Author: Michael Vlessides
Anesthesiology residents have to contend with myriad stressors, from demanding work schedules to sleepless nights. Now, a new study by a team of Brown University researchers has identified a new challenge: the risk for lawsuits.
The review of malpractice claims involving anesthesia residents and fellows concluded that residents in the Northeast region of the United States who administer general anesthesia were at highest risk for medical malpractice lawsuits. These findings, they said, illustrate the importance of structured supervision during intraoperative anesthetic management by senior faculty.
“As a resident, it intrigued me to think that residents might get sued as a part of their training,” said Feel G. Kang, MD, a resident at the Providence, R.I., institution. “Like most residents, I know very little about this because I’ve never had any exposure to it.”
Anesthesiology residents often find themselves in high-risk, critical environments, a professional milieu that makes them more liable to malpractice claims, even in the face of best-practice care. In addition to the obvious psychological and financial distress associated with such claims, they can also affect an individual’s employment prospects for months or years afterward.
The researchers queried the Westlaw database, a subscription-based legal search tool, for all state and federal malpractice litigation involving anesthesiologists in the United States between 1959 and 2018. Jury verdicts, depositions and narrative summaries were evaluated for the involvement of residents, as well as the time period of the alleged malpractice (preoperative, intraoperative and postoperative) and the type of anesthetic used.
The study’s primary outcome was indemnity payment, adjusted by inflation. Secondary outcomes included the case verdict and final patient outcome (recovery, non–life-threatening injury, permanent injury or death).
Factors Affecting Risk
As Dr. Kang reported at the 2019 annual meeting of the American Society of Anesthesiologists (abstract F1091), 2,386 cases were identified, 288 of which were relevant to the study. A total of 198 cases were excluded, for several reasons: lack of anesthesia resident involvement; inaccuracy or incomplete data; duplicate cases; and lawsuits not pertaining to medical malpractice. After exclusions, 90 cases were included in the final analysis.
It was found that junior residents were more commonly involved in malpractice claims than their senior resident counterparts. Indeed, CA-1 residents were involved in 37% of claims (n=33), CA-2 residents in 14% (n=13), CA-3 residents in 11% (n=10), and CA-4 residents in 10% (n=9). In 28% of cases (n=25), the training level of the resident was unknown.
“We found out that our common notions are actually misconceptions,” Dr. Kang said in an interview with Anesthesiology News. “The common belief is that residents are 100% protected because they’re training, and that’s just not true.”
Malpractice claims also occurred more frequently during the intraoperative period. Specifically, preoperative claims accounted for 18% of the total (n=16), intraoperative claims 60% (n=54), and postoperative claims 22% (n=20). The analysis also found that claims involving general anesthesia were the most common, at 77% of cases. Regional/neuraxial anesthesia was involved in 21% of the malpractice claims, whereas the type of anesthetic was unspecified in 2% of cases.
Of note, 42% of the malpractice claims were from the Northeast region of the United States, 26% occurred in the Midwest, 17% originated in the South, and 15% in the West.
With respect to payments, they did not differ if surgical cases were performed under general anesthesia (median, $1,400,000) or neuraxial/regional anesthesia ($920,000; P=0.21). The largest claim payments occurred in pediatrics, with a median of $16,700,000.
Payments were greater if the event happened in the postoperative period ($7 million), compared with $910,000 for events occurring in the intraoperative period and $960,000 for those in the preoperative period (P=0.02).
“The awards certainly weren’t what I thought they would be—they were astronomically higher,” Dr. Kang said. “And this kind of thing can definitely ruin someone’s career even before it takes flight.”
Institutions Need to Help Protect Residents
Given the prevalence of anesthesia claims among these trainees, Dr. Kang stressed the importance of structured supervision during intraoperative anesthetic management. This will not only improve education but also possibly prevent litigation altogether.
“I think letting residents know that their actions are not 100% protected is also critical, because in many ways, they are as vulnerable as any other medical provider. In addition, residents should really learn proper documentation as a general rule of thumb,” he added.
“In the end, the purpose of our research was to tell people that residents really need to protect ourselves and practice defensively,” Dr. Kang said.
According to Jeffrey C. Gadsden, MD, an associate professor of anesthesiology and the chief of the Division of Orthopaedics, Plastics and Regional Anesthesiology at Duke University Medical Center, in Durham, N.C., institutions can help residents by both teaching them the skills to help avoid litigation and offering assistance when residents find themselves involved in lawsuits.
“You see again and again in medicolegal cases that documentation lapses often lead to awards rather than dismissals. It’s not the actual medicine most of the time—it’s an error in judgment,” Dr. Gadsden said. “So I think this is an opportunity for us all, but especially trainees, to get into good habits of how to document properly and protect ourselves against claims.”
But when litigation does occur, institutions can support their residents in other ways. “We probably don’t have a systematic approach for providing resources to residents who are involved in medicolegal suits,” Dr. Gadsden said. “So it strikes me that we could devote some resources to that.”