The frequency of doctors’ involvement with medicolegal matters has been shown to vary with sex, age, specialty, hours worked and country of practice.1-6 Doctors who are male,1-3,5,6 work in high-intervention specialties1,4-6 and work long hours1,6 are more likely to be the subject of a medicolegal matter. Some studies,1,3 but not all,6 have found that older doctors are more likely to have been involved in a medicolegal matter. The finding that 86% of interventional specialist doctors in the United States have been named in a malpractice suit at least once illustrates the extreme in medicolegal action.4
Medicolegal matters can place a great deal of stress on doctors. An Australian study of general practitioners found that psychiatric morbidity and hazardous alcohol consumption were higher in doctors who were currently involved in a medicolegal matter than in those who were not.1 Another study of Australian GPs revealed that the threat of litigation was perceived as the most severe work-related stress.7 However, as a group, doctors overestimate the likelihood of being sued,8,9 and the majority of patients entitled to make a formal complaint or claim for compensation do not.10,11
All obstetricians, gynaecologists, physicians, surgeons, anaesthetists, psychiatrists, pathologists, radiologists, paediatricians, accident and emergency specialists, general practice registrars, other registrars and specialists-in-training insured with UNITED Medical Protection were invited to participate in the study, as was a sample of GP non-proceduralists. GP proceduralists were not included, as they had taken part in a GP pilot study the previous year, the findings of which have been reported elsewhere.1,12,13
Information on psychiatric morbidity and alcohol consumption was also collected. Psychiatric morbidity was assessed using the 28-item General Health Questionnaire (GHQ),14 a validated and sensitive screening tool used to detect common non-psychotic psychiatric morbidity over the 2 weeks preceding assessment. The 28-item version of the GHQ has four subscales: somatic symptoms, anxiety and insomnia, social dysfunction and depression. When this version of the GHQ is used as a screening instrument, the recommended case identification (cut-off) score for risk of psychiatric morbidity is a combined score > 4 using the binary scoring system (with the two least symptomatic answers scoring 0 and the two most symptomatic answers scoring 1) for each of the 28 questions (eg, “Have you lost much sleep over worry?”: not at all [0], no more than usual [0], rather more than usual [1], or much more than usual [1]).
Alcohol use was assessed using the World Health Organization’s Alcohol Use Disorders Identification Test (AUDIT)15 for detecting hazardous and harmful drinking. Each of the 10 AUDIT questions is scored from 0 to 4, with subjects who score a total of 8 or more being classified as potentially hazardous drinkers.
Data were analysed using SAS software, version 9.1 (SAS Institute, Cary, NC, USA). Pearson’s χ2 test was used to test for association between involvement in a current medicolegal matter and individual categorical variables. Multivariate logistic regression analysis was also conducted on the outcome of being involved in a current medicolegal matter. Variables included were age, sex, specialty, and any other variable with a P value < 0.25 in the univariate analysis. The fit of the model was checked using the Hosmer–Lemeshow goodness-of-fit test.16
Of 8500 doctors invited to participate, 140 declined. Of the 8360 doctors to whom surveys were sent, 40 returned them unopened, 18 asked not to be included, seven indicated that they had retired, and four had died. The number of doctors in each specialty group and the response rate for each group are shown in Box 1. Completed surveys were returned by 2999 doctors (36% response rate).
Sixty-five per cent of respondents had been involved in medicolegal matters and 14% were involved in a current matter. The frequency of occurrence of the different types of medicolegal matters are summarised in Box 2. The most common were claims for compensation and complaints to a health care complaints body, and the least common were criminal charges, pharmaceutical services inquiries, anti-discrimination board complaints and disciplinary hearings. The proportions of respondents who had been involved in one or more matters were as follows: one matter (22%), two matters (16%), three matters (9%), four matters (6%), five matters (4%), and six or more matters (7%).
Results of univariate and multivariate analyses of factors associated with involvement in a current medicolegal matter are shown in Box 3. Obstetricians/gynaecologists and surgeons had the highest risk of being involved in a current medicolegal matter. Other factors associated with higher risk of involvement in medicolegal matters were being male, being partnered or divorced/separated (rather than single), working longer hours, and having a GHQ score > 4. Factors that were significant in the univariate analysis but not in the multivariate model were the country in which the doctor’s medical degree was obtained, attendance at peer review meetings, having a teaching role, type of practice (solo or non-solo) and AUDIT score. Age group and meeting CME requirements were not associated with involvement in a current medicolegal matter.
