Current Status of Obstetrics and Gynecology Resident Medical–Legal Education

Fostering guardians for frontline medical disputes: a government-led medical dispute mediator training program in Taiwan

BACKGROUND

Mediation is increasingly used for medical dispute resolution, and the particularity of such mediation necessitates specialized training. In response to the promotion of compulsory mediation ahead of a legislation in Taiwan, we invited experts with an interdisciplinary team to design a case-based mediator training workshop. Our study aimed to investigate the learning outcomes of trainees and analyze their perspectives.

METHODS

We recruited 129 trainees of a non-probability convenience sample who served as mediators or have dealt with medical dispute-related cases to undergo 2.5 h of lectures (introduction; procedure; roles of two mediators; principles and techniques of mediation; dispute arrangement; and issue analysis) and 1.5 h of case-based exercises. An after-class survey was conducted using a 4-point Likert-type scale to evaluate trainees' viewpoints and learning outcomes. A total of 104 questionnaires were collected (response rate: 80.6%).

RESULTS

The professions of the participants were medical (56%), law (16%), and administration and others (28%). Males considered the course more helpful (3.79 vs. 3.63, p = 0.053) and more important (3.88 vs. 3.74, p = 0.042) than did females. Participants with a legal background scored the highest in helpfulness (3.84), followed by medical (3.74) and administrative (3.63) professionals. Medical and administrative professionals scored the highest (3.85) and lowest (3.76), respectively, on importance. Respondents with more than 10 years (3.81) and less than 1 year (3.79) of experience produced higher scores in helpfulness. Respondents with 1-5 years of experience (3.68) were found to be less likely to agree with the practical importance of course content compared with other groups of trainees. Administrative professionals obtained the highest scores (89.68) in written examinations.

CONCLUSIONS

There are variations in mediators' perspectives based on gender, occupation, and work experience. Our nationwide mediation training workshop can be utilized to cultivate capabilities of mediators for handling medical disputes to achieve the goal of non-litigation in medical disputes.

Medical Malpractice Lawsuits Involving Trainees in Obstetrics and Gynecology in the USA

Background: While the liability risks for obstetrics and gynecology (ob/gyn) physicians are widely recognized, little is known about how trainees have been involved in ob/gyn lawsuits. Objectives: To characterize involvement of trainees in malpractice lawsuits related to ob/gyn. Methods: The legal database Westlaw was utilized to collect ob/gyn-related malpractice lawsuits involving trainees reported from 1986 to 2020 in the USA. Outcome: Forty-six malpractice cases involving ob/gyn trainees were identified, including 34 cases related to obstetrics and 12 to gynecology. There were 11 cases alleging lack of informed consent, including 7 cases alleging lack of consent for trainee involvement. Of the 34 obstetrics cases, 27 related to procedural complications, 17 to treatment, 13 to diagnosis, and 4 to informed consent. Of these, 17 were decided in favor of the physician, 6 resulted in findings of negligence, 9 had unknown outcomes, and 3 ended in settlement. For the 6 cases ending in a finding of negligence, the mean award was $2,174,472 compared to $685,000 for those that were settled. Of the 12 gynecology cases, 8 related to procedural complications, 7 to informed consent, 3 to diagnosis, and 2 to treatment. Of these, 6 were decided in favor of the physician, 3 resulted in findings of negligence, and 3 had unknown outcomes. For the cases ending in a finding of negligence, the mean award was $465,000. Conclusions and Outlook: This review of malpractice cases highlights types of situations in which trainees are sued and reveals the importance of designing curriculum around faculty training and supervision regarding trainee involvement in patient care.

Patterns and trends among physicians-in-training named in civil legal cases: a retrospective analysis of Canadian Medical Protective Association data from 1993 to 2017

BACKGROUND

Medico-legal data show opportunities to improve safe medical care; little is published on the experience of physicians-in-training with medical malpractice. The purpose of this study was to examine closed civil legal cases involving physicians-in-training over time and provide novel insights on case and physicians characteristics.

METHODS

We conducted a retrospective descriptive study of closed civil legal cases at the Canadian Medical Protective Association (CMPA), a mutual medico-legal defence organization for more than 105 000 physicians, representing an estimated 95% of physicians in Canada. Eligible cases involved at least 1 physician-in-training and were closed between 1993 and 2017 (for time trends) or 2008 and 2017 (for descriptive analyses). We analyzed case rates over time using Poisson regression and the annualized change rate. Descriptive analyses addressed case duration, medico-legal outcome and patient harm. We explored physician specialties and practice characteristics in a subset of cases.

