest 2005;15:1-5. 15. Physician Litigation Stress Resource Center. www.physicianlitigation stress.org. Accessed July 23, 2015. 16. Menke AM. Differential diagnosis: develop and disclose it. OMIC Digest 2010;20:1-5. 17. Croskerry P. Cognitive forcing strategies in clinical decision-making. Ann. Emerg Med 2003;41:110-20. 18. Menke AM. Noncompliance: a frequent prelude to malpractice lawsuits. Available at http://www.omic.com/noncompliance-guidelineswith-sample-missed-appointment-letter/. Accessed December 4, 2014. 19. Hickson GB, Wright Clayton E, Githens PB, Sloan FA. Factors that prompted families to file malpractice claims following perinatal injuries. JAMA 1992;267:1359-63. 20. Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctorpatient relationship and malpractice: lessons learned from plaintiff depositions. Arch Intern Med 1994;154:1365-70. 21. Menke AM. My doctor never told me that could happen. OMIC Digest 2007;17:1-5.
Journal of AAPOS
To summarize the claims statistics of the Ophthalmic Mutual Insurance Company (OMIC) in the field of pediatric ophthalmology and strabismus (POS). Internal OMIC case summaries and defense counsel case evaluations of all claims in the field of POS closed between December 1, 1988, and February 19, 2013 were retrospectively analyzed.
RESULTS
A total of 140 claims were closed over the 25-year study period, of which 44 were closed with an indemnity payment. Claims related to strabismus and retinopathy of prematurity (ROP) were most common, and claims related to ROP resulted in the highest indemnity and expense payments. Issues related to follow-up represented the most significant risk factor among system-related claims.
CONCLUSIONS
Claims in pediatric ophthalmology and strabismus were infrequent but associated with three times higher average indemnity payments relative to all claims paid by OMIC during the course of the study. ( J AAPOS 2015;19:535-540)
T
here has been renewed emphasis on improving quality while reducing the cost of health care in the United States. An understanding of the factors associated with professional liability claims offers one approach that may affect both. Claims in the field of pediatric ophthalmology and strabismus (POS) have not previously been the subject of comprehensive review.1-8 The Ophthalmic Mutual Insurance Company (OMIC) was founded in 1987 by the American Academy of Ophthalmology and currently is the major insurer of ophthalmologists in private practice. This study represents a retrospective analysis of the 140 claims closed in the field of POS over a 25-year period. Ophthalmologists can use the findings for risk management in their own practices, to improve the quality of care they provide their patients, and to reduce the personal and societal costs associated with professional liability litigation.
Materials and Methods This study conformed to requirements of the US Health Insurance Portability and Accountability Act of 1996. This retrospective study included all closed claims at OMIC against Author affiliations: Ophthalmic Mutual Insurance Company, San Francisco, California Financial disclosures: Robert E. Wiggins Jr, MD, MHA, is on the Board of OMIC, Robert S. Gold, MD, is an OMIC Committee member, and Anne M. Menke, RN, PhD, is the Risk Manager for OMIC. Submitted April 23, 2015. Revision accepted September 22, 2015. Correspondence: Robert E. Wiggins Jr, MD, MHA, Asheville Eye Associates, 8 Medical Park Drive, Asheville, NC 28803 (email: [email protected]). Copyright Ó 2015 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2015.09.007
Journal of AAPOS
individuals (119) or entities (21) in the field of POS since the inception of the company and covers the period from December 1, 1988, through February 19, 2013. A claim was classified as pediatric if the plaintiff was 21 years of age or younger at the time of the incident.9 The authors reviewed data from OMIC claims summaries in each case and defense counsel case evaluations in 66 of 119 individual claims.
Results A total of 117 cases (unique plaintiffs) resulting in 140 closed claims against one or more physicians and/or entities (Table 1) over a 25-year period were reviewed (Figure 1). Clinical category of the cases (n 5 117) appears in Figure 2. Characteristics of Defendants and Plaintiffs The defendants were comprised of 119 ophthalmologists (100 males) of mean age 45 years at the time of the incident (range, 29-78 years). The most common practice designation/specialty was POS (56), although the majority of the defendants (61) were not subspecialists in this field. The latter group included comprehensive ophthalmologists (35), retinal specialists (10) and a broad range of other subspecialists with 5 or fewer each. Two were not designated. All ophthalmologists had claims-made insurance coverage (ie, policy effective on the date the claim was first made and reported to the insurer). The majority (67%) had coverage of $1/$3 million (single episode/annual aggregate). The plaintiff was most commonly less than 1 year of age (Figure 3). Most cases occurred in Texas (21), Illinois (14), Louisiana (13), and California (9).
