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young urologist approached me after the presentation and sought my counsel on the following dilemma: "I'm trying to decide which of two groups to affiliate with when I finish my fellowship. One consists of two physicians. The other is a group of six physicians. Do you think, from a malpractice perspective, that I would be better protected joining the larger group or the smaller group?" I was stunned. Rather than quality-of-life issues or working environment concerns, a major decision point for this physician, despite presumed insurance protection, was exposure to malpractice liability. Here was a physician just starting out in practice, about to make an absolutely critical determination in terms of his professional life, based on something that as far as I am concerned should have been tangential to his primary focus.

I believe that one of the reasons that malpractice looms as such an incredible presence to physicians is in part the nature of the activities in which they engage. Given imperfect data, as well as highly detailed and technical training, in which the limits of knowledge are decidedly finite but the expectations of the patient and society frequently are not, the consequences of their actions are life and death—often literally. To perform in this environment, many physicians must learn to believe that they can control what is imperfect, accept the limits of their knowledge, and nevertheless act with supreme confidence. Their patients expect that confidence and rely on it.

Out of this constellation of factors, for reasons others are surely better equipped than I to elucidate, I observe that physicians as a group completely self-identify in terms of their professional roles. Asked to complete the following statement, "I am a good_____________," the vast majority of physicians will instinctively respond, "I am a good doctor," and they will believe it. Given this complete self-identification with their profession and belief in their own competence, any question that is raised about how they have performed is received in a way that goes far beyond what those of us who work in the system would think is appropriate. I generally characterize this overreaction by saying that most practicing physicians would be happier to see an FBI agent standing on their front doorstep with a gun and a badge telling them they broke some rule unrelated to their professional practice than to get a letter from a PRO posing a routine question about a specific quality issue.

Within this frame of reference, medical technology, technique, and knowledge are improving. Societal expectations about performance are also increasing. Malpractice litigation crystallizes for physicians these inherent unresolved tensions and focuses on their own imperfections, with results that they perceive as personally threatening and singularly unfair. At the same time, health care policy development is at a moment in history of intense demands

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