US Malpractice environment reduces productivity

[nexus73]

I'm just thinking with the shortage of docs, pressure at my last job was to see more and more patients. I would see follow ups for 30 minute appointments typically, never scheduling shorter appointments. My main anxiety was about missing something, not having time for crisis management, making a mistake, and ultimately malpractice claim and/or board complaint. Longer appointments IMO also means better care, for the above reasons. However, if risk of malpractice was removed and expectation as a society was to provide higher volume of care if not top quality, I could have seen many more patients per day. Possibly 4 or even more per hour.

Does the malpractice environment cause a reduction in productivity as a consequence of the penalties it imposes on doctors? If so, does society explicitly understand this and accept it?

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[PsyDr]

It's a more complex problem.



1) If you were paid $1000/hr, you could spend time with your patients, take phone calls, etc.
2) Reimbursement is lower and lower, despite rising costs of business. This means you have to increase productivity, just to stay the same.
3) But then, CMS, and by extension every insurance company, creates increasing documentation requirements for you to get paid. These are written by non-clinicians. Therefore, you are required to document in a way that can be judged by someone with a high school diploma. These requirements have no clinical utility.
4) Without those requirements, you could write a chart note in 2 minutes.

 

[Sushirolls]

Liability risks:

1. ECT manufacturers put "brain damage" on their devices now, or something to that effect because they passed on mustering up the cash to do the research to prove definitely it doesn't. So I'm not chomping at the bit to do ECT again with not wanting to have that discussion every consult.
2. I won't work for Big Box shops anymore after seeing their ever increasing policies to reduce their risk and set doctors and "providers" up for failure and blame them for problems.
3. There is a correlation of more severe/difficult cases with Big Box shops; see item 2, and those cases typically have poor paying commercial insurance, or medicaid and medicare which means their access to other higher levels of care to treat their symptoms, are proportionally less likely. So you are the one with the 'hot potato.' More risk...
4. Big Box shops strive to tear down autonomy, and will request/demand you see anything they want you to see.
5. I over document due to liability concerns. That takes time. It fuels burn out. Detracts from the ultimate goal of helping people. I now am more focused on my exit dream, being a rancher/farmer, than original dream of practicing until I drop or someone takes my license from me.
6. I am now in private practice, cut out headache insurance companies, like medicaid, some medicare flavors and Disjointed Death Care insurance company. Focusing on better paying private insurance. I am still making a positive difference and numerous peoples' lives, but I am not practicing to the 'top of my license.' Each passing day I'm more okay with that.
7. I don't do CAP because of liability, and not liking it, but liability is a big chunk of that reason.
8. I have lost sleep on some cases, or reflecting on my top 1 or 2 or 3 patients of concern. I look forward to no longer worrying about that.
9. Its a bit lonely thinking about the liability risk of things, and once I attempted to gripe to a good non-medical friend, no sympathy, "dude, that's why you make the big bucks."
10. I used to fantasize about caps, or other liability reduction things nationally, but now what I see from Big Box Shop influences, and even ARNP/PA clinical messes, I hope liability system doesn't go away. Cause I fear our future care in the next 20-30 years, and am more worried a midlevel or Big Box shop is gonna kill me as I become geriatric. The lack of trust is already rising in healthcare. Covid Era policies and edicts didn't help either. Oddly, liability may be the vector to spawn future course correction.

But to answer your question more in depth, society accepts this. But no they don't fully understand it. ...we recently passed a law for "no surprise billings" which shows society doesn't understand at all, the healthcare system.

 

[psychemdoc]

I think you’re right on the money and no society does not understand that trade off. Why did Dr miss this diagnosis? What “failed”? What regulation/additional step do we need to do in order to protect patients, society, etc.? No one considers that additional regulation, documentation, reviews, additional steps in any way is time away from taking care of patients, society, etc.

Society almost never makes that decision consciously. It’s mostly unaware of trade offs. In economic terms it’s called concentrated benefit and diffused cost. The worst kind of economic burden. When the cost is everyone in society has to fill out a few more papers, check off a few more boxes, dot a few more i’s and cross a few more t’s then it doesn’t seem like much to every individual but on the whole that is a substantial time/money savings that could be spent taking care of more patients or having a better work/life balance.