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Table 1. Claim and case classification Type of claim
Number of claims
Individual Entitya Total Defendantb 1 physician 1 physician 1 entity Entity 2 physicians 2 physicians 1 entity 3 physicians Total
119 21 140 Number of cases 92 14 5 3 2 1 117
a
The practice corporation. In most cases only a single physician was involved in the care that was alleged to be negligent. Claims with multiple physician defendants occurred where physicians comanaged the patient. The physician’s entity may also have been named in the suit.
FIG 3. Plaintiff age at time of incident. Table 2. Standard of care Expert review
Individuals, n (%)
Entities, n (%)
Standard of care Met Not met Mixed reviews No expert review
62 (52) 33 (27) 11 (9) 13 (11)a
19 (90.5) 2 (9.5)
b
a
Claim dismissal before review.
emergency room physician in one case and a pediatrician in another). Most allegations related to treatment (44), surgery (37), or diagnosis (33). Standard of Care The standard of care in each case is determined by expert reviewers hired by both the plaintiff and defense attorneys. See Table 2 for how defense experts evaluated the claims. FIG 1. Claims by time period.
FIG 2. Clinical category of cases (n 5 117).
Location of Incident and Allegations The majority of cases originated in the office (55), surgical setting (26 total, including hospital outpatient surgery department [19], ambulatory surgery center [6], or office procedure room [1]), or inpatient hospital location (25). The remainder occurred in the emergency room (8). In 2 cases, the patient was never examined by the insured ophthalmologist; both were cases of trauma, where the physician had contact only with another physician (an
Claims Course and Costs The mean time from the incident to claim opening was 2.24 years (range, 18 days-18.39 years). The mean time from claim opening to closing was 2.58 years (range, 7 days-11.72 years). The mean nominal (actual or noninflation adjusted) indemnity payment in 44 claims closed with indemnity payment (CWIP) was $470,695 (median, $201,217). When adjusted for inflation (2012 dollars), the mean was $556,106 (median, $296,735). Of the 140 claims, 119 were individual claims; 21 were entity claims. In the individual claims group, 42 cases (35%) resulted in indemnity payments. In the entity claims group, 2 (9.5%) resulted in indemnity payments. In no case did the indemnity payment exceed the insured’s limit of liability. Of 117 cases, 105 had associated expenses (mostly attorney fees) for defense of the case. Mean expenses for all cases was $66,672 (range, $35-$489,061; adjusted for inflation, $79,459). Two indemnity payments were made on behalf of entities ($1 million, $75,000). In 5 claims the outcome was determined by mediation/arbitration; in 7, by jury trial. The remainder were settled with the consent of the insured ophthalmologist or dismissed. Frequency and Severity by Condition The frequency (number of claims) and severity (percentage of claims closed with indemnity payments and the
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Table 3A. Indemnity payments by clinical category Medical condition a
Strabismus ROP Trauma Neuro-ophthalmic Cornea Retina Cataract Refractive/surgical Oculoplastics Medication Nasolacrimal Amblyopia Refractive/glasses Total
% of % Cases cases CWIP CWIP 36 18 15 12 10 8 6 3 3 2 2 1 1 117
31% 15% 13% 10% 9% 7% 5% 3% 3% 2% 2% 1% 1%
13 9 5 4 3 3 2 2 2 0 1 0 0 44
Indemnity payments (2012)
Indemnity payments (nominal)
36% $2,157,707.12 50% $8,396,347.66 33% $1,442,759.60 33% $2,661,286.00 30% $1,300,000.00 38% $1,112,500.00 33% $1,990,000.00 67% $1,030,000.00 67% $600,000.00 0% 50% $20,000.00 0% 0% 38% $20,710,600.38
$2,831,669.57 $9,479,308.62 $1,763,532.75 $2,988,744.24 $1,764,775.00 $1,208,012.50 $2,586,070.00 $1,057,450.00 $763,600.00 $25,520.00
Risk Management Factors Each claim was reviewed by one of the authors (AM) to determine the main risk management factor involved. Claims were classified as primarily patient, physician, or system related. With patient and physician issues, the acts of the patient (eg, a condition/action of a patient over which the physician has no control) or physician (eg, problems with diagnosis, judgment, knowledge, or skill), respectively, were the weak point in the process of care. Systems issues, on the other hand, cannot be attributed to a single individual; instead, these involve processes in which multiple individuals and entities are involved.10 The results by frequency and severity of claims are shown in Table 4. Systems issues accounted for most claims. In lawsuits against individual physicians, the most frequent risk management factors were informed consent, follow-up (ie, tracking of missed patient appointments, referrals, handoffs, or test results), and the litigation process (see discussion). Most claims against entities were a consequence of the litigation process itself. Plaintiff attorneys may file suit against both physicians and their practices or institutions as defendants, because this often increases the amount of money available for a settlement. On review, most entities had no responsibility for the outcome and
