Threat of litigation in obgyn?

[SandP]

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It's scares me to think that I could even get sued during residency. Any thoughts on mitigating this risk? ie. certain fellowships or just joining an academic institution? wondering what your thoughts are on this. a lawsuit is a huge stressor...would like to avoid it, but at the expense at not doing a field I love? Feeling conflicted. Would appreciate your thoughts.

 

[.hematoma.]

Do you honestly think ob/gyn is the only specialty in which you can be sued? lmao

 

[SandP]

Do you honestly think ob/gyn is the only specialty in which you can be sued? lmao

Yes but isnt it notoriously worse for obgyns, who can get sued 18 years after a baby is born?

 

[kb1900]

I did read a while ago that ob gyns pay more inn malpractice on average than most other specialities. Unsure if still true but wouldn’t be surprised

 

[mistafab]

Cmon dude

That’s like letting the threat of a knee injury ruin your basketball career. Or your fear of crashing from stopping you from racing cars...

Just accept the risk and move forward.

 

[Kgizzle]

OB/GYN pay out more in malpractice cases but don't crack top 5 in specialties sued

 

[Dr G Oogle]

It's scares me to think that I could even get sued during residency. Any thoughts on mitigating this risk? ie. certain fellowships or just joining an academic institution? wondering what your thoughts are on this. a lawsuit is a huge stressor...would like to avoid it, but at the expense at not doing a field I love? Feeling conflicted. Would appreciate your thoughts.

The biggest issue with malpractice is if you are in solo practice or somehow responsible for paying your own malpractice insurance. If you are employed, such as in academics or big multispecialty group than it is less of a financial burden. Yes you can be sued in residency and but generally residents rarely have to go up on the witness stand, you may have to endure some prep work with hospital lawyers though. You are generally more likely to be sued doing OB (Mfm and General obgyn) than one of the surgical gyn specialties

Here is a chart from NEJM article (click on results tab)

NEJM - Error

I wouldn’t recommend choosing a field based on risk of phantom lawsuit

 

[AMEHigh]

Most doctors will be sued during their career. You shouldn’t specifically not want to be an obgyn just due to fear of being sued during residency. Having good bedside manner and having appropriate documentation go a long way in protecting yourself.

 

[libertyyne]

OBGYNs are consistently one of the higher sued specialties.
The payouts tend to also be for life long injuries to neonates.
It doesnt even take an error on your behalf to become part of a suit, just a poor outcome will usually drive one forward and then retrospectively look for an error.
Think about all those FHM strips and the interpretation that goes on in them.


You will in all likelihood get sued during your career, most likely multiple times as an obgyn.

 

[Mr.S]

Cmon dude

That’s like letting the threat of a knee injury ruin your basketball career. Or your fear of crashing from stopping you from racing cars...

Just accept the risk and move forward.

L.O.L.

This post is so misguided.. You can accept the risk but still worry about it.(on a daily basis). Worrys all of us all the time. It truly is a bother, even if you accept the risk and move on.

 

[mrbreakfast]

Based on what I have heard/been taught, malpractice suit risk is mostly correlated with bedside manner and preop talk. I worked with a thyroid surgeon who spent a lot of time on the consent carefully explaining the risks and admitting to patients they had cut the recurrent before, but that it was uncommon and if it happened, they would work hard with the patient to help them recover. Never been sued despite cutting multiple times.

We've all read the "expose" editorials about how poorly OBs treat patients; I think the Times had one fairly recently. Reading them, it seems the issues stemmed from a combination of: poor communication before the birth about what would happen (leading to misguided patient expectations) and what could go wrong + poor communication during the birth about what was happening and why things were being done + poor bedside manner and generally being a jerk on the part of the physician. It seems to me that we students have gotten a lot of education on how to avoid those things.

 

[Mr.S]

malpractice suit risk is mostly correlated with bedside manner and preop talk. I worked with a thyroid surgeon who spent a lot of time on the consent carefully explaining the risks and admitting to patients they had cut the recurrent before, but that it was uncommon and if it happened, they would work hard with the patient to help them recover. Never been sued despite cutting multiple times.

We've all read the "expose" editorials about how poorly OBs treat patients; I think the Times had one fairly recently. Reading them, it seems the issues stemmed from a combination of: poor communication before the birth about what would happen (leading to misguided patient expectations) and what could go wrong + poor communication during the birth about what was happening and why things were being done + poor bedside manner and generally being a jerk on the part of the physician. It seems to me that we students have gotten a lot of education on how to avoid those things.

