Original contribution
Malpractice occurrence in Emergency Medicine: Does residency training make a difference?1

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Abstract

We evaluated the effects of Emergency Medicine (EM) residency training, EM board certification, and physician experience on the occurrence of malpractice claims and indemnity payments. This was a retrospective review of closed malpractice claims from a single insurer. Outcome measures included the occurrence of claims resulting in indemnity, indemnity amounts, and defense costs. Differences in the outcome measures were compared based on: EM residency training, EM board certification, EM residency training versus other residency training, and physician experience using both univariate and multivariate analyses. There were 428 closed EM claims with indemnity paid in 81 (18.9%). Indemnity was paid in 22.4% of closed claims against non-EM residency-trained physicians, and in only 13.3% against EM residency-trained physicians (p = 0.04). The total indemnity was $6,214,475. Non-EM trained physicians accounted for $4,440,951 (71.5%), EM residency-trained physicians accounted for $1,773,524 (28.5%). The average indemnity was $76,721 and the average defense cost was $17,775. There were no significant differences in the mean indemnity paid per closed claim or the mean cost to defend a closed claim when comparing EM-trained and non-EM residency-trained physicians. The total cost (indemnity + defense costs) per physician-year of malpractice coverage was $4,905 for non-EM residency-trained physicians and $2,212 for EM residency-trained physicians. EM residency-trained physicians account for significantly less malpractice indemnity than non-EM residency-trained physicians. This difference is not due to differences in the average indemnity but is due to significantly fewer closed claims against EM residency-trained physicians with indemnity paid. This results in a cost per physician-year of malpractice coverage for non-EM residency-trained physicians that is over twice that of EM residency-trained physicians.

Introduction

Few medical specialties allow for the analysis of outcome measures based on differences in the medical practitioner’s training. Emergency Medicine (EM) provides a unique opportunity to perform this type of analysis. As the youngest recognized medical specialty, first recognized by the American Board of Medical Specialties in 1979, EM has a large percentage of practitioners who did not train in the specialty. In addition, when compared to other more established specialties, a larger percentage of EM practitioners are not board certified in the specialty and many of those who are board certified obtained board certification via the practice track eligibility criteria rather than via traditional residency training. In recent years, EM has undergone substantial growth, with a significant increase in the number of EM residency programs and in the number of medical school applicants choosing the specialty.

This heterogeneity in training and board certification of practitioners within the specialty of Emergency Medicine permits an opportunity to analyze the effects of residency training. This would be nearly impossible to perform in any of the other long established medical specialties where virtually all practicing physicians have received residency training within their specialty.

One outcome measure for which data may be obtained is closed malpractice claims against emergency physicians. Previous studies have looked at malpractice in EM, but always from the standpoint of identifying particular complaints or medical diagnoses that are particularly high risk to result in a claim 1, 2, 3, 4, 5, 6, 7. No study to date has focused on the relationship between malpractice claims and physician characteristics such as residency training or board certification.

COPIC Insurance, the largest insurer of physicians in the state of Colorado, insuring approximately 70% of all physicians in the state, granted access to closed EM malpractice claims data. We used these closed claims against emergency physicians to ask the following questions:

  • 1.

    Are there differences in the occurrence of closed malpractice claims resulting in indemnity when comparing EM residency-trained physicians to other physicians?

  • 2.

    Are there differences in the occurrence of closed malpractice claims resulting in indemnity when comparing physicians board certified in EM to non-certified physicians?

  • 3.

    Are there differences in the occurrence of closed malpractice claims resulting in indemnity when comparing EM residency-trained physicians to physicians with residency training in another specialty?

  • 4.

    Is the occurrence of closed malpractice claims resulting in indemnity a function of physician experience?

Section snippets

Materials and methods

All closed Emergency Medicine malpractice claims from July 1, 1982 when COPIC first began insuring physicians, through November 30, 1997 were reviewed and entered into a database utilizing a standardized data collection form. Closed malpractice claims were defined as all claims for which the insurer had opened a claim file that was then resolved and closed. Costs and indemnity were reported as they were noted in the closed claim form. General demographic information, medical education, and

Results

For the period July 1, 1982 through November 30, 1997, there were 428 closed claims against 218 COPIC-insured emergency physicians (see Table 1). Of the 428 closed claims, 263 (61.4%, 95% CI 55.6–67.2%) were filed against non-EM-trained physicians and 165 (38.6%, 95% CI 32.3–45.9%) were filed against EM residency-trained physicians. As can be seen in Table 1, 54% of EM physicians had only one closed claim, 86% had 3 or fewer closed claims. There was no difference between EM residency-trained

Discussion

As the youngest of the recognized medical specialties, Emergency Medicine provides a unique opportunity to evaluate differences in outcome measures based on differences in the training of the practicing physician. No other specialty has the diversity of backgrounds, training, and certification seen in EM today. Nationwide, it is estimated that 42% of emergency physicians have neither residency training in the specialty nor board certification (8). This heterogeneity permits us to ask the

Acknowledgements

The authors would like to acknowledge Anna Baron, PhD and Howard Shapiro, PhD, for their assistance with statistical analysis.

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1

Original Contributions is coordinated by John A. Marx, MD, of Carolinas Medical Center, Charlotte, North Carolina

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