Mean (2012)
Median (nominal)
Median (2012)
$165,977.47 $217,820.74 $91,515.00 $142,398.83 $932,927.52 $1,053,256.51 $575,000.00 $841,225.00 $288,551.92 $352,706.55 $335,000.00 $176,052.73 $665,321.50 $747,186.06 $293,143.00 $372,697.12 $433,333.33 $588,258.33 $275,000.00 $386,775.00 $370,833.33 $402,670.83 $350,000.00 $355,387.50 $995,000.00 $1,293,035.00 $995,000.00 $1,293,035.00 $515,000.00 $528,725.00 $515,000.00 $528,725.00 $300,000.00 $381,800.00 $300,000.00 $381,800.00 $20,000.00 $25,520.00 $20,000.00 $25,520.00
$24,468,682.68 $470,695.46
amounts of these payments) are shown by clinical category in Table 3A-C. Strabismus accounted for the most individual cases (adults, 21; pediatric, 15). Of clinical categories with $6 cases, the highest percentage of cases closed with an indemnity payment (50%) was in retinopathy of prematurity (ROP), which was also associated with the highest mean indemnity payments and highest total dollars spent by OMIC when allocated defense expenses were included. ROP comprised 15% of all cases but accounted for 37% of the total dollars expended by OMIC in the field of POS over the course of this study.
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Mean (nominal)
$556,106.42
$201,217.00
$296,735.00
Table 3B. Defense expenses by clinical category Medical condition a
Strabismus ROP Trauma Neuro-ophthalmic Cornea Retina Cataract Refractive/surgical Oculoplastics Medication Nasolacrimal Amblyopia Refractive/glasses Total
Expenses (nominal)
Expenses (2012)
$969,935.52 $2,234,592.03 $1,038,822.35 $305,298.68 $401,412.20 $438,900.76 $848,149.55 $265,912.69 $536,052.25 $204,658.93 $530,444.80 $25,530.69 $866.01 $7,800,576.46
$1,247,634.32 $2,651,139.33 $1,152,282.75 $376,995.01 $535,591.80 $482,960.06 $1,024,703.29 $277,841.94 $756,651.09 $215,505.85 $541,698.51 $32,577.16 $1,122.35 $9,296,703.46
were dismissed (Table 5). The highest total indemnity payments among system issues were paid on behalf of insured individuals or entities in the category of “follow-up” (Table 6).
Discussion The 140 closed claims in the field of POS are lowfrequency events and represent only 4% of the entire OMIC closed claims in the 25-year history reported in this study. However, the severity of the claims, as measured by the percentage closed with an indemnity payment (31%), was relatively high compared to all claims (21%) at OMIC over this period (OMIC internal communication). Another measure of severity, the mean indemnity payment ($470,695), was also higher in the field of POS compared to that for all claims ($156,043) at OMIC (OMIC internal communication). A study from the United Kingdom evaluating clinical negligence in ophthalmology found that pediatric claims were low in frequency but had the second highest indemnity payments, second only to neuro-ophthalmology.5 Reasons cited for large payments involving children
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Table 3C. Total costs by clinical category Medical condition a
Strabismus ROP Trauma Neuro-ophthalmic Cornea Retina Cataract Refractive/surgical Oculoplastics Medication Nasolacrimal Amblyopia Refractive/glasses Total
Total (nominal)
Total (2012)
Cost/Case (nominal)
Cost/case (2012)
$3,127,642.64 $10,630,939.69 $2,481,581.95 $2,966,584.68 $1,701,412.20 $1,551,400.76 $2,838,149.55 $1,295,912.69 $1,136,052.25 $204,658.93 $550,444.80 $25,530.69 $866.01 $28,511,176.84
$4,079,303.89 $12,130,447.95 $2,915,815.50 $3,365,739.25 $2,300,366.80 $1,690,972.56 $3,610,773.29 $1,335,291.94 $1,520,251.09 $215,505.85 $567,218.51 $32,577.16 $1,122.35 $33,765,386.14
$86,878.96 $590,607.76 $165,438.80 $247,215.39 $170,141.22 $193,925.10 $473,024.93 $431,970.90 $378,684.08 $102,329.47 $275,222.40 $25,530.69 $866.01 $243,685.27
$113,314.00 $673,913.78 $194,387.70 $280,478.27 $230,036.68 $211,371.57 $601,795.55 $445,097.31 $506,750.36 $107,752.93 $283,609.26 $32,577.16 $1,122.35 $288,593.04
ROP, retinopathy of prematurity. a 21 adult, 15 pediatric.
