July 26, 2012 – Sometimes, when things go badly between patients and doctors—wrong diagnoses, ineffective treatments, medication problems, surgical complications—legal disputes follow. But epidemiologist David Studdert, who spoke at Harvard School of Public Health (HSPH) on July 3, 2012, hopes that new research from his team at the University of Melbourne in Australia can help predict which doctors are most likely to face this sort of trouble—and therefore help prevent it from occurring in the first place.
Studdert is an adjunct professor of law and public health at HSPH and has a joint appointment as a professor at the Melbourne Law School and the Melbourne School of Population Health. Much of his research focuses on medical liability issues.
Analyzing data collected on all doctors in Australia between 2000 and 2011—about 72,000—Studdert and his colleagues found that most patient complaints were about quality of care—treatment, diagnosis, medication, or other clinical care. A few doctors typically get the most complaints; Studdert calls them “frequent flyers.” Most of the complaints (47%) were against general practitioners, who make up more than half of all doctors in Australia; 14% were against surgeons. Among specialists, plastic surgeons received the most complaints, followed by dermatologists, then obstetricians/gynecologists.
Studdert said that when he reported his findings to the Australian health boards and commissions that handle patient complaints, they were “stunned” that most were against particular doctors and specialties. They’d been only generally aware of which doctors faced the most complaints. Studdert noted that, until now, there’s been no reliable, population-wide method to predict which doctors are most likely to face future complaints. Rather, the system is focused on handling such issues only after they occur, by either providing patients with financial compensation or formal apologies.
With regards to prevention, Studdert said the current approach is “scattershot.” There are occasional training or review sessions aimed at helping doctors avoid legal issues, he said, but their effectiveness is unclear. As one British liability insurer recently told him, “When we put on these activities, we always feel like we have the wrong people in the room. The guys we really want? Either they won’t come, or, if you make them come, they sit there and do their email.”
A predictive, preventive tool
A better solution, said Studdert, would be to prevent problems before they occur. “If you could figure out ahead of time who the high-risk practitioners are, it should open up the way for interventions that help them stay out of trouble, and help patients avoid these unhappy episodes,” Studdert said.
To help predict individual doctors’ risks of facing formal complaints, Studdert’s team is in the process of developing a scoring system called PRONE (PRobability of New Events). The prediction tool is based on several factors, including a doctor’s age, gender, and specialty, as well as the number or type of prior complaints against him or her in the previous six-month period. Studdert noted that a doctor’s PRONE score should be recalculated every six months to account for changes in data that might affect the score.
Using the new scoring system to predict future risk of patient complaints, Studdert and his colleagues estimate that male doctors would have a 40% percent higher risk than female doctors, and older doctors would have a 30%-40% higher risk than younger ones. They also predict that the greater the number of prior complaints a doctor has, the greater are his or her chances of having future complaints—and the risk rises exponentially with each additional prior complaint.
Based on a doctor’s PRONE score, various interventions could be implemented, Studdert said. For example, a doctor with a low PRONE score might be sent a letter warning him or her of the potential risk of complaints. A doctor with a middle-range PRONE score might be urged to take continuing medical education courses. A high PRONE score might require that a doctor be referred to a medical regulator for further action.
“Selling” prevention to medical regulators
Studdert admitted that it’s not an easy sell to convince regulators to focus on prevention. “The legal culture focuses on individuals and single events, while the public health culture looks at systems, prevention, and patterns,” he noted. He said he does hope, however, that those who handle patient complaints come to realize that his team has found a powerful method for predicting doctors’ future risk of patient complaints—and that this method could help them develop interventions that could reduce the number of complaints and boost patient satisfaction.