la J Rodrarron Oncoio~y Biol Phy.5 Vol. 20. pp. 563-566 Printed I” the U.S.A. All nghts reserved.
Copy&t
0360-3016/91 $3.00 + .oO 0 1991 Pergamon Press plc
0 Special Feature PROFESSIONAL LIABILITY IN RADIOTHERAPY: EXPERIENCE OF THE FLETCHER SOCIETY NEIL E. SHERMAN,
M.D., TYVIN A. RICH, M.D.
AND LESTER J. PETERS,
M.D.
Department of Clinical Radiotherapy, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030 We have conducted a study to ascertain the pattern and background of lawsuits related to the practice of radiotherapy among physician-members of the Gilbert H. Fletcher Society. Eighty-four percent of the members of the society replied to the questionnaire; one-third have sustained a lawsuit with an actuarial probability of 30% at 10 years, 50% at 20 years, and 65% at 30 years. Lawsuits occurred across the spectrum of practice type, location, experience, disease site, and technique. Two-thirds of the suits were dropped or successfully defended. Regardless of the outcome, the experience of being sued was found to have influenced 33% of those sued to practice more conservatively. Recommendations of the membership directed towards minimizing the risk of being sued, while maintaining an aggressive treatment philosophy, are presented. Based on this study, we believe that formal medicolegal education should be included in the curriculum of radiotherapy residents’ training program. Radiotherapy, Radiation therapy, Professional liability, Malpractice, Lawsuits.
evaluated by therapeutic intent (palliative vs curative), patient gender, site of primary disease, use of simulation, radiotherapy technique (external alone, brachytherapy alone, external plus brachytherapy. radiotherapy plus concurrent chemotherapy, preoperative radiotherapy, and postoperative radiotherapy), suit outcome (pending, dropped, won, lost), and dollar value of settlement or judgment. We also queried physicians’ perception of changes in their practice as a consequence of being sued, whether the outcome was favorable or not. We coded a favorable outcome when a suit was dropped, or won through a trial, and an unfavorable outcome when a suit resulted in a settlement prior to a trial, or proceeded through a trial to a verdict for the plaintiff. The data were entered into database IV on a personal computer. Using the statistical package for the social sciences (SPSS), the actuarial probability of a lawsuit was calculated by the Berkson-Gage life table method.
INTRODUCTION
A recent report (8) from the American Medical Association reviewed the increasing and persistent problem of medical malpractice liability and its economic consequences. Specific information is available for the majority of medical and surgical specialties, but there are no data regarding the patterns and outcome of professional liability suits in the practice of radiotherapy. To help address this issue, we conducted a survey of a group of physicians who practice radiation therapy within the United States, and report a preliminary analysis. METHODS
AND
MATERIALS
The Gilbert H. Fletcher Society is composed of physicians who were trained by or associated with Dr. Gilbert H. Fletcher at The University of Texas M. D. Anderson Cancer Center or who were trained elsewhere by trainees of Dr. Fletcher. In March 1989, a confidential questionnaire regarding professional liability lawsuits was mailed to the 234 members of the Gilbert H. Fletcher Society who practice radiotherapy in the United States. The frequency of lawsuits was ascertained, and suits were further
RESULTS
Eighty-four percent ( 196/234) of the physician-members responded to the questionnaire. Sixty-six physicians (one-third of respondents) have sustained 107 lawsuits
Reprint requests to: Neil E. Sherman, M.D., Dept. of Clinical Radiotherapy, Box 97, M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030. Acknowledgemenr-We wish to thank Dr. Gilbert H. Fletcher for support and encouragement, and Mary Jane Oswald for help with the statistical analysis.
Supported in parts by grants CA06294 and CA 16772 awarded by the National Cancer Institute, United States Department of Health and Human Services. Accepted for publication 12 September 1990.
