Sex differences in medico-legal action against doctors: a systematic review and meta-analysis

Retrospective Analysis of US Litigations Involving Dermatologists From 2011 to 2022

BACKGROUND

Physician malpractice lawsuits are climbing, and the reasons underlying litigation against dermatologists are unclear.

OBJECTIVE

To determine the reasons patients pursue litigation against dermatologists or dermatology practices.

MATERIALS AND METHODS

A retrospective analysis of all state and federal cases between 2011 and 2022 was performed after a query using "Dermatology" and "dermatologist" as search terms on 2 national legal data repositories.

RESULTS

The authors identified a total of 48 (37 state and 11 federal) lawsuits in which a practicing dermatologist or dermatology group practice was the defendant. The most common reason for litigation was unexpected harm (26 cases, 54.2%), followed by diagnostic error (e.g. incorrect or delayed diagnoses) (16 cases, 33.3%). Six cases resulted from the dermatologist failing to communicate important information, such as medication side effects or obtaining informed consent. Male dermatologists were sued at a rate 3.1 times higher than female dermatologists.

CONCLUSION

Although lawsuits from patients against dermatologists largely involve injury from elective procedures, clinicians should practice caution regarding missed diagnoses and ensure critical information is shared with patients to safeguard against easily avoidable litigation.

Patient characteristics of, and remedial interventions for, complaints and medico-legal claims against doctors: a rapid review of the literature

BACKGROUND

It is uncertain if patient's characteristics are associated with complaints and claims against doctors. Additionally, evidence for the effectiveness of remedial interventions on rates of complaints and claims against doctors has not been synthesised.

METHODS

We conducted a rapid review of recent literature to answer: Question 1 "What are the common characteristics and circumstances of patients who are most likely to complain or bring a claim about the care they have received from a doctor?" and Question 2 "What initiatives or interventions have been shown to be effective at reducing complaints and claims about the care patients have received from a doctor?". We used a systematic search (most recently in July 2023) of PubMed, Scopus, Web of Science and grey literature. Studies were screened against inclusion criteria and critically appraised in duplicate using standard tools. Results were summarised using narrative synthesis.

RESULTS

From 8079 search results, we reviewed the full text of 250 studies. We included 25 studies: seven for Question 1 (6 comparative studies with controls and one systematic review) and 18 studies for Question 2 (14 uncontrolled pre-post studies, 2 comparative studies with controls and 2 systematic reviews). Most studies were set in hospitals across a mix of medical specialties. Other than for patients with mental health conditions (two studies), no other patient characteristics demonstrated either a strong or consistent effect on the rate of complaints or claims against their treating doctors. Risk management programs (6 studies), and communication and resolution programs (5 studies) were the most studied of 6 intervention types. Evidence for reducing complaints and medico-legal claims, costs or premiums and more timely management was apparent for both types of programs. Only 1 to 3 studies were included for peer programs, medical remediation, shared decision-making, simulation training and continuing professional development, with few generalisable results.

CONCLUSION

Few patient characteristics can be reliably related to the likelihood of medico-legal complaints or claims. There is some evidence that interventions can reduce the number and costs of claims, the number of complaints, and the timeliness of claims. However, across both questions, the strength of the evidence is very weak and is based on only a few studies or study designs that are highly prone to bias.

Prevalence of occupational injury and its associated factors among emergency department physicians in China: A large sample, cross-sectional study

BACKGROUND

Medical personnel, particularly emergency department (ED) physicians, face a variety of occupational hazards. However, the current state of occupational injuries among ED physicians remains unknown. This study aimed to assess the occupational injury of Chinese ED physicians and to identify its associated factors.

METHODS

From July to August 2018, a cross-sectional survey was conducted in Chinese emergency departments. A structured questionnaire covering sociodemographic characteristics, individual health behaviours, and work-related characteristics was completed by 10,457 ED physicians. Binary logistic regression was used to analyse the factors associated with occupational injuries.

RESULTS

In this study, 81.13% of ED physicians reported occupational injuries in the previous 12 months. All participants who had experienced occupational injuries had suffered verbal violence. Among physicians who experienced at least one injury, 76.57% and 71.30% reported injuries sustained while moving patients and from falls, slips, and sprains during office visits, respectively. Occupational injuries were significantly associated with gender, education level, drinking behaviour, sleep quality, the frequency of night shifts per month, self-perceived physician shortage, and work-family conflict. Physicians who experienced effort-reward imbalance were at a higher risk of occupational injury.

CONCLUSION

In China, occupational injuries are common among ED physicians. Individual factors as well as work-related factors are independently linked to occupational injuries. To reduce the rate of occupational injuries among ED physicians, health policymakers and healthcare facility managers should consider multi-injury interventions.

The effects of academic unprofessional behaviour on disciplinary action by medical boards: Systematic review and meta-analysis

OBJECTIVE

The objective of this study is to evaluate the association of disciplinary actions by regulatory councils and unprofessional behaviour during medical graduation.

METHODS

A search strategy was developed using the terms: 'physicians', 'disciplinary action', 'education', 'medical', 'undergraduate' and their synonyms, subsequently applied to the electronic databases MEDLINE, Embase, Cochrane Library, LILACs and grey literature, with searches up to November 2023. The risk of bias was assessed using the Newcastle-Ottawa scale and statistical analysis was performed using the RevMan software.

RESULTS

A total of 400 studies were found in the databases, and 15 studies were selected for full-texting reading. Four studies met the inclusion criteria and were included, bringing together a total of 3341 evaluated physicians. Three studies were included in the meta-analysis, showing a greater chance of disciplinary actions among physicians who exhibited unprofessional behaviour during medical graduation (OR: 2.54; 95%CI: 1.87-3.44; I2 : 0%; P < 0.0001; 3077 participants; physicians with disciplinary action: 107/323; control physicians: 222/2754).

CONCLUSIONS

There is a statistically significant association between unprofessional behaviour during medical undergraduate study and subsequent disciplinary actions by Medical Councils. The tools for periodic assessments of student behaviour during undergraduate studies can be a perspective for future studies aimed at reducing disciplinary actions among physicians.

Risk identification and prediction of complaints and misconduct against health practitioners: a scoping review

Identifying the risk and predicting complaints and misconduct against health practitioners are essential for healthcare regulators to implement early interventions and develop long-term prevention strategies to improve professional practice and enhance patient safety. This scoping review aims to map out existing literature on the risk identification and prediction of complaints and misconduct against health practitioners. This scoping review followed Arksey and O'Malley's five-stage methodological framework. A comprehensive literature search was conducted on MEDLINE, EMBASE, and CINAHL databases and finished on the same day (6 September 2021). Articles meeting the eligibility criteria were charted and descriptively analysed through a narrative analysis method. The initial search generated 5473 articles. After the identification, screening, and inclusion process, 81 eligible studies were included for data charting. Three key themes were reported: methods used for identifying risk factors and predictors of the complaints and misconduct, synthesis of identified risk factors and predictors in eligible studies, and predictive tools developed for complaints and misconduct against health practitioners. The findings reveal that risk identification and prediction of complaints and misconduct are complex issues influenced by multiple factors, exhibiting non-linear patterns and being context specific. Further efforts are needed to understand the characteristics and interactions of risk factors, develop systematic risk prediction tools, and facilitate the application in the regulatory environment.

Prediction of Medical Disputes Between Health Care Workers and Patients in Terms of Hospital Legal Construction Using Machine Learning Techniques: Externally Validated Cross-Sectional Study

BACKGROUND

Medical disputes are a global public health issue that is receiving increasing attention. However, studies investigating the relationship between hospital legal construction and medical disputes are scarce. The development of a multicenter model incorporating machine learning (ML) techniques for the individualized prediction of medical disputes would be beneficial for medical workers.

OBJECTIVE

This study aimed to identify predictors related to medical disputes from the perspective of hospital legal construction and the use of ML techniques to build models for predicting the risk of medical disputes.