 

[Merovinge]

I think you’re right on the money and no society does not understand that trade off. Why did Dr miss this diagnosis? What “failed”? What regulation/additional step do we need to do in order to protect patients, society, etc.? No one considers that additional regulation, documentation, reviews, additional steps in any way is time away from taking care of patients, society, etc.

Society almost never makes that decision consciously. It’s mostly unaware of trade offs. In economic terms it’s called concentrated benefit and diffused cost. The worst kind of economic burden. When the cost is everyone in society has to fill out a few more papers, check off a few more boxes, dot a few more i’s and cross a few more t’s then it doesn’t seem like much to every individual but on the whole that is a substantial time/money savings that could be spent taking care of more patients or having a better work/life balance.

Great point about the diffused cost. We really pooped the bed societally not have more economists designing/implementing policy.

 

[G Sheb]

I think you’re right on the money and no society does not understand that trade off. Why did Dr miss this diagnosis? What “failed”? What regulation/additional step do we need to do in order to protect patients, society, etc.? No one considers that additional regulation, documentation, reviews, additional steps in any way is time away from taking care of patients, society, etc.

Society almost never makes that decision consciously. It’s mostly unaware of trade offs. In economic terms it’s called concentrated benefit and diffused cost. The worst kind of economic burden. When the cost is everyone in society has to fill out a few more papers, check off a few more boxes, dot a few more i’s and cross a few more t’s then it doesn’t seem like much to every individual but on the whole that is a substantial time/money savings that could be spent taking care of more patients or having a better work/life balance.

It does come down to liability.
Those higher ups, and that definitely include clinicians, want to protect themselves by inserting x stupid documentation requirement so the liability does not fall on them.
Though this varies from system to system. Some are more reasonable and have kept the nonsense to a minimum.

But I think the OP was hinting at a different point. Jeapordizing quality of care for seeing more patients.
I don't agree with this approach and it's not because of liability.
The reality is that we need to talk to our patients to figure out what's going on.
Providing bs care for more people isn't an improvement in 'productivity' and will hurt our specialty in the long run.

 

[rjs2131]

I think this is true for most (all?) physicians but is especially important for psychiatrists. I don't believe you can adequately assess someone's anxiety, depression, ADHD, x, y, z by spending 10-15 min with them every few months. Will you get it right more often than not? Maybe. But you will also miss a lot and won't get to know your patients on a personal level - I think that higher level therapeutic relationship plays a significant role in patient outcomes. It's easy enough to use rating scales and all but I think you end up missing a big part of the patient's human experience - hard to treat someone thoroughly if you don't understand them as a human being.

 

[the5thelement]

The US spends the most on healthcare in the western world with less than optimal results for the vast majority unfortunately. I think the fear of getting sued interferes with the building of a therapeutic alliance which is essential in the healing process.

 

[allantois]

I think that the malpractice environment leads to over treatment and the practice of defensive medicine which is probably less pronounced in our field. It absolutely also leads to physicians trying to mitigate their risk by perhaps seeing fewer patients, certainly seeing fewer high-risk patients. We will absolutely not be able to achieve universal healthcare without addressing the issue of tort reform, which of course will never happen in this country. The other day I was contemplating volunteering my time at a free clinic, however, was dissuaded due to liability concerns.

 

[WisNeuro]

I dunno, there's an upside to lawsuits and bad medicine, once it gets to the legal system, it means I get paid very well

 

[PikminOC]

The US spends the most on healthcare in the western world with less than optimal results for the vast majority unfortunately. I think the fear of getting sued interferes with the building of a therapeutic alliance which is essential in the healing process.

Us also has the most amount of lawsuits and lawyers. So defensive medicine also costs more...

 

[Merovinge]

Us also has the most amount of lawsuits and lawyers. So defensive medicine also costs more...

It does, it's a problem, and I generally have nothing positive to say about malpractice attorneys, however every cost study I have ever seen, done by big name MDs that have no reason to prop up JDs, is that this is a tiny portion of overall healthcare spending. It pales in comparison to the administrative bloat or executive pay or private equity profits or end-of-life care in the system.

