Dr. Richard Peters is an angry man. One of these days, he may have to tell the 6,000 patients who come to his Women's Comprehensive Health Center on 17th Street NW not to return.
Although he is trained in obstetrics and gynecology, has gone to good schools (New York University School of Medicine; University of California at Berkeley School of Public Health) and has never been sued for malpractice, the cost of malpractice insurance has prompted him to consider closing his office. The fee to insure his four-year-old practice jumped 380 percent this year, from $15,817 in 1984 to $57,817 in 1985.
"I cannot afford to pay it," says Peters, 44, who has borrowed heavily to set up his practice. "I say we have got a crisis."
Many physicians, especially obstetricians and doctors in high-risk specialities such as neurosurgery, have a similar problem.
The price of malpractice insurance -- which has jumped 80 percent from 1975 to 1983 -- appears to be affecting both health care costs and how medicine is practiced in the United States. In New York, doctors threatened slowdowns until new state laws offered some relief from soaring malpractice costs -- premiums go as high as $100,000 a year for some specialities. Newspapers run headlines of multimillion dollar settlements for babies brain damaged at birth; overall, the average malpractice settlement is $330,000.
National organizations on every side of the issue, from the American Medical Association to the American Trial Lawyers Association, have performed studies, organized task forces and drawn up their proposed solutions.
This week, the International Childbirth Education Association cosponsored with federal agencies, a forum to develop a consensus among doctors, lawyers, insurance and patients' representatives about solutions for the growing obstetrics malpractice crisis.
Although there are problems with malpractice, a number of experts argue that it isn't clear whether a crisis exists.
"It's artificial to say whether there is a crisis or not. It is in the eyes of the beholder," says Randall R. Bovbjerg, an attorney and senior research associate at the Urban Institute in Washington and cochairman of a recent malpractice conference. "The premiums really are going up, but they are not going up too far out of line with the rise in health care costs generally."
The real crisis is not monetary, says attorney Sylvia Law, a professor at the New York University School of Law and author of "Pain and Profit: The Politics of Malpractice." It is a crisis in "the day-to-day relationships between doctors and patients that are not as mutually respectful and communicative and jointly participating in the healing process as they should be.
"And there is a crisis in the sense that there are lots of people who are injured by incompetent medical care and a profession which has a poor capacity to be self-critical."
A central question is this: Does the threat of a malpractice lawsuit change the way physicians practice medicine in a positive or a negative way, and does it affect the quality of care?
It is clear that malpractice concerns have affected the relationship betweeen doctors and patients. For example, an American Medical Association survey of its members shows that doctors say they are changing the way they practice medicine as a direct result of malpractice concerns. The survey found that 31 percent of physicians now maintain more detailed medical records; 20 percent are ordering more diagnostic tests and performing more procedures; 17 percent have increased the number of follow-up visits; and 17 percent spend more time with their patients.
"I think the only good side that I see is that it the threat of a suit does make us stop and look at the total picture of the patient and think about what studies and medicines we order," says Dr. Byron Thames, an Orlando, Fla., family physician and board member of the American Academy of Family Physicians. "I think the thought process of making us more cautious is a good one."
Dr. James E. Davis, a surgeon from Durham, N.C., and speaker of the American Medical Association's House of Delegates, disagrees. "Professional people do not need to be intimidated to do their best work. The fear of regulation and outside pressures interferes with the doctor-patient relationship and interferes in the quality of the care provided."
Both doctors agreed that physicians avoid some new patients who they fear may sue them, and that extra tests are ordered simply to document that everything that could have been done was done. Where a doctor probably would not have ordered an x-ray for a bump on the head 15 years ago, most doctors will now order an x-ray and a brain scan.
"Today a physician cannot afford to practice good common-sense medicine of that sort," says Davis. "You are not treating the patient. You are treating the jury some three or four years down the road."
Besides changing the doctor-patient relationship, malpractice has increased the cost of medical care. The AMA estimates that the extra diagnostic tests and procedures of defensive medicine boost expenses by between $15 billion and $40 billion a year.
But it's not clear that fear of malpractice lawsuits discourages any doctors who might be giving inadequate care. "There are a lot of doctors out there committing malpractice . . . doing things beyond their ability and abusing drugs and alcohol," says NYU's Law. "Theoretically, malpractice is supposed to discourage those kinds of things. It fails because the lessons of the malpractice never get translated into modificiations of behavior on the part of doctors."
Doctors don't perceive a malpractice action as a problem with the medical profession, Law contends, but "as a stroke of lightning or as an injustice. Instead of being self-critical, doctors develop a bunker mentality and close the wagons in a circle. They try to cover up mistakes, rather than use the facts of a failure as an opportunity for learning and avoiding that problem in the future."
"There are several studies which have shown that the rate of injury due to medical negligence is not trivial," says Patricia Danzon from the Center for Health Policy at Duke University. Her 1983 study, financed by the Department of Health and Human Services, concluded that only one in 25 instances of malpractice is compensated.
"I doubt that very much," counters the AMA's Davis. "Only 18 percent of the claims we receive at the North Carolina doctor-owned insurance company ever deserve any payout. I think that all the malpractice that exists is being reported. Beyond negligence, we are getting all kinds of cases which reflect unrealizable expectations on the part of the public which expects perfection from medicine, which is an inexact science."
More claims of malpractice are being filed. Before 1980, there were an average of three claims filed for every 100 physicians, says the AMA. Between 1980 and 1984, the number of filed claims jumped to 8.4 for every 100 physicians.
A number of experts say, however, that the rise in malpractice premiums has less to do with multimillion dollar awards than a change in the insurance industry and the overall economy. Tom Goddard, state legislative council for the Association of Trial Lawyers of America in Washington, says rates are going up because "the entire casuality industry has suffered a drop in the value of its portfolio." Insurance companies make their money not from premiums but from the way they invest those premiums. Since interest rates are down, earnings are down. To boost earnings, he says, companies are raising premiums.
Right now, Dr. Richard Peters is less concerned about insurance company portfolios and sociological ramifications than where he is supposed to get $57,817 to stay in business.
For him, all decisions are on hold. He may drop his current insurance company and sign up with a physician-sponsored malpractice insurance company that currently has lower premiums, or he may struggle to find a way to raise the money for his present carrier.
One thing, however, is certain. "I already started charging my patients more," Peters says. "The bottom line is that the patient is going to pay."