REPORT OF THE COUNCIL ON MEDICAL EDUCATION

									CME Report 2-I-05

Subject:	Impact of US Medical Liability Premiums on Clinical Medical Education
		(Resolutions 909 and 920, I-04)

Presented by:	Carl A. Sirio, MD, Chair

Referred to:	Reference Committee L
		(George R. Green, MD, Chair)

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Resolution 909 (I-04), “US Medical Liability Crisis and the Impact on Clinical Medical Education,” which was submitted by the Medical Student Section and Resolution 920 (I-04), “US Medical Liability Crisis and the Impact on Clinical Medical Education” which was submitted by the Nebraska Delegation and were referred to the Board of Trustees, contained three distinct resolves and asked that:

Our American Medical Association recognize that undergraduate and graduate medical education are negatively impacted by the medical liability crisis;

Our AMA oppose the administration of increased medical liability insurance premiums based solely on preceptor or volunteer faculty status; and

Our AMA study the scope, potential impact, and possible solutions of the medical liability crisis on volunteer faculty liability premium costs and the impact on medical education, and report back at the 2005 Annual Meeting.

Background

Clinical education of medical students is dependent on contributions made by volunteer and part-time members of the faculty of medical schools.  These clinical preceptors make important contributions to the education of medical students, particularly in the ambulatory and office-based settings.  Concerns were raised by the authors of the resolutions that insurance underwriters perceive that a physician’s status as a medical school faculty member or preceptor is an additional exposure to liability.  On that basis, it was stated that medical liability coverage had been denied or premiums had been increased forcing physicians to abandon their teaching roles.  Testimony at the reference committee hearing identified a lack of information regarding the medical liability premiums of volunteer faculty and of evidence of any change in teaching activities.  Representatives from the Council on Medical Education agreed to research this issue and report back to the House of Delegates.

Existing AMA Policy

The AMA has long-standing policy that supports the role of part-time and volunteer members of the faculty in educating medical students.  Policy H-295.995 (AMA Policy Database), “Recommendations for Future Directions for Medical Education,” was first adopted at the Annual Meeting in 1982 and was most recently reaffirmed at the Interim Meeting in 2003.  This policy establishes in part that “Medical schools should continue to recognize that the instruction provided by volunteer and part-time members of the faculty and the use of facilities in which they practice make important contributions to the education of medical students.”  Policy H-305.942, “The Ecology of Medical Education: The Infrastructure for Clinical Education,” includes the statement that “Affiliated health care institutions and volunteer faculty members be included in medical school resource planning for clinical education when appropriate.”  In addition, Policy H-435.959, “Liability Reform,” identifies medical liability reform as the highest legislative priority.

Discussion

Three separate activities were carried out to collect information regarding the contribution of teaching activities to medical liability premiums.  All Liaison Committee on Medical Education (LCME)-accredited medical schools were surveyed to determine if higher insurance premiums could be related to teaching efforts and the potential impact of higher insurance premiums on the availability of volunteer faculty to teach.  Individual state medical associations were polled to determine if they were aware of any problems in recruiting or retaining volunteer clinical faculty to teach medical students or resident physicians related to medical liability insurance premiums and if there was evidence that such premiums had been raised based on teaching activities.  Graduate medical education program directors were asked to respond to questions about medical liability insurance premiums and availability of volunteer faculty to teach resident physicians.

2004-2005 LCME Annual Medical School Questionnaire Part II

This questionnaire included two questions:  “Are your volunteer faculty experiencing higher medical liability insurance premiums specifically as a result of their participation in medical student teaching?” and “Is the cost of medical liability insurance causing problems in recruiting volunteer faculty to teach medical students?”  The annual questionnaire has a 100% response rate, all 125 medical schools providing responses to both questions.