 

[PikminOC]

It does, it's a problem, and I generally have nothing positive to say about malpractice attorneys, however every cost study I have ever seen, done by big name MDs that have no reason to prop up JDs, is that this is a tiny portion of overall healthcare spending. It pales in comparison to the administrative bloat or executive pay or private equity profits or end-of-life care in the system.

Yes but that's all part of why is healthcare is so expensive

 

[Stagg737]

It does, it's a problem, and I generally have nothing positive to say about malpractice attorneys, however every cost study I have ever seen, done by big name MDs that have no reason to prop up JDs, is that this is a tiny portion of overall healthcare spending. It pales in comparison to the administrative bloat or executive pay or private equity profits or end-of-life care in the system.

I think that it probably plays a bigger role than that. Last I checked the biggest expense in medicine came from ordering of unnecessary tests, consults, etc. followed closely by administrative expenses. Idk what the breakdown of the cause for excessive testing is and can think of many reasons (incompetence, research, clinician anxiety/'thoroughness'), but I do imagine that there would probably be a solid decrease in excessive orders if there wasn't such a perceived need to CYA.

 

[SeniorWrangler]

The shocking thing for me is how little of the judgement goes to the plaintiff at the end of the process, once the attorney's fees and costs have been deducted.

 

[psych_0]

I have a friend who is a malpractice attorney. Sues doctors for a living. When I first started I asked him how often he sues psychiatrists and he just hit me with a "Lol. Never." So I pushed him on it and asked him how many times he had sued psychiatrists in his career. Between him and his two partners at the firm (>20 years experience in the oldest partner alone), he said "Maybe once or twice. There's no money in that. It's a waste of my time." I think we greatly exaggerate the risk of getting sued in our minds, especially in psychiatry. Granted, this is the south so your miles may vary.

 

[forchinet121]

I have a friend who is a malpractice attorney. Sues doctors for a living. When I first started I asked him how often he sues psychiatrists and he just hit me with a "Lol. Never." So I pushed him on it and asked him how many times he had sued psychiatrists in his career. Between him and his two partners at the firm (>20 years experience in the oldest partner alone), he said "Maybe once or twice. There's no money in that. It's a waste of my time." I think we greatly exaggerate the risk of getting sued in our minds, especially in psychiatry. Granted, this is the south so your miles may vary.

This is also what the data says but similar to our patients we are very neurotic, disregard the data, and continue to catastrophize

 

[nexus73]

I have a friend who is a malpractice attorney. Sues doctors for a living. When I first started I asked him how often he sues psychiatrists and he just hit me with a "Lol. Never." So I pushed him on it and asked him how many times he had sued psychiatrists in his career. Between him and his two partners at the firm (>20 years experience in the oldest partner alone), he said "Maybe once or twice. There's no money in that. It's a waste of my time." I think we greatly exaggerate the risk of getting sued in our minds, especially in psychiatry. Granted, this is the south so your miles may vary.

what kind of cases does he take if not suing doctors?

 

[forchinet121]

what kind of cases does he take if not suing doctors?

He sues doctors..just not psychiatrists..because it’s so hard to successfully sue a psychiatrist..

 

[splik]

I have a friend who is a malpractice attorney. Sues doctors for a living. When I first started I asked him how often he sues psychiatrists and he just hit me with a "Lol. Never." So I pushed him on it and asked him how many times he had sued psychiatrists in his career. Between him and his two partners at the firm (>20 years experience in the oldest partner alone), he said "Maybe once or twice. There's no money in that. It's a waste of my time." I think we greatly exaggerate the risk of getting sued in our minds, especially in psychiatry. Granted, this is the south so your miles may vary.

There are only a handful of malpractice attorneys who do most of the suicide malpractice cases in the country. Other than that, it's plaintiff's attorneys who usually do other things (other medmal and personal injury cases) who pick up the odd psychiatric case. There is far less money in psychiatric malpractice cases than orthopedic cases, OB cases, etc. As a forensic expert I am often asked to review malpractice cases that aren't actually about psychiatric malpractice but where there are neuropsychiatric complications of negligent treatment.

