Medical Professional Liability and the Delivery of Obstetrical Care Volume I (1989) / Chapter Skim
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5 The Effects of Medical Professional Liability on the Practice of Obstetrics
5 The Effects of Medical Professional Liability on the Practice of Obstetrics
Pages 73-91
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From page 73... ...
Finally, what has been the effect of medical professional liability concerns on the physician-patient relationship, and what are the implications of these changes? CHANGES IN PRACTICE PA1Y ERNS OF INDIVIDUAL PHYSICIANS There is no question that physicians themselves firmly believe that the current medical liability climate has prompted them to change the way in which they practice obstetrics.
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From page 74... ...
The committee believes that, for the most part, these are examples of how the current liability climate has led to better patient care and has enhanced the physician-patient relationship. Family physicians also report that the professional liability climate is altering the way in which they practice obstetrics.
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From page 75... ...
Overall, it has been estimated that 48 percent of the increase in cesarean sections is due to repeat cesarean sections and 16 percent to fetal distress (Taffel et al., 19871. Additional factors contributing to the increase in cesarean sections include abandonment of vaginal breech deliveries; increased use of cesarean deliveries for infants with very low birthweights and, for multiple pregnancies, decreased use of mi~forceps deliveries; and the medical-legal environment (Sachs, 19891.
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From page 76... ...
, all studies show that cesarean section delivery does increase maternal morbidity, including increased incidence of infection, longer hospitalization, problems of bonding with the infant, as well as rarer complications, including hysterectomy and bowel trauma. Electronic Fetal Monitoring The objective of obstetrical care is the birth of a normal baby to a healthy mother.
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From page 77... ...
In a recent review by the Harvard Risk Management Foundation of 54 open and closed obstetrics-related cases managed over a 10-year period, nearly two-thirds of the losses involved alleged problems with fetal monitoring or related documentation (Risk Management Foundation, 19861. The committee believed it important to examine the role of EFM in obstetrical care, the history of its development and acceptance as an intervention, the evidence related to its efficacy, and how professional liability concerns have influenced its use.
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From page 78... ...
Many leaders of the academic obstetrical community were at the forefront of EFM use, and they communicated their enthusiasm in respected medical journals and at professional meetings. The use of EFM spread rapidly, both in academic medical centers and among individual practitioners.
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From page 79... ...
Until recently, cerebral palsy was thought to be linked to abnormal parturition, diff~cult labor, premature birth, and hypoxia or asphyxia of the infant. The committee evaluated more recent data that cast serious doubt on the correlation between presumed hypoxia and later cerebral palsy.
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From page 80... ...
The outcome at 7 years was known for 45,559 children born as singleton infants of 51,285 pregnancies. In a univariate analysis of risks associated with cerebral palsy, Nelson and Ellenberg found that the characteristics associated with the highest relative risk were newborn seizures, respiratory distress syndrome, aspiration, being in an incubator for three or more days, and having an Apgar score of O to 3 at five minutes (listed in decreasing order)
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From page 81... ...
The insurance data reviewed by the committee confirmed that indemnity payments related to claims for neurologically impaired children comprise more than 27 percent of all indemnity payments paid (GAO, 1986; Medical Underwriters of California, 19871. One malpractice insurer, Physicians Insurance Association of America, calculated that cerebral palsy is the second highest diagnosis (following breast cancer)
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From page 82... ...
Its purpose was to make a preliminary assessment of whether departments of obstetrics at academic medical centers were, in fact, making changes in the patterns of the delivery of care at an institutional level that had implications for access to and delivery of care. The committee received letters containing both data and opinions about how the current medical liability climate has affected the practice of obstetrics in university hospitals and academic medical centers.
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From page 83... ...
Other practice changes reportedly brought about by the professional liability climate included avoidance of mi~forceps delivery, decrease in the frequency of outlet forceps deliveries, increased antepartum testing, increased documentation, and increased use of consultation and referrals for "high-risk" and "potential high-risk patients," often solely for the purpose of avoiding litigation (see Table 5.21. Another commonly cited response was increased use of continuous EFM during labor, even for low-risk patients: The sole purpose of such surveillance may be only to provide a heartbeat-toheartbeat credible objective record for defense purposes in the event of future litigation.
