Federal Panel Urges Steps to Halt Flight of Doctors From Obstetrics : Medicine: Shielding physicians from malpractice costs and offering incentives to practice in under-served areas are proposed.

WASHINGTON —  Federal and state governments must take “immediate steps” to curb the flight of physicians and other health professionals from the practice of obstetrics and to ensure access to care for all women who need it, especially the poor, an Institute of Medicine panel recommended Wednesday.

The specter of malpractice litigation represents “a serious threat to the delivery of obstetrical care in this nation,” according to the committee, which conducted a two-year study for the institute.

Increasing liability costs and the fear of being sued have affected the availability of care, especially in rural areas, and many health care professionals have limited their practices, particularly for women with high-risk pregnancies, the panel said.

The 15-member committee comprised individuals with expertise in medicine, law, ethics, insurance, economics and public policy. The Institute of Medicine is an affiliate of the prestigious National Academy of Sciences, a congressionally chartered private organization that advises the federal government on matters of science and technology.

“While liability issues have been a growing concern for all medical specialties, the issue is particularly acute in obstetrics,” said Roger J. Bulger, president of the Assn. of Academic Health Centers, who headed the committee. “The result is a serious shortage of obstetrical care in many rural and inner-city areas.”

Further, Bulger said at a press conference, the committee determined that “all too often, the trust relationship that used to be typical of a provider-patient contract has become adversarial in nature.”

The committee found that the number of obstetrics providers in rural areas has fallen by 20% during the last five years. Bulger said that the decline “has left sizable rural areas, such as entire counties, without obstetrical care.”

Rural areas have been disproportionately affected, he said, because the family physicians and nurse-midwives who deliver more than two-thirds of babies born there have relatively low incomes and are harder hit by rising malpractice costs.

For the short term, the panel suggested new measures to improve the access of poor women to obstetrical care.

It recommended that the federal government put providers of maternity care in government-financed community and migrant health centers under the Federal Torts Claims Act, which permits an injured party to sue the government under certain circumstances.

“This would relieve practitioners of steep malpractice insurance and of personal liability, while providing plaintiffs a legal remedy,” Bulger said.

The panel recommended also that states establish programs that either indemnify or subsidize the medical liability premiums of obstetrical providers who participate in Medicaid or who otherwise provide care to low-income women.

Finally, the panel proposed that the National Health Service Corps, a federal program, “be revived and expanded” through improved scholarships and loan options to help increase the number of physicians in under-served areas.

For the long term, the panel suggested alternatives to the current legal system, including no-fault compensation for certain injuries, such as neurological impairment of a newborn, and privately negotiated contracts between patients and providers that would establish in advance that binding arbitration or some other mechanism would be used to settle disputes.

Also, the panel said that it supported a proposal already made by the American Medical Assn. to set up a fault-based administrative process in which state agencies would review claims, determine fault, fix awards and discipline offenders.

The federal government should encourage these changes by funding pilot projects in various states, the panel said.

“Regardless of which alternatives work best for individual states, one course we should not take is inaction,” Bulger said.

Rep. Ron Wyden (D-Ore.), chairman of a House panel that is scheduled to conduct hearings today on the impact of malpractice on obstetrics, said the new report “shows that, without dramatic immediate action, we will see the plight of low-income pregnant women worsening alarmingly.”

Wyden, who heads the subcommittee on regulation, business opportunities and energy of the House Small Business Committee, said that “the government and the medical community must do more to protect patients and we must realistically assess the causes of the problem in order to formulate long-term workable solutions.”

Before reaching its conclusions, the panel commissioned more than 20 papers by experts in various fields, initiated three surveys to collect new data and studied more than 50 previously conducted surveys, Bulger said.

In general, obstetrician-gynecologists are “more than twice as likely” as other physicians to be sued, and claims against them generally run “two to three times higher” than for other medical specialties, the panel said.

Moreover, when a case comes to trial, the jury finds for the plaintiff “twice as often” as is the case for other specialties, the report said.

“It is easy to understand this situation, since most cases involve brain-damaged infants whose parents generally are without resources to provide for a lifetime of complex care,” Bulger said.

Panel members said they found that the day-to-day practice of obstetrics has been affected by liability issues.

Some of these changes have been beneficial, Bulger said, such as improved patient record-keeping and “better discussion with patients about health risks and options in obstetrical care.”

But he called other changes “questionable,” such as the routine use of electronic fetal monitoring, which he said increases the likelihood of unnecessary Cesarean deliveries.