METHODS

This study enrolled 38,053 medical workers from 130 tertiary hospitals in Hunan province, China. The participants were randomly divided into a training cohort (34,286/38,053, 90.1%) and an internal validation cohort (3767/38,053, 9.9%). Medical workers from 87 tertiary hospitals in Beijing were included in an external validation cohort (26,285/26,285, 100%). This study used logistic regression and 5 ML techniques: decision tree, random forest, support vector machine, gradient boosting decision tree (GBDT), and deep neural network. In total, 12 metrics, including discrimination and calibration, were used for performance evaluation. A scoring system was developed to select the optimal model. Shapley additive explanations was used to generate the importance coefficients for characteristics. To promote the clinical practice of our proposed optimal model, reclassification of patients was performed, and a web-based app for medical dispute prediction was created, which can be easily accessed by the public.

RESULTS

Medical disputes occurred among 46.06% (17,527/38,053) of the medical workers in Hunan province, China. Among the 26 clinical characteristics, multivariate analysis demonstrated that 18 characteristics were significantly associated with medical disputes, and these characteristics were used for ML model development. Among the ML techniques, GBDT was identified as the optimal model, demonstrating the lowest Brier score (0.205), highest area under the receiver operating characteristic curve (0.738, 95% CI 0.722-0.754), and the largest discrimination slope (0.172) and Youden index (1.355). In addition, it achieved the highest metrics score (63 points), followed by deep neural network (46 points) and random forest (45 points), in the internal validation set. In the external validation set, GBDT still performed comparably, achieving the second highest metrics score (52 points). The high-risk group had more than twice the odds of experiencing medical disputes compared with the low-risk group.

CONCLUSIONS

We established a prediction model to stratify medical workers into different risk groups for encountering medical disputes. Among the 5 ML models, GBDT demonstrated the optimal comprehensive performance and was used to construct the web-based app. Our proposed model can serve as a useful tool for identifying medical workers at high risk of medical disputes. We believe that preventive strategies should be implemented for the high-risk group.

Relationship Between the American Board of Ophthalmology Maintenance of Certification Program and Actions Against the Medical License

PURPOSE

To evaluate the likelihood of disciplinary actions against medical licenses of ophthalmologists who maintained board certification through successful completion of the American Board of Ophthalmology Maintenance of Certification program compared with ophthalmologists who did not maintain certification.

METHODS

This was a retrospective cohort study of ophthalmologists certified by the American Board of Ophthalmology from 1992 to 2012 with time-limited certificates. Rates and severity of disciplinary actions against medical licenses were analyzed among ophthalmologists who did and did not maintain certification.

RESULTS

Of 9111 ophthalmologists who earned initial board certification between 1992 and 2012, 8073 (88.6%) maintained their certification and 1038 (11.4%) did not maintain their certification. A total of 234 license actions were identified in the study group. Among ophthalmologists who did not maintain board certification, the risk of a license action was more than 2 times that of those who maintained board certification (hazard ratio = 2.34, 95% CI=1.73-3.18). License actions were significantly higher in men than in women (hazard ratio = 2.02, 95% CI=1.43-2.86). Ophthalmologists who had a lapse in their certification had a higher severity of disciplinary actions (χ² = 9.21, p <.01) than ophthalmologists who maintained their certification.

CONCLUSIONS

This study supports prior literature in other specialties demonstrating a higher risk of disciplinary licensure actions in physicians who did not maintain board certification as compared with those who did. Physicians who did not maintain certification were also more likely to have actions against their license reflecting a higher severity violation. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Pharmacist Disciplinary Action: What Do Pharmacists Get in Trouble for?

Objective

This study aims to determine the reasons for disciplinary action and resultant consequences for Canadian pharmacists and any associations with demographic factors.

Methods

Regulatory body disciplinary action cases from 10 Canadian provinces were coded. Demographic information was coded.

Results

There were 665 pharmacist cases from nine provinces between January 2010 and December 2020. The rate of disciplinary action was low (1.37 cases/1,000 practitioners/year). Professional misconduct was the most common category of violation. Male pharmacists were overrepresented in disciplinary action cases. Most cases involved community pharmacists.

Conclusion

This study is the first, to our knowledge, in Canada to analyze the demographic factors of pharmacists subjected to disciplinary action. It updates a previous review of pharmacist disciplinary action (Foong et al. 2018).

Dentist Disciplinary Action: What Do Dentists Get in Trouble for?

Objective

This study aims to determine the reasons for disciplinary action, the consequences and any associations with demographic factors for Canadian dentists.

Methods

Publicly available regulatory body disciplinary action cases from 10 Canadian provinces were coded. Demographic factors were also coded.

Results

There were 344 dentist cases from five provinces between January 2010 and December 2020. The rate of disciplinary action was low (1.38 cases/1,000 practitioners/year). Clinical incompetence was the most common category of disciplinary action, followed by professional misconduct and dishonest business practices. Male dentists were overrepresented in the disciplinary action cases compared to the rest of the workforce.

Conclusion

This study is the first, to our knowledge, to describe the outcomes of regulatory body disciplinary action for Canadian dentists.

Impact of the medical care act amendment on the medical malpractice litigation in Taiwan

Medical malpractice leads to medical criminal liability and claims. The national data of medical criminal liabilities across various specializations, before and after the Medical Care Act amendment, was lacking in Taiwan. The aim of this study is to clarify the impact of the law amendment. A comprehensive retrospective analysis of medical crimes was conducted from January 2001 to December 2020 in Taiwan. The number of medical criminal litigation, defendants, people who plead guilty, conviction rate, and punishment sentences were analyzed. Additionally, the number of practicing physicians in the year was used as the baseline to determine the rate of the accused and guilty rate per 10,000 physician-years, respectively. From 2001 to 2020, there were 249 criminal litigations of medical professionals, which gave rise to 335 defendants. The proportion of defendants by specialization was 19.1% in internal medicine, 26.3% in surgery and orthopedics, 11.9% in obstetrics and gynecology, 3.3% in pediatrics, 25.7% in physicians (who were not related to the aforementioned 4 specializations), and 13.7% in non-physician staff. After the amendment to the Medical Care Act in 2017, the accused rates per 10,000 physician-years decreased significantly in aggregate and by specialization between 2016 and 2020; the guilty rate per 10,000 physician-years during 2016 to 2020 was the minimum, compared to the past. The amendment to the Medical Care Act in 2017 reduced the number of vexatious criminal proceedings. The amendment also reduced criminal liabilities by reducing the guilty rate during 2016 to 2020, compared to the previous period.

Why Is Patient Safety a Challenge? Insights From the Professionalism Opinions of Medical Students' Research

OBJECTIVES

Despite increased emphasis on education and training for patient safety in medical schools, there is little known about factors influencing decision making regarding patient safety behaviors. This study examined the nature and magnitude of factors that may influence opinions around patient safety-related behaviors as a means of providing insights into how Australian doctors and medical students view these issues relative to members of the public.

METHODS

A national, multicenter, prospective, cross-sectional survey was conducted using responses to hypothetical patient safety scenarios involving the following: fabricating results, personal protective equipment, presenteeism, and reporting concerns.Australian enrolled medical students, medical doctors, and members of the public were surveyed.Participant responses were compared for the different contextual variables within the scenarios and the participants' demographic characteristics.

RESULTS

In total, 2602 medical student, 809 doctors, and 503 members of the Australian public participated. The 3 demographic groups had significantly differing opinions on many of the patient safety dilemmas. Doctors were more tolerant of medical students not reporting concerning behaviors and attending placements despite recent illness. Medical students' opinions frequently demonstrated a "transition effect," bridging between the doctors and publics' attitudes, consistent with professional identity formation.

CONCLUSIONS

Opinions on the acceptability of medical students' patient safety-related behaviors were influenced by the demographics of the cohort and the contextual complexity of the scenario. Although the survey used hypothetical scenarios, doctors and medical students' opinions seem to be influenced by cognitive dissonances, biases, and heuristics, which may negatively affect patient safety.

Association between hospital legal constructions and medical disputes: A multi-center analysis of 130 tertiary hospitals in Hunan Province, China

Background

Medical disputes are common in hospitals and a major challenge for the operations of medical institutions. However, few studies have looked into the association between medical disputes and hospital legal constructions. The purpose of the study was to investigate the relationship between hospital legal constructions and medical disputes, and it also aimed to develop a nomogram to estimate the likelihood of medical disputes.

