Discussion

This is the first study to longitudinally analyse demographic, vocational and psychosocial predictors of medical negligence claims in Australia. It is also the first to adjust for confounding factors and to stratify according to sex. Previous research shows that older male doctors working in surgical and psychiatric specialties with a prior complaints history are at the highest risk of complaints to Australian medical regulators.18 Internationally, the risk of being sued is also highest among older surgeons, with high workloads, long working hours and a history of prior claims.19 While our results lend weight to these earlier findings, they also reveal insights into additional psychosocial and workplace factors that may be associated with claims. Existing medicolegal risk prediction tools, such as the PRONE score,20 focus on demographic factors and prior claims history, which are not modifiable. This limits opportunities for remedial action and does not explain why there is variation within high-risk categories: for example, being an older male surgeon does not guarantee that a doctor will be sued. Hence, there is a pressing need to better understand the role of psychosocial well-being, workplace stress and sociodemographic factors in medical litigation.21 Our study addresses this need.

The most important and novel findings in this study are that doctors with lower self-rated health, lower self-rated life satisfaction (especially for male doctors) and those who had experienced a recent serious personal injury or illness were more likely to be sued. Prior studies have shown that poor doctor well-being, higher levels of burnout22 and chronic illness among doctors can lead to poor patient safety outcomes and medical errors.23 Our study reveals that acute and recent injury may also contribute to this risk. This suggests that the quality of treatment and workplace support offered to doctors experiencing recent illness or injury can impact on patient care. Our results also reinforce previous recommendations that preventive efforts to improve doctors’ health and well-being need to be intensified. For example, healthy lifestyle and positive psychology interventions can boost doctors’ subjective well-being, enhance patients’ perceptions of doctors’ empathy and improve clinical outcomes.24 This is particularly important because we know from numerous studies that being sued can negatively impact on doctors’ health and well-being.25 Therefore, it is imperative to intervene early to prevent poor doctor health leading to claims that can then further compromise doctors’ health.

Prior research has also demonstrated that male doctors are at higher risk of medicolegal claims than female doctors.26 A recent meta-analysis of 32 studies found that, in 27 studies, male doctors were more likely to experience a claim over time and across jurisdictions.27 For this reason, we stratified demographic, vocational and psychosocial predictors of medical negligence claims by sex. This identified differences in the risk factors experienced by male and female doctors. Noticeably, working long hours and having a recent serious injury or illness increased the risk of medical negligence claims more in female doctors, whereas working in a regional area, experiencing poor self-rated life satisfaction and low work–life balance increased the risk more in male doctors. The effect of age and specialty was similar in both sexes. The reasons for these differences are unclear but may be linked to other variables not studied here, including the extent of perceived gender equality within a relationship and performing invisible household labour.

Workplace location is also associated with medical negligence claims. Compared with metropolitan doctors, we found that doctors practising in regional areas were at increased risk of being sued, while those in remote areas were not. There is a relative undersupply of doctors in both regional and remote Australia,28 which adversely impacts on healthcare access29 and health outcomes in these communities.30 Similar problems exist in Canada31 and the United States.32 With increasing remoteness from Australian capital cities, the number of doctors per capita diminishes, while working hours, on-call demands and job complexity all increase.33 Therefore, our findings are surprising, as we would expect medicolegal risk to increase with increasing remoteness. We propose several possible explanations. First, regional areas may have small hospitals that provide doctors with more opportunities for procedural work than in many remote Australian communities. Undertaking procedural work is a known risk factor for medical negligence claims.34 Second, remote communities are often serviced by fly-in-fly-out doctors from nearby regional centres, due to a lack of suitable long-term accommodation in remote locations.35 Doctors living in regional centres who visit remote communities may be less familiar with patients, staff or health systems in remote areas, and this may increase the risk of medical errors due to a lack of continuity of care.36 Third, patients in remote areas may be required to access care in regional centres due to a lack of access to medical services in remote areas.

