and trains physicians to be better defendants in the event of a claim.6 Risk-management education courses are

346 Articles Role of Previous Claims and Specialty on the Effectiveness of Risk-Management Education for Office-Based Physicians PAUL R. FRISCH, JD, Portland, Oregon; and SARA C. CHARLES, MD; ROBERT D. GIBBONS, PhD; and DONALD HEDEKER, PhD, Chicago, Illinois We analyzed the medical malpractice claims data of 1,903 physicians between 1981 and 1990 to assess the efficacy-a reduced incidence of future claims and decreased payout in the event of a claimof risk-management education for office-based physicians. Physicians were participants in the Oregon Medical Association's medical liability program and represented all recognized specialties and all geographic areas of the state. Each physician's claim and payout history before and after 4 sequential riskmanagement education programs was entered into a random-effects probit model that allowed for a longitudinal rather than a cross-sectional analysis. For most physicians, there was increased claim vulnerability following 1 or 2 risk-management education courses but decreased vulnerability after additional courses. Among all physicians, having a previous claim substantially increased the risk for a future claim. Risk for an additional claim doubled (from 7% to 14%) for physicians who had a claim in the previous year. Of all specialists who have had claims, anesthesiologists (reduction in claims incidence from 18.8% to 9.1% and in payout from 14.6% to 5%) and obstetrician-gynecologists (reduction in claims incidence from 23.3% to 15.2% and in payout from 11.6% to 4.2%) benefit most from cumulative risk-management education. (Frisch PR, Charles SC, Gibbons RD, Hedeker D: Role of previous claims and specialty on the effectiveness of risk-management education for office-based physicians. West j Med 1995; 163:346-350) T he role that physicians play in the generation of medical malpractice claims is a subject of continuous debate. Why do some physicians experience one or more claims during their careers and other physicians have none? The central question is whether or not identifiable aspects of office-based practice are associated with increased vulnerability to claims. For example, physician characteristics such as surgical specialty,`3 male sex,' and years in practice associated with increasing age3 all have been linked with an increased risk of claims. A history of a previous claim also has been associated with having future claims."4,' Whether this last association can be attributed to deficiencies in practice, underlying and unobservable physician characteristics, or some other factor is unclear. The presumption among risk managers, however, is that certain controllable events in practice render a physician more or less vulnerable to malpractice claims. For more than a generation, risk-management education (RME) courses have focused on such events in physicians' practices. Often sponsored by insurers, RME teaches physicians how to exert control over their practices and avoid incidents that cause injuries to patients and trains physicians to be better defendants in the event of a claim.6 Risk-management education courses are increasingly based on a review of closed claims and, as such, are increasingly specialty-specific. Although RME enjoys considerable economic and legislative support, its influence on preventing claims has not been studied extensively.`'9 A reduction in the incidence of hospitalbased claims associated with in-house risk management and quality assurance programs has been shown,10 but studies have not been done of the effectiveness of RME programs on office-based practitioners. To assess the efficacy of RME for office-based physicians in reduced claims incidence and decreased payout in the event of a claim, our group applied a statistical model described previously" and that differs from those used by other medical malpractice researchers.42"-4 The analysis was based on available claims histories for physicians over a ten-year period and on the amount of payout for each claim. Using longitudinal data, we were able to estimate static effects (specialty and sex) and From the Oregon Medical Association (Mr Frisch) and the Departments of Psychiatry (Drs Charles and Gibbons) and of Biometry (Drs Gibbons and Hedeker), University of Illinois at Chicago. This study was done with the support of the Doctors Company, Napa, Califomia, and the Oregon Medical Association, Portland. Reprint requests to Paul R. Frisch, JD, Oregon Medical Association, 5210 SW Corbett Ave, Portland, OR 97201.

