Medical malpractice experience of Taiwan: 2005 versus 1991

Internal Medicine Journal 39 (2009) 237 242 ORIGINAL ARTICLE Medical malpractice experience of Taiwan: 2005 versus 1991 C.-Y. Wu, 1 4 H.-J. Lai 5 and R.-C. Chen 5 8 1 Division of Gastroenterology, Taichung Veterans General Hospital, 2 Law Department, Social Science college, Tunghai University and 3 College of Public Health, China Medical University, Taichung and 4 Faculty of Medicine, National Yang-Ming University, 6 En Chu Kong Hospital, 7 Taipei Medical University and 8 Ten Chen Medical Group, Taipei and 5 Center for Health Policy Research and Development, National Health Research Institutes, Miaoli, Taiwan Key words malpractice, prevalence, litigation, settlement. Correspondence Rong-Chi Chen, En Chu Kong Hospital, 399 Fushing Road, Sanhsia, Taipei, 23702 Taiwan. Email: rongchichen@gmail.com Received 20 October 2007; accepted 27 July 2008. doi:10.1111/j.1445-5994.2009.01801.x Abstract Background: Medical malpractice litigation has become an important issue worldwide. Although many epidemiological studies have been carried out, most studies were conducted cross-sectionally in developed countries and focused on malpractice litigation. We conducted nationwide surveys to investigate physicians experiences associated with malpractice in 1991 and 2005, respectively. Methods: By stratified systemic sampling, questionnaires were mailed to physicians in 1991 and 2005. Physicians were asked about the experience of medical malpractice and outcomes of malpractice. The outcomes of the malpractice were classified as resolution, settlement and lawsuit. We also collected physicians demographic and professional characteristics. Results: The prevalence of malpractice experience decreased from 44.1% in 1991 to 36.0% in 2005 (P = 0.004). The estimated annual malpractice claims decreased from 0.14 to 0.10 per physician in 1991 and 2005, respectively (P < 0.001). Physicians 45 64 years of age, obstetrician/gynaecologists and surgeons had significantly higher risk of malpractice. Compared with 1991, malpractice claims in 2005 were more likely to be brought into courts (23.1% in 2005 vs 15.7% in 1991, odds ratio (OR) = 1.48, P = 0.020). In litigation cases, malpractice events in 2005 had more than triple the risk of 1991 to be sued in both civil and criminal courts (12.4% in 2005 vs 4.1% in 1991, OR = 3.31, P < 0.001). Conclusion: Compared with 1991, medical malpractice experiences were decreasing in prevalence, but increasing in severity in 2005. Additional studies, especially among different legal systems, are necessary to confirm these observations. Introduction In past decades, medical malpractice litigation has become an important issue worldwide. Malpractice litigation not only interferes with career satisfaction 1 and increases defensive medicine 2 but also raises social burden of medical care. 3 5 In high-risk specialties, such as obstetrics and gynaecology, nearly all (96%) residents Funding: This work was supported in part by the Department of Health (DOH94-TD-M-113-009) and National Health Research Institutes (HD-096-PP-22, HD-097-PP-22), Taiwan. Potential conflicts of interest: None were concerned about malpractice. Their concerns for malpractice were correlated to emotional exhaustion and inversely correlated to career satisfaction. Concerns about malpractice were also related to their attitudes to pursue fellowship. 1 In a mail survey of physicians in high-risk specialties, as much as 93% of physicians reported practising defensive medicine. 2 In a recent report, malpractice litigation was found possibly adding up to 25% of medical negligence doubly increased from 1998 to 2002. 5 The rising malpractice litigation was observed not only in Western countries, 6,7 but also in Eastern countries, such as Japan and Taiwan. 8 10 Malpractice litigation increased from 102 to 1019 cases between 1960 and 2003 in Japan. 8 The annual number of Journal compilation 2009 Royal Australasian College of Physicians 237