Our investigation is the largest study of its kind to examine factors associated with doctors’ involvement in medicolegal matters.1,3,4,6 Our findings were similar to those of the GP pilot study,1,12,13 and concur with other studies showing that doctors who are male, work in high-intervention areas of medicine, and work longer hours are more likely to be involved in a medicolegal matter.1-4,6
Strengths of our study were the size and representativeness of the sample. Respondents reflected a broad cross-section of the Australian medical workforce — in particular, medical specialist groups. Comparing our figures with data reported in the 2005 Australian medical workforce survey,17 we estimate that our sample of 2999 doctors represents 5% of the Australian medical workforce and about 10% of specialty groups (range, 9% [physicians] to 12% [anaesthetists]). The mean number of hours worked per week by doctors in our sample (44.8 overall; 48.0 for males and 37.1 for females) was similar to the mean number reported in the 2005 workforce survey (43.7 overall; 46.7 for males and 37.6 for females). However, the mean age of doctors in our sample (51.7 years overall; 53.6 years for males and 46.9 years for females) was higher than the mean age in the 2005 survey (45.1 years overall; 47.3 years for males and 40.6 years for females), owing to the exclusion of most junior doctors from our sample.
A limitation of our study was the low response rate. However, survey research challenges the idea that a high response rate (> 60%) is necessary.18,19 We were able to compare respondents and non-respondents with respect to age, sex and type of medicolegal matter. Although there were statistically significant differences in age and sex, the differences were very small. Respondents were more likely than non-respondents to have been the subject of claims for compensation, health care complaints and coronial inquiries, but again, these differences were small. Our results may have slightly overestimated the occurrence of medicolegal matters.
To further examine the non-response issue, we conducted a sensitivity analysis by weighting the results according to the response rate of each specialty.20 This changed the estimated proportion of doctors who had ever been involved in a medicolegal matter from 65% to 63%. Similarly, all other weighted percentages differed by less than 2% from the unweighted percentages. When weighting was applied to the logistic regression analysis, the estimated odd ratios differed by less than 10% from those for the unweighted analysis. The most notable changes were that having a teaching role and having an AUDIT score ≥ 8 became significantly associated with involvement in a current medicolegal matter (P values, 0.03 and 0.02, respectively).
To our knowledge, no other studies (apart from the GP pilot study1,12,13) have tested for an association between GHQ and AUDIT scores and doctors’ involvement in medicolegal matters. Our results using these instruments raise questions about causation: do doctors involved in a current medicolegal matter have higher scores due to the stress of the medicolegal process, or do their higher levels of psychiatric morbidity make them more likely to be the subject of a complaint or inquiry? This issue will be explored in a later article.
1 Response rate to survey, by medical specialty
GP = general practitioner. * UNITED Medical Protection (became Avant after merging with another company in July 2007). † Response rate: number of surveys completed divided by number of surveys sent, expressed as a percentage. ‡ A random sample of non-proceduralist GPs was drawn from 7275. Of 8216 GPs insured with UNITED Medical Protection, 941 had been surveyed in the previous GP study1,12,13 and thus were not included in our study. § Although the total number of respondents was 2999, two had deleted their identification number from the survey, and thus their specialties were unknown. |
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2 Proportion of doctors ever involved in a medicolegal matter, by medical specialty and type of medicolegal matter*
- Louise M Nash1,2,3
- Patrick J Kelly4
- Michele G Daly5
- Garry Walter2,6,7
- Elizabeth H van Ekert8
- Merrilyn Walton9
- Simon M Willcock5
- Christopher C Tennant2
- 1 New South Wales Institute of Psychiatry, Sydney, NSW.
- 2 Discipline of Psychological Medicine, University of Sydney, Sydney, NSW.
- 3 Greater Western Area Health Service, NSW.
- 4 School of Public Health, University of Sydney, Sydney, NSW.
- 5 Academic General Practice Unit, Hornsby Ku-ring-gai Hospital, University of Sydney, Sydney, NSW.
- 6 Child and Adolescent Mental Health Services, Northern Sydney Central Coast Health, Sydney, NSW.
- 7 Department of Psychiatry, Dalhousie University, Halifax, NS, Canada.
- 8 MDA National, Sydney, NSW.
- 9 Office of Postgraduate Medical Education, University of Sydney, Sydney, NSW.
Our study was funded by a Northern Sydney Health research grant, the McGeorge Bequest (through the University of Sydney) and Avant. The New South Wales Institute of Psychiatry provided a part-time research fellowship to Louise Nash.
