PHILADELPHIA, PA  -— The medical malpractice crisis gripping Pennsylvania has sown widespread discontent among doctors in high-risk specialties, affecting the quality of health care their patients receive, according to a new study released today by The Project on Medical Liability in Pennsylvania and funded by The Pew Charitable Trusts. Malpractice concerns could be harmful to the physician-patient relationship, as the interplay between financial and market pressures changes how physicians approach their work, the study says.

“Physician satisfaction is often neglected or discounted as self-serving in policy debates,” the authors say. “In this paper we outline a framework for understanding why physician satisfaction matters for patient care and what factors influence it. Professional dissatisfaction deserves policy attention if it has damaging consequences for patients.”

Nearly 40 percent of Pennsylvania high-risk specialists surveyed in 2003 were dissatisfied with the practice of medicine, twice as high as the national rate in 1999. Studies have shown that satisfied physicians tend to be more attentive to their patients and have higher levels of satisfaction among their patients. But dissatisfied physicians have been linked to riskier prescribing practices or engaging in “defensive medicine” when treating patients.

“Our findings suggest that the malpractice crisis in Pennsylvania is decreasing specialist physicians’ satisfaction with medical practice in ways that may affect the quality of care. The relationship may be cumulative, with an acute malpractice crisis acting as a ‘last straw’ among the physicians who are most affected by it,” the report’s authors conclude.

The report, “Caring For Patients In A Malpractice Crisis: Physician Satisfaction and Quality Of Care,” is part of a special section published in “Health Affairs” containing several other articles showing the complexity of the medical malpractice crisis.

According to the American Medical Association, about two-thirds of U.S. states are now in the midst of a malpractice crisis or showing signs of trouble. Nowhere is the problem more acute than in Pennsylvania, where several insurers have left the market and premiums for coverage through the remaining insurers have increased dramatically. To investigate the effects of the malpractice crisis on patient care, the authors conducted a series of interviews with representatives from Pennsylvania physician groups, hospitals, and insurers, followed by a mail survey of 824 Pennsylvania physicians in high-risk specialties (emergency medicine physicians, general surgeons, neurosurgeons, OB/GYNs, orthopedic surgeons, and radiologists).

KEY FINDINGS

Pervasive Job Dissatisfaction
Nearly 40 percent of the Pennsylvania high-risk specialists surveyed in 2003 were dissatisfied with the practice of medicine. OB/GYNs were most likely to report dissatisfaction. Career satisfaction among Pennsylvania high-risk specialists was much lower than a 1999 national sample—39 percent compared to 19 percent.

Low Marks for Pennsylvania
Seventy percent of specialists said that they would be very or somewhat likely to recommend their specialty to someone graduating from medical school today, but only 15 percent were willing to recommend practicing in Pennsylvania. Nearly half responded that they were not at all likely to recommend Pennsylvania. Specialists who had strong personal ties to the state (either grew up or attended medical school in Pennsylvania) were no more likely than those who did not to recommend practicing here.

Income Squeeze
Rising liability insurance premiums and static or declining reimbursements are putting physicians in an income bind. Specialists surveyed who felt heavily burdened by malpractice insurance costs were least likely to report satisfaction with their practice. Asked to characterize their current professional liability insurance premium levels, 40 percent of specialists described their premiums as an “extreme burden,” 40 percent said that they were a “major burden,” 12 percent called them a “minor burden,” and 2 percent said that they were “not at all a burden.”

Fraying Relations with Patients
Liability pressures may affect physicians’ satisfaction and the quality of care by impinging upon the physician/patient relationship. Just over half of surveyed specialists denied that malpractice concerns made them less candid with their patients, but a sizable minority felt that they did. Physicians who felt “wounded” by the malpractice system and those with high premium burdens were significantly more likely to report such changes in patient relations. Three-fourths of specialists agreed with the statement, “Because of concerns about malpractice liability, I view every patient as a potential malpractice lawsuit.”