Wu et al. malpractice lawsuits also significantly increased from 0.09 to 0.25 per 100 physicians in 1970 and 1998, respectively. 11 In Taiwan, cases of medical malpractice flagged by judges or prosecutors for authentication increased from 129 cases in 1991 to 455 cases in 2002. 9 Although there have been many epidemiological studies about medical malpractice in the past, several issues continue to exist. First, most studies were crosssectional, the results of which lack the characteristics for a comparison of malpractice in different time frames. Second, most studies focused on malpractice litigation only, but lawsuits alone are too limited for assessing the full impact of malpractice events. To overcome these limitations, we conducted nationwide surveys in Taiwan to investigate physicians medical malpractice experience in 1991 and 2005, respectively. Specifically, we investigated the differences between 1991 and 2005, focusing on occurrence and outcomes of malpractice experience. Patients and methods Study subjects In 1991, a sample of 6411 physicians was drawn from the population of 19 921 physicians who registered in Taiwan Medical Association (TMA). These study subjects were chosen by stratified systemic sampling. We first stratified the physicians according to the county in which they were registered. Then we sorted them by their TMA registration numbers and designated every third physician as a sample case. Before mailing the survey, we published an announcement letter to explain the specific aims of this study and the contents of the questionnaire in the TMA monthly journal to increase response rate. The survey was mailed to selected sampled physicians, along with a letter to explain the aims and the importance of this study. The details of the study design were published as Taiwan s medical practice dispute: current status and management (in Chinese). 10 In 2005, we used the same stratified systemic sampling process as 1991, but designated every five physicians in each stratum to create another sample of 6673 physicians from a population of 33 036 physicians registered in TMA. The same questionnaire as 1991 was mailed to the sampled physicians, along with a letter explaining the aims and importance of this study. The National Health Research Institute ethics committee approved the study. Survey questionnaire An eight-page questionnaire was developed based on the questionnaire of medical malpractice survey by American Medical Association, modified to suit Taiwan s background, including questionnaires to investigate the attitudes of physicians about Taiwan s medical malpractice authentication mechanism, litigation system and malpractice resolution measures. An expert committee examined the questionnaire and provided comments for revision. We pre-tested this questionnaire by interviewing physicians in the targeted strata. The questionnaire was revised again according to the pre-test interview results. In the final version of the questionnaire, medical malpractice experience was defined as a potential malpractice litigation event, either civil or criminal litigation. Respondents were asked about their demographic data, personal experience with medical malpractice, subjective opinions and defensive medicine arising from medical malpractice. In the section of medical malpractice experience, respondents were asked about the frequency of medical malpractice claims within the most recent year and within the last 5 years, whether ever having experienced malpractice since their practice began, the number of malpractice events, patients demographic data, severity of medical injury and outcomes of malpractice claims. The outcomes of the malpractice claims were classified as resolution (no settlement or litigation after mediation), settlement (money paid after mediation) and lawsuit. For each physician, we collected demographic (age, gender) and professional (county or city of practice, specialty, years of practice, and board certification) characteristics. The full text of the questionnaire was published in Taiwan s medical practice dispute: current status and management (in Chinese). 