WJM, WIMOcoeI October 1995-Vol 95Vl13 163, No. o 4 Risk-Management e teuainfic Education-Frisch etaal 3474 R s - a a e dynamic effects (those that change over time such as age, previous claim history, and RME courses), illuminating the influence and relative strength of some dynamic factors on vulnerability to claims rather than examining the issue over a fixed time interval, as in cross-sectional studies. Data Set The study sample consisted of 1,903 physicians representing 16,083 practice years insured under the Oregon Medical Association's malpractice liability insurance program between 1981 and 1990. All recognized specialties and all geographic areas in the state were represented. Information on each subject was obtained from several databases from the medical society. A malpractice claims database provided each physician's claims history, disposition (closed with payment, closed without payment, and open), and the amount of any award or settlement. The membership database provided age, sex, specialty, and dates of attendance at four sequential RME courses (described in Figure 1) developed and offered by the state medical society. Only written demands for money or services were counted as claims. The date of the claim used in this study is the date of the alleged injury, which bears a direct relationship to the usefulness of RME intervention. This definition is distinguished from the date the claim was reported to the insurance carrier or when a suit was filed. Statistical Methods The Oregon data (1981 to 1990) on medical malpractice claims was analyzed using a random-effects probit model."' The model estimates vulnerability to a medical malpractice claim in each practice year for each physician conditional on a mixture of time-varying and time-invariant covariates. In this application, timeinvariant covariates were physician's sex and specialty (surgical versus nonsurgical). Time-varying covariates were age, the number of RME courses taken by physician i to year k, and previous claim history. In addition, the model incorporates a random effect of "claim vulnerability," assumed to be normally distributed in the population of physicians. This random effect represents unobservable or unmeasured characteristics that place one physician at a greater risk for expenencing a malpractice claim than another physician. In addition, we determined whether the effects of RME on claim vulnerability differ before and after a physician's first malpractice claim. More detailed discussion of the strengths and weaknesses of the random-effects probit model are provided elsewhere, including a discussion of robustness to violations of assumptions." In the past, Poisson process models have been used to analyze claims incidence data.4,"-4 Using Poisson process models, however, we could have examined only the relationship between the total amount of RME courses and the total number of claims for the entire Risk-Management Education Course Description Workshop Series One: 1979-1981 All participants during this period attended the same workshop, the purpose of which was to develop statewide a common medicolegal lexicon and an understanding of the state's medical malpractice statutes and case law. Particular emphasis was placed on the process of obtaining informed consent, the importance of not inappropriately altering medical records, and how to report and respond to malpractice claims. Workshop Series Two: 1982-1984 The medical society created on videotape and introduced a series of vignettes to illustrate key nonclinical communications concerns that frequently turned unexpectedly bad outcomes into claims. The medicolegal lexicon, case law, and claims handling segments were updated. Workshop Series Three: 1985-1987 For the first time, the society bifurcated its RME programs. Those who attended the first and second series received advanced training building on the second series program segments. Physicians new to the sponsored liability insurance program received an updated, though simplified, version. Most important, the society offered specialty-specific versions of the advanced workshop to obstetrician-gynecologists, family physicians doing obstetrics, and anesthesiologists, all under the joint sponsorship of the respective state specialty societies. Workshop Series Four: 1988-1990 At this point, two distinct programs emerged. "Basic Training in Malpractice Loss Prevention" became the society's entry-level RME course. It encompassed updates of the segments discussed in the previous series of programs. An advanced course, "From the Exam Room to the Courtroom," taught physicians to assist effectively in the defense of their claims. Updates on state statutory and case law and current claims trends were included. Specialty-specific versions of the advanced course were offered to anesthesiologists, family physicians, general surgeons, orthopedists, radiologists, and pathologists. Also during this period, all physicians and hospitals involved in obstetrics agreed to the use of a Uniform Prenatal Form to document patient care. In addition, anesthesiologists who follow their national specialty society's intraoperative monitoring guidelines received substantial premium discounts, in the form of reductions in rate classification, signifying a corresponding decrease in risk exposure. Figure 1.-The risk-management education (RME) courses developed by the Oregon Medical Association's Loss Prevention Education Program are described.

