September 7, 2004
Malpractice debate hides subtleties
Author: Sarah Avery; Staff Writer
Dr. Andrea Torsone has a genuine story to tell about the high rates she paid for medical malpractice insurance and how the added expense prompted her to quit delivering babies in Raleigh.
Her story is one of many told by doctors angry about rising insurance costs, and it indicates that doctors in specialties such as obstetrics, general surgery, emergency medicine and neurology are being forced out of their practices and leaving patients with diminished access to care.
But the numbers tell a different story.
The number of doctors practicing in North Carolina continues to increase as quickly as the population rate, suggesting that situations such as Torsone's do not add up to a crisis.
As national and statewide candidates have lined up behind one side or the other in the medical malpractice debate, such seemingly conflicting evidence often gets cast in stark black or white -- a problem vs. no problem.
The reality is far more gray.
Doctors' decisions to leave or alter their practices are often distilled to one -- malpractice rates -- while many factors are often involved. Similarly, the raw numbers of doctors practicing in North Carolina disguise a growing unease about the future availability of practitioners willing to deliver babies, treat brain injuries and patch up accident victims.
Such subtleties are lost when money is at stake. Doctors are pressing for new laws to cap pain-and-suffering damages, which cover the loss of enjoyment of life for medically injured patients. They contend that patients hoping to cash in are filing frivolous lawsuits and that this has driven doctors' coverage rates sky high.
Lawyers and patient advocates oppose caps on malpractice awards, contending that medical mistakes often create life-altering problems that cannot be compensated in a one-size-fits-all $250,000 award. They challenge the notion that injured people are making frivolous claims and blame insurance companies for gouging doctors to recoup losses unrelated to lawsuit payouts.
Both sides are waging political battles, putting money behind state and national candidates who support their respective points of view.
In North Carolina, Republican Congressman Richard Burr in his U.S. Senate bid has won doctor support for favoring caps, while his Democratic opponent, Erskine Bowles, has collected money from trial lawyers who oppose caps.
Beneath the rhetoric on both sides lies valid evidence. Many doctors, faced with higher insurance rates, are altering their practices, retiring or leaving the state.
"It's going to reach a point where access to care is going to be impacted," said Dr. Robert E. Littleton, a Raleigh obstetrician and past president of the N.C. Obstetrical and Gynecological Society. He named a half-dozen Raleigh doctors he knows who have quit practicing medicine or stopped delivering babies because of high rates.
Torsone is one of them. She is 33, and practiced obstetrics and gynecology in Raleigh for three years before dropping the baby business this summer.
But her case has nuance. As the mother of two young children, she had been practicing part-time to accommodate family obligations. When her malpractice rates doubled for the second time in two years, her part-time earnings did not offset the higher expense.
"It's definitely too bad," Torsone said about her decision to quit delivering babies. "It's hard to accept that I spent a lot of years training for this, and to give it up early in my career is distressing."
Littleton acknowledged that family obligations often come into play when obstetricians decide to alter their practices. More and more, he said, OB/GYNs graduating from medical schools are women. When these young doctors start families of their own, they often practice part time or curtail the obstetrics part of their business to avoid crazy hours.
"There are pressures on female partners to quote-unquote 'mother' their children," Littleton said. "So there are still stresses on my female partners that I as a male would not have. They have less incentive to continue to practice."
Thomas Ricketts, who studies the supply of health-care professionals at the Cecil G. Sheps Center at UNC-Chapel Hill, said surveys of doctors indicate that many factors combine when doctors decide to leave or change their practices. Managed-care hassles, hospital bureaucracies, mounting paperwork, fear of lawsuits -- all erode job satisfaction, he said.
"There are a lot of things that are happening, and medical malpractice is just one of them," Ricketts said. "I feel it is an influence, but it's not the overwhelming influence that some people want to paint it as. It creates a tipping point. They may say, 'I'm not going to deliver babies, or do a certain sort of surgery, or practice in a certain type of setting.' "
Stability -- for now
Such decisions have not yet affected the supply of doctors in North Carolina, but there is evidence that problems could arise, Ricketts said. Last year, 17,090 doctors were licensed to practice in North Carolina, compared with 16,769 in 2002, an increase of 2 percent.
For both years, there were 20 doctors for every 10,000 state residents, according to Sheps Center data.
Soon, however, the population rate may outpace the supply of doctors. Ricketts said the trends "are pointing to some situation where we might see a palpable shortage" in some areas.
That trend is occurring nationwide, so leaders of medical schools are discussing ways to increase the number of graduates. But it's a complicated process. In North Carolina, each of the state's four medical schools accepts a set number of new students based on its capacity to teach them.
Now, there is no shortage of students wanting to become doctors. At Duke University School of Medicine, 5,000 students applied last year for 101 slots; at UNC's medical school, 2,972 students vied for 160 slots; at East Carolina University, 705 competed for 72 openings.
Interest in specialties such as obstetrics, general surgery and emergency medicine also remained strong despite the medical malpractice debate. Dr. Edward Halperin, vice dean of Duke's medical school, said the issue is not cited as a major factor in Duke students' decisions to pick a medical specialty. Instead, he said, they gravitate to specialties based on scientific interest and, increasingly, a desire to have more control over their personal lives.
The malpractice issue has had a negative influence, however, in the kinds of learning opportunities medical schools offer. In years past, Halperin said, schools routinely let students do training stints at hospitals around the country. Now this practice is being curtailed, because medical schools are leery of carrying the liability for students working outside their hospitals.
Such subtle problems seldom get mentioned in the debate, but Halperin said the effect is long term. "It's inhibiting access to educational opportunities," he said.
Copyright 2004 by The News & Observer Pub. Co.
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