For many residents, the litany of mind-numbing statistics on the medical liability crisis may seem unreal. The average cost of professional liability insurance for neurosurgeons has increased from $44,000 to $73,000 per year, and 19 percent of neurosurgeons have reported a greater than 100 percent increase in their premiums, according to the 2002 report, Neurosurgery in a State of Crisis. The report further indicates that an increasing number of neurosurgeons are retiring (300 in 2001), and that there are fewer than 3,000 board-certified neurosurgeons in the United States.
The impact of liability suits on practitioners can be significant: a single lawsuit can raise insurance premiums to a level that can curtail the types of procedures one can perform, or, in the extreme, dissolve a practice entirely. And surgeons are not the only ones suffering. Patients in some areas are finding that their access to neurosurgical services is significantly reduced, or even nonexistent in an emergency situation.
In response to this crisis, we must learn how to make ourselves less vulnerable to litigation without resorting to defensive medicine and becoming advocates for changing a broken medicolegal system. Residency is an ideal time to begin this process.
For residents who believe that they are protected by virtue of being in a training program, let me dispel that myth now. You can be named in a lawsuit and you may be asked to testify. The two key elements in a successful lawsuit are negligence (was it below the prevailing community standard of care at the time of treatment?) and causation (no harm, no foul), and both are necessary for a case to proceed. But keep in mind, it is widely accepted that most lawsuits come from disgruntled patients or their families.
Therefore, I propose Triple H therapy—Honesty, Hypervigilance, and Hospitality. Treatment outcomes and unexpected side effects or complications need to be discussed honestly, immediately and directly with the patient and family. It is no longer appropriate to “spare the patient anxiety” by downplaying the risks of a treatment or its alternatives. Be hypervigilant regarding any labs, scans, and consults that you order. Finally, take your time with patients and families. Make sure they feel comfortable with the treatment decisions being made and make them a partner in the process.
Get Active Now
Of course, while it sometimes may not feel like it, there is also life outside the hospital, and if we are to change a system that is forcing good, reputable, hard-working physicians from their practices, we have to get active. The best solution includes passage of federal legislation that limits noneconomic damages to $250,000. Such a bill passed the House of Representatives last year, but has failed this year in the Senate. Other proposals—enforced pretrial arbitration, or penalizing lawyers who file more than three frivolous lawsuits—insufficiently address the problem. So, what is the best way for a young neurosurgeon to get involved in this process? I have several suggestions:
- Become educated. Go to the Web sites of Neurosurgeons to Preserve Health Care Access (NPHCA), www.neuros2preservecare.org, and Doctors for Liability Reform (DMLR), www.protectpatientsnow.org, and watch the videos. Regularly read the updates from the Washington Committee.
- Contribute. Make a contribution, however small or large, to the NPHCA. (In fact, as I write this, I am sending my check off.)
- Start sending e-mails. Write your congressional representatives to remind them of the imminent threat to our public health system. If you follow the links from www.AANS.org, you can send a customized e-mail to your representatives and senators in less than one minute. According to Washington staffers, the impact of e-mail is the same as a letter sent by regular mail. Short of making an appointment, this is the best way to make your voice heard.
- Attend the LLDC in Washington. Make plans to attend the 2004 Leibrock Leadership Development Conference (LLDC) July 18-20, organized by the Council of State Neurosurgical Societies. The conference will be followed by a visit to Capitol Hill, where you will make your voice heard.
- Network. The AANS Young Neurosurgeons Committee has formed a task force to assist NPHCA in its efforts. Contact a member of this committee (Mark McLaughlin, MD, Brian Subach, MD, or Larry Chin, MD), or make plans to attend the open session of the Young Neurosurgeons Committee meeting, which is usually held on a Monday night during the annual meeting of the American Association of Neurological Surgeons or the Congress of Neurological Surgeons.
Despite the new demands placed upon us, we must not allow fear to rule the way we practice medicine. Start your career by taking the positive steps I have outlined, and help strengthen the future of neurosurgery.
Lawrence S. Chin, MD, is a neurosurgeon at the University of Maryland Medical Center in Baltimore. He is vice chair of the AANS Young Neurosurgeons Committee and the committee’s liaison to the AANS/CNS Washington Committee.