RESULTS

Over a 25-year period (1993-2017), 4921 physicians-in-training were named in 2951 closed civil legal cases, and case rates decreased significantly (β = -0.04, 95% confidence interval -0.05 to -0.03, where β was the 1-year difference in log case rates). The annualized change rate was -1.1% per year. Between 2008 and 2017, 1901 (4.1%) of 45 967 physicians-in-training were named in 1107 civil legal cases. Cases with physicians-in-training generally involved more severe patient harm than cases without physicians-in-training. In a subgroup with available information (n = 951), surgical specialties were named most often (n = 531, 55.8%).

INTERPRETATION

The rate of civil legal cases involving physicians-in-training has diminished over time, but more recent cases featured severe patient harm and death. Efforts to promote patient safety may enhance medical care and reduce the frequency and severity of malpractice issues for physicians-in-training.

Developing an innovative medical ethics and law curriculum-constructing a situation-based, interdisciplinary, court-based learning course: a mixed methods study

BACKGROUND

Traditional lecture-based medical ethics and law courses deliver knowledge but may not improve students' learning motivation. To bridge this theory-to-practice gap and facilitate students' learning effectiveness, we applied situated-learning theory to design an interdisciplinary court-based learning (CBL) component within the curriculum. Our study aimed to investigate students' learning feedbacks and propose a creative course design.

METHODS

A total of 135 fourth-year medical students participated in this course. The CBL component included 1 h of introduction, 1 h of court attendance, and 2 h of interdisciplinary discussion with senior physicians, judges, and prosecutors. After the class, we conducted a survey using a mixed-methods approach to gauge students' perceptions of engagement, performance, and satisfaction.

RESULTS

A total of 97 questionnaires were received (72% response rate). Over 70% of respondents were satisfied and felt that the class was useful except for role-playing activities (60%). More than 60% reported a better understanding of the practical applications of medical law. Approximately half (54%) reported less anxiety about medical disputes. 73% reported that the lecture provided awareness of potential medical disputes, and most respondents expressed an interest in medical law courses after the court visit (78%). 80% of the respondents were able to display empathy and apply mediation skills. Qualitative analyses showed that students demonstrated new knowledge, including recognizing the significance of the medical profession, distinguishing the importance of physician-patient communication, having confidence in the fairness of the justice system, and being willing to increase their legal knowledge.

CONCLUSIONS

CBL curriculum increases students' learning motivation in strengthening medical professionalism and medical law, develops students' empathy for patients and communication skills, as well as builds up students' trust in the justice system. This novel course design can be applied to teach medical ethics and law.

Knowledge, Attitudes, and Perceptions About Medicolegal Education: A Survey of OB/GYN Residents

INTRODUCTION

Medicolegal concerns affect the career decisions of obstetrics/gynecology (OB/GYN) residents; however, their exposure to medicolegal education during residency training is virtually unknown.

OBJECTIVE

To assess the knowledge, attitudes, and perceptions of medicolegal concepts among OB/GYN residents.

METHODS

All residents in an accredited residency training program in OB/GYN in the United States during the 2017-2018 academic year were invited to complete an anonymous online survey.

RESULTS

Of the 5152 OB/GYN residents invited to complete the survey; nearly 17% (n = 866) responded. Basic medicolegal knowledge was poor. Almost 60% of respondents (n = 500) could not identify malpractice as a form of tort liability. Among respondents, 44% (n = 378) reported receiving no medicolegal education during residency, 21% (n = 181) were unsure, and 34% (n = 293) reported receiving some education. Of those who reported receiving medicolegal education, the majority, 66% (n = 549), received it informally: by "word of mouth" or by "observing colleagues." Most (67%, n = 571) of the residents did not believe they had adequate exposure to medicolegal topics, and 19% (n = 163) were unsure. Ninety-two percent of residents (n = 782) reported concerns about being sued, and 67% (n = 571) believed that formal instruction during residency training may prevent lawsuits.

CONCLUSION

Exposure to medicolegal topics during OB/GYN residency training is very limited and unstructured. This study showed that residents desire a more formalized medicolegal curriculum during postgraduate training and that implementation may have several benefits.