348 WJM, October 1995-Vol 163, No. 4 6,N.4Rs-aaeetEuainFic Risk-Management Education-Frisch ettaal ~ ~ ~ ~ study period, regardless of whether or not RME preceded a claim. The model used in the analysis of these longitudinal data examines the effects of measured and unmeasured physician characteristics on the probability of a claim in each practice year. Claim propensity is allowed to vary randomly from physician to physician. Because we focus on the probability of a claim in each individual year and not the rate over the entire period, we can directly examine the effects of physician characteristics that vary from year to year-the effect of having a claim in the previous year on the probability of having a claim in the current year. Perhaps of greatest importance in this article is determining the effect of RME courses taken before year t on claim propensity in year t. In this way, we compare claim proneness before and after RME in the same physician. Results Efficacy ofrisk-management Education Applying the final statistical model to ten years of malpractice claims data shows that efficacy-decreased vulnerability to claim and decreased payout-of RME is related primarily to previous claims history and to specialty. The effects of RME are both linear (P <.01) and quadratic (P <.0 1), with claims vulnerability following one or two courses increasing for most physicians but decreasing with additional courses. Risk-Management Education and Previous Claims Experience A significant age-by-rme interaction was observed in the earlier models, indicating that as physicians age, they benefit more from RME than when they were younger (P <.01). When a history of a previous claim and the quadratic effects of age and RME were added to the statistical model, the RME-by-age interaction was no longer significant, but RME by previous claim remained statistically significant (P <.01). Cumulative RME, therefore, was associated with lower vulnerability and fewer payouts significantly more often for physicians who had a previous claim than for those who had never had a claim, regardless of age. Claims Vulnerability and Specialty The surgical and nonsurgical specialties were further subdivided into eight categories and added to the model (Table 1). Differences between specialties were significant (P <.01). For those physicians who have never had a claim, cumulative RME has a limited, even adverse, effect. In contrast, the cumulative effect of RME on those physicians with previous claims remains beneficial in terms of decreased vulnerability to claims and decreased payout (P<.01). Anesthesiologists have an increased vulnerability to claims after two or more courses but decreased payout if a physician has had no previous claims. Once a physician TABLE 1.-Observed Yearly Claim and Payout Incidence Per Specialty, Influenced by Number of Risk-Management Education (RME) Courses and History of Previous Claims (Yearly Percentage Risk to a Physician) Before ist Claim Aftes- 1st C!airn RME All All Swecic!1y Coalses Clir.,s Pcayou"t c/a.nts PayoLt Anesthesiology 0 9.2 2.9 18.8 14.6 1 8.0 4.5 7.0 4.7 >2 12.3 1.5 9.1 5.0 Radiology 0 7.6 1.7 9.3 0.4 1 12.0 3.3 7.1 2.7 >2 5.9 1.5 5.8 1.4 Obstetrics.0 11.5 3.5 23.3 11.6 1 17.8 7.4 19.8 7.0 >2 13.5 8.1 15.2 4.2 Primary care... 0 5.1 1.5 8.9 3.1 1 5.4 2.2 9.2 3.6.2 5.5 1.4 5.7 1.5 Medical... 0 3.3 0.8 6.7 1.1 1 6.4 1.0 7.4 1.6 >2 3.6 0.8 4.5 1.7 Surgerv.... 0 6.4 1.1 14.0 4.1 1 11.4 4.4 15.0 4.2 >2 7.8 2.3 8.9 2.5 Special surgery... 0 9.5 3.1 1 3.8 5.9 1 10.9 4.8 20.2 5.2 >2 1 3.1 1.6 15.7 3.7 Other.0 1.8 0.5 8.3 1.4 1 5.7 3.1 6.1 1.5 >2 4.2 0.0 3.1 1.6 'SIltes vvere rkr or, tole kociets sne'r i3e-. ceionativs ri0tinq alnn grouri:i cr risk expaosro puridl>sr as fowlos: s e, ai ars> h ogy and obstetrica arreotrrsiiioiog; R~do'oio diirii.:ic redo n.o herpi>li0 rscirongy arci ultrasonrorraphy; urics,-»r.'' olhtetrics, olrs>e:-rics-i,i>x.olojof Pr: sir': Price. csereral p0racice, ntewr, rl dcir dain edi a r s.'s aceoitc i)i >,.u erg a ni InIruio, cardiology.: crilicai care niedicintr s rrdiovrscu!jr disease, dririrrstolosgo diaoetes, edrdocriirology, epileprsy gastroerrteiolog..nedical genet,cs, irfect(00sdiseases, ilrllullotog, rniaierilla eta redoicn. r'i CeL roloct, n> orr nccr.c o >Jim.r vdisease, r-eprclduct ive errcorrrfolgogrou!tlo0l0a(civa0isciirlarc r me ci id. re in rgerr ernercgemlc r, edicirre gyo cloc.g', maxiofa sa rgero> ophthalmologyoc orir orireary, oto.arrrygoiogy, pediatric sloqer\n pils'icrs. rgero prota rger rrolo r, t s! wors; car'idi c s}urgero,'\ riewrn~r r slcgerxz horiredi. s arae.o ort irserjoecics tsrtesoo no. horacoc sl;rgero, - caisr IrsLo,er O aacohol chem :cs ileperodence, ibiochiemriti. orilca developrment. child psvc0iatryr c icai par.orogys dermatopathology, geriatrics. lireiatology, irospita admirisrration,r o nero c 'no icirre lega -nedicorcciiiical 'Lition, occuparonal nrrd rine, natitholo"ia pen 'tricsphar!nt.og(0 ooj. 'sl5 mdcio nr -eab3 r:aic'ro, prreevertive medclre psyciiiatri- psycnori,.sis, psychiosorlaticinedicine, a d DUblic -ealtr. 'TRelative to "Otheri specialtiesi al but, rriedica! subspec alties sllowrvd significatit dtfferenrces at.001 or 05.S has incurred a claim, cumulative RME is associated with dramatic decreases in claim vulnerability and payout. Among obstetrician-gynecologists who have never had a claim, cumulative RME is associated with increased vulnerability and payout. Following a claim, however, cumulative RME is associated with a decrease in vulnerability and payout almost as dramatic as that noted among anesthesiologists. Surgeons have a profile somewhat similar to anesthesiologists and obstetrician-gynecologists but to a less dramatic degree. Special surgeons show a unique pattern among the specialties. Risk-management education, regardless of previous claims history, appears to decrease payout despite a persistent increased vulnerability to claims.