563
564
I. J. Radiation Oncology 0 Biology 0 Physics
March 1991. Volume 20. Number 3
from 1954 through
1989. Forty-two physicians sustained 1 suit, 13 physicians sustained 2 suits, 7 physicians had 3 suits, 2 physicians had 4 suits and 2 physicians had 5 suits. Thirty-one percent of the physicians are in academic radiotherapy and 69% are in private practice. Eighty-three percent of the suits involved potentially curative, and 17% palliative radiation therapy. The actuarial probability of remaining free of a lawsuit as a function of years in practice is shown in Figure I. After 20 years, 50% of the physicians sustained a suit, and this figure rose to 65% at 30 years. The percentage of physicians sued by decade of training is shown in Figure 2. Only 6.6%) of physician members trained in the 1980’s have sustained a suit. but this reflects their short time in practice. The organ sites involved by suits are indicated in Table I. The most common treatment method was external beam technique alone in 64 patients, followed by external beam plus brachytherapy in 10, radiotherapy plus chemotherapy in 8, and brachytherapy alone in 7 cases. For 18 suits, the radiotherapy method was not stated. The question regarding simulation was answered for 83 of the 107 lawsuits; simulators were used in 6 I cases and not used in 22 cases. Use of the simulator was associated with a favorable outcome in 33 of 50 closed cases (66%,) versus 9 of 22 closed cases (4 1%) without simulation. p = 0.084. Patient gender was identified in 103 of the 107 cases, with 42 males and 6 1 females. In Table 2, the status of the suit is shown, including 92 cases closed and 14 pending cases. For the 34 cases settled or lost, the dollar value of settlements or judgments ranged from $300 to $7.6 million, uncorrected for inflation, with a median of $62,500. There were three settlements or judgments of $1 million dollars or greater. With respect to practice type, there was no difference in the probability of a lawsuit for academic versus private practice, 32% versus 34%, respectively. Evaluation of suit outcome as a function of therapeutic intent (palliative vs curative) revealed no differences. The probability of a favorable suit outcome by organ site is shown in Table 3, with no major differences between the five most common organ sites
P
60
f v) s
40 20 0
Fig. 2. Percent of physician-members
of
80-89
Training
sued by decade of training.
treated. The data on radiotherapeutic method were available for 76 ofthe 107 lawsuits, and revealed no significant difference in the probability of a favorable outcome. Of the 66 physicians sued, 52 have had their lawsuits closed and have an evaluable response to the query about changes in practice pattern. These changes are (a) an intent to use less radical doses, (b) an intent to avoid treating certain types of patients. and (c) an intention to retire early. In Table 4, we show practice changes based on the suit outcome. It is evident that even with a favorable lawsuit outcome, one-third of physicians reported some change in their practice style. Physicians who sustained an unfavorable outcome to a lawsuit had a slightly higher likelihood of reporting all three practice changes (5 of 17 with an unfavorable outcome versus 2 of 35 with a favorable outcome, p = 0.03). With respect to national region. there were no significant differences in the probability of a lawsuit for the seven states having at least five physician members practicing radiotherapy. The type of patient injuries that were the basis for these lawsuits are being analyzed in more detail: from preliminary information representative injuries include transverse myelitis. laryngeal edema, soft tissue fibrosis, brachial plexopathy.
Site
site
Number*
Percentage
0.8
0.6
z 2=
70-79
Table I. Suit/organ
.Z
;,
60-69 Final Year
1.0
g
50-59
0.4
$ “0 0.2 h
0.0’ 0
4
8
12
16
20
24
26
32
36
40
Years
Fig. 1. Probability suit as a function
of a physician-member remaining free of lawof years in practice (actuarial method).
Gynecologic Breast Head and neck Urologic Metastases Lymphoma Central nervous system Lung Gastrointestinal Pediatric tumors Eye Miscellaneous * Site not specified in 4 cases.
I8 17 I5 I3 10 8 6 6
16.8 15.9 14.0 12.1 9.3 7.5 5.6 5.6 2.8 2.8 0.9 2.8
Radiotherapy professional liability 0 N. E.
Number
Dropped W0l-l
Settled Lost Pending Unknown Total
Percentage
50 8 32 2 14 1
46.1 7.5 29.9 1.9 13.0 1.0
107
100.0
skin reactions, pneumonitis, enteritis, cystitis, pulmonary fibrosis, peticarditis, and sterility. Physicians’ comments and recommendations were nu-
merous. The most frequently mentioned strategies to prevent a lawsuit can be expressed as “the 4 R’s” proposed by Rasinski (6): (a) try to increase rapport with patients and family, (b) pay more attention to documentation of the adequacy of treatment in the radiotherapy record, (c) show more respect for the wishes of the patient, and (d) continue to review what you are doing for each patient as well as what you are doing for groups of patients. One member wisely suggested: “Now and then pick up an old chart, see if you can trace all of your steps in making decisions and executing treatments. Would this chart be sufficient to defend yourself against a malpractice claim?’
