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Malpractice threatens doctor-patient bond

Health-care professionals are expressing growing concern that the nation's rising malpractice insurance costs and the constant threat of legal action are damaging the quality of medical care and the integrity of the doctor-patient relationship.

"Small communities are losing doctors right and left, so this increase in premiums is very significant," said Peter Kussin, associate professor of pulmonary medicine at the Medical Center. "It definitely threatens care."

Peter Smith, chief of thoracic surgery at the Medical Center, explained that many doctors are left with few choices. "Insurance premiums are either astronomically high or unavailable for certain specialties," he said. "When the insurance costs are more than you earn, there's not much to do.... It's a substantial tragedy that's going on in America."

However, physicians say the effects run far deeper than more limited access to health care--subtle, troubling changes are creeping into the doctor-patient relationship.

Smith explained that many doctors are now practicing "defensive medicine," ordering unnecessary and expensive tests--the costs for which are often passed on to patients--to minimize their liability in potential malpractice suits.

"The situation starts getting physicians to look at their practices from an economic perspective," said Robert Seligson, chief executive officer of the North Carolina Medical Society, the state branch of the American Medical Association. "The trend is to order more tests, to be more cautious. [Doctors] recognize they're operating in a more litigious environment."

Because malpractice insurance normally increases following a lawsuit, doctors are becoming more hesitant to treat difficult cases, Smith said. "[Malpractice costs] have the potential to cause physicians to pause before offering medical services to high-risk patients. Any adverse outcome has the potential to turn into a malpractice suit," he said. "It's like car insurance��if rates are rising, you'll do anything to avoid an accident."

This hesitance often translates into doctor shortages in emergency rooms and trauma wards, Seligson said. He also explained that malpractice costs put more financial pressures on hospitals.

"[Hospitals] can't afford these excessive [malpractice] awards," he said. "It only takes one or two of them before they're in serious jeopardy."

Rises in insurance costs are also particularly affecting the poor and elderly, Smith said. Reimbursements given to doctors for treating Medicare and Medicaid recipients include a portion for malpractice insurance, but the compensation is not keeping pace with the insurance premium cost, he explained. As a result, doctors are becoming less willing to treat those patients.

It is also inevitable that rising malpractice insurance will drive up medical costs, because many doctors will simply resort to passing on the price increases to patients, Seligson said. And because costs for medical treatment are normally included in malpractice settlements, the price increases will only fuel higher insurance premiums, creating a vicious cycle.

In addition, the malpractice crisis is occurring at a time of already rapidly increasing medical costs.

"[Insurance increases are] coming at a time when hospital costs for several other items are going up: blood, drugs, labor, technology, regulatory compliance with federal laws, plus the cost of treating the uninsured," said Don Dalton, a spokesperson for the North Carolina Hospital Association.

Although Duke University Health System officials said they will not be curtailing any services or deliberately changing their approach to patients, malpractice's increasing financial impact is a concern for Duke physicians and officials.

"The effect [of malpractice costs] has really been in making it harder to support the research and educational missions we have," Smith said. "If our insurance costs continue to rise, everything else suffers. Clearly it's taking money away from more valuable services."

Rising malpractice concerns do not seem to be affecting the choices of medical school students, however. "Although students are aware of liability issues, they don't seem to be including this in their specialty decision in a conscious way," said Caroline Haynes, director of student affairs at the School of Medicine.

Because DUHS maintains its own insurance company, its reaction to malpractice costs has been focused on increasing safety and minimizing risk.

"We have a risk management department that spends all of its time trying to predict and control risks that might result in claims," said Kenneth Morris, chief financial officer of DUHS. "They've redoubled their efforts."

Particular attention has been paid to the highest-risk areas, like surgery and obstetrics, Morris said. "Those areas have been worked over pretty good," he said. "Reevaluating safety, risk management��those are the things that everyone needs to be doing, and we do that continuously."

Despite the emphasis on reduced risk, Medical Center doctors said they are determined to maintain the quality of Duke's care.

"There's obviously an emphasis [at Duke] on maintaining good patient relationships," Smith said.

Because Duke provides Medical Center physicians with insurance and thereby insulates them from malpractice costs, DUHS can maintain its place as the primary caretaker for both poor- and high-risk patients in the Southern United States, Smith added.

To that end, Kussin stressed the importance of the Medical Center retaining high-quality medical care above any financial concerns.

"If we practice good, evidence-based medicine, then that's the solution on our part," he said. "Duke needs to have a role in promoting good medicine."

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