Analysis of Medical Litigation Among Patients with Medical Disputes in Cosmetic Surgery in Taiwan

Transcription

1 DOI /s ORIGINAL ARTICLE Analysis of Medical Litigation Among Patients with Medical Disputes in Cosmetic Surgery in Taiwan Shu-Yu Lyu Chuh-Kai Liao Kao-Ping Chang Shang-Ta Tsai Ming-Been Lee Feng-Chou Tsai Received: 12 December 2010 / Accepted: 11 February 2011 Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2011 Abstract Background This study aimed to investigate the key factors in medical disputes (arguments) among female patients after cosmetic surgery in Taiwan and to explore the correlates of medical litigation. Methods A total of 6,888 patients (3,210 patients from two hospitals and 3,678 patients from two clinics) received cosmetic surgery from January 2001 to December S.-Y. Lyu School of Public Health, Taipei Medical University, 250 Wu-Hsing Street, Taipei 11031, Taiwan sylyu@tmu.edu.tw C.-K. Liao Department of Family Medicine, Taipei Municipal Wan Fang Hospital, Taipei, Taiwan m @tmu.edu.tw K.-P. Chang Division of Plastic Surgery, Department of Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan kapich@kmu.edu.tw S.-T. Tsai Division of General Surgery, Department of Surgery, Taiwan Adventist Hospital, Taipei, Taiwan Shang_Ta@tmu.edu.tw M.-B. Lee Department of Psychiatry, National Taiwan University Hospital, 7, Chung-Shan South Road, Taipei, Taiwan mingbeen@ntu.edu.tw F.-C. Tsai (&) Division of Plastic Surgery, Department of Surgery, Center for Mathematical Biology, Taipei Medical University Hospital, Taipei Medical University, 252, Wu-Hsing Street, Taipei 11031, Taiwan biopattern@gmail.com The inclusion criteria specified female patients with a medical dispute. Chi-square testing and multiple logistic regression analysis were used to analyze the data. Results Of the 43 patients who had a medical dispute (hospitals, 0.53%; clinics, 0.73%), 9 plaintiffs eventually filed suit against their plastic surgeons. Such an outcome exhibited a decreasing annual trend. The hospitals and clinics did not differ significantly in terms of patient profiles. The Chi-square test showed that most patients with a medical dispute (p \ 0.05) were older than 30 years, were divorced or married, had received operations under general anesthesia, had no economic stress, had a history of medical litigation, and eventually did not sue the surgeons. The test results also showed that the surgeon s seniority and experience significantly influenced the possibility of medical dispute and nonlitigation. Multiple logistical regression analysis further showed that the patients who did decide to enter into litigation had two main related factors: marital stress (odds ratio [OR], 10.67; 95% confidence interval [CI], ) and an education level below junior college (OR, 9.33; 95% CI, ). Conclusion The study findings suggest that the key characteristics of patients and surgeons should be taken into consideration not only in the search for ways to enhance pre- and postoperative communication but also as useful information for expert testimony in the inquisitorial law system. Keywords Cosmetic surgery Lawsuits Litigation Malpractice Medical dispute Human rights and democracy in Taiwan have greatly improved since the end of martial law was declared in The increasing trend in medical malpractice lawsuits

2 reflects how people have gradually begun to pursue their rights. The court system in Taiwan is an inquisitorial system enacted in 1967 based on the continental German system and not an adversarial (accusatorial) system with trial by jury. Studies indicate that approximately 44% of physicians faced medical litigation in 2009 [1, 2] Taiwan has the following specific medicolegal characteristics: 1. Medical malpractice law is under the authority of the central government in Taiwan [3]. 2. Physicians practicing in Taiwan rarely carry medical malpractice insurance for two reasons: (1) Taiwanese insurance companies consider surgeons to be in a highrisk career for lawsuits. (2) Surgeons themselves have limited understanding of medical malpractice. 3. Plastic surgeons in Taiwan are not permitted to practice in both a hospital and a clinic at the same time. These advantages can be used to analyze the differences in medical disputes and litigation among different institutions and clinical practice styles because this specific medicolegal group in Taiwan has more uniformity, limited variability, and less confounding bias. The definition of various terms must be clarified first [4] Medical malpractice is defined as any act or error by a physician during treatment of a patient that deviates from the accepted norms of practice in the medical community and causes injury to the patient. This is judged by the court or an official medical committee. Medical dispute (argument) is defined as a patient proposal in return for the argument (any form of request