Impact of malpractice liability among spine surgeons: A national survey of French private neurosurgeons

Epidemiology of the causes of complaints after discectomy collected from a French insurance company

INTRODUCTION

Lumbar discectomy is a frequent procedure performed by surgeons from specialties at risk of patient complaints. The objective of the study was to analyze the causes of litigations following lumbar discectomy to be able to reduce their frequency.

MATERIAL AND METHODS

This observational, retrospective study was carried out at a French insurance company (Branchet). All files opened between the 1st of January 2003 and the 31st of December 2020, following lumbar discectomy without instrumentation and without any other associated code, undertaken by a surgeon insured by Branchet, were analyzed. The data was extracted from the database by a consultant from the insurance company and analyzed by an orthopedic surgeon.

RESULTS

One hundred and forty-four records met all inclusion criteria and were complete and available for analysis. Infection was the leading cause of litigation, responsible for 27% of complaints. Residual postoperative pain was the second cause of complaint with 26% of cases, of which 93% had persistent pain. Neurological deficits were the third cause of complaint with 25% of cases among which 76% were related to the appearance of a deficit and 20% related to the persistence of an existing deficit. Early recurrence of herniated disc also appeared as a cause of complaint, accounting for 7% of cases.

CONCLUSION

Surgical site infection, persistence of pain, and the appearance or persistence of neurological disorders are the primary causes of complaints leading to investigation in the aftermath of lumbar discectomy. It seems essential to us that this information be brought to the attention of surgeons to enable them to better adapt their explanations in the delivery of preoperative information.

LEVEL OF EVIDENCE

IV.

Malpractice litigation after spinal surgery: A review of allegations in France in 1990-2020

OBJECTIVE

Spinal surgery is among the specialities with the highest rates of complications and of peri-operative morbidity and mortality. The number of spinal surgeries performed is rising year on year in France. The objectives of this study were to identify the main reasons for malpractice claims after spinal surgery in France, to evaluate the impact of avoidable errors, and to examine differences between civil lawsuits (private institutions) and administrative lawsuits (public institutions).

HYPOTHESIS

The leading reasons for malpractice litigation are avoidable errors such as inadequate patient information, errors in indications, and inadequate post-operative monitoring.

MATERIAL AND METHODS

We reviewed malpractice claims related to spinal surgery and recorded in two French databases (Legifrance and Doctrine) in 1990-2020. We combined the indexing term "surgery" with any of the following terms: "disc", "spine", "cervical", "vertebral", "lumbar", "scoliosis", "disc replacement", and "fusion". The search was performed by three orthopaedic surgeons who were blind to patient data and recorded the allegations, verdicts, and pay-outs.

RESULTS

We included 275 claims. The main plaintiff allegations were inadequate information (34.5%), infection (22%), spinal-cord injury (17%), and errors in indication (13%). Among these reasons, 56.7% may have been partly avoidable. In private institutions, claims for infection and for erroneous indication were significantly more common than in public institutions (p=0.02 for both), whereas the opposite was true for spinal-cord injury (p<0.001).

CONCLUSION

After spinal surgery in France, the most common malpractice allegation was inadequate information. Over half the claims were related to potentially avoidable factors. Among allegations, errors in indication were significantly more common in civil than in administrative lawsuits.

LEVEL OF PROOF

IV, retrospective observational database study.

Medical negligence claims and the health and life satisfaction of Australian doctors: a prospective cohort analysis of the MABEL survey

OBJECTIVE

To assess the association between medical negligence claims and doctors' self-rated health and life satisfaction.

DESIGN

Prospective cohort study.

PARTICIPANTS

Registered doctors practising in Australia who participated in waves 4 to 11 of the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey between 2011 and 2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

Self-rated health and self-rated life satisfaction.