10 Statistical analysis The returned questionnaires were entered into an electronic database and verified by an independent researcher. The demographic characteristics of respondents and total physicians were compared using the c 2 -test. The frequencies of malpractice experience in 1991 and 2005 were compared using the c 2 -test as well. Logistic regression analyses were conducted to evaluate the characteristics of physicians who had malpractice experience in 1991 and 2005.Outcomes of the malpractice experience cases were analysed by logistic regression. Data were analysed by the SPSS programme for Windows 11.0 (SPSS, Chicago, IL, USA). Results Demographic data of respondents and total physicians in 1991 and 2005 In the 1991 survey, among the 6411 sampled physicians, 1131 effective questionnaires (17.6%) were returned. In 238 Journal compilation 2009 Royal Australasian College of Physicians

Malpractice in Taiwan the 2005 survey, among the 6673 sampled physicians, 71 physicians were ineligible because of relocation. 678 physicians (10.3%) answered the questionnaire, not counting the exclusion of these ineligible physicians. Demographic data of respondents and all physicians are shown in Table 1. In the 1991 survey, female physicians and the youngest age group of physicians (25 34 years of age) were less likely to answer the questionnaires. In the 2005 survey, there was no gender difference between respondents and total number of physicians. However, the youngest physicians (physicians 25 34 years of age) still had the significantly lowest rate of response. Frequencies of malpractice experience in 1991 and 2005 In Figure 1, we compared the frequencies of malpractice experience in the 1991 and 2005 surveys. The percentage of physicians who ever experienced malpractice was as high as 44.1% in the 1991 survey, which was significantly higher than the percentage of 36.0% in the 2005 survey (P = 0.004). Under the category of experiencing malpractice within the last 5 years, the 1991 percentage of 26.3% physicians was also significantly higher than the 2005 percentage of 22.1% physicians (P = 0.043). The percentages of experiencing malpractice within the last year were not significantly different in the 1991 and 2005 surveys. According to the results, we estimated annual malpractice events by weighing the number of malpractice events reported. In 1991 and 2005, 2781 and 3451 malpractice events were estimated, respectively. For physicians with malpractice experience within the last year, the annual events decreased slightly, but significantly, from 1.29 to 1.15 events per physician in 1991 and 2005, respectively (P < 0.001). For all physicians, the annual number of malpractice claims also decreased from 0.14 to 0.10 per physician in 1991 and 2005, respectively (P < 0.001). Characteristics of physicians with malpractice experience in 1991 and 2005 In Table 2, we analysed characteristics of physicians with malpractice experience in the 1991 survey. Female physicians had significantly lower odds of malpractice (odds ratio, OR = 0.53, P = 0.043). Compared with physicians who were 25 34 years of age, physicians 35 44, 45 54, 55 64 and 65 years of age or older, had significantly higher risk of experiencing malpractice events (OR = 1.98, P = 0.001; OR = 2.66, P < 0.001; OR = 18.4, P = 0.012; OR = 1.86, P = 0.008, respectively). Malpractice experiences were more frequent in physicians of surgery or obstetrics/gynaecology specialties. Compared with general physicians, obstetricians/gynaecologists had the highest risk of malpractice (OR = 1.76, P = 0.003), followed by surgeons (OR = 1.62, P = 0.011). In 1991, 63.3% surgeons and 68.9% obstetrician/gynaecologists had some sort of malpractice experience. In Table 3, we analysed characteristics of physicians with malpractice experience in 2005. Female physicians did not have a significantly lower risk of malpractice in 2005. Compared with physicians in the youngest