such as a threat, apology, or reimbursement), which may or may not correlate with medical malpractice. Medical litigation occurs when the patient files a lawsuit against the physician over a medical dispute. Medical dispute or malpractice does not necessarily lead to medical litigation. The process of medical litigation does, however, involve a medical dispute, as shown in Fig. 1. For example, plastic surgery generally does not result in medical malpractice, but subjective dissatisfaction Fig. 1 Relation between medical malpractice, dispute, and litigation with the aesthetic outcome often leads to a medical dispute. Due to the nature of the specialty, patients approach plastic surgeons for aesthetic needs rather than medical diseases [5]. Unfortunately, the literature provides little information for improving the understanding of medical disputes (not only malpractice) or of references for expert testimony (witness) in cases of alleged medical malpractice in plastic surgery [6 8]. Physicians may be put in a difficult position during future lawsuits if no references can be cited. To our knowledge, this study was the first to broaden the scope of discussion to include medical disputes and to analyze which factors increase the likelihood of medical disputes and the subsequent shift to medical litigation. The current culture of medicine with its steep authority hierarchies and propensity to punish people who err is detrimental to the willingness of physicians to discuss medical errors [9]. In a worst-case scenario, physicians develop a defensive medicine approach. Those who adopt this stance develop diagnostic examinations and treatment plans with the goal of refusing or transferring high-risk patients, increasing the number of tests and follow-up visits, and obtaining detailed informed consent to lower the number of medical malpractice lawsuits. Systematic studies of defensive medicine have shown that excessive medical treatment is based on fear of legal liability rather than the patient s best interests [10, 11]. Physicians practicing defensive medicine tend to be more conservative in their choices of treatment [12]. In the past, physicians received little training in medical malpractice, dispute, and litigation during the long medical education process. Our study was therefore aimed at investigating the prevalence of medical disputes in plastic surgery among female patients in Taiwan and to explore the factors correlated with medical litigation in the hospital and the clinic. Patients and Methods The target population of the study included all patients receiving cosmetic surgery at two teaching hospitals (n = 3,210) and two clinics (private facilities, n = 3678) in Taiwan from January 2001 to December Data were collected from the patients medical records, with the inclusion criteria requiring the study subject to be a female with a medical dispute (hospital, n = 17; clinic, n = 27). All 35 plastic surgeons in the study (hospital, n = 20; clinic, n = 15) were board certified. Three patients and one surgeon were excluded because of incomplete data. Male patients with a medical dispute were not included because the number of cases was relatively small in all target populations (n = 1). Reports of poor service from medical personnel, unreasonable medical costs, and an unfavorable

3 medical environment were included based on the definition of medical dispute used in this study. We compared the differences in stratified variables within and between the medical institutions in the same medical dispute and litigation event from the viewpoint of patients and surgeons characteristics. The patients were given preoperative explanations and signed informed consents that included the process of procedures, the difficulty, the recovery time, the possible complications, and so forth. The design of many variables was aimed at decreasing the confounding bias in our study. We hoped to clarify which factors had a major influence on medical dispute and litigation. The variables were selected according to the questionnaire opinions of all the plastic surgeons involved in the study. The variables for analyses included the following: Patients Characteristics 1. Demographics including age, level of education, and marital status. 2. Patient s help-seeking behaviors a. The reason for choosing a particular physician (e.g., recommendation by family members and friends, the physician s fame, random selection). b. Source of medical payment (e.g., loans, borrowed money, or credit card payment). c. Medical dispute records (e.g., any previous record of medical dispute/litigation or whether the patients eventually sued their plastic surgeons). 