Preceptors battle liability insurance hikes

BY LESLIE CHAMPLIN

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Precepting tomorrow's doctors poses "an additional exposure" that justifies increased premiums or loss of coverage -- that's what liability insurance companies have told three family physicians in Ohio and Virginia.

Two of the physicians fended off such moves. The third currently is in negotiations with his insurer. But if imitated by other underwriters, the companies' attempts bode ill for tomorrow's health care system, according to educators. Facing battles with malpractice underwriters, volunteer physician educators may stop sharing their expertise with students and residents, say these educators.

"This could have a significantly negative impact on our specialty," said George Kikano, M.D., chair of family medicine at Case Western Reserve University School of Medicine, Cleveland, and a member of the Ohio AFP Board of Directors. "Keeping preceptors is key to every other thing we are trying to do as an Academy."

Company breaks tradition

Most medical liability actuaries don't formally include teaching in determining a physician's malpractice premiums, according to James Hurley, chair of the Medical Malpractice Subcommittee at the American Academy of Actuaries.

"I don't know of anyone who has made adjustments on the basis of preceptorship," said Hurley. In fact, many actuaries would reduce premiums for physicians who are academic health center faculty, he added.

"A faculty physician may be seen as having less contact than a full-time physician with patients," Hurley said.

However, last year, a national underwriter sent a letter to a Case Western Reserve University medical school preceptor, declining to renew his coverage. The reason: He was teaching medical students. The correspondence was made available to FP Report by the Academy of Medicine of Cleveland, which preferred not to identify the underwriter or the preceptor.

"Additionally, the doctors (in the FP's practice) indicated that they are supervising medical students for CWRU," the company wrote to the physician. "Underwriting does not feel comfortable with this exposure."

Decisive action turns the tide

The letter reached CWRU's Kikano. He took it to the Ohio AFP and the Academy of Medicine of Cleveland (he is a member of the AMC Board of Directors).

The two groups jumped on the letter, demanding an explanation from the underwriter's president. "What is your loss experience with medical students? What criteria did you use to determine that the supervision of medical students in a physician's practice (is) an additional liability risk?" they asked in a letter from AMC to the underwriter.

"There is no precedent that a malpractice suit was initiated against a physician due to a student encounter in an office," said Kikano. "In fact, there are data that show patients' satisfaction is higher with the perception that their physician is a teacher."

The physician perspective prevailed. Within three months, the underwriting company confirmed it "does not believe physicians who choose to supervise medical students in their practice represent a high liability risk. Thus, they (the doctors) will not see an increase in either their rates or a change in their coverage based solely on the fact that they supervise students in their practices."

Resident supervisors at risk

Liability woes aren't limited to medical student preceptors. Two Virginia family physicians learned last year that their rates would rise because they supervised residents, according to Charles Driscoll, M.D., director of the Lynchburg Family Practice Residency, Lynchburg, Va.

One FP, Robert Elliott, M.D., of Hurt, Va., saw his premiums double because he supervised residents providing uncomplicated prenatal care in his rural practice. His role was part of a cooperative agreement with a hospital-based obstetrician 30 miles away.

The fallout: During the year that he negotiated with the company, Elliott dropped prenatal services and the teaching that went with it.

Driscoll cited another family physician who worked in the local emergency department and who occasionally supervised residents by covering the faculty call schedule for events such as faculty retreats or graduation exercises. When that physician's insurer raised his rates, he stopped supervising residents for the program. He and the company are still in negotiations.

These situations demonstrate the danger such policies pose for the future of medicine, said Tom Banning, director of legislative and public affairs at the Texas AFP.

"You're choking off the future of new physicians," Banning said. "Without preceptors and other community-based teaching, you're not getting a pipeline of physicians into the community. It would have a serious detrimental effect five, 10, or 15 years out."

To reach writer Leslie Champlin, e-mail lchampli@aafp.org.

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