Methods

Between July and September 2021, 2,716 administrators from 130 hospitals were enrolled for analysis. The study collected seventeen variables for examination. To establish a nomogram, administrators were randomly split into a training group (n = 1,358) and a validation group (n = 1,358) with a 50:50 ratio. The nomogram was developed using data from participants in the training group, and it was validated in the validation group. The nomogram contained significant variables that were linked to medical disputes and were identified by multivariate analysis. The nomogram's predictive performance was assessed utilizing discriminative and calibrating ability. A web calculator was developed to be conducive to model utility.

Results

Medical disputes were observed in 41.53% (1,128/2,716) of participants. Five characteristics, including male gender, higher professional ranks, longer length of service, worse understanding of the hospital charters, and worse construction status of hospital rule of law, were significantly associated with more medical disputes based on the multivariate analysis. As a result, these variables were included in the nomogram development. The AUROC was 0.67 [95% confident interval (CI): 0.64-0.70] in the training group and 0.68 (95% CI: 0.66-0.71) in the validation group. The corresponding calibration slopes were 1.00 and 1.05, respectively, and intercepts were 0.00 and -0.06, respectively. Three risk groups were created among the participants: Those in the high-risk group experienced medical disputes 2.83 times more frequently than those in the low-risk group (P < 0.001).

Conclusion

Medical dispute is prevailing among hospital administrators, and it can be reduced by the effective constructions of hospital rule of law. This study proposes a novel nomogram to estimate the likelihood of medical disputes specifically among administrators in tertiary hospitals, and a web calculator can be available at https://ymgarden.shinyapps.io/Predictionofmedicaldisputes/.

Vocational and psychosocial predictors of medical negligence claims among Australian doctors: a prospective cohort analysis of the MABEL survey

OBJECTIVE

To understand the association between medical negligence claims and doctors' sex, age, specialty, working hours, work location, personality, social supports, family circumstances, self-rated health, self-rated life satisfaction and presence of recent injury or illness.

DESIGN AND SETTING

Prospective cohort study of Australian doctors.

PARTICIPANTS

12 134 doctors who completed the Medicine in Australia: Balancing Employment and Life survey between 2013 and 2019.

PRIMARY OUTCOME MEASURE

Doctors named as a defendant in a medical negligence claim in the preceding 12 months.

RESULTS

649 (5.35%) doctors reported being named in a medical negligence claim during the study period. In addition to previously identified demographic factors (sex, age and specialty), we identified the following vocational and psychosocial risk factors for claims: working full time (OR=1.48, 95% CI 1.13 to 1.94) or overtime hours (OR 1.70, 95% CI 1.29 to 2.23), working in a regional centre (OR 1.69, 95% CI 1.37 to 2.08), increasing job demands (OR 1.16, 95% CI 1.04 to 1.30), low self-rated life satisfaction (OR 1.43, 95% CI 1.08 to 1.91) and recent serious personal injury or illness (OR 1.40, 95% CI 1.13 to 1.72). Having an agreeable personality was mildly protective (OR 0.91, 95% CI 0.83 to 1.00). When stratified according to sex, we found that working in a regional area, low self-rated life satisfaction and not achieving work-life balance predicted medical negligence claims in male, but not female, doctors. However, working more than part-time hours and having a recent personal injury or illness predicted medical negligence claims in female, but not male, doctors. Increasing age predicted claims more strongly in male doctors. Personality type predicted claims in both male and female doctors.

CONCLUSIONS

Modifiable risk factors contribute to an increased risk of medical negligence claims among doctors in Australia. Creating more supportive work environments and targeting interventions that improve doctors' health and well-being could reduce the risk of medical negligence claims and contribute to improved patient safety.

Socio-Demographic, Professional and Institutional Characteristics That Make Romanian Doctors More Prone to Malpractice Complaints

Background and objectives: Medical malpractice is a phenomenon that shadows current medical practice, the number of complaints following an upward trend worldwide. The background for complaints is related both to the doctor and medical practice in general, as well as to the patient. The aim of this study was to identify a profile of the Romanian doctors who are more prone to receiving complaints, by analyzing the socio-demographic, professional and institutional characteristics. Materials and Methods: We conducted a quantitative, prospective research, the data being collected using a newly developed questionnaire. Data analysis was performed with the IBM Statistical Package for Social Sciences (SPSS, version 24). We used counts, percentages, means and standard deviation, and comparative and correlational analyses. A logistic regression model was applied to select a statistically best-fit model to identify independent predictors for receiving complaints; a Hosmer–Lemeshow test was used to check the performance of the prediction model. Results: The study group consisted of 1684 doctors, of which 16.1% had been involved in a malpractice complaint. Results showed that men, senior doctors from surgical specialties who perform a greater number of on-call shifts, those who work in regional or county hospitals, those who have greater fear of receiving complaints and those whose life partner is a doctor with the same specialty are more prone to receiving complaints. Conclusions: The profile identified by the present research underlines the main characteristics that could be targeted with specific measures in order to prevent the ongoing increase of malpractice complaints in Romania.

Litigability and defensibility in neurology and neurosurgery. A "therapeutic" model for handling claims for malpractice care

Despite its indisputable importance, there are not many official data on claims for malpractice at the national level in Spain, mainly due to transfers from Health to the Autonomous Communities. This lack of unified information, together with other variables related to modern Healthcare Medicine (type of healthcare system, ethical aspects, consent, patients' rights, new technologies, etc.), complicates the healthcare professional's response to claims, and could not guarantee adequate protection of this against possible liability. This article analyzes the current situation in Spain and emphasizes aspects such as defensibility and liability in malpractice claims, taking as a model the Neurosurgery Specialty, one of the most prone to this type of situation. Prevention and action guidelines are offered, through a model aimed at reinforcing defensibility and reducing liability. This approach, which we call a "therapeutic model", considers the problem analogously to a disease, providing the basis for its prevention and management. We believe that this approach can be useful both to the Neurosurgeon and to any healthcare provider at a time, such as today, when there is some confusion on these issues and some reluctance of insurance companies to provide coverage in some cases.

Physician factors associated with medical errors in Norwegian primary care emergency services

OBJECTIVE

The aim of this study was to examine the associations between characteristics of physicians working in primary care emergency units (PCEUs) and the outcome of assessments of the medical records.

DESIGN

Data from a previous case-control study was used to evaluate factors related to medical errors.

SETTING

Ten Norwegian PCEUs were included.

SUBJECTS

Physicians that had evoked a patient complaint, and a random sample of three physicians from the same PCEU and time period as the physician who had evoked a complaint. Recorded physician characteristics were: gender, seniority, citizenship at, and years after authorization as a physician, specialty in general practice, and workload at the PCEU. Main outcome measures: Assessments of the medical records: errors that may have led to harm, no medical error, or inconclusive.

RESULTS

In the complaint group 77 physicians were included, and in the random sample group 217. In the first group, 53.2% of the medical records were assessed as revealing medical errors. In the random sample group, this percentage was 3.2. In the complaint group the percentages for no-error and inconclusive for the female physicians were 30.8 and 15.4; and for the male physicians 9.8 and 27.3, p = 0.027.

CONCLUSION

In the group of complaints there was a higher percentage with no assessed medical error, and a lower percentage with inconclusive assessments of medical errors, among female physicians compared to their male colleagues. We found no other physician factors that were associated with assessed medical errors. Future research should focus on the underlying elements of these findings.Key pointsMedical errors are among the leading causes of death and they are essentially avoidable. Primary care emergency units are a vulnerable arena for committing medical errors.By assessing the medical records of a group of physicians who had evoked a complaint, no differences related to physician factors were revealed in the incidence of medical errors.In the group of female physicians, the proportion of no-errors, was higher, and the percentage of inconclusive medical records was lower than for their male colleagues.The Norwegian regulations on independent participation in PCEUs may have modulated these results.

Disciplinary complaints concerning transgressive behaviour by healthcare professionals: an analysis of 5 years jurisprudence in the Netherlands

OBJECTIVES

To study the frequency of observed cases of disciplinary law complaints concerning transgressive behaviour in Dutch healthcare by analysing disciplinary cases handled in Dutch disciplinary law.

