Impact of Malpractice Liability Among Spine Surgeons: A National Survey of French Private Neurosurgeons

Journal Pre-proof
Impact of Malpractice Liability Among Spine Surgeons: A National
Survey of French Private Neurosurgeons
Bertrand Debono MD Olivier Hamel MD PhD Antoine Guillain Anne
Durand MD PhD Marjory Rué MD Pascal Sabatier MD Guillaume
Lonjon MD PhD Gregory Dran MD, on behalf of French Society of
Private Neurosurgeons (SFNCL)
PII:
S0028-3770(20)30334-9
DOI:
https://doi.org/doi:10.1016/j.neuchi.2020.05.003
Reference:
NEUCHI 1092
To appear in:
Neurochirurgie
Received Date:
8 January 2020
Revised Date:
3 April 2020
Accepted Date:
2 May 2020
Please cite this article as: Debono B, Hamel O, Guillain A, Durand A, Rué M, Sabatier P,
Lonjon G, Dran G, Impact of Malpractice Liability Among Spine Surgeons: A National Survey
of French Private Neurosurgeons, Neurochirurgie (2020),
doi: https://doi.org/10.1016/j.neuchi.2020.05.003
This is a PDF file of an article that has undergone enhancements after acceptance, such as
the addition of a cover page and metadata, and formatting for readability, but it is not yet the
definitive version of record. This version will undergo additional copyediting, typesetting and
review before it is published in its final form, but we are providing this version to give early
visibility of the article. Please note that, during the production process, errors may be
discovered which could affect the content, and all legal disclaimers that apply to the journal
pertain.
© 2020 Published by Elsevier.
Impact of Malpractice Liability Among Spine Surgeons: A National
Survey of French Private Neurosurgeons
Impact de la judiciarisation de la pratique chirurgicale : Une enquête nationale
auprès des neurochirurgiens libéraux français
Bertrand Debono, MD1, Olivier Hamel, MD, PhD1, Antoine Guillain2,3, Anne Durand, MD, PhD4,
Marjory Rué, MD5, Pascal Sabatier, MD1, Guillaume Lonjon, MD, PhD6, Gregory Dran, MD7 on behalf
of French Society of Private Neurosurgeons (SFNCL)
1
Ramsay-Clinique des Cèdres, Neurosurgery, Cornebarrieu, France
2
Sorbonne Study Group on Methods of Sociological Analysis of the Sorbonne (GEMASS), Sorbonne
3
oo
f
University, Paris, France
SiRIC CURAMUS (Integrated cancer research site), Assistance Publique-Hôpitaux de Paris, Sorbonne
pr
University, Paris, France
Infirmerie Protestante, Neurosurgery, Caluire, France
5
Endoscopic Spine Center, Bordeaux, France
6
Orthosud, Spine Surgery Department, Montpellier, France
7
Clinique du millénaire, Neurosurgery, Montpellier, France
Pr
al
Corresponding author
Bertrand Debono, MD
e-
4
Jo
ur
n
Department of Neurosurgery, Neuroscience Pole
Ramsay – Clinique des Cèdres
31700 Cornebarrieu
France
+33 562133190
+33 562133189
[email protected]
orcid.org/0000-0003-4638-1075
The authors report no conflict of interest. The manuscript submitted does not contain information about
medical device(s)/drug(s). No funds were received in support of this work.
Original Article in English
Page 1 of 19
Impact of Malpractice Liability Among Spine Surgeons: A National
Survey of French Private Neurosurgeons
Impact de la judiciarisation de la pratique chirurgicale : Une enquête nationale
auprès des neurochirurgiens libéraux français
The authors report no conflict of interest. The manuscript submitted does not contain information about
Jo
ur
n
al
Pr
e-
pr
oo
f
medical device(s)/drug(s). No funds were received in support of this work.
Page 2 of 19
Abstract in English
Purpose
In the general context of medical judicialization, spine surgeons are impacted by the part that medical
responsibility and the risk of malpractice play in their actions and decisions. Our aim was to evaluate
possible shifts in practices among private neurosurgeons who are highly exposed to this judicial risk and
detect alterations in their pleasure in exercising their profession. We present the first national survey on
French physicians’ perception of surgical judicialization and consequences on their practice.