DISCUSSION Assuming that members of the Gilbert H. Fletcher Society are representative of the radiation oncology community at large, we can estimate that the average radiotherapist practicing in the U.S.A. runs a risk of approximately 50% of being sued after 20 years in practice. Why are there so many lawsuits against American physicians? In our litigious society many people believe that someone must pay for their misfortune. Our adversarial tort system is inefficient and expensive (4), even though it theoretically provides equal access to the courts to people of all social and economic strata. Malpractice tort law requires fixation of blame for recovery. The contingency
Table 3.
565
et al.
Table 4. Practice change versus suit outcome
Table 2. Suit outcome Status
SHERMAN
Site of tumor versus outcome of suit
Site
Favorable outcome (W)
Central nervous system Metastases Genitourinary Gynecologic Lymphoma All other Breast Head and neck Lung
83 83 69 65 62 62 51 42 20
Practice change
Favorable
None Lower dose Type patient accepted Retire early All 3 Any
24 2 4 3 2 1 l/35
Unfavorable 10 0 I I 5 7117
fee system may encourage suits that are marginal given the high cost of defending non-meritorious cases and the tendency for some insurance carriers to settle frivolous suits rather than bearing the cost of defending them. Some of these problems reflect a tendency to shift to medicine larger question reflecting inherent risks in life. High technology medicine, particularly radiotherapy, may be associated with expectations that exceed reality. Patients with an unfavorable outcome may assume wrongly that someone must be at fault and seek out a personal injury attorney. The high cost of medicine may aggravate patient feelings, compounding further the depersonalization of health care and the loss of trust and familiarity with the physician. Further, the perception of medicine as a business rather than a profession may also lower the threshold for patients to sue when they are unhappy with the outcome (7, 9). We need a system that will compensate quickly and fairly patients with bonajide injuries resulting from medical care that is in error or inappropriate. We need to identify physicians whose practice styles produce a higher risk of patient maloccurrences. We need an improved informed consent (5) and a reduction of the incentive for patients and attorneys to file suits that are without merit. In this study, two-thirds (58 of 92) of the suits were apparently without merit since they were either dropped (50 cases) or won (8 cases). Unfortunately, the high cost of defending these suits is borne by all patients as a pass through expense. We need better identification of social problems with appropriate risk management, rather than assuming that a fault-based tort system will properly redistribute economic resources to injured patients. We need the elimination of the concept of “‘joint and several liability” (3, 4), which in reality translates into a search for the biggest “deep pocket,” even when physician responsibility for patient injury is minimal. We also need mandatory instructions to juries that a bad outcome does not, per se, mean malpractice. The professional liability crisis will not go away without action by those most educated and involved, America’s physicians. We believe that the problem can be reduced in scope and magnitude through physician ( 1, 2, 6) and patient education as well as tort reform (4). Physicians who are training the next generation of radiotherapists now have ample data to justify education in medicine
566
I. J.
Radiation
Oncology
and the law for their residents. Perhaps we need to educate our trainees to be the same time being as therapeutically essary to maximize each patient’s chance
0 Biology
0 Physics
most important, prudent while at aggressive as necof cure. We have
March
1991. Volume
20. Number
3
shown that one-third of sued physicians intend to pursue less intensive cancer management programs. It would indeed be tragic if lawsuit paranoia resulted in curable patients being lost through too conservative treatment.
REFERENCES 1. Dunn, J. D. Texas medical malpractice: a guide for the health sciences. St. Louis, MO: C. V. Mosby Co.; 1989.
2. Fiscina. S. Medical law for the attending bondale,
3. Harney, lottesville,
IL: Southern
Illinois University
D. M. Medical malpractice, VA: Michie Co.: 1987.
physician, CarPress: 1982.
2nd edition.
4. Huber, P. W. Liability: the legal revolution quences.
Char-
and its conse-
New York: Basic Books Inc.: 1989.
5. Ozzi, W. M. Survey of the law of informed
consent in physician-patient relationship. In: Wecht. C. H., ed. Legal medicine. Philadelphia, PA: W. B. Saunders: 1982:l 17-135.
Rasinski, G. Medical malpractice prevention. In: Wecht, C. H., ed. Legal medicine. Philadelphia, PA: W. B. Saunders: 1982:177-186. Rosenberg, C. The care of strangers: the rise of America’s hospital system. New York: Basic Books Inc.: 1987. Slora. E. J.: Gonzalez, M. I. Socio-economic characteristics of medical practice. In: Gonzalez. M. L., Emmons. D. W.. eds. Medical professional liability claims and premiums: AMA Center for Health Policy Research 1985-1987. Chicago. IL: American Medical Association; 1988: 18-22. Starr, P. The social transformation of American medicine. New York: Basic Books Inc.: 1982.