DESIGN

Retrospective review of complaints in the Dutch disciplinary law tribunals from the period 1 January 2015 to 1 January 2020.

SETTING

Dutch healthcare.

METHOD

Descriptive retrospective study. All judgements at regional disciplinary tribunals in the first instance from the period 1 January 2015 to 1 January 2020 concerning transgressive behaviour were investigated. The following was studied: year of judgement, number and nature of complaints, type of complainants, profession of defendant.

RESULTS

Over the study period, 139 complaints about transgressive behaviour were handled, 90 of which involved sexual behaviour. 66/139 complaints were submitted by patients themselves (47.5%). Most complaints were directed against physicians (44.6%; n=62), followed by nurses (30.2%; n=42), psychologists (11.5%; n=16) and physiotherapists (7.9%; n=11). 80.6% of the complaints were directed against a male healthcare professional (OR 4.25; 95% CI 1.7590 to 10.2685; p=0.0013). 104/139 of the complaints originated from an outpatient work setting and about half of the complaints originated from mental healthcare. Of the 90 disciplinary cases in which the complaint was related to sexually transgressive behaviour, 83.3% (n=75) were ruled to be substantiated (5 of which partially) with a measure imposed in all cases: 6 formal warnings (8%), 11 reprimands (14.7%), 10 denials (partial suspension) (13.3%), 26 temporary suspensions (34.7%) and 22 cancellations of the licence to practice (29.3%).

CONCLUSION

This study describes jurisprudence of disciplinary cases about transgressive behaviour of healthcare professionals in the Netherlands. The results of this study can be used to monitor trends in observed cases of transgressive behaviour.

Physician factors associated with increased risk for complaints in primary care emergency services: a case - control study

BACKGROUND

Patient safety incidents defined as any unintended or unexpected incident that could have or were judged to have led to patient harm, are reported as relatively common. In this study patient complaints have been used as an indicator to uncover the occurrence of patient safety incidents in primary care emergency units (PCEUs) in Norway.

METHODS

Ten PCEUs in major cities and rural parts of Norway participated. These units cover one third of the Norwegian population. A case-control design was applied. The case was the physician that evoked a complaint. The controls were three randomly chosen physicians from the same PCEU as the physician having evoked the complaint. The following variables regarding the physicians were chosen: gender, citizenship at, and years after authorization as physician, and specialty in general practice. The magnitude of patient contact was defined as the workload at the PCEU. The physicians' characteristics and workload were extracted from the medical records from the fourteen-day period prior to the consultation that elicited the complaint. The rest of the variables were then obtained from the Norwegian physician position register. Logistic regression was used to estimate odds ratio for complaints both unadjusted and adjusted for the independent variables. The data were analyzed using SPSS (Version25) and STATA.

RESULTS

A total of 78 cases and 217 controls were included during 18 months (September 1st 2015 till March 1st 2017). The risk of evoking a complaint was significantly higher for physicians without specialty in general practice, and lower for those with medium low and medium high workload compared to physicians with no duty during the fourteen-day period prior to the index consultation. The limited strength of the study did not make it possible to assess any correlation between workload and the other variables (physician's gender, seniority and citizenship at time of authorization).

CONCLUSIONS

Continuous medical training and achieving the specialty in general practice were decisively associated with a reduced risk for complaints in primary care emergency services. Future research should focus on elements promoting quality of care such as continuing education, duty rosters and other structural and organizational factors.

The Association Between Physician Race/Ethnicity and Patient Satisfaction: an Exploration in Direct to Consumer Telemedicine

BACKGROUND

Patient satisfaction measures have important implications for physicians. Patient bias against non-White physicians may impact physician satisfaction ratings, but this has not been widely studied.

OBJECTIVE

To assess differences in patient satisfaction by physician race/ethnicity.

DESIGN

A cross-sectional observational study.

PARTICIPANTS

Patients seeking care on a large nationwide direct to consumer telemedicine platform between July 2016 and July 2018 and their physicians.

MAIN MEASURES

Patient satisfaction was ascertained immediately following the encounter on scales of 1 to 5 stars and scored two ways: (1) top-box satisfaction (5 stars versus fewer) and (2) dissatisfaction (2 or fewer stars versus 3 or more). To approximate the information patients would use to make assumptions about physician race/ethnicity, four reviewers classified physicians into categories based on physician name and photo. These included White American, Black American, South Asian, Middle Eastern, Hispanic, and East Asian. Mixed effects logistic regression was used to assess differences in patient top-box satisfaction and patient dissatisfaction by physician race/ethnicity, controlling for patient characteristics, prescription receipt, physician specialty, and whether the physician trained in the USA versus internationally.

KEY RESULTS

The sample included 119,016 encounters with 390 physicians. Sixty percent were White American, 14% South Asian, 7% Black American, 7% Hispanic, 6% Middle Eastern, and 6% East Asian. Encounters with South Asian physicians (aOR 0.70; 95% CI 0.54-0.91) and East Asian physicians (aOR 0.72; 95% CI 0.53-0.99) were significantly less likely than those with White American physicians to result in top-box satisfaction. Compared to encounters with White American physicians, those with Black American physicians (aOR 1.72; 95% CI 1.12-2.64), South Asian physicians (aOR 1.77; 95% CI 1.23-2.56), and East Asian physicians (aOR 2.10; 95% CI 1.38-3.20) were more likely to result in patient dissatisfaction.

CONCLUSIONS

In our study, patients reported lower satisfaction with some groups of non-White American physicians, which may have implications for their compensation, professional reputation, and job satisfaction.

Characteristics and predictors of regulatory immediate action imposed on registered health practitioners in Australia: a retrospective cohort study

Objective Immediate action is an emergency power available to Australian health practitioner regulatory boards to protect the public. The aim of this study was to better understand the frequency, determinants and characteristics of immediate action use in Australia. Methods This was a retrospective cohort study of 11200 health practitioners named in notifications to the Australian Health Practitioner Regulation Agency (AHPRA) between January 2011 and December 2013. All cases were followed until December 2016 to determine their final outcome. Results Of 13939 finalised notifications, 3.7% involved immediate action and 9.7% resulted in restrictive final action. Among notifications where restrictive final action was taken, 79% did not involve prior immediate action. Among notifications where immediate action was taken, 48% did not result in restrictive final action. Compared with notifications from the public, the odds of immediate action were higher for notifications lodged by employers (mandatory notifications OR=21.3, 95% CI 13.7-33.2; non-mandatory notifications OR=10.9, 95% CI 6.7-17.8) and by other health practitioners (mandatory notifications OR=11.6, 95% CI 7.6-17.8). Odds of immediate action were also higher if the notification was regulator-initiated (OR=11.6, 95% CI 7.6-17.8), lodged by an external agency such as the police (OR=11.8, 95% CI 7.7-18.1) or was a self-notification by the health practitioner themselves (OR=9.4, 95% CI 5.5-16.0). The odds of immediate action were higher for notifications about substance abuse (OR=9.9, 95% CI 6.9-14.2) and sexual misconduct (OR=5.3, 95% CI 3.5-8.3) than for notifications about communication and clinical care. Conclusions Health practitioner regulatory boards in Australia rarely used immediate action as a regulatory tool, but were more likely to do so in response to mandatory notifications or notifications pertaining to substance abuse or sexual misconduct. What is known about this topic Health practitioner regulatory boards protect the public from harm and maintain quality and standards of health care. Where the perceived risk to public safety is high, boards may suspend or restrict the practice of health practitioners before an investigation has concluded. What does this paper add? This paper is the first study in Australia, and the largest internationally, to examine the frequency, characteristics and predictors of the use of immediate action by health regulatory boards. Although immediate action is rarely used, it is most commonly employed in response to mandatory notifications or notifications pertaining to substance abuse or sexual misconduct. What are the implications for practitioners? Immediate action is a vital regulatory tool. Failing to immediately sanction a health practitioner may expose the public to preventable harm, whereas imposing immediate action where allegations are unfounded can irreparably damage a health practitioner's career. We hope that this study will assist boards to balance the interests of the public with those of health practitioners.

