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Examining the Evidence


Can a change in practice patterns reduce the number of OB malpractice claims?

April 2009 · Vol. 21, No. 04

This article, like any other written about litigation in obstetrics, is sure to spark much discussion and many opinions. And because the article states that most of the cases reviewed for the study involved substandard medical care, emotions will flare and many physicians will disagree. Many readers will ignore the findings because the authors do not conclude that tort reform is the major solution to the professional liability crisis.

Most obstetricians have been sued at some point in their career. The cost of these lawsuits can be measured in both financial and human terms—from the expense of mounting a defense to enormous stress and loss of physician productivity. Fear of litigation also leads to the practice of defensive medicine, driving up the cost of health care and further limiting our procedural options.

Suggestions for reform, such as modifying the tort system and reining in medical experts, have met with limited success. Neither an obstetric practice nor a hospital—let alone an individual obstetrician—can hope to effect these kinds of changes. The best solution for mitigating the cost of obstetric litigation is to make care safer. Safer obstetrics may lower obstetricians’ costs while reducing the financial and emotional toll that injury takes on our patients and their families.

A few caveats

The case series by Clark and colleagues is limited because it does not include a comparison group or address cases that were dropped, defended successfully, or filed despite good care. Nor do the authors fully explain how “substandard” care is defined or the evidence on which this finding is based.

In obstetric liability cases, decades may pass between the delivery of an infant and the delivery of a jury verdict, which limits the applicability of these findings to modern obstetric care.

As a case series, this study is hypothesis-generating. It offers four practice- or hospital-level solutions without proving that they work. The authors’ expert opinion should stimulate analytic research that utilizes a comparison group so that associations can be made.

Despite these weaknesses, the conclusions that:

  • most cases were a result of substandard care
  • documentation is often lacking or inadequate
  • use of oxytocin should be standardized
  • obstetric coverage should be 24/7

are all correct, and have been described in other articles dating back to 1988.1,2

The blame game can be destructive

We live in a blame-based society, exemplified by the obstetric-litigation environment. The study by Clark and colleagues is a welcome step toward realigning our priorities and lowering costs by eliminating preventable errors.

WHAT THIS MEANS FOR PRACTICE

The authors offer four practical recommendations to lower the number of obstetric liability claims:

  • Deliver in a facility with 24-hour in-house obstetric coverage
  • Adhere to published high-risk medication protocols, especially for oxytocin, misoprostol, and magnesium sulfate
  • Limit vaginal birth after cesarean (VBAC) to spontaneous labors progressing without augmentation and without repetitive moderate or severe variable decelerations
  • Use a comprehensive, standardized procedure note in cases of shoulder dystocia.

Although this study does not provide proof, it does suggest that it will cost obstetricians much more if they do not follow these four simple recommendations.—JASON K. BAXTER, MD, MSCP, AND LOUIS WEINSTEIN, MD

References

1. Weinstein L. Malpractice—the syndrome of the 80s. Obstet Gynecol. 1988;72:130-135.

2. Hayes EJ, Weinstein L. Improving patient safety and uniformity of care by a standardized regimen for the use of oxytocin. Am J Obstet Gynecol. 2008;198:622.e1-622.e7.

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