Tough to communicate all those things when you have 3-5 mins to discuss those things and you have 10 patients to round on and surgeries to do etc etc etc.. My point is, reimbursement has gone down so much that you have to triple the volume of 20 years ago to make a living. That leaves lttle time to discuss (what to expect, how do you feel, etc etc etc) to prevent getting sued.
The point is, generally the whole system is rigged against you. You are the only person that knows the risks that you are putting yourself and the patient into. The administrators could not care less about your liability and what you go through when you get sued. Not one IOTA.

I cant even believe they can find obstetricians to do what they do for the salary that they do it for..

And, with respect to injuring the recurrent laryngeal nerve, depending on the severity. If it is injured you can almost guarantee a lawsuit..

 

[DrSnips]

OB/GYN pay out more in malpractice cases but don't crack top 5 in specialties sued

True, but I think the ratio of malpractice premiums to earnings is an important metric to look at, because it will affect you whether you get sued or not. On that metric, OB must be the worst (in most states).

Not that it should dissuade a person from choosing that career path. Choose whatever best suits your interests, lifestyle, etc.

 

[SandP]

My father-in-law was an OB/GYN in a rural private practice. He eventually had to give up the OB side of it because he could no longer afford his malpractice insurance if he wanted his practice to continue. I am not saying this to frighten you away from the field, only to say that your fears are not unfounded.

His advice is to be employed by a large group/hospital. You will lose some autonomy, but will have your cost and risk mitigated. While this is true for all fields, you have to ask yourself whether or not losing your autonomy is worth the cost benefit. For OB/GYN, it likely is. Yes, all fields have the risk of litigation. But OB/GYN and Peds both have unique risk associated with them given the extremely long statute of limitation.

What type of autonomy do you lose if you join a hospital? Can you please elaborate? Also, how is the risk mitigated--is it that hospitals are less likely to be sued or that hospitals cover malpractice insurance?

 

[VA Hopeful Dr]

L.O.L.

This post is so misguided.. You can accept the risk but still worry about it.(on a daily basis). Worrys all of us all the time. It truly is a bother, even if you accept the risk and move on.

Umm, what?

I would venture that many if not most doctors don't worry about malpractice suits on a daily basis. I know I don't. My OB/GYN father-in-law doesn't either (no lawsuits in 40 years, FYI).

 

[doc05]

It's scares me to think that I could even get sued during residency. Any thoughts on mitigating this risk? ie. certain fellowships or just joining an academic institution? wondering what your thoughts are on this. a lawsuit is a huge stressor...would like to avoid it, but at the expense at not doing a field I love? Feeling conflicted. Would appreciate your thoughts.

If the risk of a lawsuit is a "huge stressor" then you should choose another field. That's just common sense.

 

[Oh_Gee]

If you own your own practice, you are your own boss. In other words: You work the hours you want to work. You hire your own staff. You see the patients you want to see when you want to see them. And you pay your own overhead and malpractice insurance. You have the potential for higher pay, but you will have more costs.

If you are EMPLOYED by a hospital (not just have hospital privileges), overhead of nursing/allied health staff, admin staff, equipment, building space, and insurance is covered, but you lose the ability to "be in your own boss" in many ways. You will likely make less than some private practice physicians, but will incur less costs (especially in OB). So your net may be equal to or better than your private practice counterparts depending on location/specialty/etc.

A loose analogy would be like living on your own versus with your parents. On your own you can eat twinkies every day for breakfast if you feel like it, but you have to pony up for rent, insurance, etc. At home, your parents are paying those bills, but you have a curfew and chores. If you would be living an area where rent is high, then living at home might be worth the curfew/chores. If you live in an area with low cost of living, it might be worth it to trek out on your own.

this may be one of the best analogies i've ever read

 

[afib123]

This was not brought up during my Ob/gyn rotation by any of the residents but my family med preceptor working in a large healthcare group setting did say her employer doesn't want to pay the malpractice for OB side of things, so she and her partner do not do take care of any OB patients anymore. So I guess it is true, but you should probably direct this question to an OB/Gyn advisor in your school.

 

[Cognovi]

Here's a obgyn case that was in the news recently because the widower testified in Congress:
https://thehatchettfirm.com/wp-content/uploads/2017/05/Hatchett-Johnson-Complaint.pdf

Everyone involved was named, including attending, fellow, senior resident, and intern.

I would imagine that MFM is particularly high risk as a subspecialty.

Radiologists often gladly give up obstetric ultrasound turf to the MFMs because of the malpractice risk.

 

[Raney Schauer]

Whats a windower?

 

[Cognovi]

Whats a windower?

oops, widower

 

[mistafab]

Gyn also offers the fellowship in urogyn which is basically a field of surgery where there are no emergencies ever.

The whole field is about improving QOL. Pretty difficult to get sued in that scenario (no dead babies). Also pretty interesting anatomy/cases.