Methods
oo
f
An online survey was submitted to the 121 members of the French Society of Private Neurosurgery,
who represent 29.1% of the total number of spine surgeons and perform 36.0% of the national total spine
surgery activity. The French law (no-fault out-of-court scheme) significantly impacts these surgeons in
pr
the event of litigation.
Results
e-
A total of 78 surveys were completed (64.5% response rate): 89.7% of respondents experienced
alteration of doctor-patient relationship related to judicialization and 60.2% had already refused to
Pr
perform risky surgeries. Fear of being sued added negative pressure during surgery for 55.1% of
respondents and 37.2% of them had already considered stopping their practice because of this litigation
Conclusion
al
context.
Jo
ur
n
The increasing impact of medical liability is prompting practitioners to change their practice and
perceptions. The doctor-patient relationship appears to be altered, negative pressure is placed on
physicians and defensively, some neurosurgeons may refuse high-risk patients and procedures. This
situation causes professional disenchantment and can ultimately prove disadvantageous for both doctors
and patients.
Abstract en français
Introduction
Dans le contexte général de la judiciarisation des pratiques médicale, les chirurgiens du rachis sont
particulièrement impactés par le rôle de la responsabilité médicale et du risque de faute professionnelle
dans leurs actions et leurs décisions. Notre objectif était d'évaluer les évolutions possibles de la pratique
des neurochirurgiens privés fortement exposés à ce risque judiciaire et de détecter les altérations de leur
plaisir à exercer de leur profession. Nous présentons la première enquête française sur la perception par
des praticiens de la judiciarisation chirurgicale et de ses conséquences sur leur pratique.
Page 3 of 19
Méthodes
Une enquête en ligne a été soumise aux 121 membres de la Société Française des Neurochirurgiens
Libéraux (SFNCL), qui représentent 29,1% du nombre total de chirurgiens du rachis en France et
réalisent 36,0% de l'activité nationale totale des chirurgies rachidiennes. La loi française (Loi de 2002,
commission conciliation indemnisation) a un impact important sur les chirurgiens privés exposés en cas
de litige.
Résultats
Au total, 78 réponses ont été obtenues (taux de réponse de 64,5 %) : 89,7 % des répondants ont décrit
une dégradation de la relation médecin-patient liée à la judiciarisation et 60,2 % ont déjà refusé de
oo
f
pratiquer des interventions à risque. La crainte d'une procédure judiciaire a ajouté une pression négative
pendant les interventions chez 55,1 % des répondants et 37,2 % d'entre eux ont déjà envisagé de cesser
leur pratique en raison de ce contexte accru de litige.
pr
Conclusion
L'impact croissant des procédures de plainte incite les praticiens à modifier leur pratique et leurs
e-
perceptions. La relation médecin-patient en est modifiée, des pressions négatives sont exercées sur les
médecins et, sur le plan défensif, certains neurochirurgiens peuvent refuser des patients et des
Pr
interventions à risque élevé. Cette situation provoque un désenchantement professionnel et peut
Jo
ur
n
al
finalement s'avérer désavantageuse tant pour les médecins que pour les patients.
Page 4 of 19
English Keywords : Malpractice litigation; Practice pattern; Spine Surgery; Insurance liability;
Burn-out; Claim
Mots-clés en français
Plainte, Responsabilité professionnelle, Chirurgie du rachis, Burn-out, Médico-légal, évaluation des
Jo
ur
n
al
Pr
e-
pr
oo
f
pratiques
Page 5 of 19
Introduction
The ever-increasing judicialization of medicine adversely impacts many areas, including spinal surgery
[1], resulting in the deterioration of professional fulfillment among practitioners who describe insurance
consequences and the advent of defensive practices[2,3]. Some authors have even proposed the concepts
of second victim surgeon and litigaphobia [4].
Spinal surgery, particularly for degenerative diseases, carries risks of complications and subsequent
complaints due to intrinsic neurological risks and the random nature of its functional results, which may
disappoint patients’ expectations [2].
