Letters

hol dependence, which bode well for developing a potential medication to relieve a significant amount of human suffering and cost to our health care system.

Author Affiliation: Department of Family and Social Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.

Barbara J. Mason, PhD Vivian Goodell, MPH Farhad Shadan, MD, PhD

Conflict of Interest Disclosures: None reported. 1. Schiff GD, Puopolo AL, Huben-Kearney A, et al. Primary care closed claims experience of Massachusetts malpractice insurers. JAMA Intern Med. 2013;173 (22):2063-2068.

Author Affiliations: The Scripps Research Institute, Pearson Center for Alcoholism and Addiction, Research, La Jolla, California (Mason, Goodell, Shadan); Scripps Clinic and Scripps Green Hospital, La Jolla, California (Shadan). Corresponding Author: Barbara J. Mason, PhD, Committee on the Neurobiology of Addictive Disorders, The Scripps Research Institute, 10550 N Torrey Pines Rd, TPC-5, La Jolla, CA 92037 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Mason BJ, Quello S, Goodell V, Shadan F, Kyle M, Begovic A. Gabapentin treatment for alcohol dependence: a randomized clinical trial. JAMA Intern Med. 2014;174(1):70-77. 2. Pelc I, Verbanck P, Le Bon O, Gavrilovic M, Lion K, Lehert P. Efficacy and safety of acamprosate in the treatment of detoxified alcohol-dependent patients: a 90-day placebo-controlled dose-finding study. Br J Psychiatry. 1997; 171:73-77. 3. Schwenk TL. Gabapentin improves rates of abstinence in alcohol-dependent patients. NEJM Journal Watch. November 21, 2013. http://www.jwatch.org /na32870/2013/11/21/gabapentin-improves-rates-abstinence-alcohol -dependent. Accessed March 7, 2014. 4. Maisel NC, Blodgett JC, Wilbourne PL, Humphreys K, Finney JW. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction. 2013;108(2):275-293.

We Have Strict Statutes and Most Biting Laws To the Editor In their recent article, Schiff and colleagues1 computed the rate of malpractice claims filed against adult primary care physicians (PCPs) in Massachusetts. They found an annual rate of 3.3% (roughly 110 cases per year for 3305 physicians), noting that the rate was remarkably stable over the 5-year study period. A lawsuit rate of 3.3% per year may not seem like much. (Hyman and Sage2 proclaimed it a relatively “modest rate” in their Invited Commentary on the article by Schiff et al.1) But annual rates convey a false sense of well-being. A more meaningful indicator of risk is the career likelihood of a malpractice claim. Using the following binomial probability formula: 1 – (1 – λ)t, where λ is the annual risk of suit (eg, Schiff and coauthors’ rate of 0.033) and t is the duration of a medical career (eg, 40 years), I calculate that the probability of a Massachusetts PCP being sued at least once during his or her career as 74%. The binomial rests on a few assumptions: the annual risk of suit is the same each year, all PCPs face the same risk, and the risk to physicians each year is independent to what happened to them in any earlier year. While it is anticipated that reality will depart to some extent from the probability model, a 74% chance of suit, even as a first approximation, suggests that many PCPs will feel pressure to practice medicine defensively. A noteworthy contribution, then, is the authors’ identification of the breakdowns points in the process of care that most often result in legal liability. Rebecca Arden Harris, MD 1202

Corresponding Author: Rebecca Arden Harris, MD, 654 Lindley Rd, Glenside, PA 19038 ([email protected]).

2. Hyman DA, Sage WM. Medical malpractice in the outpatient setting: through a glass, darkly. JAMA Intern Med. 2013;173(22):2069-2070.

In Reply We thank Dr Harris for acknowledging the importance of malpractice risk that primary care physicians (and, we would add, their patients) painfully face, particularly the significant burden that the 3.3% annual rate translates to as it cumulatively accrues over a physician’s career. Dr Harris’ calculations, as well our findings, are consistent with other reported data.1,2 Aside from emphasis on the high statistical lifetime likelihood that a primary care physician might be sued, the author points out the value of the “identification of the breakdowns in care,” as well as raising the potential for resulting “defensive” medical practices. The Agency for Healthcare Research and Quality–funded PROMISES (Proactive Reduction of Outpatient Malpractice: Improving Safety, Efficiency, and Satisfaction) project, under whose auspices the Massachusetts insurers pooled the data we analyzed, specifically aimed to lower such risk by preventing failures and dropped balls in targeted areas of test result, referral, and medication management, as well as overarching communication breakdowns. However, we would point out that based on the literature and our work with participating Massachusetts primary care offices, practicing “defensive medicine” by ordering more tests and referrals can also add risks if health care practitioners do not reliably follow up and act on those results and referral recommendations. We hope that whatever added anxieties and stresses of malpractice "biting laws" Dr Harris invokes can also positively motivate and guide efforts to significantly improve primary care office systems. Toward that end, the PROMISES project has developed and made freely available a series of videos and guides on how to ensure safer and more reliable systems.3 Finally, regarding the need to practice more defensively, we also note the importance of being less defensive. Practitioners, particularly primary care physicians, need to build and maintain the trust of their patients, even when things go wrong. Thus candor, honest disclosure, willingness to modestly recognize that patients’ criticisms and concerns can both help us become better physicians and help in reducing malpractice suits and risks. Among the resources we have developed are a guide and video interview with Lucian Leape, MD, which give practical advice about how to share errors with patients and families.4,5 Gordon D. Schiff, MD Madeleine Biondolillo, MD Author Affiliations: Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts (Schiff); Department of Medicine, Harvard Medical School, Boston, Massachusetts (Schiff); Bureau of