Copy&t
0360-3016/91 $3.00 + .oO 0 1991 Pergamon Press plc
0 Special Feature PROFESSIONAL LIABILITY IN RADIOTHERAPY: EXPERIENCE OF THE FLETCHER SOCIETY NEIL E. SHERMAN,
M.D., TYVIN A. RICH, M.D.
AND LESTER J. PETERS,
M.D.
Department of Clinical Radiotherapy, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030 We have conducted a study to ascertain the pattern and background of lawsuits related to the practice of radiotherapy among physician-members of the Gilbert H. Fletcher Society. Eighty-four percent of the members of the society replied to the questionnaire; one-third have sustained a lawsuit with an actuarial probability of 30% at 10 years, 50% at 20 years, and 65% at 30 years. Lawsuits occurred across the spectrum of practice type, location, experience, disease site, and technique. Two-thirds of the suits were dropped or successfully defended. Regardless of the outcome, the experience of being sued was found to have influenced 33% of those sued to practice more conservatively. Recommendations of the membership directed towards minimizing the risk of being sued, while maintaining an aggressive treatment philosophy, are presented. Based on this study, we believe that formal medicolegal education should be included in the curriculum of radiotherapy residents’ training program. Radiotherapy, Radiation therapy, Professional liability, Malpractice, Lawsuits.
evaluated by therapeutic intent (palliative vs curative), patient gender, site of primary disease, use of simulation, radiotherapy technique (external alone, brachytherapy alone, external plus brachytherapy. radiotherapy plus concurrent chemotherapy, preoperative radiotherapy, and postoperative radiotherapy), suit outcome (pending, dropped, won, lost), and dollar value of settlement or judgment. We also queried physicians’ perception of changes in their practice as a consequence of being sued, whether the outcome was favorable or not. We coded a favorable outcome when a suit was dropped, or won through a trial, and an unfavorable outcome when a suit resulted in a settlement prior to a trial, or proceeded through a trial to a verdict for the plaintiff. The data were entered into database IV on a personal computer. Using the statistical package for the social sciences (SPSS), the actuarial probability of a lawsuit was calculated by the Berkson-Gage life table method.
INTRODUCTION
A recent report (8) from the American Medical Association reviewed the increasing and persistent problem of medical malpractice liability and its economic consequences. Specific information is available for the majority of medical and surgical specialties, but there are no data regarding the patterns and outcome of professional liability suits in the practice of radiotherapy. To help address this issue, we conducted a survey of a group of physicians who practice radiation therapy within the United States, and report a preliminary analysis. METHODS
AND
MATERIALS
The Gilbert H. Fletcher Society is composed of physicians who were trained by or associated with Dr. Gilbert H. Fletcher at The University of Texas M. D. Anderson Cancer Center or who were trained elsewhere by trainees of Dr. Fletcher. In March 1989, a confidential questionnaire regarding professional liability lawsuits was mailed to the 234 members of the Gilbert H. Fletcher Society who practice radiotherapy in the United States. The frequency of lawsuits was ascertained, and suits were further
RESULTS
Eighty-four percent ( 196/234) of the physician-members responded to the questionnaire. Sixty-six physicians (one-third of respondents) have sustained 107 lawsuits
Reprint requests to: Neil E. Sherman, M.D., Dept. of Clinical Radiotherapy, Box 97, M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030. Acknowledgemenr-We wish to thank Dr. Gilbert H. Fletcher for support and encouragement, and Mary Jane Oswald for help with the statistical analysis.
Supported in parts by grants CA06294 and CA 16772 awarded by the National Cancer Institute, United States Department of Health and Human Services. Accepted for publication 12 September 1990.