Table 4. Frequency and severity (percentage of indemnity payments per category) of risk issues Type
No. individual No. No. % eye MD entities paid paid
Physician
40
0
System
72
21
Patient
7
0
Examples from this study
23/40 58 Telephone treatment of postoperative strabismus patient despite 4 phone calls who on subsequent office evaluation proved to have endophthalmitis 20/93 22 Surgery on the incorrect eye after nurse prepped and draped the incorrect eye 1/7 14 Patient aspirated during strabismus surgery and died; found on autopsy not to have fasted
include the accumulated lifetime expenses of lost earnings and caring for a child with a permanent disability, sympathy for children with disabilities, and use of malpractice payments as a form of “social insurance” to help care for a child with devastating disabilities, regardless of whether the injury was caused by malpractice or not.11 The decreased frequency in claims in the most recent years parallels that of OMIC as a whole, where the average frequency of claims between 2004 and 2013 was nearly 40% lower than the average between 1996 and 2003 (OMIC internal communication). The causes for this may include factors such as improved quality of care, risk management education (eg, the ROP “safety net” program introduced by OMIC in 2006 and wrong site initiatives), and tort reform.12,13 The mean time from the incident to filing of claim was just over 2 years but ranged to as long as 18 years. The long duration in some cases, relative to claims for the
Table 5. Frequency analysis of systems issue Risk/defendant
Physician
Entities
Total
Litigation Informed consent Follow-up Identification of surgical site Telephone care Evolving standard of care Payment issues Equipment (cautery fire)
16 24 19 4 3 2 1 1
13 2 3 1 1 0 1 0
29 26 21 5 4 2 2 1
entire field of ophthalmology, related to the lengthy statute of limitations (SOL) in some states in which claims may be filed in pediatric cases. There was an additional 2.5 years mean duration from time of filing a claim to time of settlement. Whereas the costs of indemnity payments and expenses to insure a claim are readily available, it is difficult to calculate the costs of physician time spent defending a claim or to assign a value to nonmonetary factors such as anxiety and lack of closure on both the part of the physician and patients and their families during the lengthy litigation process.11,14 Resources are available to manage litigation stress.15
Clinical Conditions We found that plaintiffs were most commonly \1 year of age at the time of the incident. Five clinical categories had 10 or more claims. Strabismus was the most frequent medical condition resulting in claims, with those in adults more frequent than in children. The most common reasons for the claims in this category were lack of timely referral to a strabismus specialist, poor documentation of the decision-making process, inadequate management of patient expectations about the surgical procedure, and not performing the planned surgery. The informed consent process was a major driver in strabismus claims. Although claims related to strabismus were most common in terms
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Table 6. Severity analysis of systems issues Amount aid Type
No. paid
Nominal
2012 inflation adjusted
Follow-up Evolving standard of care Telephone care Equipment (cautery fire) Identification of surgical site Informed consent Litigation Payment issues
9/21 2/2 1/4 1/1 4/5 3/26 0/29 0/2
$5,630,967 $376,666 $337,500 $200,000 $185,265 $67,500 $0 $0
$6,712,168 $399,910 $355,387 $200,000 $250,326 $86,825 $0 $0
of frequency, the mean indemnity payment of $165,977 was among the lowest. The second most common number of claims related to ROP, which was associated with the greatest severity both in terms of percentage of CWIP claims (50%) and mean indemnity payment ($932,928). Systems errors are discussed below. The third most common category was claims related to trauma. The treatment window is often narrow in these patients, and claims of patients presenting emergently were typically associated with allegations of delays in diagnosis or treatment. Telephone care played a role in 4 cases. Contact form checklists help mitigate the risk of professional liability, prompting ophthalmologists to ask patients and referring physicians questions about traumatic ocular injuries and help to document the conversation. When the patient is referred by another physician, the ophthalmologist cannot assume that physician has the requisite knowledge and skill to identify serious ocular injuries and should have a low threshold for personally evaluating the patient. Neuro-ophthalmic pediatric claims represented the fourth most common source of claims and, following ROP, were associated with the second highest total indemnity payments. These claims were frequently associated with allegations of delays in diagnosis or treatment. Developing and documenting a differential diagnosis, meticulous follow-up of patients and laboratory results, and obtaining consultations may help reduce risk in these low-frequency, high-severity cases.16 The fifth most common disease category, corneal disorders, commonly resulted from a delay in diagnosis and management of infection. Ruling out infection, particularly prior to beginning corticosteroids, careful followup, and early referral to a corneal specialist when the patient is not responding to treatment are important risk management strategies for this population.