age group, physicians 45 54 and 55 64 years of age had a significantly higher risk of experiencing malpractice (OR = 2.27, P = 0.001; OR = 2.46, P = 0.002, respectively). Surgeons and obstetrician/gynaecologists still had a significantly higher risk of malpractice (OR = 1.85, P = 0.045; OR = 2.40, P = 0.004, respectively). In 2005, 56.5% surgeons and 73.2% obstetrician/gynaecologists had some sort of malpractice experience. Outcomes of malpractice experience: 2005 versus 1991 We carried the investigation further into the outcomes of malpractice claims in 1991 and 2005 (Table 4). Compared Table 1 Demographic data of responders and total physicians in 1991 and 2005 1991 2005 Responders (n = 1131) Total physicians (n = 19 921) P-value Responders (n = 678) Total physicians (n = 33 036) P-value Gender, n (%) Male 1070 (94.6) 18546 (93.1) 0.303 578 (85.3) 28909 (87.5) 0.268 Female 54 (4.8) 1375 (6.9) 0.003 88 (13.0) 4127 (12.5) 0.356 Unknown 7 (0.6) 12 (1.8) Age in years, n (%) 25 34 149 (13.2) 4960 (24.9) <0.001 123 (18.1) 8527 (25.8) <0.001 35 44 409 (36.2) 5797 (29.1) <0.001 217 (32.0) 10957 (33.2) 0.305 45 54 209 (18.5) 2410 (12.1) <0.001 184 (27.1) 7768 (23.5) 0.029 55 64 169 (14.9) 3108 (15.6) 0.295 86 (12.7) 3196 (9.7) 0.008 >65 181 (16.0) 3646 (18.3) 0.037 51 (7.5) 2588 (7.8) 0.395 Unknown 14 (1.2) 17 (2.5) Journal compilation 2009 Royal Australasian College of Physicians 239

Wu et al. P = 0.004 P = 0.043 settlement amount ( US$30 000) was higher in 2005, although not statistically significant (OR = 1.67, P = 0.177). P = 0.145 Ever Last 5Y Last 1Y Figure 1 Frequencies of malpractice experience in 1991 and 2005 (ever experienced, experienced in last 5 years and in last 1 year). with 1991, malpractice events in 2005 were more likely to be brought into courts (23.1% in 2005 vs 15.7% in 1991, OR = 1.48, P = 0.020). In litigation cases, malpractice claims had more than triple the risk of being sued in both civil and criminal courts in 2005 than in 1991 (12.4% in 2005 vs 4.1% in 1991, OR = 3.31, P < 0.001). Among malpractice claims that did not reach litigation stage, 49.8 and 45.4% were resolved with settlement in 1991 and 2005, respectively. The settlement amounts paid in these cases were similar in 1991 and 2005, except the likelihood of receiving median amount of settlement (US$3000 30 000) was significantly lower in 2005 (OR = 0.63, P = 0.011). The likelihood of receiving a large Discussion In the present study, we systematically compared physicians malpractice history in 1991 and 2005. Several findings are noteworthy. First, physicians 25 34 years of age were less likely to answer the questionnaires. Second, the percentage of physicians ever having experienced malpractice events was significantly lower in 2005 compared with the percentage in 1991. The annual number of malpractice claims for all physicians or physicians with malpractice history also decreased significantly. Third, the highest risk populations with malpractice in 1991 were physicians 35 44 and 45 54 years of age; however, the highest-risk population in 2005 were physicians 45 54 and 55 64 years of age. Fourth, surgeons and obstetrician/gynaecologists had a significantly higher risk of malpractice in both 1991 and 2005. Fifth, malpractice claims in 2005 were more likely to be brought to trial, as there was more than triple the risk to be used in both civil and criminal courts. Nearly all the physicians 25 29 years of age in Taiwan were residents or serving in the armed forces, which may contribute to their lower response rate because of higher likelihood of changing contact addresses, being busier than other age groups in subspecialty preparation, or developing medical careers and so on. For physicians Table 2 Characteristics of physicians with malpractice experience in 1991 Total responders (n = 1131) Malpractice experience (n = 499) Odds ratio (95%CI) P-value Gender, n (%) Male 1070 (94.6) 483 (96.8) 1 Female 54 (4.8) 13 (2.6) 0.53 (0.26 1.00) 0.043 Unknown 7 (0.6) 3 (0.6) Age, n (%) 25 34 149 (13.2) 34 (6.8) 1 35 44 409 (36.2) 185 (37.1) 1.98 (1.30 3.09) 0.001 45 54 209 (18.5) 127 (25.5) 2.66 (1.70 4.24) <0.001 55 64 169 (14.9) 71 (14.2) 1.84 (1.13 3.02) 0.012 65 181 (16.0) 77 (15.4) 1.86 (1.15 3.05) 0.008 Unknown 14 (1.2) 5 (1.0) Specialties, n (%) General physician 282 (24.9) 110 (22.0) 1 Internal medicine 271 (24.0) 114 (22.8) 1.08 (0.78 1.49) 0.636 Paediatricians 149 (13.2) 60 (12.0) 1.03 (0.70 1.52) 0.924 Surgeons 120 (10.6) 76 (15.2) 1.62 (1.11 2.37) 0.011 Obstetricians and gynaecologists 109 (9.6) 75 (15.0) 1.76 (1.20 2.59) 0.003 Others 177 (15.6) 54 (10.8) 0.78 (0.53 1.16) 0.221 Unknown 23 (2.0) 10 (2.0) CI, confidence interval. 240 Journal compilation 2009 Royal Australasian College of Physicians

Malpractice in Taiwan Table 3 Characteristics of physicians with malpractice experience in 2005 Total responders (n = 678) Malpractice experience (n = 244) Odds ratio (95%CI) P-value Gender, n (%) Male 578 (85.3) 215 (88.1) 1 Female 88 (13.0) 23 (9.4) 0.70 (0.41 1.16) 0.168 Unknown 12 (1.8) 6 (2.5) Age in years, n (%) 25 34 123 (18.1) 25 (10.2) 1 35 44 217 (32.0) 73 (29.9) 1.66 (0.98 2.87) 0.052 45 54 184 (27.1) 85 (34.8) 2.27 (1.35 3.92) 0.001 55 64 86 (12.7) 43 (17.6) 2.46 (1.35 4.52) 0.002 65 51 (7.5) 11 (4.5) 1.06 (0.44 2.44) 0.844 Unknown 17 (2.5) 7 (2.9) Specialties, n (%) General physician 164 (24.2) 50 (20.5) 1 Internal medicine 169 (24.9) 61 (25.0) 1.18 (0.75 1.87) 0.511 Paediatricians 76 (11.2) 19 (7.8) 0.82 (0.43 1.53) 0.556 Surgeons 46 (6.8) 26 (10.7) 1.85 (0.99 3.41) 0.045 Obstetricians and gynaecologists 41 (6.0) 30 (12.3) 2.40 (1.30 4.39) 0.004 Others 169 (24.9) 52 (21.3) 1.01 (0.63 1.61) 1.000 Unknown 13 (1.9) 6 (2.5) CI, confidence interval. 30 34 years of age, the response rate was similar to other age groups. Furthermore, physicians who have experienced malpractice events are more likely to have motivation to answer the self-report questionnaires. Selection bias towards the high-risk population cannot be excluded in this study. Similarly lower response rate was observed in female physicians in 1991, whereas female physicians had a significantly lower risk of malpractice experience in 1991. The lower response rate and less frequent malpractice experience for female physicians in 1991 may be related to the significantly lower female : male physician ratios of surgery or obstetrics/gynaecology specialties. In Table 4 Outcomes of malpractice experience: 2005 versus 1991 1991 (n = 1117) 2005 (n = 338) Odds ratio (95%CI) P-value Results, n (%) Resolved 473 (42.3) 142 (42.0) 1 Settled 469 (42.0) 118 (34.9) 0.84 (0.63 1.11) 0.234 Litigation 175 (15.7) 78 (23.1) 1.48 (1.05 2.08) 0.020 Litigation, n (%) No litigation 942 (84.3) 260 (76.9) 1 Civil litigation 31 (2.8) 14 (4.1) 1.64 (0.79 3.22) 0.143 Criminal litigation 98 (8.8) 22 (6.5) 0.81 (0.48 1.33) 0.483 Both 46 (4.1) 42 (12.4) 3.31 (2.07 5.26) <0.001 Settlement, n (%) No settlement 473 (50.2) 142 (54.6) 1 <US$3000 188 (20.0) 58 (22.3) 1.03 (0.71 1.47) 0.878 US$3000 30 000 259 (27.5) 49 (18.8) 0.63 (0.43 0.91) 0.011 US$30 000 22 (2.3) 11 (4.2) 1.67 (0.71 3.69) 0.177 CI, confidence interval. 2005, the female : male ratios increased in these specialties, which could be the reason to explain why the gender difference became non-significant in 2005. Inconsistent with previous reports, surgeons became non-significant in 2005. Inconsistent with previous reports, surgeons and obstetrician/gynaecologists remained the highest risk of malpractice both in 1991 and 2005. In contrast to the assumption that malpractice events are increasing, we found the prevalence of malpractice experience and the estimated annual malpractice events were decreasing, not only for all physicians, but also for physicians with malpractice history. However, the likelihood of malpractice experience increased for physicians of high-risk specialties. Compared with general physicians, and odds ratio of malpractice experience increased from 1.67 in 1991 to 2.40 in 2005 for obstetrician/ gynaecologist and increased from 1.62 in 1991 to 1.85 in 2005 