 

[AMEHigh]

Here's a obgyn case that was in the news recently because the widower testified in Congress:
https://thehatchettfirm.com/wp-content/uploads/2017/05/Hatchett-Johnson-Complaint.pdf

Everyone involved was named, including attending, fellow, senior resident, and intern.

I would imagine that MFM is particularly high risk as a subspecialty.

Radiologists often gladly give up obstetric ultrasound turf to the MFMs because of the malpractice risk.

Wow what a sad case. If all those facts presented are true then I do hope the doctor faces consequences. I do think many things need to be addressed in regards to the maternal morbidity and mortality rate in this country, especially in regards to patients of color.

I’m in family med and I know residents who have also been named in cases. Luckily in both cases they had documented well their physical exam and assessment/plan so it really helped them.

 

[Dr G Oogle]

Here's a obgyn case that was in the news recently because the widower testified in Congress:
https://thehatchettfirm.com/wp-content/uploads/2017/05/Hatchett-Johnson-Complaint.pdf

Everyone involved was named, including attending, fellow, senior resident, and intern.

I would imagine that MFM is particularly high risk as a subspecialty.

Radiologists often gladly give up obstetric ultrasound turf to the MFMs because of the malpractice risk.

Normally a lot of litigation in medicine and OB in particular are BS this is definitely not one of them, Ive seen this exact scenario play out (though happily without the deaths) in my residency, I am unaware of any litigation of those results but I know those attendings were sent to do only outpatient. This is probably where the field is heading with more subspecialization even in non-fellowship areas like laborists, office gyn/OB and most surgeries being performed by fellowship people and true generalists being mostly found in rural and underserved areas. This will lead to a reduction in both egregious and none egregious lawsuits such as the one above.

With regard to urogyn, we still have to handle emergencies (who do you think gets called in for all those bladder injuries on L&D) and many academic places have started relegating 3rd and 4th degree lacerations to Urogyns though that’s not that common yet. Some places call urogyns for cesarean hysterectomies (usually handled by oncology) and sometimes we get called in for retrogrades and stenting (depending on training of urogyn). And while we do not see as much litigation as OB, people can and do get sued for complications, especially mesh related ones.

However I must again emphasize that if a career will make you happy, the specter of a lawsuit should not deter you from practicing medicine in the field of your choice.

 

[SandP]

Normally a lot of litigation in medicine and OB in particular are BS this is definitely not one of them, Ive seen this exact scenario play out (though happily without the deaths) in my residency, I am unaware of any litigation of those results but I know those attendings were sent to do only outpatient. This is probably where the field is heading with more subspecialization even in non-fellowship areas like laborists, office gyn/OB and most surgeries being performed by fellowship people and true generalists being mostly found in rural and underserved areas. This will lead to a reduction in both egregious and none egregious lawsuits such as the one above.

With regard to urogyn, we still have to handle emergencies (who do you think gets called in for all those bladder injuries on L&D) and many academic places have started relegating 3rd and 4th degree lacerations to Urogyns though that’s not that common yet. Some places call urogyns for cesarean hysterectomies (usually handled by oncology) and sometimes we get called in for retrogrades and stenting (depending on training of urogyn). And while we do not see as much litigation as OB, people can and do get sued for complications, especially mesh related ones.

However I must again emphasize that if a career will make you happy, the specter of a lawsuit should not deter you from practicing medicine in the field of your choice.

With regard to that case, out of curiosity, what would have been the best mode of action and what things would you have corrected? Was it to just proceed immediately with surgery after a repeat foley showed red blood? Also, I want to make sure I understand--the hemoperitoneum was due to bladder damage during the C-section, correct?

 

[Cognovi]

With regard to that case, out of curiosity, what would have been the best mode of action and what things would you have corrected? Was it to just proceed immediately with surgery after a repeat foley showed red blood? Also, I want to make sure I understand--the hemoperitoneum was due to bladder damage during the C-section, correct?

Not an OB here but the diagnosis was confusing to me too. The team wanted a CT urogram to evaluate for bladder or ureter injury but that never got done for some reason. Maybe radiology shares some of the fault for the delay, or maybe the patient was too unstable to go to CT and the primary team just waffled about going directly to the OR.

 

[Dr G Oogle]

Not an OB here but the diagnosis was confusing to me too. The team wanted a CT urogram to evaluate for bladder or ureter injury but that never got done for some reason. Maybe radiology shares some of the fault for the delay, or maybe the patient was too unstable to go to CT and the primary team just waffled about going directly to the OR.