WIM. ctobe 1 WJM, October 1995-Vol 163, No. 4 Risk-Management Education-Frisch et al 349 99-Vot63, o. 4 isk-mnagemnt Edcatio-Frish et l 34 For primary care physicians who have never had a claim, RME minimally affects claims vulnerability or payout. After sustaining a claim, both are positively influenced. Medical specialists appear similar to primary care practitioners, except that they show a slight increase in payout when they have had both a previous claim and increased RME. Among radiologists, RME contributes to some decreased vulnerability to claims in those with or without a previous claim. Risk-management education, however, appears to have little effect or even an adverse effect on payout. Among all other specialties, RME is associated with an increased vulnerability to claims if a physician has no previous claims history and a decreased vulnerability to claims if the physician has a previous history of claims. Risk-management education appears to have little effect on payout. Other Factors Contributing to Vulnerability to Claims Surgical specialty (P <.01) and male sex (P <.01) contribute significantly to whether or not a physician has a claim. Age is significantly correlated with a vulnerability to claims, and the correlation of age to vulnerability increases with advancing age (P <.01). The effect of age is quadratic; that is, the observed incidence of claims trends upward and then tapers off so that the incidence of claims is highest between the ages of 40 and 60. A history of previous claims among all physicians of all ages and specialties significantly increased the risk for future claims (P <.01). The risk for an additional claim doubled, from 7% to 14%, for physicians who had a claim in the preceding year. In addition, there is a significant random physician effect or heterogeneity (P <.01). This means that a vulnerability to claims is at least partially attributable to individual physician characteristics not measured and, perhaps, not observable. Discussion At first glance, RME for office-based physicians appears to be more detrimental than helpful. That is, the more RME physicians receive, the more vulnerable they are to future claims. We do not know why RME fails to benefit most physicians who have never had a claim or why it may even increase their risk for future claims. Physicians who have never had a claim may use the psychological defense mechanisms of denial, rationalization, or both to protect them from feeling vulnerable to a claim. This means that they would either be able to remain unaware of the possibility of a claim or have a "good reason" why they are not vulnerable to a claim. In practice, therefore, such physicians would dismiss the possible malfunctioning of anesthetic equipment as an impossibility or think, "I have good relationships with my patients, so I don't need to worry about malpractice claims." Such psychological maneuvering, while largely unconscious and minimizing anxiety, may simultaneously "demotivate" the physician and remove any interest in or felt need for RME education. In this instance, the physician is also effectively impervious to educational interventions and therefore inhibited from introducing changes into practice. Conversely, the structure and content of the RME courses may be at fault. As noted, courses were initially general in nature and predominantly nonclinical; only later courses were targeted to specialty-specific clinical problems (see Figure 1). Nonetheless, the beneficial effects of RME for most specialists emerge after a claim occurs. We hypothesize that the emotionally disturbing and intensely human event of having a claim brought renders physicians more amenable to introducing changes into their practice than if they have not experienced a claim. In addition, the undeniable and sobering experience of litigation impresses on physicians the importance of risk-management strategies in preparing a defense of their case. Beneficial Effects ofrisk-management Education Risk-management education appears more beneficial in decreasing vulnerability to claims and decreasing payout for some specialists than for others. Anesthesiologists appear to benefit most from RME. This may be a function of the risk-management strategies specific to the specialty, such as the American Society of Anesthesiologists' intraoperative guidelines, which largely involve the use and maintenance of specific types of equipment.'" Risk-management education for obstetricians and gynecologists, another group that appears to benefit from instruction, also involves specific indicators, checklists, and procedures, such as the Oregon Uniform Prenatal Form, in given clinical situations. Checklists and procedural forms may involve more concrete "things to do" than attempting to