3. Medical history of the patients a. The types of surgical procedures that caused the dispute were grouped as general operations (e.g., liposuction and augmentation mammaplasty) or local anesthesia (e.g., blepharoplasty and rhinoplasty) as a way to reflect the complexity of the procedure. b. The history of plastic surgery detailed whether the patients had three or more cosmetic operations in different medical institutions. c. The history of psychiatric diagnoses such as bipolar disorder, borderline personality disorder, and insomnia was described. The records were obtained from patients self-report of psychiatric clinic visits or from medical records. 3. Whether the surgeons have medical malpractice insurance or not. Statistical Analysis Chi-square testing was used to evaluate the association between the hospital and patient characteristics. Multiple logistic regression analysis was used to determine which patient variables significantly affected the odds of medical litigation. The odds ratio value was adopted to evaluate the strength of correlation, and the significance level was set at Results The incidence of medical disputes was 0.53% for the hospitals and 0.73% for the clinics, and that of medical litigation was respectively 0.09 and 0.16%. The mean age of the patients with medical disputes was ± 7.05 years at the hospitals and ± 7.99 years at the clinics. The patients were mainly in the middle-age group. The number of medical disputes and litigations showed a declining trend for both the hospitals and the clinics (Fig. 2). The occurrence of disputes in the first 5 years of a surgeon s practice was 76.2% in the hospitals and 80.3% in the clinics. The characteristics of the patients with medical disputes are listed in Table 1. In general, the Chi-square test showed that most patients with a medical dispute had the following characteristics (p \ 0.05): Patient factors age older than 30 years, divorce or marriage status, experience of surgery under general anesthesia, no money borrowed using credit card or bank Surgeons Characteristics 1. Surgeons seniority. A senior surgeon is defined as a surgeon with surgical experience longer than 5 years. 2. Surgeons previous experience with medical litigation. Fig. 2 Number of medical disputes and litigation cases by medical institution,

4 Table 1 Characteristics of patients with medical disputes in different medical institutions Variable Hospital (n = 17) Clinic (n = 27) p Value a Total (n = 44) p Value b Patients characteristics Age (years) 0.46 \0.001* B30 3 (17.6) 2 (7.4) 5 (11.4) [30 14 (82.4) 25 (92.6) 39 (88.6) Marital status 0.72 \0.001* Divorced 6 (35.3) 12 (44.4) 18 (40.9) Married 7 (41.2) 11 (40.7) 18 (40.9) Never married 4 (23.5) 4 (14.9) 8 (18.2) Level of education Under junior college 11 (64.7) 10 (37.1) 21 (47.7) Junior college and above 6 (35.3) 17 (62.9) 23 (52.3) Anesthesia type during surgery 0.54 \0.001* Local anesthesia 4 (23.5) 5 (18.5) 9 (20.5) General anesthesia 13 (76.5) 22 (81.5) 35 (79.5) History of psychological stress or psychiatric clinic visit Yes 8 (47.1) 18 (66.7) 26 (59.1) No 9 (52.9) 9 (33.3) 18 (40.9) Information factor (had heard about their doctor before seeking the operation) (58.8) 10 (37.1) 20 (45.5) No 7 (41.2) 17 (62.9) 14 (54.5) Economic stress (borrowed money * to pay for their surgery) Yes 5 (29.4) 8 (29.6) 13 (29.5) No 12 (70.6) 19 (70.4) 31 (70.5) History of at least three previous cosmetic operation experiences Yes 4 (23.5) 12 (44.4) 16 (36.4) No 13 (76.5) 15 (55.6) 28 (63.6) History of medical dispute/litigation 0.77 \0.001* (5.9) 3 (11.1) 4 (9.1) No 16 (94.1) 24 (88.9) 40 (90.9) Finally sued the plastic surgeons 0.57 \0.001* Yes 3 (17.6) 6 (22.2) 9 (20.5) No 14 (82.4) 21 (77.8) 35 (79.5) Surgeons characteristics Surgeons seniority * Seniority 4 (23.5) 8 (29.6) 12 (27.3) No seniority 13 (76.5) 19 (70.4) 32 (72.7) Experience with medical litigation 0.46 \0.001* Yes 2 (11.8) 6 (22.2) 8 (18.2) No 15 (88.2) 21 (77.8) 36 (81.8)

5 Table 1 continued Variable Hospital (n = 17) Clinic (n = 27) p Value a Total (n = 44) p Value b Medical insurance 0.52 \0.001* Yes 0 (0) 2 (7.4) 2 (4.5) No 17 (100) 25 (92.6) 42 (95.5) a Comparison of the characteristics of patients in the two medical institutions b Statistical analysis of the specific factor in whole population * p \ 0.05 Fig. 3 Distribution of operation type related to medical litigation in the hospital and the clinic disputes: 94.1% of the hospital patients and 88.9% for the clinic patients. Among the hospital patients 17.6% eventually sued their plastic surgeons, whereas 22.2% of the clinic patients eventually did the same. Furthermore, the results of multiple regression analysis showed that divorce (odds ratio [OR], 10.67; 95% confidence interval [CI], ) and an education level below junior college (OR, 9.33; 95% CI, ) were two factors significantly associated with patients entering into litigation. In contrast, there was no statistical correlation between surgeon factors and medical litigation (Table 2). Discussion loan, a history of medical litigation, and eventually no suit against the