An Investigation of the Relationship Between COMLEX-USA Licensure Examination Performance and State Licensing Board Disciplinary Actions

PURPOSE

Passing the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) serves as a licensing requirement, yet there is limited understanding between this high-stakes exam and performance outcomes. This study examined the relationship between COMLEX-USA scores and disciplinary actions received by osteopathic physicians.

METHOD

Data for osteopathic physicians (N = 26,383) who graduated from medical school between 2004 and 2013 were analyzed using multinomial logistic regression to assess the relationship between COMLEX-USA scores and placement into one of 3 disciplinary action categories relative to no action received, controlling for years in practice and gender.

RESULTS

Less than 1% of physicians in this study (n = 187) had a disciplinary action(s). Controlling for all COMLEX-USA levels, years in practice, and gender, higher Level 3 scores were associated with significant decreased odds for all action categories: revoked licensed (odds ratio [OR] = 0.51, 95% confidence interval [CI] 0.36, 0.72; P < .001), imposed limitations to practice (OR = 0.59, 95% CI 0.41, 0.84; P < .01), and other action imposed (OR = 0.48, 95% CI 0.33, 0.69; P < .001), relative to not receiving an action. In these same models, higher Level 2 Performance Evaluation Biomedical/Biomechanical Domain scores decreased the odds for an action that revoked a license (OR = 0.75, 95% CI 0.58, 0.98; P < .05) and imposed limitations to practice (OR = 0.64, 95% CI 0.49, 0.84; P < .001).

CONCLUSIONS

These findings provide evidence that the COMLEX-USA delivers useful information regarding the likelihood of a practitioner receiving state board disciplinary actions.

Factors associated with severity of sanctions among pharmacy professionals facing disciplinary proceedings

BACKGROUND

The outcome of disciplinary proceedings against a pharmacy professional can strongly impact their career. The severity of outcomes at tribunal is often attributed to specific factors outside the control of the practitioner, including area of practice and level of experience; as well as to personal choices, including attendance at the hearing and the presence of a legal representative.

OBJECTIVE

To determine which of these factors are associated with removal from the professional register at General Pharmaceutical Council's (GPhC) disciplinary hearings.

METHODS

Pearson's Χ² or Fisher's exact tests were carried out for associations between all variable pairs identified in 127 case determinations published by the GPhC between 1 January 2016 and 31 December 2019. Relative risk calculations were applied to compare the likelihood of an event occurring between two groups.

RESULTS

Personal characteristics are unrelated to seriousness of regulatory outcomes in these cases. The composition of the panel is unrelated to the outcome. Engagement with the regulatory process (attendance and legal representation) is strongly associated with less severe sanctions.

CONCLUSIONS

The data demonstrates that failing to engage with the fitness to practise process virtually invites removal from the Register.

Trends in Pediatric Malpractice Claims 1987-2015: Results From the Periodic Survey of Fellows

BACKGROUND

Pediatricians are less frequently sued than other physicians. When suits are successful, however, the average payout is higher. Little is known about changes in the risk of litigation over time. We sought to characterize malpractice lawsuit trends for pediatricians over time.

METHODS

The Periodic Survey is a national random sample survey of American Academy of Pediatrics members. Seven surveys between 1987 and 2015 asked questions regarding malpractice (n = 5731). Bivariate and multivariable analyses examined trends and factors associated with risk and outcome of malpractice claims and lawsuits. Descriptive analyses examined potential change in indemnity amount over time.

RESULTS

In 2015, 21% of pediatricians reported ever having been the subject of any claim or lawsuit, down from a peak of 33% in 1990. Report of successful outcomes in the most-recent suit trended upward between 1987 and 2015, greatest in 2015 at 58%. Median indemnity was unchanged, averaging $128 000 in 2018 dollars. In multivariate analysis, male sex, hospital-based subspecialty (neonatology, pediatric critical care, pediatric emergency medicine, and hospital medicine), longer career, and more work hours were associated with a greater risk of malpractice claim.

CONCLUSIONS

From 1987 to 2015, the proportion of pediatricians sued has decreased and median indemnity has remained unchanged. Male pediatricians and hospital-based subspecialists were more likely to have been sued. Greater knowledge of the epidemiology of malpractice claims against pediatricians is valuable because it can impact practice arrangements, advise risk-management decisions, influence quality and safety projects, and provide data to guide advocacy for appropriate tort reform and future research.

Engagement, not personal characteristics, was associated with the seriousness of regulatory adjudication decisions about physicians: a cross-sectional study

BACKGROUND

Outcomes of processes questioning a physician's ability to practise -e.g. disciplinary or regulatory- may strongly impact their career and provided care. However, it is unclear what factors relate systematically to such outcomes.

METHODS

In this cross-sectional study, we investigate this via multivariate, step-wise, statistical modelling of all 1049 physicians referred for regulatory adjudication at the UK medical tribunal, from June 2012 to May 2017, within a population of 310,659. In order of increasing seriousness, outcomes were: no impairment (of ability to practise), impairment, suspension (of right to practise), or erasure (its loss). This gave adjusted odds ratios (OR) for: age, race, sex, whether physicians first qualified domestically or internationally, area of practice (e.g. GP, specialist), source of initial referral, allegation type, whether physicians attended their outcome hearing, and whether they were legally represented for it.

RESULTS

There was no systematic association between the seriousness of outcomes and the age, race, sex, domestic/international qualification, or the area of practice of physicians (ORs p≥0.05), except for specialists who tended to receive outcomes milder than suspension or erasure. Crucially, an apparent relationship of outcomes to age (Kruskal-Wallis, p=0.009) or domestic/international qualification (χ²,p=0.014) disappeared once controlling for hearing attendance (ORs p≥0.05). Both non-attendance and lack of legal representation were consistently related to more serious outcomes (ORs [95% confidence intervals], 5.28 [3.89, 7.18] and 1.87 [1.34, 2.60], respectively, p<0.001).

CONCLUSIONS

All else equal, personal characteristics or first qualification place were unrelated to the seriousness of regulatory outcomes in the UK. Instead, engagement (attendance and legal representation), allegation type, and referral source were importantly associated to outcomes. All this may generalize to other countries and professions.

Physician Workforce Disparities and Patient Care: A Narrative Review

Background: Ensuring the strength of the physician workforce is essential to optimizing patient care. Challenges that undermine the profession include inequities in advancement, high levels of burnout, reduced career duration, and elevated risk for mental health problems, including suicide. This narrative review explores whether physicians within four subpopulations represented in the workforce at levels lower than predicted from their numbers in the general population—women, racial and ethnic minorities in medicine, sexual and gender minorities, and people with disabilities—are at elevated risk for these problems, and if present, how these problems might be addressed to support patient care. In essence, the underlying question this narrative review explores is as follows: Do physician workforce disparities affect patient care? While numerous articles and high-profile reports have examined the relationship between workforce diversity and patient care, to our knowledge, this is the first review to examine the important relationship between diversity-related workforce disparities and patient care.

Methods: Five databases (PubMed, the Cochrane Library of Systematic Reviews, EMBASE, Web of Knowledge, and EBSCO Discovery Service) were searched by a librarian. Additional resources were included by authors, as deemed relevant to the investigation.

Results: The initial database searches identified 440 potentially relevant articles. Articles were categorized according to subtopics, including (1) underrepresented physicians and support for vulnerable patient populations; (2) factors that could exacerbate the projected physician deficit; (3) methods of addressing disparities among underrepresented physicians to support patient care; or (4) excluded (n=155). The authors identified another 220 potentially relevant articles. Of 505 potentially relevant articles, 199 (39.4%) were included in this review.

Conclusions: This report demonstrates an important gap in the literature regarding the impact of physician workforce disparities and their effect on patient care. This is a critical public health issue and should be urgently addressed in future research and considered in clinical practice and policy decision-making.

A focused mapping review and synthesis of a priori risk factors associated with medical misconduct

Background

Medical misconduct is an international problem. It is judged according to whether a doctor has endangered the health of the public. Little is known about the risk factors associated with medical misconduct. To inform patient safety, we undertook a focused mapping review and synthesis (FMRS) of tribunal reports retrieved from the Medical Practitioners Tribunal Service (MPTS).

