Targeting Substandard Care

According to the Bush administration, tort reformis the primary tool to fix the country's medicalmalpractice crisis, which has many physicianscutting back on high-risk areas of their practice, migratingto states that have acted to rein in runaway litigation,or simply quitting the medical profession entirely.But according to a study commissioned by the federalgovernment, identifying and disciplining doctors whoare prone to making medical errors would also go a longway toward alleviating the problem.

The study, conducted by the University of Iowa andthe Urban Institute, concluded that more aggressivepolicing of incompetent doctors and more effective discipliningof those who engage in substandard care couldsignificantly cut back on the number of malpractice suits.

Easier Said than Done

Getting state medical boards to be more assertivewith incompetent doctors may not be so easy. Boards aretypically hamstrung by skimpy budgets and small, overworkedstaffs handling thousands of complaints. In all,state medical boards fielded more than 5200 complaintsin 2003, up 7% from the previous year and up 41% froma decade earlier.

Revoking a physician's license may take years and costthousands of dollars, especially if the case goes to a hearingin front of the entire board. Some medical boardmembers also note that disciplining a doctor based onincompetence is not without difficulty. Most disciplinaryactions against doctors do not, in fact, stem from allegationsof substandard care, but from criminal conduct,drug or alcohol abuse, sexual misconduct, or otherunprofessional behavior.

Hardball in the Bay State

In Massachusetts, the Board of Registration in Medicinehas taken a proactive approach to the problem.Recognizing that fewer than 100 of the more than 37,300licensed doctors in the state account for more than 13%of the malpractice payments, the board now routinelyperforms a clinical review of any doctor who has paidthree or more malpractice judgments to patients.

The Massachusetts board's approach, aimed at identifyingdoctors who provide substandard care, highlightsone of the most difficult aspects of policing medicalcare. A report by the American Association of Critical-Care Nurses (www.aacn.org) concluded that 80% of doctorsand almost 66% of all nurses fail to report or confrontcolleagues they see performing substandard care.The survey, which covered 1700 nurses, doctors, and clinicalcare staff, also showed that 88% of doctors and nearly50% of the nurses say they work with colleagues whodemonstrate poor clinical judgment, yet only 10% ofthose surveyed confront the colleague involved.