Patients and Physicians These few claims highlight the fact that while ophthalmologists may be sued for poor outcomes, they are generally not held liable for the conditions or actions of patients over which they have no control. Careful, repeated, well-
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documented instructions and educational efforts facilitate the defense of such claims. Claims involving physician factors were associated with high severity in terms of total indemnity payments and percentage of claims closed with indemnity payments. Diagnostic errors led this category. Analysis of diagnostic failures highlight the cognitive problems inherent in the way physicians reason, formulate judgments, and make decisions.17 Strategies that encourage physicians to examine their thinking process may help. Two key safety steps are to consider what else could produce the same signs and symptoms and to consider, even briefly, the worst-case scenario.16 For example, a retinal specialist diagnosed a child with Coats disease. The child had several intraocular surgeries and was eventually diagnosed with retinoblastoma, which had never been ruled out. The case was settled after the child died from the disease. The majority of ophthalmologists in this series were not POS specialists and encompassed a broad range of comprehensive and other subspecialty providers. Physician factors were more common in claims against ophthalmologists who were not POS specialists (61% vs 40%); thus, subspecialty training in POS may decrease the risk of claims in this category. For example, expert reviewers opined that complex strabismus surgery should have been performed by strabismus specialists and that nonspecialists often did not refer the patient in a timely manner. Systems Issues Systems issues involve care processes in which multiple individuals and entities are involved and accounted for the majority of claims in this series. The three most common issues are follow-up, informed consent, and the litigation process. Follow-up issues led the severity list both in amount of money paid and the number of claims settled, and ranked second in frequency in claims against physicians. It is therefore a key area of loss prevention to emerge from this study. Ophthalmologists must develop robust follow-up systems to track appointments, referrals to specialists, hand-offs of patients transitioning from the hospital to outpatient setting, and test results. Lawsuits alleging failure to follow-up included those related to ROP, amblyopia, emergent care, and neurological conditions. The clear message from the number of claims, settlements, and jury verdicts related to follow-up is that physicians are expected to notice when prescribed care has not been obtained and take steps to address it by having appointment, referral, and test tracking mechanisms in place. Sample tracking protocols for ROP care in the hospital and office setting, as well as sample appointment, test, and referral tracking for all practices are available.12,18 Physicians are urged to review these documents and to contact the risk manager of their professional liability company for assistance in customizing and implementing these crucial loss prevention measures.
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The physician and the patient play obvious roles in informed consent. However, linguistic and cultural differences, educational material, consent forms, and education provided by staff also affect the informed consent process. Problems in this area were the most common source of systems claims against physicians and resulted in 2 entity claims. Although not as costly as claims related to followup, 3 of 26 claims were settled. Failure to properly obtain informed consent is a common allegation in medical malpractice lawsuits. One study that attempted to determine why patients sue their physicians found that doctors who were perceived as “hurried, uninterested, and unwilling to listen and answer questions” were much more likely to be sued.19 Another study found that communication breakdowns occurred in 70% of malpractice claims.20 Some of the communication problems can be avoided by engaging the patient and family in a constructive, ongoing informed consent dialogue designed to invite participation in their care, clarify misconceptions, and minimize unrealistic expectations.21 Rather than being a purely legal function performed prior to invasive procedures, consent becomes an opportunity to establish a therapeutic alliance between the ophthalmologist and the patient wherein each recognizes the clinical uncertainties that exist to some degree with each medical or surgical intervention. All but 1 of the 16 surgical informed consent claims involved strabismus surgery; the vast majority were for adult strabismus surgery. In particular, the patients/parents did not “hear” that a second surgery might be needed, that surgery might be complicated by prior surgery or the underlying disease, that surgery might not correct all symptoms, and that diplopia might not resolve. The use of a procedure-specific consent form is recommended. It is best to provide the patient with a copy to review at home. Finally, ophthalmologists should decline to perform the surgery if unrealistic expectations cannot be successfully managed. The most frequent vulnerability identified in suits against entities and the third most frequent system issue against individual ophthalmologists is the litigation process. Admittedly, in the early days of a lawsuit, it may be difficult for the plaintiff attorney to determine who, if anyone, may be negligent, and defendants may be named with limited investigation as the statute of limitations approaches. The claims in this category were, however, deemed to be without merit by claims department staff, defense attorneys, and expert witnesses, and all these defendants were dismissed without indemnity payments. Physicians should cooperate fully during the litigation process, regardless of the perceived merit of the case, as failure to meet legal deadlines can have serious consequences.
