Do anesthesiologists have the highest malpractice insurance rates?
In a word, “No.”
Anesthesia mishaps can lead to critical events such as death or coma, but in recent decades improvements in operating room technology and education have led to fewer such events.
Prior to 1985, anesthesia malpractice claims for death or brain death were most often due to lack of oxygen the patient’s heart or brain. Two significant breakthroughs arrived in the 1980’s to help anesthesiologists care for you: 1) the pulse oximeter, and 2) the end-tidal carbon dioxide monitor.
The pulse oximeter, developed by Nellcor and Stanford anesthesiologist William New, M.D., is a device that clips to a patient’s fingertip. A light-emitting diode shines a red light through the finger, and a sensor on the opposite side of the finger measures the degree of redness in the pulsatile blood flow within the finger. The more red the color of the blood, the more oxygen is present. A computer in the pulse oximeter calculates a score, called the oxygen saturation, which is a number from 0-100%. An oxygen saturation equal to or greater that 90% correlates with a safe amount of oxygen in the arterial blood. A score of 89% or lower correlates with a dangerously low oxygen level in the blood.
The pulse oximeter monitor enables doctors to know, second-to-second, whether a patient is getting sufficient oxygen. If the oxygen saturation goes below 90%, doctors will act quickly to diagnose and treat the cause of the low oxygen level. A patient can usually sustain a short period low oxygen saturation, e.g. up to 2 or 3 minutes, without permanent damage to the brain or cardiac arrest by an oxygen-starved heart.
The end-tidal carbon dioxide (CO2) monitor is a device that measures the concentration of CO2 in the gas exhaled by a patient on every breath. During normal ventilation, every exhaled breath contains CO2. When no CO2 is measured, there is no ventilation, and the doctor must act quickly to diagnose and treat the cause of the lack of ventilation.
Prior to the invention of these two monitors, it was possible for an anesthesiologist to mistakenly place a breathing tube in a patient’s esophagus, instead of the trachea, and not know of the error until the patient sustained a cardiac arrest. With the addition of the two monitors, the lack of CO2 (there is no CO2 in the stomach or esophagus) from the end-tidal CO2 monitor immediately indicates that the tube is in the wrong place. The anesthesiologist can then remove the tube, resume mask ventilation with oxygen, and attempt to replace the tube into the windpipe. If the oxygen level to the patient’s blood dips below 90%, this is a second piece of data that indicates that the patient is in danger of brain damage or cardiac arrest.
In addition, in the early 1990’s the American Society of Anesthesiologists created the Difficult Airway Algorithm, which is a step-by-step approach for anesthesiologists to follow when the task of placing a breathing tube for an anesthetic is challenging or difficulty. This Algorithm dictates a standard of care for practitioners, and this advance in education lowered the number of mismanaged airways.
In the 1980’s, surgical anesthesia claims were 80% of closed malpractice claims against anesthesiologists (American Society of Anesthesiologists Closed Claims database). By the 2000’s, this number dropped to 65%. Brain damage represented 9% of claims, and nerve injury accounted for 22% of claims (23% were permanent and disabling, including loss of limb function, or paraplegia or quadriplegia) Less common claims were airway injury (7% of claims), emotional distress, (5% of claims), eye injuries including blindness (4% of claims), and awareness during general anesthesia (2% of claims).
Decreasing anesthesiologist malpractice premiums reflect the decrease in the number of catastrophic anesthesia claims for esophageal intubation, death, and brain death.
In 1985, the average malpractice insurance premium was $36,224 per year for a $1 Million per claim/$3 Million per year policy. By 2009, this decreased to $21,480, a striking 40% drop. (Anesthesia in the United States 2009, Anesthesia Quality Institute http://aqihq.org/Anesthesia%20in%20the%20US%202_19_10.pdf).
Specialties with the highest risk of facing malpractice claims are neurosurgery (19.1 percent), thoracic and cardiovascular surgery (18.9 percent) and general surgery (15.3 percent). Specialties with the lowest risks are family medicine (5.2 percent), pediatrics (3.1 percent) and psychiatry (2.6 percent). Anesthesiologists rank in the middle of the pack, at 7%. (Malpractice Risk According to Physician Specialty, Jena, et al, N Engl J Med 2011; 365:629-636.) From 1991 to 2005, this article identified 66 malpractice awards that exceeded $1 million dollars, which accounted for less than 1% of all payments. Obstetrics and gynecology accounted for the most payments (11), followed by pathology (10), anesthesiology (7), and pediatrics (7).
At the American Society of Anesthesiologists (ASA) Annual Meeting in San Diego in October 2015, the following numbers were presented from the National Practitioner Data Bank (presented as abstract A2097):
- The yearly spending on malpractice payments against anesthesiologists decreased from $174.4 million in 2005 to $91.1 million in 2013, a decrease of $83.3 million, or a 41.4% decrease.
- Of the 2,408 payments made during the 9-year period from 2005 – 2013, 567 (23.5%) were for outpatient events, and 1,841 (76.5%) were from inpatient events.
- The average payment was $245,000, with inpatient anesthesia claims being significantly more expensive ($261,742 to $189,349 respectively). Inpatient claims accounted for 82% of the total amount paid.
- Death was the most common outcome in both the inpatient and outpatient claims.
A second abstract from the same ASA meeting (abstract A1009) showed that non-operating room payments were significantly higher than operating room payments ($554,000 vs. $285,000; p=0.003).
A take home message is that anesthesia has serious risks, but those risks have decreased significantly in recent years, most likely because of improvements in monitoring and education. Compared to other specialties, the risk of an anesthesiologist being sued is about average among American medical specialties.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too.
Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode.
In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
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