Future Fears

 Medical Students Antsy About Liability Climate That Awaits Them

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Medical Education Feature -- March 2004

By  Ken Ortolon
Senior Editor

America's medical students are increasingly anxious about the threat of lawsuits that will hang over them when they graduate and begin practicing medicine. That anxiety could spell bad news for the availability of skilled physicians in specialties hardest hit by the nation's medical liability crisis.

At least two recent surveys show that medical students across the country believe medical liability is a crisis, and it's affecting their decisions on taking up a high-risk specialty and applying for residency training in states considered liability hot zones.

"The conclusion is frightening but obvious," said David A. Rosman, a fourth-year student at the University of Massachusetts Medical School and medical student trustee on the American Medical Association Board of Trustees. "We're going to see tremendous shortages of physicians in high-risk specialties, and the result will be a massive and frightening decrease in access to care."

Even in Texas, where a constitutional amendment and legislation recently passed, capping noneconomic damages in medical liability cases, students seem only cautiously optimistic about the liability climate.

"Texas has made big steps recently, and the situation is not quite as severe as in some highlighted counties and states, but there is a lot that remains to be seen," said Lindsay K. Botsford, an officer in the Texas Medical Association student chapter at Baylor College of Medicine in Houston.

Student Attitudes

In December, AMA released the results of its first survey on the impact the nation's medical liability environment is having on medical students' decision making. The results, which included responses from nearly 4,000 students in 45 states and the District of Columbia, showed that 86 percent of students believe medical liability is a crisis or a major problem. Half also said medical liability was a factor in their specialty choice, and 39 percent said it was a factor in their choice of the state in which they want to complete residency training.

The results were similar to another survey conducted by the Association of American Medical Colleges. Its 2003 Medical School Graduation Questionnaire, which annually questions recent graduates on a variety of topics, found that 94.5 percent of 2003 graduates believe physicians' legal liabilities and the high cost of professional liability insurance are major problems. That was up from 82.5 percent in 2001 and 84.3 percent in 2002.

While there are no formal data on Texas medical students' attitudes about medical liability, students at Texas medical schools say there is considerable concern among their classmates.

"In an informal poll conducted of our first-year class, medical liability was the No. 2 issue concerning students, behind health care for the uninsured and before tobacco use," said Ms. Botsford. "Personally, it is a concern that is shaping my decisions to explore certain specialties and areas of the country to locate."

Heather Shipman, a third-year student at The University of Texas Medical Branch at Galveston and chair of TMA's Medical Student Section, says students there also are keeping a keen eye on the liability climate.

"I have been impressed with the number of students who follow the medical liability crisis," Ms. Shipman said. "Their concern is usually in regard to what specialty they will choose, especially obstetrics and gynecology. While many students have limited knowledge of the liability crisis, they know enough to know which specialties are most affected."

Mr. Rosman says the results of the student survey were not really surprising. "Being educated in today's environment, I think it would be difficult not to think it's a major problem," he said. "I've seen concern over liability increase in the time I've been here. In that time, I've watched it change from a topic never discussed, and which seemed not really to be of importance to medical students, to one on which medical students -- and certainly residents -- are focusing much more than you'd hope they would have to in an educational environment."

Risk Avoidance

Some medical students say the liability crisis has had no impact on their choice of specialty. "Although surgery is a high-risk specialty, it still remains the only specialty in which I have interest," said Thomas B. Roshek III, who is scheduled to graduate from UT Medical School at Houston in 2005.

However, others fear the liability situation will significantly impact the number of students pursuing careers in obstetrics-gynecology, neurosurgery, emergency medicine, and a handful of other high-risk specialties.

"I interview quite a few students for TMA loans every year," said TMA President Charles W. Bailey Jr., MD. "Very rarely do I find one who is going into OB-Gyn or neurosurgery."

Dr. Bailey says he believes the students' decisions are affected not only by fear of being sued but also by the high premium costs they will have to pay as young physicians in high-risk specialties. "It's just a question of having large student loans and not being able to afford the first year's premium for a lot of these high-risk specialties. They're likely to say, 'If I go into pediatrics, my premiums will be lower and I can probably pay off my loan three, four, or five years quicker than I would if I tried to be an obstetrician.'"

Mr. Rosman says that with the average medical student now graduating with a debt in excess of $100,000 it makes sense to choose a specialty for which liability premiums are lower. "The result of that is that any sort of decision where you're going to end up in a field where you've got a liability expense of tens of thousands, and in some cases hundreds of thousands, of dollars can very clearly and, sadly, justifiably affect specialty choice."

Houston emergency physician Diana Fite, MD, chair of TMA's Council on Medical Education, says she also believes liability concerns are having an impact on the overall number of students interested in medicine.

"We definitely think it has a lot to do with the still overall declining number of applicants to medical school," Dr. Fite said. "We've talked about this at length, and we think this is a definite part of the problem."

Easing the Crisis

Texas is one of 19 states that AMA considers to be "states in crisis" in terms of their medical liability climate and high liability insurance premiums. Texas physicians, however, hope that will change due to passage of Proposition 12, the constitutional amendment that authorized caps on noneconomic damages in liability cases. While those caps prompted the Texas Medical Liability Trust to lower its premiums across the board by 12 percent and may be luring new liability carriers into the Texas market, students here seem to be taking a wait-and-see attitude about whether the caps will be enough to keep them from going elsewhere for their residency training.

"I think everyone is hopeful that it will effect change in both insurance premiums and litigation, but I think some will remain skeptical about the magnitude of the change until they see actual results," Ms. Botsford said. "The changes probably increase my likelihood to stay in Texas because the policy environment seemed friendly to physicians' concerns, but I don't think they have yet to change my eagerness to go into a high-risk specialty."

Sarah Hicks, a student at Texas College of Osteopathic Medicine in Fort Worth and a TMA delegate, also says she is encouraged by the reforms enacted in 2003. "The passage of House Bill 4 and the caps have made Texas, in my eyes, a safer place for obstetrics. I intend to practice rural medicine, family practice, but I would like to be able to deliver babies for my patients. Before the recent reform in Texas, I was not considering returning to Texas. I'm glad it's an option now because this is where I grew up."

Looking to Washington

So far, there appears to be no shortage of residents lining up for training in Texas despite the liability climate. The overall residency program match rate for Texas in 2003 was 92 percent, higher than the national average and the highest rate in five years. Even high-risk specialty programs had high match rates, says Marcia Collins, director of TMA's Medical Education Department. The state's obstetrics-gynecology residency programs matched at rates higher than those for family practice, she says.

But there is still concern that if the liability crisis is not fixed, crisis states such as Texas will see real physician shortages in high-risk specialties because of early retirement by veteran physicians and relocation of other doctors to more liability-friendly states.

"The ultimate reason why we need to fix the liability system has very little to do with physicians and much more to do with protecting access to care," Mr. Rosman said.

But fixing the liability problem at the national level does not appear to be in the cards any time soon without a drastic change in the political makeup of the U.S. Senate, says William Gamel, MD, of Austin, chair of the Texas Delegation to the AMA and incoming chair of the AMA Council on Legislation. The U.S. House passed medical liability reform legislation last year and President George W. Bush has made it a priority again this year. Senate Democrats, however, are blocking consideration of the bill, and Republicans lack the necessary votes to prevent a Democratic filibuster.

"This has turned into a partisan fight, and we need votes from both sides of the aisle," Dr. Gamel said. "If physicians want liability reform to pass in the next session of Congress, they need to get busy in U.S. Senate races across the country to change the representation in the U.S. Senate."           

Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.

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