Originally published in Forum, Vol 18 No 3, October 1997; Revised January 2005

by RMF Staff

Twenty-four percent of CRICO claims since 1995 named residents and fellows. Those claims represent 14 percent of the total dollars incurred in that time period. Residents and fellows make up about 21 percent of all physician defendants named; a third of the time, no attending physician is named.

Since 1995, 509 residents and fellows were named in 371 claims and suits. While the frequency of claims naming house staff is declining, the issues leading to those claims remain constant.

CRICO Claims Naming Residents and Fellows 1995-2004

Top Specialties Named*

* Double counting occurs since there can be multiple defendants/specialties named in a single claim

Top Allegations

The number of residents and fellows insured by CRICO increased 13 percent from 2,576 in 1995 to 2,975 in 2004, resulting in a rate of 1.4 claims per 100 physician coverage years over the period. The rate for staff physicians over the same period is 2.7 per 100 physician coverage years.

Harvard’s largest residency programs are in general medicine, anesthesiology, and pediatrics. However, in proportion to their numbers, residents and fellows in surgical specialties are more likely to be named in a claim or suit. This is consistent with the experience of staff physicians in surgical specialties.

Generally, malpractice cases involving residents and fellows are related to clinical judgment in assessing and treating patients, communication with other providers and with the patient and family, issues with documentation, and technical skills in performing procedures.

For example:

• A resident in the emergency department (ED) treated a patient for minor abrasions following a fall down a flight of stairs. Later in the week, X-rays taken at another heath center revealed facial fractures.
• A neurosurgical resident operated on a herniated L4-L5 disc. The patient did well in recovery and the anesthesia resident transferred him to the floor. The covering neurosurgery resident increased IV fluids in response to low blood pressure. Early the next morning the patient was found unresponsive, surgery revealed that the left iliac vein was avulsed from the inferior vena cava. His family discontinued life support.
• A junior resident elected to use forceps in the delivery of a baby who later developed Erb’s palsy. The medical record did not reflect the rationale behind using the forceps, nor was it consistent in detailing the stage of labor the mother was in when the decision was made.
• A post-operative central line for nutrition was inadvertently placed in the patient’s carotid artery by the resident. Subsequently, the patient suffered an embolus, stroke, and further complications.
• Two urology residents reviewed the KUB ordered for an elderly patient with significant pain after the placement of a uretal stent. They judged the stent was properly placed, a radiology fellow confirmed the residents’ (incorrect) judgment the next day and the patient was discharged. Two days later a CT scan revealed the stent had perforated the ureter. Near the conclusion of the subsequent procedure, the patient suffered a respiratory, and then a cardiac arrest. He sustained severe brain damage.

Operating and recovery rooms are the top named locations, accounting for 20 percent of all claims and suits involving residents and fellows. Although the ED is still frequently identified, the frequency has decreased to 10 percent of claims and suits against residents and fellows over the past 10 years down from 15 percent in the mid-1980s.

The rate of ambulatory care claims (including EDs) has remained constant for residents and fellows in the Harvard system during the period 1985-2004. Residents and fellows often encounter problems related to inexperience and lack of adequate supervision when rotating through different institutions and specialties.

For example:

On general surgery rotation, an oral surgery resident was involved in the placement of a subclavian line. The attending physician left the resident to close and the patient subsequently experienced cardiac arrest. Secondary surgery revealed the catheter tip in the pericardial sac.

The shift of care to ambulatory sites is also reflected in the resident and fellows claims. Clinic and physician offices (combined) now account for 16 percent of these claims. They rank equivalent with inpatient units at number two in frequency behind surgical locations. Emergency is the third most often named ambulatory care location.

In the office and clinic setting, residents are often confronted by difficult patients and seemingly routine diagnostic issues that prove to be complex. In those situations, supervision of an attending is important for both optimizing patient care and decreasing potential liability. The opportunity to discuss the case with a more experienced physician and review the interim diagnosis and documentation benefits the provider and the patient.

For example:

A clinic patient with low back pain after heavy lifting was seen by a resident who had never seen him before. The resident did have access to the patient’s medical record, which included a long history of alcohol abuse. The physical exam was unremarkable except for 1) the back pain that could not be evaluated due to local tenderness, and 2) continuing alcohol withdrawal. The resident prescribed an anti-anxiety medication and scheduled the patient for re-evaluation in three days. The next day, however, the patient was admitted with a kidney infection. He subsequently died of renal failure.

Patients who present with common complaints, but who also have complicating physical and psychosocial factors, create special diagnostic problems, especially for the less experienced clinicians. Such situations call for increased vigilance on the part of the residents–to check out the scenarios with a more experienced clinician – and on the part of the more experienced clinicians to recognize when advice might be useful.

Since CRICO insures primarily teaching institutions, the number of claims naming residents and fellows is not surprising. And since the Massachusetts charitable immunity law caps jury awards at $20,000, plaintiffs, generally, seek to name individual clinicians in malpractice lawsuits.

While some adverse events that lead to claims against less experienced physicians may not be preventable, more experienced clinicians need to recognize when a physician-in-training requires more guidance. On their part, residents and fellows need to understand the limits of their knowledge and seek the appropriate level of consultation.