In France, a law enacted in 2002 created the concept of a no-fault out-of-court scheme, avoiding a court
oo
f
trial. However, this facilitated the potential for frivolous lawsuits due to the simplicity and cost-free
nature of the procedure for patients [5]. This is one of the elements that contributed to the development
of a growing and significant demand for compensation for malpractice in spinal surgery[6].
pr
Private neurosurgeons, subject to civil law and performing spinal surgery, are therefore a highly exposed
group to the consequences of judicialization in their professional and personal lives[7]. To our
e-
knowledge, surveys on this subject are rare [8] and this is the first attempt in Europe that seeks to
highlight the harmful consequences of this societal evolution in our profession by lending practitioners
Pr
a direct voice.
Methods
al
An online survey was submitted to members of our national private neurosurgery society between March
and May 2019. This survey included questions on six basic domains: 1) surgeon demographics, 2)
Jo
ur
n
physician practice pattern, 3) malpractice insurance, 4) surgeon perceptions related to the modification
of the doctor-patient relationship, 5) adoption by the surgeon of defensive behaviors, and 6) alteration
of the practitioner’s pleasure in practicing his/her profession. Then, the survey was sent to all 121
members of the French Society of Private Neurosurgeons (SFNCL) with a valid email address. The
SFNCL represents the country’s entire population of private neurosurgeons. The survey was presented
to the SFNCL members via an online survey tool and was conducted over an eight-week period. To
improve the response rate of this electronic survey, we adopted recommended techniques, such as
providing a short contextualization, using the word “survey” in the subject line of the email, having a
white background, and sending out a survey reminder after one month [9].
Focus on national neurosurgical and spinal surgery pattern
In our country, private neurosurgeons are united in a single scientific society (SFNCL) with 121 active
members. These represent 29.1% of the total of 442 French spine surgeons, combining neurosurgeons
and orthopedists [10]. Private practitioners perform 36.0% of the national activity of spinal surgery,
Page 6 of 19
covering all degenerative, traumatic, and oncological disorders, regardless of the severity of the cases
[11].
Focus on medical malpractice and compensation in France (Figure 1)
Since 2002, a complementary legal route to obtain compensation “quickly” and more easily was
established with a new law. This established the current French no-fault out-of-court scheme. Any
patient can start it free of charge under the admissibility criteria. The advantage is the simplification of
the procedure for the patient in case of medical negligence, the creation of the concept of no-fault hazard,
and the relief of court congestion. The disadvantage is the increased pressure on the surgeon due to the
ease and cost-free nature of the procedure handled by national solidarity [5].
oo
f
Focus on the insurance system
Recent data from the insurance company covering almost all SFNCL members at the time of this
pr
survey indicate a high frequency of claims and a very high cost of compensation.
The claims rate for private neurosurgeons is the highest of all surgical specialties. The rate of
requests for amicable conciliation is less than 15% (50% for other specialties). There is a high and
e-
stable proportion (66%) of cases with no risk of liability after expertise. However, the
compensation, when retained by the judges, is increasingly expensive and explains the high
Pr
insurance premiums [6].
Both the Ethics Committee of the French College of Neurosurgery and the Data Protection Authority
al
approved this study. Informed consent was not obtained given that this was a de-identified anonymous
Jo
ur
n
online survey. The purpose of this study was disclosed to the participants prior to the survey.
Page 7 of 19
Results
The key results are summarized in Figure 2.
Surgeons’ demographics
Of the 121 surgeons invited to participate, 78 (64.5%) returned the completed survey. There were 70
men and 8 women, with a mean age of 52.5 ± 11 years (range, 39–68). The average practice duration
was 22 ± 11 years (range: 8-35).
Physicians’ practice pattern
The average number of annual operative cases was 440 patients (range: 200–850). The number of
oo
f
surgeons in practice was one in 14.1% of cases, 2-3 in 42.3%, 4-6 in 37.2%, and >6 in 6.4%.
Malpractice insurance
pr
The average amount of the professional liability insurance premium was €23025 (range: €11000-42000)
at the time of the survey, and 30 participants (37.78%) reported an increase in their premium over the
e-
previous 2 years.
The average annual number of claims against the respondents in the past 3 years was 1.15 (range: 0-6).
