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Warning Signs

Program assesses malpractice risk and advises physicians of possible danger ahead

By Nancy Humphrey
February 2012

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A cloud of malpractice risk appears to hover over a very small subset of physicians. They may be well-trained and highly credentialed, even on a “best doctors” list somewhere, but for different reasons some physicians are at more risk to be sued for malpractice. The statistics are surprising.

Only 2 percent to 8 percent of physicians per discipline are responsible for up to 30 percent of all malpractice claims in that discipline.

Many malpractice claims can be prevented, say those involved in Vanderbilt’s Center for Patient and Professional Advocacy (CPPA), which, through the Patient Advocacy Reporting System (PARS) conducts yearly risk assessments for physicians across the country. The center, working with leadership at 60 sites including Stanford, Emory, University of Pennsylvania and Loyola, collects data on the institution’s physicians and identifies those at risk.

“I like to think of it like one of those traffic signs that flashes and tells you how fast you’re driving,” said Gerald B. Hickson, M.D., assistant vice chancellor for Medical Affairs, associate dean for Faculty Affairs, and director of the center. “Our goal is to let some of our physician colleagues know ‘you’re driving 45 in a 30-mile-per-hour zone, and we thought you’d want to know.’”

“Our goal is to let some of our physician colleagues know they are driving 45 in a 30-mile-per-hour zone,” says Gerald Hickson, M.D., director of the Center for Patient and Professional Advocacy. Photo by Daniel Dubois.

“Our goal is to let some of our physician colleagues know they are driving 45 in a 30-mile-per-hour zone,” says Gerald Hickson, M.D., director of the Center for Patient and Professional Advocacy. Photo by Daniel Dubois.

Hickson has studied malpractice claims for more than 25 years. Center
co-director James Pichert, Ph.D., and Hickson combined their expertise 18 years ago when Hickson was conducting research on why patients and their families sue their doctors, and Pichert was researching provider-patient communication. The marriage of those two areas of interest led to the creation of CPPA. The center, which has a staff of 36 and five faculty members, has an additional area of focus – training professionals about professionalism, including the disclosure of adverse events and medical errors.

“Early on I was stunned at the lack of any science, just war stories and anecdotes (about malpractice),” Hickson said. “But over the years we’ve learned that families observe or experience things within their health care setting that fail to meet or exceed their expectations. And when they do, a small subset of them will let us know – it may be that the physician’s office is disorganized or that the physician doesn’t seem to listen or that there is no follow-up.”

The CPPA team has learned to use what families say to help identify physicians who have more than their fair share of malpractice risk. Many of the groups using PARS “partners” are academic medical centers like Vanderbilt, but the center is now working with more regional and community hospitals, as well as health systems and physician/medical groups. In addition, the center has initiated work to include other health care providers such as advance practice nurses (APNs) and physician assistants (PAs).

In their database, the CPPA has compilations from yearly risk assessments on more than 35,000 physicians. Partnering hospitals and medical groups electronically transmit data about their physicians – how much they work, what families are saying about each of them – and the center’s data team converts it into risk indexes with local, regional and discipline comparisons. This compelling evidence-based information is then delivered to the leadership at each partnering site. Using CPPA-trained peer messengers at each site, the information is delivered to the physicians in an intervention. “The goal is to encourage the physicians to pause and reflect on why they stand out. It’s a pretty powerful process,” Hickson said.

Only about 4 percent of physicians need to be made aware that they stand out, he added. Since 1998 Vanderbilt’s PARS program has facilitated more than 3,000 interventions with physicians, APNs and PAs around the country. At Vanderbilt, about 100 high-risk physicians have been identified over the past 13 years. “Seventy have done well. Fourteen have departed, and the rest are getting additional assistance,” Hickson said.

Delivering the Message

Once it’s determined that a physician might benefit from an intervention, CPPA professionals train physician-peers at each institution how to deliver the message to their colleagues during what Hickson calls “awareness conversations.”

The peer training identifies what types of behavior issues have been noted, what the barriers are for addressing the problems, and how to address them in a constructive way.