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Literature Search PubMed was last searched July 23, 2015 for Englishlanguage results using the following terms: professional liability, malpractice claims, pediatric ophthalmology, and strabismus. References 1. Bettman JW. Seven hundred medicolegal claims in ophthalmology. Ophthalmology 1990;97:1379-84. 2. Craven ER. Risk management issues in glaucoma: diagnosis and management. Surv Ophthalmol 1996;40:459-62. 3. Ellis JH, Abbott RL, Brick DC, Weber P. Liability issues associated with PRK and the excimer laser. Surv Ophthalmol 1997;42:279-82. 4. Abbott RL, Ou RJ, Bird M. Medical malpractice predictors and risk factors for ophthalmologists performing LASIK and photorefractive keratectomy surgery. Ophthalmology 2003;110:2137-46. 5. Rashmi RG, Ferguson V, Hingorani M. Clinical negligence in ophthalmology: fifteen years of National Health Service litigation authority data. Ophthalmology 2013;120:859-64. 6. Demorest BH. Retinopathy of prematurity requires diligent followup care. Surv Ophthalmol 1996;41:175-8. 7. Reynolds JD. Malpractice and the quality of care in retinopathy of prematurity. Trans Am Ophthalmol SOC 2007;125: 1515-22. 8. Day S, Menke AM, Abbott RL. Retinopathy of prematurity claims: the Ophthalmic Mutual Insurance Company experience. Arch Ophthalmol 2009;127:794-8. 9. American Academy of Pediatrics. Policy Statement: AAP Publications Reaffirmed. Pediatrics 2012;129:2.e561. 10. Smetzer JL, Cohen MR. Lesson from the Denver medication error/ criminal negligence case: look beyond blaming individuals. Hospital Pharmacy 1998;33:640-57. 11. Jena AB, Chandra A, Seabury SA. Malpractice risk among US pediatricians. Pediatrics 2013;131:1148-54. 12. Menke AM. ROP: materials for creating a hospital safety net. Available at http://www.omic.com/rop-creating-a-safety-net/. Accessed December 4, 2014. 13. AAO Wrong Site Task Force. Recommendations of the American Academy of Ophthalmology Wrong-Site-Task Force. Available at http://one.aao.org/patient-safety-statement/recommendations-ofamerican-academy-ophthalmology-. Accessed December 4, 2014. 14. Charles S. Surviving the aftershocks of malpractice litigation. OMIC Digest 2005;15:1-5. 15. Physician Litigation Stress Resource Center. www.physicianlitigation stress.org. Accessed July 23, 2015. 16. Menke AM. Differential diagnosis: develop and disclose it. OMIC Digest 2010;20:1-5. 17. Croskerry P. Cognitive forcing strategies in clinical decision-making. Ann. Emerg Med 2003;41:110-20. 18. Menke AM. Noncompliance: a frequent prelude to malpractice lawsuits. Available at http://www.omic.com/noncompliance-guidelineswith-sample-missed-appointment-letter/. Accessed December 4, 2014. 19. Hickson GB, Wright Clayton E, Githens PB, Sloan FA. Factors that prompted families to file malpractice claims following perinatal injuries. JAMA 1992;267:1359-63. 20. Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctorpatient relationship and malpractice: lessons learned from plaintiff depositions. Arch Intern Med 1994;154:1365-70. 21. Menke AM. My doctor never told me that could happen. OMIC Digest 2007;17:1-5.
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