Pr
Surgeon perceptions related to the modification of the doctor-patient relationship
Table one presents the responses to questions exploring surgeons’ perceptions of their interactions with
al
patients in the context of the judicialization of medical practice. Concerning the doctor-patient
relationship, 89.7% of respondents experienced a change in this relationship related to judicialization,
Jo
ur
n
60.3% of them considered that their approach to the patient had deteriorated owing to complaints
received over the course of the years. In the presence of a new patient, 92.3% of respondents thought
(systematically or sometimes) about the complainant he/she could become. During the consultation,
93.6% of respondents sought (systematically or sometimes) to detect any sign of procedural personality
in their patients and 34.6% had identified a typical patient profile to try not to operate.
Adoption of defensive behavior
Table two outlines responses to a series of questions related to avoidance strategies. Faced with a patient
identified as capable of initiating a complaint in the event of a complication, 87.1% of respondents
reported (often or sometimes) deciding to abstain from surgery and 60.2% had already refused to
perform heavy and/or risky surgeries solely because they feared complications, despite feeling
technically competent to perform them. Regarding the patient’s preoperative information, 83.3% of
respondents had modified it because of the judicialization of their practice. Further, 50% considered that
Page 8 of 19
too much information about potential complications and including the most exceptional risks is not a
good thing for the patient. Additionally, 65.3% of respondents were often or sometimes concerned about
being completely transparent with their patient because of the risk of a claim.
Alteration of the pleasure in practicing surgery
Table three reports the results of the respondents’ professional alteration and disenchantment. Fear of
being sued added negative pressure during an operation for 55.1% of respondents. When confronted
with a complication during surgery, the surgeon systematically or occasionally thought of a possible
claim in 92.3% of cases. Concerning the doctor-patient relationship, 65.4% of respondents considered
that this binary colloquium had become a three-party relationship involving the lawyer.
oo
f
The judicialization of medical practice impacts their passion for the profession and their pleasure in
practicing it for 80.8% of respondents and 37.2% of them had already considered stopping their activity
Jo
ur
n
al
Pr
e-
pr
because of this medico-legal stress.
Page 9 of 19
Discussion
Results overview (Figure 2)
Our study identified the consequences of the increase in the number of malpractice claims among French
private neurosurgeons: alteration of the doctor-patient relationship, emergence of defensive attitudes,
permanent pressure on the practitioner during his/her operating days, irruption of the lawyer between
the patient and the surgeon, and eventual professional demotivation.
Performing high-risk surgery in a changing society
The challenges of spinal surgery expose the physician to increased risks in the practice of his profession
oo
f
in a society that is evolving and increasingly refusing risks [12]. One of the important developments
highlighted by several authors is the tacit shift from the obligation of means to the obligation of result.
A bad result is no longer tolerated, opening the door to defensive practices, deterioration of patient care,
pr
and of physicians’ motivation [13,14].
In fact, the French system, since the 2002 law, has caused private practitioners a certain discomfort.
e-
Admittedly, the patient is better protected in the event of a proven error, the civil courts are relieved of
congestion, but this is accompanied by a simplified and free-of-charge procedure (if the eligibility
Pr
criteria are met); the private surgeon must submit to contradictory procedures, in particular expertise,
which is unanimously perceived as very unpleasant [15]. Practitioners in the public system, who are
governed by administrative law, do not necessarily have to submit to these procedures. The result may
explain the unfavorable experience reported in this study. Some authors have even mentioned the
al
concept of the surgeon as a “second victim” with a deterioration of the daily routine even in private life,
Jo
ur
n
a decrease in empathy for the patient, and early signs of burn-out [16].
Impact of claims
Our participants reported an average of 1.15 complaints per year [6]. Insurers’ data show that the
conclusion is unfavorable to the surgeon only in 15% litigations, (withholding his/her fault), which tends
to demonstrate that the negative impact that physicians report concerns more a perceived than an
objective fear [17]. We can re-emphasize the term litigaphobia, which was coined a few decades ago,
defining this permanent anxiety of being sued as a sword of Damocles. We found this in our respondents
who felt this permanent pressure as soon as they operated and even more so in the event of a
complication [4]. It is nevertheless revealing to note that the path chosen by the French plaintiffs is a
simple conciliation or settlement in 15% of cases in spinal surgery only, while it is in 50% of cases in
all specialties combined, which clearly shows that in the particular field of spinal surgery the complaint
process immediately takes a more threatening turn for the physician [17].