“The goal is not to be judgmental or to play ‘gotcha,’ but respectful, non-judgmental sharing that ‘for some reason, you or your practice just stands out,’” Hickson said. “Sometimes the busy professional doesn’t see what they’re doing. These may be professionals with great technical or cognitive skills, but sometimes the systems within which they practice are poorly designed, and sometimes it may be the individual. Regardless, no matter what they think about the data, they need to pause and reflect why they stand out.” Many even become very effective messengers themselves, he said.

“Ultimately it’s about helping the individual understand their personal accountability to the patients they serve. We can get so busy that we need help seeing a situation from the patient’s perspective.”

Teamwork and Respect

Bryan Bohman, M.D., associate chief medical officer of Stanford Hospitals and Clinics, said that Stanford “leapt” at the chance in 2009 to implement Vanderbilt’s PARS program. “We didn’t have a good system for addressing disruptive behavior and risk in a systematic way. It isn’t the old-style heroic doctor taking care of the patient and everybody else is an afterthought. It’s a different world and to function well you need an atmosphere of teamwork, trust and respect.

Bryan Bohman, M.D., implemented Vanderbilt’s Patient Advocacy Reporting System at Stanford.

Bryan Bohman, M.D., implemented Vanderbilt’s Patient Advocacy Reporting System at Stanford.

“We had some professionals who were ‘toxic’ to the Stanford environment,” Bohman said. “We told them they needed to improve or depart, to be blunt.”

The most beneficial part of the PARS program is its scientific basis and that it has been validated, he said. “When someone is identified as being at risk through the PARS program, it’s a lot easier for us to deal with them than by acting on one patient complaint at a time.”

Bohman said that some of the data provided by the PARS program was unexpected. “We had one individual who was a surprising person to see on the list. He isn’t prickly or short-tempered. This individual was ‘everybody’s favorite guy.’ When we took a closer look at the complaints we found that many of his patients with chronic pain felt like he promised to make them better and couldn’t. He was giving them a false promise or sense of hope.”

Armed with helpful information from the PARS program the physician changed the way he conducted introductory meetings with patients. Bohman said he believes the PARS program has improved physician behavior at Stanford. “I’m a scientist and I normally don’t put much stock in anecdotal reports, but we have anecdotal reports from our nursing staff that they’re seeing a change. Mostly, there’s a lot more awareness that patient concerns need to be addressed.”

Impact of Tort Reform

In May 2011, Tennessee’s lawmakers passed the Tennessee Civil Justice Act of 2011, a major tort reform package and a legislative priority of Gov. Bill Haslam. It caps “non-economic” and punitive damage awards in personal injury and health care malpractice lawsuits. Non-economic losses are difficult to quantify financially, like pain and suffering and loss of enjoyment of life. Awards will be capped at $750,000, in most cases, and at $1 million when victims suffer spinal-cord injuries that lead to loss of use of two or more limbs. Economic damages, which reimburse victims for actual costs like medical care and loss of income, are not capped.

Allen Kaiser, M.D., Vanderbilt University Hospital Chief of Staff, said that the CPPA has not only had an impact on Vanderbilt’s malpractice experience, but on tort reform in general. “There’s a huge debate on the national scene of the lack of tort reform, and this center is having the most meaningful impact that I know of. Our data shows that the severity of the outcome is not always the strongest driver of a patient and family looking to sue,” he said. “It’s absolutely tied to the ability of a physician to accurately and compassionately communicate.

“Jerry Hickson saw the problem, had an idea, and was able to implement a new vision into the day-to-day activities of physicians and nurses in the real world of health care,” Kaiser said. “The center is having an enormous impact on Vanderbilt’s malpractice experience and our ability to 1) identify who’s at risk; 2) retrain physicians when possible on appropriate communication strategies; and 3) train all physicians in how to communicate about adverse outcomes and medical errors. I don’t think Jerry will get a Nobel Prize for his work, but it’s certainly genius in my opinion.”

Ultimately, the end goal of the center is simple, Hickson said. “We are committed to making medicine kinder, safer and more reliable, thinking about the health and well-being of those we serve and those who deliver their care.”


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