RESULTS

Of the 15 105 doctors in the study, 885 reported being named in a medical negligence claim. Fixed-effects linear regression analysis showed that both self-rated health and self-rated life satisfaction declined for all doctors over the course of the MABEL survey, with no association between wave and being sued. However, being sued was not associated with any additional declines in self-rated health (coef.=-0.02, 95% CI -0.06 to 0.02, p=0.39) or self-rated life satisfaction (coef.=-0.01, 95% CI -0.08 to 0.07, p=0.91) after controlling for a range of job factors. Instead, we found that working conditions and job satisfaction were the strongest predictors of self-rated health and self-rated life satisfaction in sued doctors. In analyses restricted to doctors who were sued, we observed no changes in self-rated health (p=0.99) or self-rated life satisfaction (p=0.59) in the years immediately following a claim.

CONCLUSIONS

In contrast to prior overseas cross-sectional survey studies, we show that medical negligence claims do not adversely affect the well-being of doctors in Australia when adjusting for time trends and previously established covariates. This may be because: (1) prior studies failed to adequately address issues of causation and confounding; or (2) legal processes governing medical negligence claims in Australia cause less distress compared with those in other jurisdictions. Our findings suggest that the interaction between medical negligence claims and poor doctors' health is more complex than revealed through previous studies.

Socio-Demographic, Professional and Institutional Characteristics That Make Romanian Doctors More Prone to Malpractice Complaints

Background and objectives: Medical malpractice is a phenomenon that shadows current medical practice, the number of complaints following an upward trend worldwide. The background for complaints is related both to the doctor and medical practice in general, as well as to the patient. The aim of this study was to identify a profile of the Romanian doctors who are more prone to receiving complaints, by analyzing the socio-demographic, professional and institutional characteristics. Materials and Methods: We conducted a quantitative, prospective research, the data being collected using a newly developed questionnaire. Data analysis was performed with the IBM Statistical Package for Social Sciences (SPSS, version 24). We used counts, percentages, means and standard deviation, and comparative and correlational analyses. A logistic regression model was applied to select a statistically best-fit model to identify independent predictors for receiving complaints; a Hosmer–Lemeshow test was used to check the performance of the prediction model. Results: The study group consisted of 1684 doctors, of which 16.1% had been involved in a malpractice complaint. Results showed that men, senior doctors from surgical specialties who perform a greater number of on-call shifts, those who work in regional or county hospitals, those who have greater fear of receiving complaints and those whose life partner is a doctor with the same specialty are more prone to receiving complaints. Conclusions: The profile identified by the present research underlines the main characteristics that could be targeted with specific measures in order to prevent the ongoing increase of malpractice complaints in Romania.

The Personal and Professional Impact of Patients' Complaints on Doctors-A Qualitative Approach

Background: Complaints regarding medical practice represent a harsh reality of the current world. Patients have the right to receive explanations and compensation when they are injured during the medical act, but the increased potential for exposure to complaints determines personal and professional consequences for the doctors, with significant impact on their health and practice. Thus, the aim of our research was to analyze in depth the impact of complaints on the doctors involved. Materials and methods: The authors conducted a qualitative study, using a semi-structured interview, addressed to doctors who had complaints from patients. The participants in our research were identified using an adapted version of the snowball method. Results: After the analysis of the interviews using the inductive method, nine themes resulted, seven of which are addressed in this paper: injustice, personal impact, professional impact, difficulties, supportive factors, the attitude of the hospital management and the attitude of colleagues. At the personal level, the doctors were overwhelmed by insomnia, nightmares, stress and anxiety, and at the professional level by doubts about medical decisions, fear, anxiety and the tendency to avoid patients with severe diseases. Conclusions: The study revealed that physicians who had complaints from patients are deeply affected by the complaint itself and the associated investigation procedure, even if, to a lesser extent, some of the participants found motivation for a better management of the situation. The study also showed the need for changes in the legal and medical systems in order to create mechanisms to support the doctors during the investigation process.