Coping strategies
Page 10 of 19
Although the fear of litigation improved information given to the patient to obtain informed consent, the
problem of optimal transparency remains. Many practitioners point out that the exhaustive list of
complications may not be a good strategy for the patient [18]. The identification of high-risk profiles,
or the refusal of risky interventions due to insurance coverage risk is a trend that cannot ultimately
benefit either the society or patient [19,20]. However, the adoption of defensive practices does not reach
the level described in the USA [2] where Nahed et al. showed that 45% of the 3344 surveyed
neurosurgeons eliminated high-risk procedures from their practice due to liability issues [8]. Studdert et
al. reported that 39% of neurosurgeons and 42% of orthopedics avoided some complex surgeries and
38% of neurosurgeons and 57% of orthopedics avoided care for high-risk patients [21].
oo
f
Professional disenchantment
Despite institutional or insurance support measures, sued surgeons often find themselves isolated when
faced with litigation and its professional and personal impact [22]. In an individualistic profession and
defiance to psychological assistance or administrative measures, there is still a long way to go to prevent
pr
demotivation or burn-out [23]. In a survey of 2999 Australian doctors, Nash et al. demonstrated that
concerns about medicolegal issues led to 33% of them considering giving up medicine, 32% considering
e-
reducing their working hours, and 40% considering retiring early [24]. There is an echo of this among
the respondents of our survey where more than a third of whom have already considered ceasing surgical
Pr
activity because of this evolution [25].
Limitations
al
First, the population size is small. However, the response rate was 64.5% of the total number of private
neurosurgeons (n=121) who themselves perform more than one-third of all spine surgeries in the
Jo
ur
n
country. We believe that this group’s feedback is relevant. Second, a survey may differ from actual
practice patterns. The results presented here are subject to a response bias with respondents more
concerned about claims and liability than non-responders. Third, the subject of our survey (i.e.
malpractice) may have caused frustration and/or anxiety in some surgeons, inducing extreme responses
[8]. Despite being a purely declarative online survey, without any previous basis for comparison, the
expression of this feeling which reflected a deterioration in the pleasure of performing surgery, seems
to us worthy of communicating to our medical community.
Some ways to address this situation
At the end of this survey, we could suggest the following points to avoid disenchantment and
professional fatigue: optimize patient selection (in particular psychological evaluation for
degenerative conditions), participate in boards to discuss indications, ask for second opinions,
work in multidisciplinary teams, improve one' s legal training and the management of medical
charts, not neglect continuing education despite the high workload, lighten schedules, fight against
Page 11 of 19
the lack of serenity and stress which create a vicious loop that can lead to burn-out and the
degradation of one' s relationship with patients.
Conclusion
Our survey revealed the suffering of the interviewed practitioners which can impact their personal and
professional quality of life and the care they provide to their patients. The risky nature of spinal surgery
(neurological risk and functional uncertainty), the legal environment in which they operate combined
with societal changes that refuse complications can alter the enjoyment of their profession, demotivate
them, and result in an early cessation of their activity. Beyond litigations, which are not so frequent and
rarely demonstrate the responsibility of the practitioner, there is an overall deterioration in the pleasure
oo
f
of operating, practicing surgery, establishing trust with the patient in a worrying era of suspicion and
compassion fatigue among a group of surgeons who perform a significant part of spinal surgery at the
Jo
ur
n
al
Pr
e-
pr
national level.
Page 12 of 19
Conflict of Interest
All authors certify that they have no affiliations with or involvement in any organization or entity with
any financial interest (such as honoraria; educational grants; participation in speakers' bureaus;
membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony
or patent-licensing arrangements), or non-financial interest (such as personal or professional
relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this
manuscript.