563
564
I. J. Radiation Oncology 0 Biology 0 Physics
March 1991. Volume 20. Number 3
from 1954 through
1989. Forty-two physicians sustained 1 suit, 13 physicians sustained 2 suits, 7 physicians had 3 suits, 2 physicians had 4 suits and 2 physicians had 5 suits. Thirty-one percent of the physicians are in academic radiotherapy and 69% are in private practice. Eighty-three percent of the suits involved potentially curative, and 17% palliative radiation therapy. The actuarial probability of remaining free of a lawsuit as a function of years in practice is shown in Figure I. After 20 years, 50% of the physicians sustained a suit, and this figure rose to 65% at 30 years. The percentage of physicians sued by decade of training is shown in Figure 2. Only 6.6%) of physician members trained in the 1980’s have sustained a suit. but this reflects their short time in practice. The organ sites involved by suits are indicated in Table I. The most common treatment method was external beam technique alone in 64 patients, followed by external beam plus brachytherapy in 10, radiotherapy plus chemotherapy in 8, and brachytherapy alone in 7 cases. For 18 suits, the radiotherapy method was not stated. The question regarding simulation was answered for 83 of the 107 lawsuits; simulators were used in 6 I cases and not used in 22 cases. Use of the simulator was associated with a favorable outcome in 33 of 50 closed cases (66%,) versus 9 of 22 closed cases (4 1%) without simulation. p = 0.084. Patient gender was identified in 103 of the 107 cases, with 42 males and 6 1 females. In Table 2, the status of the suit is shown, including 92 cases closed and 14 pending cases. For the 34 cases settled or lost, the dollar value of settlements or judgments ranged from $300 to $7.6 million, uncorrected for inflation, with a median of $62,500. There were three settlements or judgments of $1 million dollars or greater. With respect to practice type, there was no difference in the probability of a lawsuit for academic versus private practice, 32% versus 34%, respectively. Evaluation of suit outcome as a function of therapeutic intent (palliative vs curative) revealed no differences. The probability of a favorable suit outcome by organ site is shown in Table 3, with no major differences between the five most common organ sites
P
60
f v) s
40 20 0
Fig. 2. Percent of physician-members
of
80-89
Training
sued by decade of training.
treated. The data on radiotherapeutic method were available for 76 ofthe 107 lawsuits, and revealed no significant difference in the probability of a favorable outcome. Of the 66 physicians sued, 52 have had their lawsuits closed and have an evaluable response to the query about changes in practice pattern. These changes are (a) an intent to use less radical doses, (b) an intent to avoid treating certain types of patients. and (c) an intention to retire early. In Table 4, we show practice changes based on the suit outcome. It is evident that even with a favorable lawsuit outcome, one-third of physicians reported some change in their practice style. Physicians who sustained an unfavorable outcome to a lawsuit had a slightly higher likelihood of reporting all three practice changes (5 of 17 with an unfavorable outcome versus 2 of 35 with a favorable outcome, p = 0.03). With respect to national region. there were no significant differences in the probability of a lawsuit for the seven states having at least five physician members practicing radiotherapy. The type of patient injuries that were the basis for these lawsuits are being analyzed in more detail: from preliminary information representative injuries include transverse myelitis. laryngeal edema, soft tissue fibrosis, brachial plexopathy.
Site
site
Number*
Percentage
0.8
0.6
z 2=
70-79
Table I. Suit/organ
.Z
;,
60-69 Final Year
1.0
g
50-59
0.4
$ “0 0.2 h
0.0’ 0
4
8
12
16
20
24
26
32
36
40
Years
Fig. 1. Probability suit as a function
of a physician-member remaining free of lawof years in practice (actuarial method).
Gynecologic Breast Head and neck Urologic Metastases Lymphoma Central nervous system Lung Gastrointestinal Pediatric tumors Eye Miscellaneous * Site not specified in 4 cases.
I8 17 I5 I3 10 8 6 6
16.8 15.9 14.0 12.1 9.3 7.5 5.6 5.6 2.8 2.8 0.9 2.8
Radiotherapy professional liability 0 N. E.
Number
Dropped W0l-l
Settled Lost Pending Unknown Total
Percentage
50 8 32 2 14 1
46.1 7.5 29.9 1.9 13.0 1.0
107
100.0
skin reactions, pneumonitis, enteritis, cystitis, pulmonary fibrosis, peticarditis, and sterility. Physicians’ comments and recommendations were nu-
merous. The most frequently mentioned strategies to prevent a lawsuit can be expressed as “the 4 R’s” proposed by Rasinski (6): (a) try to increase rapport with patients and family, (b) pay more attention to documentation of the adequacy of treatment in the radiotherapy record, (c) show more respect for the wishes of the patient, and (d) continue to review what you are doing for each patient as well as what you are doing for groups of patients. One member wisely suggested: “Now and then pick up an old chart, see if you can trace all of your steps in making decisions and executing treatments. Would this chart be sufficient to defend yourself against a malpractice claim?’
DISCUSSION Assuming that members of the Gilbert H. Fletcher Society are representative of the radiation oncology community at large, we can estimate that the average radiotherapist practicing in the U.S.A. runs a risk of approximately 50% of being sued after 20 years in practice. Why are there so many lawsuits against American physicians? In our litigious society many people believe that someone must pay for their misfortune. Our adversarial tort system is inefficient and expensive (4), even though it theoretically provides equal access to the courts to people of all social and economic strata. Malpractice tort law requires fixation of blame for recovery. The contingency
Table 3.