Spine Surgery Infection, Litigation, and Financial Compensation: Analysis of 98 Claims Involving French Spine Surgeons Between 2015 and 2019

OBJECTIVE

Since 2002, France has adopted the Patients' Rights Law, an alternative malpractice scheme creating a faster, less expensive out-of-court settlement ensuring compensation even in the absence of fault. We aimed to describe the implications of this system by analyzing 5 years of claims for infections related to spinal surgeries collected by the main insurer of French spine surgeons.

METHODS

We retrospectively analyzed 98 anonymized malpractice claims from 2015 to 2019 (20% of overall claims), including anonymized medical records of the patients, reports of the independent experts, final judgments, and entities supporting the compensation if any.

RESULTS

Claims included 8 deaths and 17 newly acquired neurological sequelae. The conclusions identified 22 faulty cases. The most frequent fault was a delay in diagnosis (10 cases), followed by inadequate surgical management (6 cases), inadequate antibiotic therapy (5 cases), and inadequate follow-up (1 case). Among the 67 cases (68.4%) proved not to be at fault, 10 were covered by the national solidarity fund because of their severity, and the remaining 57 were covered by hospitals.

CONCLUSIONS

Since the 2002 Patients' Rights Law, patients with postoperative infections have always received compensation. The out-of-court settlement offers the patients incurring morbidities the assurance of faster compensation. Although certainly subject to selection criteria, this procedure is free and does not necessitate the presence of a lawyer. The analysis of expert reports and the resulting court decisions imply prevention, anticipation, and collaboration of all health care providers and open an opportunity to improve their practices to limit these crucial followings.

Litigations following spinal neurosurgery in France: “out-of-court system,” therapeutic hazard, and welfare state

OBJECTIVE

Spinal surgeries carry risks of malpractice litigation due to the random nature of their functional results, which may not meet patient expectations, and the hazards associated with these complex procedures. Claims are frequent and costly. In France, since 2002, a new law, the Patients’ Rights Law of March 4, 2002, has created an alternative, out-of-court scheme, which established a simplified, rapid, free-of-charge procedure (Commission for Conciliation and Compensation [CCI]). Moreover, this law has optimized the compensation provided to patients for therapeutic hazards by use of a national solidarity fund. The authors analyzed the consequences of this alternative route in the case of claims against private neurosurgeons in France.

METHODS

From the data bank of the insurer Mutuelle d’Assurances du Corps de Santé Français (MACSF), the main insurance company for private neurosurgeons in France, the authors retrospectively analyzed 193 files covering the period 2015–2019. These computerized files comprised the anonymized medical records of the patients, the reports of the independent experts, and the final judgments of the CCI and the entities supporting the compensation, if any.

RESULTS

During the 5-year study period (2015–2019), the insurance company recorded 494 complaints involving private neurosurgeons for spinal surgery procedures, of which 126 (25.5%) were in civil court, 123 (24.9%) were under amicable procedure, and 245 (49.6%) were in the out-of-court scheme administered by the CCI. Out of these 245 cases, only 193 were closed due to delays. The conclusions of the commission were rejection/incompetence decisions in 47.2% of the cases, therapeutic hazards in 21.2%, nosocomial infections in 17.6%, and practitioner fault in 13.5%. National solidarity compensated for 48 complaints (24.8%). The final decision of the CCI is not always consistent with the conclusions of the experts mandated by it, illustrating the difficulty in defining the concept of hazards. The authors found that the therapeutic hazards retained and compensated by the national solidarity included decompensated spondylotic myelopathies (15% of the 40 cases) and cauda equina syndromes (30%). As allowed by law, 11.5% of the patients who were not satisfied triggered a classical procedure in a court.

CONCLUSIONS

In the French out-of-court system, trial decisions resulting in rulings of proven medical malpractice are rare, but patients can start a new procedure in the classical courts. The therapeutic hazard remains a subtle definition, which may be problematic and require further discussion between experts and magistrates. In spite of the imperfections, this out-of-court system proposes a major evolution to move patients and medical providers from legal battles to reconciliations.