Irrespective of geographical location, doctors with higher self-rated job demand scores were more likely to be sued than those with lower scores. Many doctors work excessive hours and research has shown that this can contribute to misdiagnoses37 and other medical errors.38 While this may also translate into increased medicolegal risk, we need to interpret this cautiously. First, it is possible that the association between work hours and medicolegal risk may be explained by increased patient volume. Second, a very recent report suggests that the quality of care rendered by part-time doctors may be inferior to that of doctors working full time.39 The association between work hours and medicolegal risk is therefore complex. Adding to this complexity is our finding that the risk of medical negligence claims in doctors working long hours is more pronounced in female doctors.

It is similarly difficult to interpret our finding that doctors who perceived lower levels of job control were less likely to be sued. Although the effect size was small, we postulate that while highly structured workplaces afford doctors less autonomy, they may also enforce well-defined scopes of practice, surgical safety checklists or other patient safety initiatives that reduce medical errors. Moreover, doctors with higher job control may be more senior members of the clinical team, who carry greater clinical responsibility for adverse patient outcomes and may be more likely to face litigation.

Finally, we found that agreeableness, unlike other personality types, conferred a modest protective effect on the risk of being sued. Prior studies have not found a consistent association between personality type and medicolegal risk. However, studies of medical students’ personality have shown that agreeableness is associated with greater empathy, which improves professionalism and patient communication.40 This may protect agreeable doctors from being sued. Personality may also influence how a doctor responds following an adverse event, and this may also determine the risk of medical litigation. For instance, patients may feel less angry and less motivated to sue a doctor who expresses genuine empathy and regret following an adverse event.

Our findings add weight to ongoing calls41 to address doctor fatigue and other system-wide causes of poor doctor health that could have far-reaching benefits both for doctors’ health and patient safety. Our study has four important strengths. First, it assessed a wider range of demographic, vocational and psychosocial risks for claims than previous studies, facilitating a deeper analysis of the factors associated with medical negligence claims. Second, the use of longitudinal cohort data enabled identification of exposure variables present before medical negligence claims occurred. Prior research has largely relied on cross-sectional surveys that limit the ability of researchers to distinguish predictors from consequences of medical negligence claims (ie, whether poor health increases the risk of being sued or whether being sued increases the risk of poor health). In contrast, we were able to draw clearer causal inferences because of the longitudinal cohort design and because we controlled for possible confounding relationships (noting that a temporal association is only one of a number of criteria that need to be satisfied to establish a causal association). Third, we stratified our exposure variables according to sex. Fourth, invitation into the survey was independent of whether doctors had been sued in the previous 12 months, so we believe that our results are an unbiased assessment of the association between the factors we studied and medical negligence claims.

Our study has several limitations. First, although invitation into the survey was independent of whether doctors had been sued, doctors who accepted the invitation to join the MABEL study may differ from those who did not. However, MABEL measured a wide range of variables and was prospective in nature, so we believe that this was unlikely to have biased our results. Moreover, MABEL respondents have been shown to be broadly representative of Australian doctors in terms of other key characteristics, including age, sex, specialty, geographic location and hours worked.42 Second, the cohort relied on recall when responding to survey questions. In particular, it relied on recall, rather than evidence of, a medical negligence claim. Despite this, we believe participant recall was likely to be reliable because being sued is a significant life event for a doctor. Third, we did not have data on claims outcomes. Cases that were settled, withdrawn or found in favour of the doctor may differ from those where the doctor was found negligent. However, regardless of the outcome, we believe that the prosecution of medical negligence claims shines a light on patient experiences and perceived quality of care. Fourth, we did not have data on patient numbers, so it is unclear whether the risk associated with long working hours was due to increased patient volumes or other factors. Finally, the survey did not identify doctors with multiple claims. This is important, as prior claims history is a strong predictor of future medicolegal events and may have been an influential confounding variable.

Despite these limitations, we believe that our paper contributes to a more nuanced understanding of the risks and predictors of medical negligence claims in Australia. While Australia is geographically unique, its legal and healthcare systems are broadly similar to comparable jurisdictions, including the UK, Canada and New Zealand, allowing our findings to be extrapolated to other jurisdictions and healthcare settings.