Methods

A four-phase FMRS was undertaken: (1) identification and retrieval of 1-year tribunal transcripts from the MPTS (focus), (2) analysis of transcripts to identify patterns mapped to 'a priori' risk factors (mapping), (3) peer review of the data (calibration) and (4) creation of a risk profile (synthesis).

Results

Out of the 351 investigative tribunals, 249 (70.94%) resulted in a guilty verdict. 82.73% of all guilty verdicts led to the removal of the doctor from practice. Through the identification of four a priori risk factors, we developed a model of risk associated with medical misconduct: (1) being male, (2) primary medical qualification (PMQ) outside of the UK, (3) working within general practice and surgical specialties, and (4) having passed PMQ more than 20 years ago. Notable 'unconfirmed' factors, such as locum work, PMQ achieved outside of the European Union, increasing age and lack of clinical guidance are also relevant to what is deemed professional behaviour and what is not.

Conclusions

The findings can inform debates about patient safety and lay the groundwork for further research into medical misconduct. Prospective studies should focus on confirming the contributory factors and relationship between these four a priori risk factors for medical misconduct: being male, PMQ outside of the UK, increasing age and working in general practice or surgical settings.

Characteristics of Medical Liability Claims Against Dermatologists From 1991 Through 2015

Importance

Recognizing malpractice trends in the field of dermatology is important for establishing safeguards for patient care and minimizing liability. However, there is a lack of published data on malpractice claims against dermatologists.

Objective

To determine characteristics of medical professional liability claims in the field of dermatology and to compare these claims with those against all physicians.

Design, Setting, and Participants

We examined malpractice liability data collected on dermatologists and other physicians insured by companies that report data to the Physician Insurers Association of America Data Sharing Project (PIAA-DSP), a nationally representative liability claims registry. Data analyzed spanned the years 1991 through 2015.

Main Outcomes and Measures

Demographic characteristics of dermatologists subject to claims, characteristics of closed claims, medical errors associated with closed claims, and patient outcomes leading to closed claims.

Results

Data on a total of 90 743 closed claims were analyzed, 1084 (1.2%) against dermatologists and 89 659 (98.8%) against nondermatologists. More lawsuits were brought against male (n = 753, 69.5%) than female dermatologists (n = 270, 24.9%); 5.6% of claims (n = 61) did not identify the physician's sex. Full-time practitioners (n = 1035, 95.5%) and those in solo practice (n = 600, 55.4%) were more likely to be sued than those in group practices (n = 429, 39.6%) and institutions (n = 31, 2.9%). Most claims against dermatologists were abandoned, withdrawn, or dismissed (n = 735, 67.8%). Between 2006 and 2015, trial verdicts favoring defendants exceeded trial verdicts favoring plaintiffs by a factor of 7. Errors that occurred during a procedure spawned the most claims (n = 305), of which 102 were paid. Misdiagnoses comprised the second-highest number of claims (n = 192), of which 62 were paid. The average recovery per claim was $238 145. The most common procedure leading to claims was skin operations (420 claims, of which 130 were paid). The most common adverse patient outcome associated with claims was dyschromia, resulting in 171 claims, of which 40 were paid.

Conclusions and Relevance

Male dermatologists were sued more often than female dermatologists. Overall, alleged errors in procedures and misdiagnosis gave rise to the most lawsuits. Dyschromia was the most common adverse outcome alleged in lawsuits.

Changes in Practice among Physicians with Malpractice Claims

BACKGROUND

Physicians with poor malpractice liability records may pose a risk to patient safety. There are long-standing concerns that such physicians tend to relocate for a fresh start, but little is known about whether, how, and where they continue to practice.

METHODS

We linked an extract of the National Practitioner Data Bank to the Medicare Data on Provider Practice and Specialty data set to create a national cohort of physicians 35 to 65 years of age who practiced during the period from 2008 through 2015. We analyzed associations between the number of paid malpractice claims that physicians accrued and exits from medical practice, changes in clinical volume, geographic relocation, and change in practice-group size.

RESULTS

The cohort consisted of 480,894 physicians who had 68,956 paid claims from 2003 through 2015. A total of 89.0% of the physicians had no claims, 8.8% had 1 claim, and the remaining 2.3% had 2 or more claims and accounted for 38.9% of all claims. The number of claims was positively associated with the odds of leaving the practice of medicine (odds ratio for 1 claim vs. no claims, 1.09; 95% confidence interval [CI], 1.06 to 1.11; odds ratio for ≥5 claims, 1.45; 95% CI, 1.20 to 1.74). The number of claims was not associated with geographic relocation but was positively associated with shifts into smaller practice settings. For example, physicians with 5 or more claims had more than twice the odds of moving into solo practice than physicians with no claims (odds ratio, 2.39; 95% CI, 1.79 to 3.20).

CONCLUSIONS

Physicians with multiple malpractice claims were no more likely to relocate geographically than those with no claims, but they were more likely to stop practicing medicine or switch to smaller practice settings. (Funded by SUMIT Insurance and the Australian Research Council.).

Effect of sex on specialty training application outcomes: a longitudinal administrative data study of UK medical graduates

OBJECTIVES

To examine sex differences in the specialty training recruitment outcomes of UK medical graduates; and whether sex differences were explained by prior academic attainment and previous fitness to practise (FtP) declarations.

DESIGN

Retrospective longitudinal cohort study.

SETTING

Administrative data on entrants to all UK medical schools from the UK Medical Education Database.

PARTICIPANTS

10 559 doctors (6 155; 58% female) who entered a UK medical school in 2007 or 2008 and were eligible to apply for specialty training by 2015.

PRIMARY OUTCOME MEASURE

Odds of application, offer and acceptance to any specialty training programme, and on to each of the nine largest training programmes, adjusting for sex, other demographics, prior academic attainment, FtP declaration and medical school.

RESULTS

Across all specialties, there were no sex differences in applications for specialty training, but women had increased odds of getting an offer (OR=1.40; 95% CI=1.25 to 1.57; p<0.001) and accepting one (OR=1.43; 95% CI=1.19 to 1.71; p<0.001). Seven of the nine largest specialties showed significant sex differences in applications, which remained after adjusting for other factors. In the adjusted models, Paediatrics (OR=1.57; 95% CI=1.01 to 2.46; p=0.046) and general practice (GP) (OR=1.23; 95% CI=1.03 to 1.46; p=0.017) were the only specialties to show sex differences in offers, both favouring women. GP alone showed sex differences in acceptances, with women being more likely to accept (OR=1.34; 95% CI=1.03 to 1.76; p=0.03). Doctors with an FtP declaration were slightly less likely to apply to specialty training overall (OR=0.84; 95% CI=0.71 to 1.00; p=0.048) and less likely to accept an offer to any programme (OR=0.71; 95% CI=0.52 to 0.98; p=0.036), after adjusting for confounders.

CONCLUSIONS

Sex segregation between medical specialties is due to differential application, although research is needed to understand why men are less likely to be offered a place on to GP and Paediatrics training, and if offered GP are less likely to accept.

Will I lose my license for that? A closer look at Canadian disciplinary hearings and what it means for pharmacists' practice to full scope

Objective

Concerns about liability from clinical errors have been cited as a barrier preventing greater adoption of practice change. Our objective was to determine the most common actions or omissions that result in disciplinary action for pharmacists and the restrictive actions imposed.

Methods

Canadian disciplinary reports were reviewed. Cases were coded as charges of professional misconduct, unskilled practice or dishonest business practices.

Results

There were 558 disciplinary cases from 10 provinces that occurred between January 2010 and July 2017. Professional misconduct charges commonly involved stealing/diverting or inappropriately dispensing narcotic drugs, pharmacy supervision/premises charges and refusing to cooperate with the college. Charges of unskilled practice included dispensing the wrong drug, failing to assess the appropriateness of a drug order, providing the wrong dose and failing to counsel. Fraudulent billing practices and accepting rebates from generic drug companies were the most common dishonest business practices. Professional misconduct, unskilled practice and dishonest business practice charges were involved in 342 (61%), 169 (30%) and 191 (34%) cases, respectively. Most cases occurred in community pharmacies and were not caused by an isolated clinical error. Fines were the most common penalty, followed by temporary license suspensions, professional development and reprimands. License revocations were the least common (4%), often involving professional misconduct.