Trends in malpractice claims for obstetric and gynecologic procedures, 2005 through 2014

BACKGROUND

Interest in medical malpractice and areas of medicolegal vulnerability for practicing obstetricians and gynecologists has grown substantially, and many providers report changing surgical practice out of fear of litigation. Furthermore, education on medical malpractice and risk management is lacking for obstetrics and gynecology trainees. Recent obstetric and gynecologic malpractice claims data are lacking. We report on recent trends in malpractice claims for obstetrics and gynecology procedures, and compare these trends to those of other medical specialties.

OBJECTIVE

We sought to evaluate recent trends in malpractice claims for obstetrics and gynecology procedures and compare these to other medical specialties.

STUDY DESIGN

A search was performed on all medicolegal claims data for obstetrics and gynecology procedures from Jan. 1, 2005, through Dec. 31, 2014, using the Physician Insurers' Association of America data-sharing project, which was created to identify medical professional liability trends. Data from 20 insurance carriers were reviewed based on a search using International Classification of Diseases, Ninth Revision codes and unique database-specific codes.

RESULTS

Of the 10,915 total claims closed from 2005 through 2014, the majority (59.5%) were dropped, withdrawn, or dismissed. The average indemnity of the remaining paid claims (31.1%) was $423,250. The most frequently litigated procedure was operative procedures on the uterus; 27.8% of cases were paid with an average indemnity of $279,384. The procedure associated with the highest proportion of paid claims was vacuum extraction. The average indemnity for paid obstetrics and gynecology procedural claims was 27% higher than that for all medical specialties combined. Obstetrics and gynecology procedural claims had the second highest average indemnity payment and the fifth highest paid-to-closed ratio of all medical specialties.

CONCLUSION

Litigation claims for obstetrics and gynecology procedures have higher average indemnity payments and higher paid-to-closed ratios than most other medical specialties. Claims most frequently relate to gynecologic surgery, but obstetric procedures are more expensive. Possible factors may include procedural experience and unique perioperative complications. We encourage efforts addressing procedures, litigation, and quality interventions to improve outcomes, mitigate risk, and potentially lower indemnity payments.

Medico-legal education: a pilot curriculum to fill the identified knowledge gap

PURPOSE

We sought to determine if a medico-legal educational curriculum designed to increase physicians' familiarity with the legal system in a nonthreatening environment-a didactic and interactive educational seminar-would positively influence learners' knowledge base and self-awareness.

METHODS

Because neither the Accreditation Council for Graduate Medical Education nor its Residency Review Committees specifically addresses medico-legal liability education, we designed a 2-day intensive medico-legal educational curriculum and piloted it in 2007 and 2008 at a large academic tertiary-referral medical center. Postcurriculum evaluations and precurriculum and postcurriculum testing were used to identify areas of common and/or persisting knowledge deficit.

RESULTS

A total of 50 graduating residents, fellows, and community practitioners participated in the course. Common areas of knowledge deficit were "privilege," "discovery," statutes of limitations, and basic legal procedure. Discordance in physician interpretation of patient perspective and misunderstanding among physicians of the impact of the legal suit were evident.

CONCLUSIONS

Concentrated legal education at selected times during medical training may support physicians' motivations to improve the assurance of quality and continuity of care. We continue to revise the curriculum to address issues of lecturer style, lecture content, and overall attitudinal values related to clinical practice, legal education, long-term impact on practice patterns, job satisfaction and its effect on attention to quality and continuity-of-care issues, and health care provider attitudes about the provider's role within the legal system and the community. We plan to conduct follow-up of participants to assess retention and subsequent use of this knowledge.

Risk assessment and risk distortion: finding the balance

Pregnancy and birth have been conceptualized as medically problematic, with all pregnant women considered at risk and in need of medical monitoring. Universal application of risk scoring and surveillance as preemptive strategies in an effort to reduce risk is now standard obstetric practice. Labeling women "high risk" can result in more unnecessary interventions and have negative psychologic sequelae. When perceived pregnancy risk is out of proportion to the real risk, and when risk management procedures are applied to all women with benefit for only a few, the use of technology in caring for pregnant women becomes normalized. A learned reliance on technology can diminish women's own authoritative knowledge of pregnancy and birth. This may also have the unintended consequence of contributing to birth fear, a phenomena becoming more widely recognized. Health care provider-patient communication about pregnancy risk can be presented in a manner that encourages informed compliance rather than informed choice. Evidence-based risk assessment is essential to providing optimal prenatal care. Using tools such as the Paling Palette can help health care providers present balanced and readily understood information about risk.