The term “medical malpractice stress syndrome” refers to the personal toll litigation takes on EPs, a concept fairly well-established. “But we didn’t know what effect getting sued has on their performance in the ED,” says Jestin Carlson, MD, the study’s lead author.

To learn more, Carlson and colleagues compared practice patterns of 65 EPs named in at least one malpractice claim, with a group of 110 EPs who had never been sued. The analysis included 59 EDs in 11 states from 2010 to 2015. To be certain the two groups of EPs were comparable, researchers identified EPs who were working in the same EDs at the same time. The researchers fully expected to see that the sued EPs admitted more patients, used more resources, or worked slower because they were afraid of missing something.

“We thought they might practice in a more conservative manner,” offers Carlson, national director of clinical education at US Acute Care Solutions. In fact, the sued EPs’ admission rates, resources used, and pace did not change. “This was very surprising,” Carlson reports.

Researchers used “relative value units” to determine how much resources the EPs used. These give an overall idea of the amount of resources used, but do not give specifics on certain types of tests. “We did not have details on how many times somebody ordered a lab test or CT scan or X-ray,” Carlson notes.

It is entirely possible some sued EPs did, in fact, order more tests for specific patient groups. For instance, if someone was sued for failing to obtain a CT scan in a missed stroke case, that EP might have ordered more CT scans for patients with suspected stroke. Overall, though, the amount of resources used by the sued EPs did not change. “It really made us step back and ask why we might be seeing that,” Carlson says.

The study revealed no concrete answers on that point. One possibility is that EPs’ established practice patterns are so deeply ingrained that even litigation does not really change them much. “It suggests that many of our practice patterns are less sensitive to a big event like a malpractice lawsuit than we would have thought,” Carlson observes.

Another possibility is the sued EPs’ practice did change, but only for the specific patient groups that were similar to the plaintiff in the malpractice lawsuit. “They may change behavior only with a small set of specific cases that weren’t captured in our data,” Carlson suggests.

For instance, if the EP was sued for missed myocardial infarction (MI), that EP might be more likely to admit future patients with suspected MI. “That same EP may be no more likely to admit other patients, though — such as COPD exacerbation or cellulitis — and continue managing them on an outpatient basis,” Carlson says.

Patient satisfaction was the one thing that did change for EPs named in lawsuits. Researchers used Press Ganey scores to measure this. For the EPs who were sued, there was an immediate 6.5% boost. EPs named in failure-to-diagnose claims received an even bigger boost (10.5%).

Still, the study did not reveal why the scores of the sued EPs improved. “Exactly what they are doing differently is unknown,” Carlson laments. “We don’t know what led to a pretty dramatic, pretty quick, and sustained change in Press Ganey.”

Possibly, an EP’s personal interactions are affected by the experience of litigation, more so than their clinical practices. “That ties into what we know about malpractice stress syndrome, that being sued affects people on a very personal level,” Carlson adds.


  1. Carlson JN, Foster KM, Black BS, et al. Emergency physician practice changes after being named in a malpractice claim. Ann Emerg Med 2019; Sep 9. pii: S0196-0644(19)30575-X. doi: 10.1016/j.annemergmed.2019.07.007. [Epub ahead of print].