for surgeons. Although malpractice experience and estimated malpractice events were decreasing, the outcomes of malpractice claims became more severe during the same period. The likelihood of malpractice claims to reach litigation significantly increased from 15.7% in 1991 to 23.1% in 2005. Furthermore, the likelihood to be sued both civilly and criminally significantly increased from 4.1% in 1991 to 12.4% in 2005. The median amount of settlement decreased from 27.5% in 1991 to 18.8% in 2005, but large amounts of settlement increased from 2.3% in 1991 to 4.2% in 2005. Compared with 1991, once malpractice events occurred, physicians in 2005 faced a higher risk of litigation, a higher risk to be used Journal compilation 2009 Royal Australasian College of Physicians 241

Wu et al. both civilly and criminally and a higher risk of paying higher amount of settlement. There are several limitations in our study. First, it is a self-report mail survey. Although we used a systematic sampling method to avoid selection bias, physicians with malpractice experience were more likely to have motivation to respond. Selection bias and recall bias could not be excluded. Second, the response rates were low, although we announced a letter in advance to emphasize the importance of the survey and used a secondary follow-up survey to improve the response rate. The low response rates make generalization of the results questionable. However, the present study will, nonetheless, provide invaluable evidence about the developing trends of malpractice. Third, we did not investigate other physicians characteristics reported to be associated with malpractice litigations, such as previous claims history, 12 higher caseload and lower patient satisfaction. 13,14 Conclusion In conclusion, our study provides the first evidence to compare systematically physicians malpractice experience across a decade. We found that the trends of malpractice experience were decreasing in prevalence, but increasing in severity. Additional studies, especially among different legal systems, are necessary to confirm these observations. References 1 Becker JL, Milad MP, Klock SC. Burnout, depression, and career satisfaction: cross-sectional study of obstetrics and gynecology residents. Am J Obstet Gynecol 2006; 195: 1444 9. 2 Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA 2005; 293: 2609 17. 3 Studdert DM, Mello MM, Brennan TA. Medical malpractice. N Engl J Med 2004; 350: 283 92. 4 Roberts B, Hoch I. Malpractice litigation and medical costs in Mississippi. Health Econ 2007; 16: 841 59. 5 Kessler DP, Summerton N, Graham JR. Effects of the medical liability system in Australia, the UK, and the USA. Lancet 2006; 368: 240 46. 6 Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370 76. 7 Mello MM, Hemenway D. Medical malpractice as an epidemiological problem. Soc Sci Med 2004; 59: 39 46. 8 Sasao S, Hiyama T, Tanaka S, Mukai S, Yoshihara M, Chayama K. Medical malpractice litigation in gastroenterological practice in Japan: a 22-yr review of civil court cases. Am J Gastroenterol 2006; 101: 1951 3. 9 Wu CY, Chen RC. Department of Health Research Report: Empirical Study of How Evidence-Based Medicine influences Medical Malpractice authentication System. Taiwan Department of Health; Taichung, Taiwan; 2005 Nov. 10 Chen RC. Taiwan s Medical Malpractice Dispute: Current Status and Management (in Chinese). Taipei, Taiwan: Health World Co. Ltd.; 1993. 11 Nakajima K, Keyes C, Kuroyanagi T, Tatara K. Medical malpractice and legal resolution systems in Japan. JAMA 2001; 285: 1632 40. 12 Bovbjerg RR, Petronis KR. The relationship between physicians malpractice claims history and later claims. Does the past predict the future? JAMA 1994; 272: 1421 6. 13 Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld-Jaeger J, Bost P. Patient complaints and malpractice risk. JAMA 2002; 287: 2951 7. 14 Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. AmJMed2005; 118: 1126 33. 242 Journal compilation 2009 Royal Australasian College of Physicians