plastic surgeon. Surgeon factors seniority less than 5 years and no medical malpractice insurance or experience with medical litigation. The characteristics in the two medical institution groups (hospitals and clinics) were statistically matched. Divorced patients accounted for 35.5% of the hospital patients and 44.4 % of the clinic patients. Relatively few patients were single. The anesthesia type was mainly general: 76.5% of the anesthesia at the hospitals and 81.5% of the anesthesia at the clinics (Fig. 3). Patients with psychological problems comprised 47.1% of the hospital patients and 66.7% of the clinic patients, with insomnia as the most common problem. The education level was mainly below junior college (64.7% of the hospital patients). Before the procedure, 41.2% of the hospital patients and 62.9% of the clinic patients had never heard of their physicians. Most of the patients did obtain loans or borrowed money to cover their medical expenses: 70.6% of the hospital patients and 70.4% of the clinic patients. Only 24.5% of the hospital patients had a rich history of cosmetic operations, whereas 55.6% of clinic patients had an extensive cosmetic surgery history. According to the records, almost all of the patients had no history of medical Writings on medical responsibility can be traced to 2030 B.C. in the Code of Hammurabi [13, 14]. Ancient wisdom emphasized specialization by physicians, who were themselves to blame if an error was made. Scientific analyses however have shown that 37% of closed malpractice claims did not involve medical errors [15]. Another study also showed that only 17% of the patients who filed claims actually experienced an injury due to negligence [16]. Despite the advances in modern medicine, medical malpractice cases under the transparency and complexities of medicolegal systems have shown no signs of decreasing, not only in Taiwan but also worldwide. The high-risk specialties in Taiwan are obstetrics and gynecology, anesthesiology, and surgery [1, 2, 17]. Plastic surgery ranked fourth in medical malpractice cases, at approximately 9.6%. Physicians in these specialties have responded by refusing or avoiding high-risk patients, by retiring early, and by eliminating high-risk operations [18 21]. Medical disputes obviously outnumber medical malpractice lawsuits in plastic surgery. The medical disputes generally fall into the following categories compared with other specialties: (1) claims related primarily to surgery, not diagnosis, (2) claims related to the subjective outcome, and (3) claims related to the medical service and attitude. In rare cases, the claims relate to adverse reactions to

6 Table 2 Multiple logistic regression analysis of patients entering medical litigation (lawsuits) * p \ 0.05 Variable OR (95% CI) p Value Medical institution type 0.72 Hospital 1 Clinic 1.33 ( ) Age (years) 0.82 B30 1 [ ( ) Marital status 0.58 Divorced * Married 2.29 ( ) Never married 9.33 ( ) Level of education 0.03* Under junior college 1 Junior college and above ( ) Anesthesia type during surgery 0.92 Local anesthesia 1 General anesthesia 0.15 ( ) History of psychological stress or 0.07 psychiatric clinic visit No 7.56 ( ) Information factor (had heard about their 0.13 doctor before seeking the operation) No 0.27 ( ) Economic stress (borrowed money 0.78 to pay for their surgery) No 1.25 ( ) History of at least three previous cosmetic 0.57 operation experiences No 0.65 ( ) Surgeons seniority 0.65 Seniority 1 No seniority 1.44 ( ) Experience with medical litigation 0.73 No 0.72 ( ) Medical insurance 0.91 No 1.42 ( ) anesthesia, injuries at the operation site, or lack of informed consent [22]. With people gradually starting to claim that their medical rights are similar to their consumer rights, all medical specialties should pay more attention to medical disputes in plastic surgery instead of looking only at medical malpractice, as in the past. In our study, the characteristics of most patients engaging in medical disputes, which occur mainly in the first 5 years of a surgeon s practice, were age older than 30 years, divorce or marriage status, experience of surgery under general anesthesia, no economic stress, history of medical litigation, and no eventual suit against the surgeons. First, patients with medical disputes tended to be female patients years of age in both the hospitals and the clinics. Middle-aged females who are not single evidently know how to assert their rights. Age older than

