WASHINGTON -- There is a paucity of data on dermatology-related malpractice suits, but searches of insurance claims and the legal literature show that, while it is still a low-risk field, the average claim payout is now equal to that of other specialties--around $300,000--Dr. Sandra Read said at

And contrary to popular perception, missing or misdiagnosing a melanoma is not the primary reason dermatologists are sued. A 16-year look at claims data from the Physician Insurers Association of America (PIAA) shows that nonmelanoma skin cancers, acne, and dyschromia top the list, said Dr. Read, who is in private practice in Washington.

There is a huge gap in the data, however, because the PIAA does not currently track malpractice claims related to cosmetic dermatology, she said. Since those procedures are not covered by insurance, they do not have ICD-9 codes.

Rumors that malpractice premiums have been rising with the increase in cosmetic dermatology are unfounded. "We don't know that; that's pure speculation. We need to stop speculating. We need to get data," she said.

Dr. Read and her husband, Dr. Hugh F. Hill, an emergency medicine physician at Johns Hopkins University, Baltimore, who has a law degree and consults on malpractice cases, conducted a symposium on risk management at the AAD meeting.

After a review of 10 years of cases in the legal database Westlaw, Dr. Hill found only 20 malpractice suits against dermatologists. His review of 10 years of data in Lexis found 79 cases.

A jury verdict research firm hired by Dr. Hill determined that the largest number of suits--12--was for melanoma, followed by 10 skin malignancy cases and 9 acne cases. There were a number of other reasons for suits.

But, he noted, these databases contain mostly trial outcomes, primarily of appellate cases. That makes for a biased sample and an incomplete picture since appellate decisions generally are based on technicalities, not on whether a physician has been found negligent, said Dr. Hill.

Both he and Dr. Read said the PIAA database was probably more reflective of malpractice realities for dermatologists. PIAA has 20 member companies and claims for 30 medical specialties in its database.

From 1985 to 2001, there were 187,712 total malpractice claims against physicians, and about 1,981 against dermatologists. Just over 40% of those who were sued were under age 45 years, 81% were board certified, 88% were graduates of U.S. medical schools, and 68% had previous claims filed against them.

This is important, said Dr. Read, noting that "doctors who get sued get sued again." Insurers take note and continually raise premiums.

The claims per year against dermatologists have stayed steady, averaging 123 per year from 1985 to 2001 and 135 per year from 2001 to 2003. There were 115 claims in 2005, and the last year data are available, said Dr. Read.

Out of 28 specialties, dermatology ranked 19th in terms of the number of claims filed. From 1985 to 2001, only 29% of claims against dermatologists were paid, compared with 31% for all other medical specialties, she said.

For that period, the total amount paid out for all specialties was $59 million. Payouts for dermatologists have traditionally been lower: In 1996, the average was $55,000, compared with $197,000 for other physicians. In 2005, though, the average payout jumped to $311,000, compared with $315,000 for other specialists.

"Dermatology really is a very low-risk specialty in many ways, compared to our colleagues," Dr. Read said. There is a negative trend, however. "The numbers of claims being paid are the same," she said, "out the dollars being paid out in dermatology are going up."

The average cost of defending a suit is around $28,000 but can be much higher. In Washington, where Dr. Read practices, the average cost in 2001 was $67,000.

The PIAA database reveals that dermatologists are primarily sued for improper performance of operative procedures; "no medical misadventure," a term used when a physician is named because he or she was on the letterhead or part of a corporation that is being sued; errors in diagnosis; medical errors; and failure to supervise.

Improper performance of an operative procedure on the skin accounted for 31.4% of total claims from 1985 to 2001.

Certain conditions were determined to be high risk because they were associated with the largest numbers of suits. Number one was malignant neoplasms of the skin, followed by acne, dyschromia, psoriasis, malignant melanoma, and contact dermatitis and eczema.

"Are you surprised that melanoma was No. 57" asked Dr. Read, adding, "I bet you are. I was too."

One reason why nonmelanoma skin cancers and acne were top reasons for suits: They make up a large number of cases treated by dermatologists. They also accounted for a higher than average number of claims paid out, at 38% for neoplasms and 28% for acne. Patients might sue for acne-related reasons because a physician did not mention or offer Accutane (isotretinoin), they have scars, or they were treated with tetracycline during pregnancy and the infant was harmed.

Steps should be taken to minimize dyschromia risk. "This is what makes people really mad at you when they have dyschromia from the treatment," she said. And, in perhaps a portent of things to come, dyschromia was the number-one reason dermatologists were sued in 2005.

Payouts are also more common and larger when there is either a death or a grave outcome; resulting in a serious disability. From 1985 to 2001, 6.4% of claims reported death. Twenty-eight percent of those cases resulted in a payment, which averaged $311,000. Grave outcomes--primarily associated with melanoma and malignant neoplasms--accounted for 2.6% of paid claims, with an average payout of $359,000.

Payouts for emotional trauma are also common, and while not as costly at an average $50,000, it is usually more cost effective to just settle a claim rather than incur legal costs that may rise above that figure, said Dr. Read.

Acne and psoriasis were the two most common conditions associated with emotional claims. There were no PIAA data on the basis for the claims, but patients probably alleged that they were denied treatment or not treated properly, that their condition worsened, or that the dermatologist promised they would improve and they did not, she said.

Dr. Read and Dr. Hill asked the attendees to complete a short 10-question survey on their own experience with malpractice, which will be compiled. The survey aims to fill some gaps--asking, for instance, about claims related to cosmetic dermatology.

The survey also was recently completed by 23 of 60 members of the Washington D.C. Dermatological Society Of the 23, 6 had claims filed against them in the past. Three had one claim, two had two claims, and one had three claims.

Two suits were dismissed, three were settled, and four resulted in a jury verdict for the physician and none went against the physician. The physician with three claims only provided outcomes for two, Dr. Hill noted.

When it comes to preventing lawsuits, physicians have traditionally been advised to fill out detailed charts and to practice good medicine as a potential defense, but this is no longer enough, said Dr. Read.

"You have to risk manage in a selective way," she said, adding that charting--including documenting advice and counsel to patients--is important, as is listening to the patient.

Be wary of patients who are angry. "Take it seriously. Dofft blow them off," she said. When a patient complains about another physician, "don't ever agree with them." It's possible to be drawn into a suit that way. Don't give in to patients' unrealistic expectations. "You want to be very careful about what you promise them," said Dr. Read.

If there seems to be a personality dash, or if the patient is persistently angry, it may be best to refer him or her elsewhere. "I sometimes say to a patient, "I may not be the right doctor for you,' " she said.

Finally, Dr. Read suggested that there is a new front in dermatologic malpractice that should be monitored: the use of physician extenders such as nurse practitioners and physician assistants.

"We need to realize that these people do put us at risk," she said.

BY ALICIA AULT

Associate Editor, Practice Trends