The actual psychiatric malpractice cases I've reviewed have almost always involved either suicide or homicide though I reviewed one case which was predicated on wrongful diagnosis and treatment which plaintiff's estate claimed had led to irreversible decline (there was no case in my opinion there as even though she had been wrongly diagnosed it wouldn't have changed the outcome and a general psychiatrist would not have picked up the correct diagnosis). However, other issues that come up are adverse drug reactions or sexual boundary violations. Wrongful commitment is another one but it almost never goes anywhere even when there is a legitimate case. I reviewed one case like of wrongful commitment which completely baseless (plaintiff was in denial). I've also occassionally had psychotic patients call me up asking if I can be an expert witness for them claiming their antipsychotic caused all manner of things!

A new area I've also seen is lawsuits alleging negligent supervision of NPs. In order to testify in such cases you must supervise NPs and you need to opine on the standard of care of NP supervision.

Psychiatrists have the lowest malpractice risk of all specialties because we see fewer patients, have stronger relationships with said patients and family members, the low standard of care in the profession, the lack of clinical guidelines, psychiatric patients are seen as "unreliable narrators", and there is less money in the payouts which means it is not as attractive for lawyers. But you can still get sued, and the typical psychiatrist should still expect one lawsuit in a 40 yr career.

 

[PikminOC]

The shocking thing for me is how little of the judgement goes to the plaintiff at the end of the process, once the attorney's fees and costs have been deducted.

US of Lawyers $$$

 

[Stagg737]

To add on, if you really want to know how likely docs are to get sued, just look at malpractice premiums. OB/GYN and some surgical specialties like Neurosurgery lead the way and it's easy to see why, with the former having annual insurance premiums well above $100k in some states. Geography also matters, less so in psych because our premiums are relatively miniscule compared to some other fields, but can be tens of thousands of dollars difference for some fields. Links for examples:

How malpractice premiums vary by specialty — anesthesiology, surgery & more

Specialists' annual malpractice premiums are significantly higher than those of primary care physicians, according to the Medscape Medical Malpractice Premium Report 2019.

www.beckersasc.com

How Much Is Malpractice Insurance? - NerdWallet

The cost of malpractice insurance depends on factors such as industry, specialty, state and coverage type, as well policy per-claim and aggregate claims limits.

www.nerdwallet.com

 

[Sushirolls]

There are only a handful of malpractice attorneys who do most of the suicide malpractice cases in the country. Other than that, it's plaintiff's attorneys who usually do other things (other medmal and personal injury cases) who pick up the odd psychiatric case. There is far less money in psychiatric malpractice cases than orthopedic cases, OB cases, etc. As a forensic expert I am often asked to review malpractice cases that aren't actually about psychiatric malpractice but where there are neuropsychiatric complications of negligent treatment.

The actual psychiatric malpractice cases I've reviewed have almost always involved either suicide or homicide though I reviewed one case which was predicated on wrongful diagnosis and treatment which plaintiff's estate claimed had led to irreversible decline (there was no case in my opinion there as even though she had been wrongly diagnosed it wouldn't have changed the outcome and a general psychiatrist would not have picked up the correct diagnosis). However, other issues that come up are adverse drug reactions or sexual boundary violations. Wrongful commitment is another one but it almost never goes anywhere even when there is a legitimate case. I reviewed one case like of wrongful commitment which completely baseless (plaintiff was in denial). I've also occassionally had psychotic patients call me up asking if I can be an expert witness for them claiming their antipsychotic caused all manner of things!

A new area I've also seen is lawsuits alleging negligent supervision of NPs. In order to testify in such cases you must supervise NPs and you need to opine on the standard of care of NP supervision.

Psychiatrists have the lowest malpractice risk of all specialties because we see fewer patients, have stronger relationships with said patients and family members, the low standard of care in the profession, the lack of clinical guidelines, psychiatric patients are seen as "unreliable narrators", and there is less money in the payouts which means it is not as attractive for lawyers. But you can still get sued, and the typical psychiatrist should still expect one lawsuit in a 40 yr career.

We just get beat or shot more than most medical specialties.

 

[tr]

We just get beat or shot more than most medical specialties.

I think EM might be the worst for that actually

 

[Sushirolls]

But we're perhaps #2

 

[psych_0]

what kind of cases does he take if not suing doctors?

Mainly ortho (a lot of spine), OBGYN, neurosurgery.

 

[psych_0]

the low standard of care in the profession

Having worked in both community and academic settings, the "standard" of care is non-existent.