7 30 years was the main feature of patients for medical dispute (p \ 0.001) but not litigation (OR, 3.99; 95% CI, ). Good communication or other efforts may halt the transition from medical dispute to litigation. Second, as demonstrated by Fig. 2, the number of medical disputes decreased significantly as time increased. The chances of medical litigation remained low with good control. It is encouraging to find that medical disputes experienced by surgeons themselves or learning from other colleagues can decrease the possibility of medical disputes. Our study showed that the nationwide trend toward increased medical malpractice cases may be reversible if preventive efforts are drafted correctly in the future. Third, the characteristics of the hospital and clinic patients with medical disputes all matched without any statistically significant difference. Patients in different medical institutions therefore shared similar traits regardless of location, medical institution type, or practice style. Even for the patients who eventually entered into lawsuits, no significant difference between the hospitals and the clinics was found (OR, 1.33; 95% CI, ). Preventive strategies may therefore work equally well in both types of medical institutions. Fourth, for medical disputes, there was no statistically significant difference between whether the patient had heard about their plastic surgeons before seeking the operation or not (p = 0.303). Our result meant that to date, the information factor has not contributed significantly to medical disputes. Clinic patients may thus have no knowledge of the physicians before entering the clinic. They may be following a more aggressive marketing policy through advertisements or other channels. The reasons may be good preoperative communication, detailed informed consent, and the service provided by the clinic [23]. Fifth, our study analyzed the influence of stress on the patients originating from psychological or marital status, operation, and economic problems. Of those who entered medical litigation, only patients with divorced marital status had statistical significance (OR, 9.33; 95% CI, ). Divorced or married status also was a key feature of patients with medical disputes. Marital stress therefore appeared to have a significant influence on the female patients. Psychological stress, however, did not significantly induce medical disputes (p = 0.228) or litigations (OR, 7.56; 95% CI, ), although a high percentage of patients in medical litigations had a history of psychological stress. Previous studies focused mainly on how to increase patient safety and care by the physicians to decrease medical malpractice lawsuits but concluded that this was insufficient [24]. If the patient cannot deal with the stress after the surgery, then when this is combined with the hardship of a difficult relationship, divorce, or other psychological issues, the odds of an unfavorable cosmetic operation turning into a medical dispute become relatively high [25]. Logically speaking, patients with bipolar disorder, borderline personality disorder, and particularly, insomnia may project their emotional stressors onto their appearance and seek treatment through plastic surgery. Based on our results, insomnia is the most prevalent problem among patients with medical disputes. Sixth, economic stress did not significantly influence the occurrence of medical litigation (OR, 1.25; 95% CI, ). Interestingly, most patients with medical disputes had not borrowed money or taken out a loan (p = 0.007). Economic stress is not a strong factor in medical disputes or litigation. Moreover, the patients receiving major operations under general anesthesia were significantly more likely to have a medical dispute (p = 0.001) but not medical litigation (OR, 0.15; 95% CI, ). Economic and operation stress factors therefore have no significant influence on the occurrence of medical litigation. Seventh, the level of education did not have a significant influence on medical disputes (p = 0.763) but was a statistically significant factor for litigation (OR, 10.67; 95% CI, ). This serves as a reminder to us that we should make more efforts to improve pre- and postoperative communication for people with a relatively low level of education. Finally, we looked at the factors related to the experience in both the patients and the surgeons. Our results showed that medical disputes normally occur during the first few years of a physician s practice, when the physician still is relatively young in the field. The seniority of physicians had a significant influence on patients with medical disputes (p = 0.001) but not on the probability of lawsuits (OR, 1.44, 95% CI, ). This fact means that it still is difficult to avoid having a specific part of the population with medical disputes sue the surgeon despite the best efforts. Young physicians may have inadequate surgical skills, ineffective communication strategies (especially during a medical dispute), no experience with medical litigation, and insufficient skill in identifying appropriate patients. All these make medical disputes more likely [26]. Interestingly, almost all the surgeons with medical disputes in Taiwan have no medical malpractice insurance. A relatively low final lawsuit rate was noted in this study, and this may be why surgeons elect not to have insurance. Surgeons in Taiwan should begin to value the importance of medical malpractice insurance because 51.9% of plastic surgeons older than 50 years in the United States have considered rising malpractice costs as a key factor in their decision to retire [27]. On the other hand, patients with no history of medical dispute or litigation still may become involved in a medical dispute (p = 0.001) but not litigation