565
et al.
Table 4. Practice change versus suit outcome
Table 2. Suit outcome Status
SHERMAN
Site of tumor versus outcome of suit
Site
Favorable outcome (W)
Central nervous system Metastases Genitourinary Gynecologic Lymphoma All other Breast Head and neck Lung
83 83 69 65 62 62 51 42 20
Practice change
Favorable
None Lower dose Type patient accepted Retire early All 3 Any
24 2 4 3 2 1 l/35
Unfavorable 10 0 I I 5 7117
fee system may encourage suits that are marginal given the high cost of defending non-meritorious cases and the tendency for some insurance carriers to settle frivolous suits rather than bearing the cost of defending them. Some of these problems reflect a tendency to shift to medicine larger question reflecting inherent risks in life. High technology medicine, particularly radiotherapy, may be associated with expectations that exceed reality. Patients with an unfavorable outcome may assume wrongly that someone must be at fault and seek out a personal injury attorney. The high cost of medicine may aggravate patient feelings, compounding further the depersonalization of health care and the loss of trust and familiarity with the physician. Further, the perception of medicine as a business rather than a profession may also lower the threshold for patients to sue when they are unhappy with the outcome (7, 9). We need a system that will compensate quickly and fairly patients with bonajide injuries resulting from medical care that is in error or inappropriate. We need to identify physicians whose practice styles produce a higher risk of patient maloccurrences. We need an improved informed consent (5) and a reduction of the incentive for patients and attorneys to file suits that are without merit. In this study, two-thirds (58 of 92) of the suits were apparently without merit since they were either dropped (50 cases) or won (8 cases). Unfortunately, the high cost of defending these suits is borne by all patients as a pass through expense. We need better identification of social problems with appropriate risk management, rather than assuming that a fault-based tort system will properly redistribute economic resources to injured patients. We need the elimination of the concept of “‘joint and several liability” (3, 4), which in reality translates into a search for the biggest “deep pocket,” even when physician responsibility for patient injury is minimal. We also need mandatory instructions to juries that a bad outcome does not, per se, mean malpractice. The professional liability crisis will not go away without action by those most educated and involved, America’s physicians. We believe that the problem can be reduced in scope and magnitude through physician ( 1, 2, 6) and patient education as well as tort reform (4). Physicians who are training the next generation of radiotherapists now have ample data to justify education in medicine
566
I. J.
Radiation
Oncology
and the law for their residents. Perhaps we need to educate our trainees to be the same time being as therapeutically essary to maximize each patient’s chance
0 Biology
0 Physics
most important, prudent while at aggressive as necof cure. We have
March
1991. Volume
20. Number
3
shown that one-third of sued physicians intend to pursue less intensive cancer management programs. It would indeed be tragic if lawsuit paranoia resulted in curable patients being lost through too conservative treatment.
REFERENCES 1. Dunn, J. D. Texas medical malpractice: a guide for the health sciences. St. Louis, MO: C. V. Mosby Co.; 1989.
2. Fiscina. S. Medical law for the attending bondale,
3. Harney, lottesville,
IL: Southern
Illinois University
D. M. Medical malpractice, VA: Michie Co.: 1987.
physician, CarPress: 1982.
2nd edition.
4. Huber, P. W. Liability: the legal revolution quences.
Char-
and its conse-
New York: Basic Books Inc.: 1989.
5. Ozzi, W. M. Survey of the law of informed
consent in physician-patient relationship. In: Wecht. C. H., ed. Legal medicine. Philadelphia, PA: W. B. Saunders: 1982:l 17-135.
Rasinski, G. Medical malpractice prevention. In: Wecht, C. H., ed. Legal medicine. Philadelphia, PA: W. B. Saunders: 1982:177-186. Rosenberg, C. The care of strangers: the rise of America’s hospital system. New York: Basic Books Inc.: 1987. Slora. E. J.: Gonzalez, M. I. Socio-economic characteristics of medical practice. In: Gonzalez. M. L., Emmons. D. W.. eds. Medical professional liability claims and premiums: AMA Center for Health Policy Research 1985-1987. Chicago. IL: American Medical Association; 1988: 18-22. Starr, P. The social transformation of American medicine. New York: Basic Books Inc.: 1982.