Avant provided inhouse assistance with the sample selection, as well as funding for printing and mailing of the questionnaire, independent data analysis, and payment of a research officer (Michele Daly). Simon Willcock is an elected board member of Avant. Elizabeth van Ekert was employed by UNITED Medical Protection and then Avant until October 2008.
- 1. Nash L, Daly M, Johnson M, et al. Psychological morbidity in Australian doctors who have and have not experienced a medicolegal matter: a cross sectional survey. Aust N Z J Psychiatry 2007; 41: 917-925.
- 2. Firth-Cozens J. Doctors with difficulties: why so few women? Postgrad Med J 2008; 84: 318-320.
- 3. Cunningham W, Crump R, Tomlin A. The characteristics of doctors receiving medical complaints: a cross-sectional survey of doctors in New Zealand. N Z Med J 2003; 116: U625.
- 4. Mello M, Studdert D, DesRoches C, et al. Caring for patients in a malpractice crisis: physician satisfaction and quality of care. Health Aff (Millwood) 2004; 23: 42-53.
- 5. Aasland OG, Førde R. Impact of feeling responsible for adverse events on doctors’ personal and professional lives: the importance of being open to criticism from colleagues. Qual Saf Health Care 2005; 14: 13-17.
- 6. Hickson G, Federspiel C, Pichert J, et al. Patient complaints and malpractice risk. JAMA 2002; 287: 2951-2956.
- 7. Schattner PL, Coman GJ. The stress of metropolitan general practice. Med J Aust 1998; 169: 133-137. <MJA full text>
- 8. Lawthers AG, Localio AR, Laird NM, et al. Physicians’ perceptions of the risk of being sued. J Health Polit Policy Law 1992; 17: 463-481.
- 9. Lawton R, Connolly T, DeGraaff R. Impact of physicians’ perceptions of malpractice and adaptive changes on intention to cease obstetrical practice. J Rural Health 1999; 15: 134-146.
- 10. Localio A, Lawthers A, Brennan T, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med 1991; 325: 245-251.
- 11. Bismark MM, Brennan TA, Davis PB, Studdert DM. Claiming behaviour in a no-fault system of medical injury: a descriptive analysis of claimants and non-claimants. Med J Aust 2006; 185: 203-207. <MJA full text>
- 12. Nash L, Daly M, Johnson M, et al. Personality, gender and medicolegal matters in medical practice. Australas Psychiatry 2009; 17: 19-24.
- 13. Nash L, Walton M, Daly M, et al. GPs’ concerns about medicolegal issues — how it affects their practice. Aust Fam Physician 2009; 38: 66-70.
- 14. Goldberg DP. Manual of the General Health Questionnaire. London: National Foundation for Educational Research, 1998.
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- 16. Hosmer DW, Lemeshow S. Applied logistic regression. New York: Wiley, 1989.
- 17. Australian Institute of Health and Welfare. Medical labour force 2005. Canberra: AIHW, 2008. (AIHW Cat. No. HWL 41; National Health Labour Force Series No. 40.)
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- 20. Levy PS, Lemeshow S. Sampling populations: methods and applications. 4th ed. New York: Wiley, 2008.
Abstract
Objective: To investigate the frequency of, and factors associated with, Australian doctors’ involvement in medicolegal matters.
Design, setting and participants: Cross-sectional survey of Australian doctors (specialists, trainees and general practitioners) insured with the medical insurance company Avant. A self-report questionnaire was mailed to Avant members in September 2007 to gather data on their involvement in medicolegal matters. Information on psychiatric morbidity and alcohol consumption was also collected using the General Health Questionnaire and the Alcohol Use Disorders Identification Test.
Main outcome measures: Occurrence and type of past and current medicolegal matters with which doctors have been involved.
Results: Of 8500 doctors invited to participate, 2999 returned completed surveys (36% response rate). Sixty-five per cent of respondents had been involved in a medicolegal matter at some time, and 14% were involved in a current matter. The two most common types of medicolegal matter were claims for compensation and complaints to a health care complaints body. Doctors were more likely to be involved in medicolegal matters if they were male, worked in high-intervention areas of medicine (surgery and obstretics/gynaecology), and worked longer hours.
Conclusion: Our study concurs with other studies in finding an association between medicolegal matters and being male, working long hours and working in high-intervention areas of medicine. Unlike other studies, we found no association between age and involvement in a current medicolegal matter. Our findings also pose the question of whether psychiatric morbidity in doctors is a cause or effect of the medicolegal process.