8 countries with an inquisitorial law system. Plastic surgeons working toward minimizing medical disputes and litigation can take our results into account. References Fig. 4 An algorithm for patients receiving cosmetic surgery (OR, 0.72; 95% CI, ). Patients who have received numerous cosmetic operations also may have the chance to become involved in medical disputes and litigation. Some limitations of this study should be taken into consideration. A larger sample should be used in future studies to provide a look at the characteristics of patients who have not produced a medical dispute. In the future, we should consider the factors related to management methods. Whenever a medical dispute occurs, the correct response is to deal with it immediately instead of running away from it. The priority should be on improving the physician patient relationship and patient safety. Physicians should maintain their professionalism and sincerity and respect their patients final decision even when faced with complaints or arguments [28]. Medical institutions should establish a standard contingency plan to lower their incidence or hopefully prevent them from occurring altogether (Fig. 4). Senior physicians also should share their experiences to educate younger colleagues and decrease the incidence of medical disputes in the system because a student s choice of surgical career depends heavily on his or her role model [29]. In conclusion, it may be possible to prevent lawsuits from occurring if preoperative communication is adequate and key factors related to patient safety and characteristics are identified and handled properly. Our study also provides several key factors for expert testimony to use in 1. Wu CY, Lai HJ, Chen RC (2009) Status of medicolegal problems in Taiwan. Formosan J Med 13: Wu CY, Lai HJ, Chen RC (2009) Patient characteristics predict occurrence and outcome of complaints against physicians: a study from a medical center in central Taiwan. J Formos Med Assoc 108: Sloan FA, Bovbjerg RR, Githens PB (1991) Insuring medical malpractice. Oxford University Press, New York, NY 4. Bal BS (2009) An introduction to medical malpractice. Clin Orthop Relat Res 467: Feldman EA (2009) Why patients sue doctors: the Japanese experience. J Law Med Ethics 37: Hill HF, Read S (2005) Dermatology s malpractice experience: clinical settings for risk management. J Am Acad Dermatol 53: Coleman WP, Hanke CW, Lillis PL (1999) Does the location of the surgery or the specialty of physician affect malpractice claims in liposuction? Am Soc Dermatol Surg 25: Hartz A, Green MD, Yoho R (2006) A new tool for assessing standard of care in medical malpractice cases. Plast Reconstr Surg 117: Clarke JR (2006) How a system for reporting medical errors can and cannot improve patient safety. Am Surg 72: Kessler DP, Summerton N, Graham JR (2006) Effects of the medical liability system in Australia, the UK, and the USA. Lancet 368: Bhattacharyya T, Yeon H, Harris MB (2005) The medical-legal aspects of informed consent in orthopaedic surgery. J Bone Joint Surg Am 87: Tucker WA, McKay BJ (2005) The negative impact of litigation on women s health care. Gend Med 2: Powis SJM (1999) Origin and history of hebrew law. Jones & Barlett, Boston, MA 14. Di Rocco C (2010) Malpractice and medical litigation. Childs Nerv Syst 26: Studdert DM, Mello MM, Gawande AA, Gandhi TK, Kachalia A, Yoon C, Puopolo AL, Brennan TA (2006) Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med 354: Brennan TA, Leape LL, Laird NM (1991) Incidence of adverse events and negligence in hospitalized patients: results of Harvard medical practice study I. N Engl J Med 324: Yang CM, Chiu WT (2006) The risk of malpractice litigation in care to head injury patients in comparison with other high-risk patient groups: an inpatient-based epidemiological study in Taiwan. Surg Neurol 66(S2): Dalton GD, Samaropoulos XF, Dalton AC (2008) Improvement in the safety of patient care can help end the medical malpractice crisis in the United States. Health Policy 86: Maeda S, Sakamoto N, Nobutomo K (2001) The problems of medical malpractice litigation in Japan: the significant factors responsible for the tendency of patients to avoid litigation. Legal Med 3: Hagihara A, Nishi M, Nobutomo K (2003) Standard of care and liability in medical malpractice litigation in Japan. Health Policy 65:

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