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Healthcare Safety and Quality, Boston, Massachusetts (Biondolillo); Massachusetts Department of Public Health, Boston (Biondolillo). Corresponding Author: Gordon D. Schiff, MD, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St, Third Floor, Boston, MA 02120 ([email protected]). Conflict of Interest Disclosures: None reported. Funding/Support: This project was supported by grant number R18HS019508 from the Agency for Healthcare Research and Quality (AHRQ). Role of the Sponsor: The AHRQ had no role in the preparation, review, or approval of the manuscript or the decision to submit the manuscript for publication. Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. 1. Schiff GD, Puopolo AL, Huben-Kearney A, et al. Primary care closed claims experience of Massachusetts malpractice insurers. JAMA Intern Med. 2013;173 (22):2063-2068. 2. Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice risk according to physician specialty. N Engl J Med. 2011;365(7):629-636. 3. The PROMISES Project. Brigham and Women’s Hospital website. http://www.brighamandwomens.org/PBRN/PROMISES. Accessed March 5, 2014. 4. Schiff G, Griswold P, Ellis BR, et al. Doing right by our patients when things go wrong in the ambulatory setting. Jt Comm J Qual Patient Saf. 2014;40(2):91-96. 5. The PROMISES Project. When things go wrong in the ambulatory setting. http://www.brighamandwomens.org/Research/depts/Medicine/General _Medicine/PBRN/docs/WhenThingsGoWrongInTheAmbulatorySetting.pdf. Published October 9, 2013. Accessed March 5, 2014.

In Reply Dr Harris’ calculated lifetime risk is similar to the results of a study done by Jena et al.1 Using data from a single large malpractice insurer, Jena et al1 calculated a 76.7% lifetime risk of a medical malpractice claim for physicians practicing family medicine and a 88.5% lifetime risk for physicians practicing internal medicine and subspecialties. The lifetime risk of a medical malpractice claim for physicians practicing obstetrics and gynecology (97.2%) and general surgery and surgical subspecialties (98.4%) approached certainty. We are currently conducting a study of this issue using closed claims data from Illinois. For a physician, being accused of malpractice is deeply traumatic. We do not mean to discount the emotional stakes. However, most claims do not result in payment, and malpractice insurers almost always cover the entire cost if a payment is made. Defensive medicine, in addition to being wasteful, can cause injury and economic harm to patients. So the question for Dr Harris and others is straightforward: if 1 malpractice claim over a 40-year career is sufficient to justify defensive medicine, what level of claiming will not justify defensive medicine? David A. Hyman, MD, JD William M. Sage, MD, JD Author Affiliations: College of Law and College of Medicine, University of Illinois, Champaign (Hyman); School of Law, University of Texas, Austin (Sage). Corresponding Author: David A. Hyman, MD, JD, College of Law, University of Illinois, 504 E Pennsylvania Ave, Champaign, IL 61820 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice risk according to physician specialty. N Engl J Med. 2011;365(7):629-636.

Sexual Activity in Midlife Women and Beyond To the Editor We read with interest the article by Thomas et al1 on sexual activity in midlife women. The World Health Organization has been working in the area of sexual health since at least 1974 (http://www.who.int/topics/sexual_health/en/). There are, however, some aspects of the study that need clarification to make the results straightforward. An important aspect relates to the separation of women into the 2 categories of sexually activity at baseline (Table 1 in the article by Thomas et al1): any flaw in this starting point would undermine the validity of prospective results. The prevalence of known and unknown diabetes in US women (age range, 45-64 years) is 13.7% (http://www.cdc.gov /diabetes/pubs/factsheet11.htm), which translates in nearly 82 diabetic women of the 602 who completed study year 4. However, diabetes was not mentioned in Table 1 of their article, which leads to the suspicion that it was not considered as an important factor in sexual function. Alternatively, diabetic women were excluded, but this was not stated. The same reasoning applies to hypertension, dyslipidemia, and metabolic syndrome; needless to say, all these conditions are associated with sexual dysfunction in women.2 Another aspect of the study that leaves us puzzled is the method used to separate women into sexually active vs sexually inactive groups. It is stated that the primary outcome was sexual activity at year 8, as assessed by the question: “During the past 6 months, have you engaged in any sexual activities with a partner?”1(p631) However, the reader is left confused about the construction of baseline data. If we assume that the same question was used at baseline to differentiate sexually active vs inactive women, it may be hard to accept that a single question can be used as a cutoff point, also considering that this question does not measure the “quality” of sex. This may explain, in part, the data in Table 1 indicating that sexually active women are more likely to take an antidepressant, to have vaginal dryness, and to be married, which is the opposite of what the literature says for diabetic women.3,4 Female Sexual Function Index (FSFI) is a validated instrument based on 6 domains and 19 questions: a 0.5 difference between scores of 2 groups of women is neither statistically nor biologically significant. The absence of any dispersion data (standard deviation) of FSFI score does not help, and the percentage of women falling below the cutoff of 26 was not given. The whole story can hardly help in defining the natural history of sexual activity in midlife women. Maria Ida Maiorino, MD Giuseppe Bellastella, MD, PhD Katherine Esposito, MD, PhD Author Affiliations: Department of Medical, Surgical, Neurological, Metabolic, and Geriatric Sciences, Second University of Naples, Naples, Italy (Maiorino, Bellastella); Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy (Esposito). Corresponding Author: Katherine Esposito, MD, PhD, Unit of Endocrinology and Metabolic Diseases, Department of Internal and Clinical Medicine, Second University of Naples, Piazza L. Miraglia n° 2, 80138 Naples, Italy (katherine [email protected]). Conflict of Interest Disclosures: None reported.

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