Conclusion

This review suggests that disciplinary action against a pharmacist for an isolated, unintentional clinical error is uncommon and that losing a license is rare. Fear of disciplinary action should not be a barrier to practice change or the provision of full-scope patient care services.

Gendered Expectations: Do They Contribute to High Burnout Among Female Physicians?

Patients have differing expectations of female versus male physicians. Female patients tend to seek more empathic listening and longer visits, especially with female physicians; however, female doctors are not provided more time for this. Female doctors have more female patients than male doctors, and more patients with psychosocial complexity. We propose that gender differences in patient panels and gendered expectations of female physicians may contribute to the high rate of burnout among female clinicians, as well as to the many female physicians working part-time to reduce stress in their work lives. We propose several mechanisms for addressing this, including brief increments in visit time (20, 30 and 40 min), staff awareness, training in patient expectations during medical school, adjusting for patient gender in compensation plans, and co-locating behavioral medicine specialists in primary care settings. Beneficial outcomes could include fewer malpractice suits, greater patient satisfaction, higher quality care, and lower burnout among female physicians.

Passing MRCP (UK) PACES: a cross-sectional study examining the performance of doctors by sex and country

BACKGROUND

There is much discussion about the sex differences that exist in medical education. Research from the United Kingdom (UK) and United States has found female doctors earn less, and are less likely to be senior authors on academic papers, but female doctors are also less likely to be sanctioned, and have been found to perform better academically and clinically. It is also known that international medical graduates tend to perform more poorly academically compared to home-trained graduates in the UK, US, and Canada. It is uncertain whether the magnitude and direction of sex differences in doctors' performance is variable by country. We explored the association between doctors' sex and their performance at a large international high-stakes clinical examination: the Membership of the Royal Colleges of Physicians (UK) Practical Assessment of Clinical Examination Skills (PACES). We examined how sex differences varied by the country in which the doctor received their primary medical qualification, the country in which they took the PACES examination, and by the country in which they are registered to practise.

METHODS

Seven thousand six hundred seventy-one doctors attempted PACES between October 2010 and May 2013. We analysed sex differences in first time pass rates, controlling for ethnicity, in three groups: (i) UK medical graduates (N = 3574); (ii) non-UK medical graduates registered with the UK medical regulator, the General Medical Council (GMC), and thus likely to be working in the UK (N = 1067); and (iii) non-UK medical graduates without GMC registration and so legally unable to work or train in the UK (N = 2179).

RESULTS

Female doctors were statistically significantly more likely to pass at their first attempt in all three groups, with the greatest sex effect seen in non-UK medical graduates without GMC registration (OR = 1.99; 95% CI = 1.65-2.39; P < 0.0001) and the smallest in the UK graduates (OR = 1.18; 95% CI = 1.03-1.35; P = 0.02).

CONCLUSIONS

As found in a previous format of this examination and in other clinical examinations, female doctors outperformed male doctors. Further work is required to explore why sex differences were greater in non-UK graduates, especially those without GMC registration, and to consider how examination performance may relate to performance in practice.

Predictors of fitness to practise declarations in UK medical undergraduates

BACKGROUND

Misconduct during medical school predicts subsequent fitness to practise (FtP) events in doctors, but relatively little is known about which factors are associated with such issues during undergraduate education. This study exploits the newly created UK medical education database (UKMED), with the aim of identifying predictors of conduct or health-related issues that could potentially impair FtP. The findings would have implications for policies related to both the selection and support of medical students.

METHODS

Data were available for 14,379 students obtaining provisional registration with the General Medical Council who started medical school in 2007 and 2008. FtP declarations made by students were available, as were various educational and demographic predictor variables, including self-report 'personality measures' for students who participated in UK Clinical Aptitude Test (UKCAT) pilot studies. Univariable and multivariable logistic regression models were developed to evaluate the predictors of FtP declarations.

RESULTS

Significant univariable predictors (p < 0.05) for conduct-related declarations included male gender, white ethnicity and a non-professional parental background. Male gender (OR 3.07) and higher 'self-esteem' (OR 1.45) were independently associated with an increased risk of a conduct issue. Female gender, a non-professional background, and lower self-reported 'confidence' were, among others, associated with increased odds of a health-related declaration. Only 'confidence' was a significant independent predictor of a health declaration (OR 0.69). Female gender, higher UKCAT score, a non-professional background and lower 'confidence' scores were significant predictors of reported depression, and the latter two variables were independent predictors of declared depression.

CONCLUSIONS

White ethnicity and UK nationality were associated with increased odds of both conduct and health-related declarations, as were certain personality traits. Students from non-professional backgrounds may be at increased risk of depression and therefore could benefit from targeted support. The small effect sizes observed for the 'personality measures' suggest they would offer little potential benefit for selection, over and above those measures already in use.

Perception of Resources Spent on Defensive Medicine and History of Being Sued Among Hospitalists: Results from a National Survey

The United States spends substantially more per capita for healthcare than any other nation. Defensive medicine is 1 source of such spending, but its extent is unclear. Using a national survey of approximately 1500 US hospitalists, we report the estimates the US hospitalists provided of the percent of resources spent on defensive medicine and correlates of their estimates. We also ascertained how many reported being sued. Sixty-eight percent of eligible recipients responded. Overall, respondents estimated that 37.5% of healthcare costs are due to defensive medicine. Just over 25% of our respondents, including 55% of those in practice for 20 years or more, reported being sued for medical malpractice. Veterans Affairs (VA) hospital affiliation, more years practicing as a physician, being male, and being a non-Hispanic white individual were all independently associated with decreased estimates of resources spent for defensive medicine.

Exploring the Relationships Between USMLE Performance and Disciplinary Action in Practice: A Validity Study of Score Inferences From a Licensure Examination

PURPOSE

Physicians must pass the United States Medical Licensing Examination (USMLE) to obtain an unrestricted license to practice allopathic medicine in the United States. Little is known, however, about how well USMLE performance relates to physician behavior in practice, particularly conduct inconsistent with safe, effective patient care. The authors examined the extent to which USMLE scores relate to the odds of receiving a disciplinary action from a U.S. state medical board.

METHOD

Controlling for multiple factors, the authors used non-nested multilevel logistic regression analyses to estimate the relationships between scores and receiving an action. The sample included 164,725 physicians who graduated from U.S. MD-granting medical schools between 1994 and 2006.

RESULTS

Physicians had a mean Step 1 score of 214 (standard deviation [SD] = 21) and a mean Step 2 Clinical Knowledge (CK) score of 213 (SD = 23). Of the physicians, 2,205 (1.3%) received at least one action. Physicians with higher Step 2 CK scores had lower odds of receiving an action. A 1-SD increase in Step 2 CK scores corresponded to a decrease in the chance of disciplinary action by roughly 25% (odds ratio = 0.75; 95% CI = 0.70-0.80). After accounting for Step 2 CK scores, Step 1 scores were unrelated to the odds of receiving an action.

CONCLUSIONS

USMLE Step 2 CK scores provide useful information about the odds a physician will receive an official sanction for problematic practice behavior. These results provide validity evidence supporting current interpretation and use of Step 2 CK scores.

Prevalence of GMC performance assessments in the United Kingdom: a retrospective cohort analysis by country of medical qualification

BACKGROUND

The demographics of doctors working in the UK are changing. The United Kingdom (UK) has voted to leave the European Union (EU) and there is heightened political discourse around the world about the impact of migration on healthcare services. Previous work suggests that foreign trained doctors perform worse than UK graduates in postgraduate medical examinations. We analysed the prevalence by country of primary medical qualification of doctors who were required to take an assessment by the General Medical Council (GMC) because of performance concerns.

METHODS

This was a retrospective cohort analysis of data routinely collected by the GMC. We compared doctors who had a GMC performance assessment between 1996 and 2013 with the medical register in the same period. The outcome measures were numbers experiencing performance assessments by country or region of medical qualification.