Limited Autonomy
The malpractice crisis may also be affecting physicians’ satisfaction by eroding their sense of control. Survey reports indicated that the liability environment impedes specialists’ perceived ability to deliver needed services in the way they would like. Ninety-one percent of specialists surveyed said that the malpractice system limits doctors’ ability to provide the highest-quality medical care.

Cutting Back on Care
Many specialists surveyed reported that their practice or hospital was taking steps to reduce overhead costs, and nearly two-thirds reported that their practice or hospital would likely reduce the number of clinical staff over the next two years because of liability costs. Nearly three-fourths indicated that their practice or hospital would likely reduce the number of administrative staff, and a similar percentage reported that their practice or hospital would cancel or delay capital improvements because of liability costs.

OUTLOOK

According to the report, rising liability expenses in a severe malpractice crisis impose costs on patients. Some costs are economic—state governments may divert tax dollars toward subsidies for malpractice insurance premiums, and health insurance costs may increase if provider reimbursement is raised in response to increased overhead. But other costs come in the form of lower quality and availability of health services. As the human face of such changes, physicians’ behavior—particularly their anxieties and discontent—should become a critical policy focus, the report recommends.

State legislatures typically focus on three strategies to respond to a malpractice crisis: insurance subsidies, stricter insurance regulation, and reforms to the tort liability system. Overall, these reform strategies are responsive to physician dissatisfaction, the report says, but their efficacy as a cure for the tort crisis and protection for recurring crises is open to question. The core objective of such reforms should not be to restore physicians’ job satisfaction, but to improve the malpractice system’s performance in compensating patients and promoting high-quality care. If a byproduct of reform is higher professional satisfaction, it’s the patients who stand the most to gain, the report says.

The full report and other research by the Project on Medical Liability in Pennsylvania may be found at www.medliabilitypa.org

About The Project on Medical Liability in Pennsylvania:
The goal of the two-year, $3.2 million Project on Medical Liability in Pennsylvania is to provide Pennsylvania policy makers with objective information about the medical liability system; to broaden participation in the medical liability debate to include new constituencies and perspectives; and to focus attention on the relationship between medical liability and the overall health and prosperity of the Commonwealth. The Project is working with leading health policy experts from across the nation and will continue to publish both original research based on new data and expert analyses. The Project will generate information from a broad range of perspectives, without promoting the agenda of any of the stakeholders in the debate.

The other articles in this special edition of “Health Affairs” examine the following:

William Sage, from Columbia Law School, proposes overhauling the structure and financing of malpractice liability insurance. Sage attributes much of the current crisis to a widening gap between first-party health insurance and third-party malpractice insurance. He urges Medicare and Medicaid to play a major role in the medical liability system of the future.

Carol Liebman and Chris Hyman of Columbia Law School examine a program of medical error communication and mediation-based dispute resolution that can improve patient care as well as reduce malpractice litigation. The measure can be adopted voluntarily by hospitals and physicians even if political consensus on legislative reform is lacking.

In a critical review of recent proposals for “medical courts” and “expert screening panels,” Catherine Struve, a professor at the University of Pennsylvania Law School, suggests simpler, more effective ways to help judges and juries make better-informed rulings with respect to both liability and damages.

In a study not part of the Pew research, Harvard’s David Studdert and colleagues review a sample of high-end jury verdicts that were subject to California’s cap on noneconomic damages. They conclude that the cap is unfair to patients who suffer grave injuries involving pain and disfigurement.

The researchers for this report are Michelle M. Mello, an assistant professor of health policy and law, Department of Health Policy and Management, Harvard School of Public Health. David Studdert is an associate professor of law and public health at the Harvard School of Public Health. Catherine DesRoches is a research assistant in that department. Jordon Peugh is a senior research manager at Harris Interactive in New York City, where Kinga Zapert is a vice president. Troyen Brennan is a professor of law and public health, Department of Health Policy and Management, Harvard School of Public Health, and a professor of medicine in the Department of Medicine, Harvard Medical School. William Sage is a professor of law at Columbia Law School in New York City.