New research suggests aggressive medical malpractice environments do not influence where neurosurgeons practice but may cause them to limit their practice, which may result in a critical erosion of care in some of the most critically neurological patients.
Presented here at the American Association of Neurological Surgeons 76th Annual Meeting, findings from a study examining the impact of malpractice environments on the neurosurgical workforce between 2005 to 2007 showed that US states with high malpractice claims and high malpractice-insurance premiums experienced a 5% increase in the number of practicing neurosurgeons and so-called "noncrisis" states realized a 2% decrease in the number of practicing neurosurgeons.
"At first blush, these findings may seem counterintuitive, but it suggests the malpractice environment is not the sole, or even the primary, factor that influences neurosurgeons' decisions about where to practice," study investigator Zachary Litvack, MD, from the Oregon Health & Sciences University, in Portland, told Medscape Neurology & Neurosurgery.
It is highly likely, added Dr. Litvack, that there are much larger social and economic factors governing the decision of where neurosurgeons practice, not the least of which is compensation and cost of living.
According to Dr. Litvack, neurosurgeons incur some of the highest annual malpractice premiums of any specialty, averaging more than $100,000 and going as high as $300,000 per year in some states.
In 2005 alone, neurosurgeons paid out a total of $28 million in malpractice claims, with the highest average payment per specialist surgeon ($465,000) and the single highest payment of any claim in any specialty ($5.6 million).
Restricted Practice
The impetus for the study, said Dr. Litvack, was previous research conducted by the Council of State Neurosurgical Societies (CSNS) in 2002, which surveyed practicing neurosurgeons to assess the impact of malpractice on the workforce.
As a direct result of malpractice claims and increasing malpractice insurance premiums, 43% of the survey respondents said they were considering limiting the scope of their practice; 30% said they were planning early retirement; and up to 20% said they planned to relocate to another state with better malpractice conditions.
To find out whether neurosurgeons actually did what they said they were going to do in the 2002 survey, the researchers tried to determine the effects of malpractice environments on the allocation of practicing neurosurgeons.
Dr. Litvack and colleagues analyzed data from 4584 active and retired neurosurgeons provided by the American Board of Neurological Surgeons from 2005 to 2007 and looked for correlations between numbers of practicing and retiring neurosurgeons and the malpractice environment in each state.
The researchers found that as the severity of a particular state's malpractice environment increased, so did the number of neurosurgeons per 100,000 population.
"We think neurosurgeons have done exactly what they said they were going to do — they've limited their practice in order to limit their liability."
As a result, said Dr. Litvack, a given region can support a larger absolute number of neurosurgeons because now it takes 2 or more of these specialists to provide the same care and the same access to care that was once provided by a single individual in an unrestricted practice.
"So, based on this information and data, we would say that malpractice environments do affect how we practice, but they don't necessarily affect where we practice," he said.
Gaps in Emergency Care
The fallout from the trend of neurosurgeons to limit their practice is major gaps in neurosurgical care, added Dr. Litvack.
"One of the biggest crises in neurosurgery right now is emergency room coverage for cranial trauma. There are some major metropolitan areas that can get coverage only if they pay a significant stipend to a neurosurgeon just to take call," said Dr. Litvack.
Paying such premiums is, at best, a stopgap solution, he added. Solving the overall issue of the current malpractice crisis may require legal reform that somehow limits the liability of neurosurgeons who agree to provide emergency care. In addition, he said, there is a need for a greater societal understanding of what constitutes realistic outcomes for neurosurgical patients.
"The truth is that in the case of neurosurgical emergencies, whether it's trauma or otherwise, the odds are stacked against the patient, which means the odds are stacked against the physician.
"Unfortunately, in the United States, probably more than anywhere else, there is an expectation that you will have the perfect outcome every single time, and it is those expectations that have gotten us to where we are now," said Dr. Litvack.
Dr. Litvack has no relevant disclosures.
American Association of Neurological Surgeons 76th Annual Meeting: Abstract 602. Presented April 28, 2008.
Review by Dr. Ramaz Mitaishvili