RESULTS

The rate of performance assessment varied significantly by place of medical qualification and by year; χ ²(17) = 188, p < 0.0001, pseudo-R² = 15%. Doctors who trained outside of the UK, including those trained in the European Economic Area (EEA), were more likely to have a performance assessment than UK trained doctors, with the exception of South African trained doctors.

CONCLUSIONS

The rate of performance assessment varies significantly by place of medical qualification. This is the first study to explore the risk of performance assessment by individual places of medical qualification. While concern has largely focused on the competence of non-EEA, International Medical Graduates, we discuss implications for how to ensure European trained doctors are fit to practise before their medical licence in the UK is granted. Further research is needed to investigate whether these country effects hold true when controlling for factors like doctors' sex, age, length of time working in the UK, and English language skills. This will allow evidence-based decisions to be made around the regulatory environment the UK should adopt once it leaves the EU. Patients should be reassured that the vast majority of all doctors working in the UK are competent.

Cross-sectional survey on defensive practices and defensive behaviours among Israeli psychiatrists

OBJECTIVE

Psychiatry is a low-risk specialisation; however, there is a steady increase in malpractice claims against psychiatrists. Defensive psychiatry (DP) refers to any action undertaken by a psychiatrist to avoid malpractice liability that is not for the sole benefit of the patient's mental health and well-being. The objectives of this study were to assess the scope of DP practised by psychiatrists and to understand whether awareness of DP correlated with defensive behaviours.

METHODS

A questionnaire was administered to 213 Israeli psychiatry residents and certified psychiatrists during May and June 2015 regarding demographic data and experience with malpractice claims, medicolegal literature and litigation. Four clinical scenarios represented defensive behaviours and reactions (feelings and actions) to malpractice claims.

RESULTS

Forty-four (20.6%) certified psychiatrists and four (1.9%) residents were directly involved in malpractice claims, while 132 (62.1%) participants admitted to practising DP. Residents acknowledged the practice of DP more than did senior psychiatrists (p=0.038).Awareness of DP correlated with unnecessary hospitalisation of suicidal patients, increased unnecessary follow-up visits and prescribing smaller drug dosages than required for pregnant women and elderly patients.

CONCLUSIONS

This study provides evidence that DP is well established in the routine clinical daily practice of psychiatrists. Further studies are needed to reveal whether DP effectively protects psychiatrists from malpractice suits or, rather, if it impedes providing quality psychiatric care and represents an economic burden that leads to more harm for the patient.

Predicting fitness to practise events in international medical graduates who registered as UK doctors via the Professional and Linguistic Assessments Board (PLAB) system: a national cohort study

BACKGROUND

International medical graduates working in the UK are more likely to be censured in relation to fitness to practise compared to home graduates. Performance on the General Medical Council's (GMC's) Professional and Linguistic Assessments Board (PLAB) tests and English fluency have previously been shown to predict later educational performance in this group of doctors. It is unknown whether the PLAB system is also a valid predictor of unprofessional behaviour and malpractice. The findings would have implications for regulatory policy.

METHODS

This was an observational study linking data relating to fitness to practise events (referral or censure), PLAB performance, demographic variables and English language competence, as evaluated via the International English Language Test System (IELTS). Data from 27,330 international medical graduates registered with the GMC were analysed, including 210 doctors who had been sanctioned in relation to at least one fitness to practise issue. The main outcome was risk of eventual censure (including a warning).

RESULTS

The significant univariable educational predictors of eventual censure (versus no censures or referrals) were lower PLAB part 1 (hazard ratio [HR], 0.99; 95% confidence interval, 0.98 to 1.00) and part 2 scores (HR, 0.94; 0.91 to 0.97) at first sitting, multiple attempts at both parts of the PLAB, lower IELTS reading (HR, 0.79; 0.65 to 0.94) and listening scores (HR, 0.76; 0.62 to 0.93) and higher IELTS speaking scores (HR, 1.28; 1.04 to 1.57). Multiple resits at either part of the PLAB and higher IELTS speaking score (HR, 1.49; 1.20 to 1.84) were also independent predictors of censure. We estimated that the proposed limit of four attempts at both parts of the PLAB would reduce the risk in this entire group by only approximately two censures per 5 years in this group of doctors.

CONCLUSIONS

Making the PLAB, or any replacement assessment, more stringent and raising the required standards of English reading and listening may result in fewer fitness to practice events in international medical graduates. However, the number of PLAB resits permitted would have to be further capped to meaningfully impact the risk of sanctions in this group of doctors.

Outcomes of notifications to health practitioner boards: a retrospective cohort study

BACKGROUND

Medical boards and other practitioner boards aim to protect the public from unsafe practice. Previous research has examined disciplinary actions against doctors, but other professions (e.g., nurses and midwives, dentists, psychologists, pharmacists) remain understudied. We sought to describe the outcomes of notifications of concern regarding the health, performance, and conduct of health practitioners from ten professions in Australia and to identify factors associated with the imposition of restrictive actions.

METHODS

We conducted a retrospective cohort study of all notifications lodged with the Australian Health Practitioner Regulation Agency over 24 months. Notifications were followed for 30-54 months. Our main outcome was restrictive actions, defined as decisions that imposed undertakings, conditions, or suspension or cancellation of registration.

RESULTS

There were 8307 notifications. The notification rate was highest among doctors (IR = 29.0 per 1000 practitioner years) and dentists (IR = 41.4) and lowest among nurses and midwives (IR = 4.1). One in ten notifications resulted in restrictive action; fewer than one in 300 notifications resulted in suspension or cancellation of registration. Compared with notifications about clinical care, the odds of restrictive action were higher for notifications relating to health impairments (drug misuse, OR = 7.0; alcohol misuse, OR = 4.6; mental illness, OR = 4.1, physical or cognitive illness, OR = 3.7), unlawful prescribing or use of medications (OR = 2.1) and violation of sexual boundaries (OR = 1.7). The odds were higher where the report was made by another health practitioner (OR = 2.9) or employer (OR = 6.9) rather than a patient or relative. Nurses and midwives (OR = 1.8), psychologists (OR = 4.5), dentists (OR = 4.7), and other health practitioners (OR = 5.3) all had greater odds of being subject to restrictive actions than doctors.

CONCLUSIONS

Restrictive actions are the strongest measures health practitioner boards can take to protect the public from harm and these actions can have profound effects on the livelihood, reputations and well-being of practitioners. In Australia, restrictive actions are rarely imposed and there is variation in their use depending on the source of the notification, the type of issue involved, and the profession of the practitioner.

Prevalence and Characteristics of Physicians Prone to Malpractice Claims

BACKGROUND

The distribution of malpractice claims among physicians is not well understood. If claim-prone physicians account for a substantial share of all claims, the ability to reliably identify them at an early stage could guide efforts to improve care.

METHODS

Using data from the National Practitioner Data Bank, we analyzed 66,426 claims paid against 54,099 physicians from 2005 through 2014. We calculated concentrations of claims among physicians. We used multivariable recurrent-event survival analysis to identify characteristics of physicians at high risk for recurrent claims and to quantify risk levels over time.

RESULTS

Approximately 1% of all physicians accounted for 32% of paid claims. Among physicians with paid claims, 84% incurred only one during the study period (accounting for 68% of all paid claims), 16% had at least two paid claims (accounting for 32% of the claims), and 4% had at least three paid claims (accounting for 12% of the claims). In adjusted analyses, the risk of recurrence increased with the number of previous paid claims. For example, as compared with physicians who had one previous paid claim, the 2160 physicians who had three paid claims had three times the risk of incurring another (hazard ratio, 3.11; 95% confidence interval [CI], 2.84 to 3.41); this corresponded in absolute terms to a 24% chance (95% CI, 22 to 26) of another paid claim within 2 years. Risks of recurrence also varied widely according to specialty--for example, the risk among neurosurgeons was four times as great as the risk among psychiatrists.

CONCLUSIONS

Over a recent 10-year period, a small number of physicians with distinctive characteristics accounted for a disproportionately large number of paid malpractice claims.