Only four schools agreed that their volunteer faculty members were experiencing higher premiums as a result of teaching, 49 indicated that this was not a problem, and 72 did not know if this was an issue for their volunteer faculty.  There was no pattern to the distribution of the schools responding positively to the question.  Response patterns from the 64 medical schools in the 20 states identified by the AMA as being in medical liability crisis as of June 2006 were similar to those from the remaining 61 medical schools in states not identified as being in crisis.  For those schools in crisis states, only two indicated that volunteer faculty members had higher premiums as a result of teaching, 24 did not, and 38 did not know.  

Recruiting faculty to teach medical students appeared to be a larger issue.  Sixteen medical schools responded affirmatively to the question of whether the cost of medical liability premiums was causing problems in recruiting and retaining volunteer faculty to teach medical students, 64 indicated that this was not a problem, and 45 did not know.  Of the 64 medical schools located in states with a medical liability crisis, 12 responded affirmatively.  However, 32 schools in crisis states and 32 schools in non-crisis states responded that recruitment was not being affected.  There was a greater degree of consistency in response to this question within states with more than one medical school.  In two states in crisis, all schools denied a problem.  In four states not in crisis, the response for all schools also denied a problem.  In no instance did all the schools in any state agree that it was a problem recruiting volunteer faculty to teach medical students.

Advocacy Resource Center Survey

The Advocacy Resource Center received 21 responses from states regarding increased medical liability premiums based on supervising or teaching medical students or resident physicians.  Twelve of the responses came from states identified by the AMA as being in medical liability crisis.  None of the responses identified an increase in liability premiums that was attributable to a teaching or supervising role for volunteer faculty.  In only one instance, it was noted that one carrier in one state refuses to write policies for obstetrician/gynecologists who teach obstetrical residents.  Additional comments indicated that where medical liability insurance premiums are experience-rated, avoiding teaching of medical students and resident physicians will not reduce premiums.

Graduate Medical Education E-Letter, March 2005 Survey

The Graduate Medical Education E-Letter is distributed to more than 12,000 program directors and directors of graduate medical education.  Included in the March 2005 issue was the opportunity to respond to two questions about medical liability insurance premiums and the ability to recruit and retain clinical faculty to teach resident physicians.  Unfortunately the low response rate provides only anecdotal information and precludes reporting and analyzing the results.

Summary and Recommendations

Based on the information provided above, there is not enough evidence to identify a pervasive problem of increased medical liability premiums for volunteer faculty members consequent to teaching medical students and resident physicians.  While not overwhelming in magnitude there appears to be some evidence of increasing difficulty in recruiting volunteer faculty to teach.  However, the cause of this problem cannot be directly related to medical liability insurance premiums.  The contribution of volunteer and part-time clinical faculty remains an important component of the medical education system in the US and should continue to be supported by the AMA.  In addition, the absence of findings identifying teaching medical students and resident physicians as a source of increased medical liability premiums does not diminish the crisis in liability insurance.  Liability reform must remain the highest legislative priority of the AMA.

The Council on Medical Education recommends that the following recommendations be adopted in lieu of Resolutions 909 (I-04) and 920 (I-04) and that the remainder of this report be filed.

1. That Policy H-295.995[16], “Recommendations for Future Directions for Medical Education,” be amended to state that “Medical schools and residency programs should continue to recognize that the instruction provided by volunteer and part-time members of the faculty and the use of facilities in which they practice make important contributions to the education of medical students and resident physicians.”  (Modify Current HOD Policy)

2. That Policy H-305.942[2], “The Ecology of Medical Education: The Infrastructure for Clinical Education,” be amended to state that “Affiliated health care institutions and volunteer faculty members be included in medical school and residency program resource planning for clinical education when appropriate.”  (Modify Current HOD Policy)

3. That Policy H-435.959, “Liability Reform,” identifying medical liability reform as the AMA’s highest legislative priority be reaffirmed.  (Reaffirm HOD Policy)

4. That our AMA monitor the ongoing impact of the medical liability crisis on the availability of clinical faculty for undergraduate and graduate medical education.  (Directive to Take Action)



Fiscal Note.  No Significant Fiscal Impact

CME Rep. 2-I-05--Page 2

CME Rep. X-A-04--Page 4