change a range of less easily identifiable and controllable behaviors, such as personal attitudes and the range of interactions that occur between physicians and their many patients. Of particular interest are physicians who practice special surgery. Cumulative RME is associated with decreased payout if claims occur but does not result in measurable decreased claim vulnerability. This suggests that RME enables them to be "good" defendants; that is, they have good records, have had good communication with staff and patients, and have implemented effective office procedures, all of which make these physicians easier to defend. Nonetheless, special surgeons remain vulnerable to claims because their work is predominantly high risk, often with severely ill or injured patients.3 Timing ofrisk-management Education A particularly disturbing finding is that physicians who experience a claim are twice as likely as those who do not to have an additional claim in the next 12 months. It may be that a personal event not directly related to

350 WJM, October 1995-Vol 163, No. 4 Risk-Management Education-Frisch et al clinical medicine, such as marital discord, a breakup of a practice, or some similar stress-producing event, renders a physician "at risk" during the period before and after the critical claim incident. It is also possible that the event that led to a claim was itself so psychologically disturbing that it induced physical and psychological disequilibrium and may have jeopardized the physician's ability to practice optimally during the period following the event. There is considerable research and anecdotal data to support this last hypothesis."6"7 An unpublished review of claims data over a ten-year period underscores our findings (T. Passineau, Physicians Insurance Company of Michigan [PICOM], unpublished data, June 1994). The author noted that the risk for a subsequent claim increases for a physician within 12 months, especially during the first 6 months immediately following a claim. These findings also suggest that RME might be more effective for physicians if educational interventions can be accomplished within the year immediately following a claim, preferably within the first six months. This would also be an advantageous time to offer social support and similar strategies to diminish the emotional and physical repercussions of litigation. Future Claims Trends and Risk-Management Education In this study, surgical specialty is the most significant predictor of claim vulnerability, consistent with the view that surgeons in hospitals are more vulnerable to claims than their nonsurgical colleagues. Our study, however, tracks claims trends during a decade when procedures were predominantly done in hospitals by surgeons. The most recent claim trends suggest a shift to more claims arising in outpatient settings, in addition to hospitalbased surgery claims, against primary care physicians that allege failure to diagnose cancers and heart disease as well as medication-related errors.'8 Furthermore, as health care reform efforts place greater emphasis on primary physicians as gatekeepers, the vulnerability of surgical specialists may be displaced to primary care physicians. Although not yet subjected to statistical analysis, the shift in settings may alert risk-management educators to track these trends carefully and update their activities accordingly because there are fewer beneficial effects of RME for primary care physicians than for the more procedurally oriented specialists. Updating might include identifying and developing risk-management activities that enable primary care physicians to "do" things such as following up on missed or canceled appointments or referrals, documenting telephone calls from and to patients, and instituting office processes and procedures to track prescribed and refilled medications. REFERENCES 1. Sloan FA, Mergenhagen PM, Burfield WB, Bovbjerg RR, Hassan M: Medical malpractice experience of physicians: Predictable or haphazard? JAMA 1989; 262:3291-3297 2. Brennan TA, Leape LL, Laird NM, et al: Incidence of adverse events and negligence in hospitalized patients-results of the Harvard Medical Practice Study. N Engl J Med 1991; 324:370-376 3. Charles SC, Gibbons RD, Frisch PR, Pyskoty CE, Hedeker D, Singha NK: Predicting risk for medical malpractice claims using quality-of-care characteristics. West J Med 1992; 157:433-439 4. Nye BF, Hofflander AE: Experience rating in medical professional liability insurance. 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Martin CA, Wilson JA, Fiebelman ND 3d, Gurley DN, Miller TW: Physicians' psychologic reactions to malpractice litigation. South Med J 1991; 84:1300-1304 18. Annual Report. St Paul, Minn, St Paul Fire and Marine Insurance Company, 1992