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From page 84... ...
84 MEDICAL PROFESSIONAL LIABILITY: VOLUME I TABLE 5.2 Changes Reported in the Committee's Survey, March 1988 Changes in Practice Liberalized criteria for cesarean sections Decreased frequency of vaginal breech deliveries Elimination of vaginal breech deliveries Delivery of all twins by cesarean section Avoidance of midforceps deliveries Marked decrease in frequency of outlet forceps deliveries Increased antepartum testing Obstetricians no longer provide obstetrical anesthesia Increased use of electronic fetal monitoring Universal use of electronic fetal monitoring Increased use of ultrasound Increased use of alphafetoprotein testing Increased use of amniocentesis Increased referrals to tertiary care centers for level-one ultrasound examinations Increased documentation Increased use of consultation 24-hour faculty in-house call Enhanced quality assurance and risk management programs Changes in Teaching Including medical malpractice issues in the curriculum Revised rules and regulations for residents Reduced responsibility for residents Closed mortality and morbidity conferences Diminished participation of part-time and some full-time faculty in education of residents Generally diminished participation of medical students in patient care Residents being named as codefendants in malpractice cases Changes in Practice at the Departmental Level Increased establishment of regional computer networks for integrating antepartum and intrapartum data from obstetrical patients Increased establishment of regional linkups of fetal heart monitors for fetal assessment Development of and reliance on obstetrical guidelines or protocols to standardize care Changes in Careers in Obstetrics Change in the type of medical students entering the profession Decrease in the number of students entering obstetrics Decrease in the number of students entering solo practice Diminished professional mobility due to necessity of purchasing tail coverage for occurrence-based malpractice policies Cost of malpractice insurance influencing faculty hiring in academic medical centers Access Issues Avoidance of high-risk patients Diminished care of uninsured patients More women presenting at hospitals for delivery without adequate prenatal care Routinely obtaining cord-blood gases immediately after birth for all high-risk newborns
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From page 85... ...
Moreover, because of the continually increasing cost of medical malpractice insurance, some respondents reported a diminished participation by part-time obstetrical faculty in the education of residents. There was considerable concern that the current medical liability climate is preventing obstetrical residents from assuming sufficient responsibility to meet their educational needs.
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From page 86... ...
Effects on Access to Care Although the committee's letter did not query respondents specifically about their perception of the effect of the liability problem on access issues, a number of respondents noted the increased influx of the medically underinsured into academic medical centers. Their perception is that this influx is a result ofthe professional liability crisis, which is curtailing the availability of federally subsidized obstetrical services outside these hospitals: We are being severely pressured by the number of new, medically indigent patients requiring obstetrical care.
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From page 87... ...
, it is abundantly clear that medical malpractice claims are not confined to the worst practitioners or the worst health care institutions. In fact, many observers believe that the most substandard physicians are the least likely to be sued, because they serve patients who are too poor and too uneducated to file claims.
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From page 88... ...
Together, the data accumulated and set forth in Chapters 2 through 5 relating to the effects of the professional liability crisis on access to care and on delivery patterns indicate that the result of this breakdown in trust, and the attendant surge in medical malpractice litigation, is likely to be the further deterioration of obstetrical care in the United States. Consequences of the Breakdown in Must The consequences of the disintegration of the physician-patient relationship have been costly to patients, physicians, and, ultimately, to all consumers who pay the health care bills in this nation.
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From page 89... ...
The committee found that in certain instances, at least from the physicians' perspective, professional liability concerns have contributed to transforming the patient-physician relationship from a therapeutic alliance into a more adversarial interaction. A physician-patient relationship based on a clear understanding of the roles and responsibilities of each and directed toward the patient's needs is more likely to be free of the suspicion and paranoia so often associated with medical malpractice claims.
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From page 90... ...
1984. Obstetric complications as risk factors for cerebral palsy or seizure disorders.
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From page 91... ...
1989. The impact oftechnology assessment and medical malpractice on the diffusion of medical technologies: The case of electronic fetal monitoring.
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