I was not there and I doubt the document gives the full story but what I gather happened is that they believed that there was a bladder injury and that was the cause of the anuria which is why they 1)flushed the Foley 2)replaced the foley 2) ordered the ct urogram. The hemoperitoneum was related to atony and those hysterotomy closure are not water tight so she was probably bleeding into the abdomen and not having much vaginal bleeding. The rise in fundal height was from the uterus filling up with clot. The way I would have personally managed this patient would be 1) if I thought she had a bladder injury (not a bad thought immediately postop without any hemodynamic changes and no return on flushing /replacing catheter) I would have taken straight to OR for exlap at which point atony would have been identified and fixed either with a B Lynch, Bakri or hyst if necessarY. Ordering and worse, waiting for imaging was not the right choice and rarely is in these cases. Second, with a rise in fundal height I would have immediately done a bed side ultrasound to look for intrauterine clot as it is the whole purpose of doing fundal checks, evacuated it manually to see if it resolved the atony while simultaneously administering uterotonics and considering putting in a bakri or rolling back to OR if i thought none of those things would be beneficial. PPH is the bread and butter of OB it happens in 5% of all deliveries and there is an algorithm for managing it so this kind of stuff doesn’t happen. Following the algorithm
Prevents bad outcomes most of the time (not all of the time). Reading this case I see at least three instances where they should have acted they just chose continued expectant management, it is unclear why. It is true that pregnant and postpartum women can hold their pressures better because of pregnancy related cardiovascular changes, but it looks like she got pretty tachy before anything went down which is a sure fire sign that something is up.

 

[MediCane2006]

With regard to that case, out of curiosity, what would have been the best mode of action and what things would you have corrected? Was it to just proceed immediately with surgery after a repeat foley showed red blood? Also, I want to make sure I understand--the hemoperitoneum was due to bladder damage during the C-section, correct?

@Dr G Oogle has a great answer. Bottom line this was a postpartum patient with rapidly deteriorating vital signs. Those patients need urgent action, not expectant management and CT scans (unless the MD is wheeling the stretcher to the scanner with the OR team on standby). Monday morning quarterbacking is usually not a great look, but this case really sounds like a sad lack of urgency on everyone’s part.

 

[VincentAdultman]

L.O.L.

This post is so misguided.. You can accept the risk but still worry about it.(on a daily basis). Worrys all of us all the time. It truly is a bother, even if you accept the risk and move on.

I don’t worry about malpractice on daily basis. What a terrible way to go through life.

 

[Donald Juan]

Gyn also offers the fellowship in urogyn which is basically a field of surgery where there are no emergencies ever.

The whole field is about improving QOL. Pretty difficult to get sued in that scenario (no dead babies). Also pretty interesting anatomy/cases.

You must not remember all the commercials that were on TV a few years ago saying, "did you have urethral mesh that has eroded? Call Lawyer and Lawyer LLC." I'm sure it's not as bad as the OB side of things, but thinking that QOL surgeries are immune to lawsuits is backwards. In fact, it can open you up to more litigation because the patient after the fact can start claiming they never even needed the surgery and you pushed it on them or made it seem like it was a tiny surgery with no side effects.

 

[Obnoxious Dad]

OP, the way to mitigate the risk is to train and then practice medicine in a state where full scale tort reform has taken hold or where the juries tend to side with physicians . Check out the 2014 OB GYN malpractice rates by state in this link:
How Much Does Medical Malpractice Insurance Cost?
At the highest end the rate for OB GYN docs in Florida is five times higher than the rate in Wisconsin and eight times higher than Minnesota. Wisconsin caps pain and suffering damage awards. Minnesota juries tend to side with physicians. Here's how the courts in Florida roll:
http://blog.petrieflom.law.harvard....tients-care-providers-declared-unconstitutio/
http://blog.petrieflom.law.harvard....tients-care-providers-declared-unconstitutio/

Sure, the weather is warmer in Florida but the malpractice environment in Wisconsin and Minnesota is much sunnier.

 

[anbuitachi]

It's scares me to think that I could even get sued during residency. Any thoughts on mitigating this risk? ie. certain fellowships or just joining an academic institution? wondering what your thoughts are on this. a lawsuit is a huge stressor...would like to avoid it, but at the expense at not doing a field I love? Feeling conflicted. Would appreciate your thoughts.

this is a real risk. fields like OBGYN and surgical fields are high risk specialties. some people think as a resident they will be immune from lawsuits. This is FALSE. while the attending will liekly be sued more than you, lawyers also target residents. during residency, ive heard of different surgery and anesthesiology residents involved in lawsuits

 

[VincentAdultman]

You must not remember all the commercials that were on TV a few years ago saying, "did you have urethral mesh that has eroded? Call Lawyer and Lawyer LLC." I'm sure it's not as bad as the OB side of things, but thinking that QOL surgeries are immune to lawsuits is backwards. In fact, it can open you up to more litigation because the patient after the fact can start claiming they never even needed the surgery and you pushed it on them or made it seem like it was a tiny surgery with no side effects.

Right “Quality of life surgery” is a huge part of orthopedics/