Acknowledgment
We would like to thank Editage for English language editing. We are also very grateful to Carole
oo
f
Gerson and Thierry Houselstein (Compensation and Medical Communication Department,
MACSF, Paris, France) for their valuable assistance in the analysis of the insurance data essential
to the development of this work.
pr
Acknowledgments
Jo
ur
n
al
Pr
e-
We would like to thank Editage for English language editing.
Page 13 of 19
References
[1]
Roter D. The Patient-Physician Relationship and its Implications for Malpractice Litigation.
Journal of Health Care Law and Policy 2006;9:304.
[2]
Din RS, Yan SC, Cote DJ, Acosta MA, Smith TR. Defensive Medicine in U.S. Spine
Neurosurgery. Spine 2017;42:177–85. https://doi.org/10.1097/BRS.0000000000001687.
[3]
Yan SC, Hulou MM, Cote DJ, Roytowski D, Rutka JT, Gormley WB, et al. International
Defensive Medicine in Neurosurgery: Comparison of Canada, South Africa, and the United
States. World Neurosurg 2016;95:53–61. https://doi.org/10.1016/j.wneu.2016.07.069.
Breslin FA, Taylor KR, Brodsky SL. Development of a litigaphobia scale: measurement of
oo
f
[4]
excessive fear of litigation. Psychol Rep 1986;58:547–50. https://doi.org/10.2466/pr0.1986.58.2.547.
[5]
G’Sell-Macrez F. Medical Malpractice and Compensation in France, Part I: The French Rules
pr
of Medical Liability since the Patients’ Rights Law of March 4, 2002. Chicago-Kent Law Review
2011;86:1093.
MACSF.fr. Macsf. MACSF.fr n.d. https://www.macsf.fr/Rapport-annuel-sur-le-risque-
e-
[6]
medical/risque-des-professions-de-sante (accessed April 3, 2020).
Guillain A, Moncany A-H, Hamel O, Gerson C, Bougeard R, Dran G, et al. Spine
Pr
[7]
neurosurgeons facing the judicialization of their profession: disenchantment and alteration of
020-04302-z.
Nahed BV, Babu MA, Smith TR, Heary RF. Malpractice Liability and Defensive Medicine: A
Jo
ur
n
[8]
al
daily practice-a qualitative study. Acta Neurochir (Wien) 2020. https://doi.org/10.1007/s00701-
National Survey of Neurosurgeons. PLoS One 2012;7. https://doi.org/10.1371/journal.pone.0039237.
[9]
Edwards PJ, Roberts I, Clarke MJ, DiGuiseppi C, Wentz R, Kwan I, et al. Methods to increase
response to postal and electronic questionnaires. Cochrane Database of Systematic Reviews 2009.
https://doi.org/10.1002/14651858.MR000008.pub4.
[10]
Trouver un médecin. Conseil National de l’Ordre des Médecins 2019. https://www.conseil-
national.medecin.fr/patient/cherche-medecin/trouver-medecin (accessed November 10, 2019).
[11]
Activité établissements. Activité établissement - Casemix MCO | Stats ATIH n.d.
https://www.scansante.fr/applications/casemix_ghm_cmd?secteur=MCO.%20Activite%CC%81%20e
%CC%81tablissement%20%E2%80%93%20Casemix%20MCO%20|%20Stats%20ATIH.
(accessed
November 9, 2019).
[12]
Truog RD. Patients and Doctors — The Evolution of a Relationship. N Engl J Med
Page 14 of 19
2012;366:581–5. https://doi.org/10.1056/NEJMp1110848.
[13]
Tabibian BE, Kuhn EN, Davis MC, Pritchard PR. Patient Expectations and Preferences in the
Spinal
Surgery
Clinic.
World
Neurosurg
2017;106:595–601.
https://doi.org/10.1016/j.wneu.2017.07.018.
[14]
Gupta R, Griessenauer CJ, Moore JM, Adeeb N, Patel AS, Ogilvy CS, et al. An analysis
of malpractice litigation related to the management of brain aneurysms. Journal of Neurosurgery
2016;127:1077–83. https://doi.org/10.3171/2016.9.JNS161124.
[15]
Nachbauer A, Fréminville H de. The Influence of Legal Proceedings on French General
Practice: A Qualitative Study, 2014. https://doi.org/10.4236/jss.2014.26045.
