Unwanted price to hospitalists’ growth -- more liability suits

Trends are being sorted out as claims of misdiagnosis and other legal challenges increase, and recordkeeping improves, in a fast-growing specialty.

By — Posted May 20, 2013

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Medical liability insurers said they are noticing an alarming uptick in lawsuits against hospitalists — the majority involving allegations of misdiagnosis.

A study released in the spring 2013 issue of Cryptogram,, a newsletter of the Physician Insurers Assn. of America Data Sharing Project MPL claims database, found that diagnosis errors topped the list for hospitalist claims from 2002 to 2011. Of 312 closed claims, 20% related to misdiagnosis. Similarly, a recent study by the Doctors Company found that for 247 claims against hospitalists from 2007 to 2012, 34% were diagnosis-related.

“We have seen a slightly higher frequency and severity in lawsuits against hospitalists,” said Robin Diamond, RN, senior vice president and chief patient safety officer for the Doctors Company. “We believe that as hospitalists continue to fill more roles within the hospital, and higher demands are placed on them, the risk of being sued may also increase.”

Hospitalists are one of the fastest-growing specialties in the U.S., with an estimated 35,000 physicians identifying themselves as hospitalists in 2012. Insurers note that because most company databases did not start separating out hospitalist claims until recently, it is difficult to compare recent total claims figures with previous years. It will take several more years until more in-depth studies can be completed on claims trends, said John Nelson, MD, co-founder of the Society of Hospital Medicine.

“The problem is our field really began to gather steam in higher numbers in the mid ’90s or so, but malpractice carriers didn’t start classifying hospitalists” at that point, he said. “They just lumped them with internists until just a few years ago. That means we don’t have years of [documented] history.”

Anecdotally, however, hospitalist leaders have seen an explosion of lawsuits recently. The rise probably is associated with hospitalists’ rapid growth, Dr. Nelson said.

Common accusations against hospitalists relate to poor neurological and spinal cord care, medical experts said.

“That is a particular area of risk, and it’s not hard to understand why,” Dr. Nelson. “Spinal cord issues are things that [tend to] happen in younger people. It’s not something that people die from very often, but they’re disabled, and it’s one where the diagnosis is tricky.”

Such suits often lead to large jury awards, Dr. Nelson said. Total defense payments for diagnosis errors exceeded $3 million, with an average payment of $234,038, according to the PIAA study.

Improving handoffs to reduce claims

In general, hospitalists reduce the overall legal risks for hospitals because they allow a physician always to be available at facilities, said Bob Wachter, MD, chief of the medical service at the University of California, San Francisco Medical Center. However, certain practices and behaviors raise individual legal dangers for hospitalists, he said. Poor communication during patient handoffs is one example.

“That clearly is a high-risk area, where something happened in the hospital that didn’t get transmitted effectively to the primary care doctor, or it got lost in the transition,” he said.

Hospitalists are one of the fastest-growing medical specialties in the U.S.

In the Doctors Company study, 28% of claims related to improper management of treatment, while 14% of claims in the PIAA study were attributed to “failure to monitor or supervise case.”

The lack of close patient relationships also makes hospitalists prone to suits, Dr. Nelson said.

“Hospitalists are potentially in a risk category closer to emergency department doctors and others who provide episodic care,” he said. “If you know someone for 10, 15 years, there’s trust built up, and there can sometimes be forgiveness” if a bad outcome occurs.

To combat legal risks during patient handoffs, the Doctors Company recommended limiting interruptions during transitions and requiring a repeat-back of exchanged information between physicians. For instance, physicians can review the patient’s diagnoses and current conditions, as well as recent changes, anticipated changes and warning signs of changes in the patient’s conditions.

In addition, hospitalists should attempt to connect with patients from the moment they walk into the exam room, Dr. Wachter said. He suggested sitting down, making eye contact, answering all questions and being clear about what the hospitalist’s role is. Strong recordkeeping also is essential to lowering the potential for lawsuits, he said.

“Make sure your documentation is clear, particularly when there’s a patient who’s not doing well,” he said. “Your notes should make it absolutely clear what your thinking was and why you chose option B.”

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