Han K, Bohnen JD, Peponis T, Martinez M, Nandan A, Yeh DD, et al. The Surgeon as the
oo
f
[16]
Second Victim? Results of the Boston Intraoperative Adverse Events Surgeons’ Attitude (BISA) Study.
of
the
American
College
https://doi.org/10.1016/j.jamcollsurg.2016.12.039.
[17]
Surgeons
2017;224:1048–56.
MACSF. Rapport du conseil médical par spécialités. Panorama Des Risques Professionnels En
e-
Santé 2014.
Campbell K, Parsi K. A New Age of Patient Transparency: An Organizational Framework for
Pr
[18]
of
pr
Journal
Informed Consent. J Law Med Ethics 2017;45:60–5. https://doi.org/10.1177/1073110517703100.
[19]
Mello MM, Studdert DM, DesRoches CM, Peugh J, Zapert K, Brennan TA, et al. Caring for
al
patients in a malpractice crisis: physician satisfaction and quality of care. Health Aff (Millwood)
[20]
Jo
ur
n
2004;23:42–53. https://doi.org/10.1377/hlthaff.23.4.42.
Rovit RL, Simon AS, Drew J, B.B.A, Murali R, Robb J. Neurosurgical experience with
malpractice litigation: an analysis of closed claims against neurosurgeons in New York State, 1999
through
2003.
Journal
of
Neurosurgery
2007;106:1108–14.
https://doi.org/10.3171/jns.2007.106.6.1108.
[21]
Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, et al. Defensive
medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA
2005;293:2609–17. https://doi.org/10.1001/jama.293.21.2609.
[22]
Orri M, Revah-Lévy A, Farges O. Surgeons’ Emotional Experience of Their Everyday Practice
- A Qualitative Study. PLoS One 2015;10. https://doi.org/10.1371/journal.pone.0143763.
[23]
Pinto A, Faiz O, Bicknell C, Vincent C. Surgical complications and their implications for
surgeons’ well-being. BJS 2013;100:1748–55. https://doi.org/10.1002/bjs.9308.
[24]
Nash LM, Walton MM, Daly MG, Kelly P, Walter G, Ekert EH van, et al. Perceived practice
Page 15 of 19
change in Australian doctors as a result of medicolegal concerns. The Medical Journal of Australia
2010;193:579–83. https://doi.org/10.5694/j.1326-5377.2010.tb04066.x.
[25]
Bhatt NR, Morris M, O’Neil A, Gillis A, Ridgway PF. When should surgeons retire? Br J Surg
Jo
ur
n
al
Pr
e-
pr
oo
f
2016;103:35–42. https://doi.org/10.1002/bjs.9925.
Page 16 of 19
Legends for Tables
Table 1: Surgeons’ perceptions related to the modification of the doctor-patient relationship
Table 2: Adoption of avoidance behavior
oo
f
Table 3: Surgeons’ perceptions related to the professional alteration and disenchantment
pr
Legends for Figure
Jo
ur
n
al
Pr
Figure 2: Overview of our study main results
e-
Figure 1: Synoptic description of the French medico-judicial complaints system
Page 17 of 19
Compliance with ethical standards
Funding
No funding was received for this research.
The authors report no conflict of interest.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical
e-
For this type of study formal consent is not required.
pr
and its later amendments or comparable ethical standards.
oo
f
standards of the institutional and/or national research committee and with the 1964 Helsinki declaration
Pr
Research involving human participants and/or animals
Jo
ur
n
authors.
al
This article does not contain any studies with human participants or animals performed by any of the
Page 18 of 19
Pr
epr
oo
f
Impact of Malpractice Liability Among Spine Surgeons: A
National Survey of French Private Neurosurgeons
Jo
ur
na
l
Main results
1. The increasing impact of
medical liability is prompting
practitioners to change their
practice and perceptions.
2. The doctor-patient relationship
appears to be altered, negative
pressure is placed on physicians
and defensively, some
neurosurgeons may refuse highrisk patients and procedures.
3. This situation causes
professional disenchantment and
can ultimately prove
disadvantageous for both doctors
and patients.
Page 19 of 19