Medical negligence claims and the health and life satisfaction of Australian doctors: a prospective cohort analysis of the MABEL survey

Objective To assess the association between medical negligence claims and doctors’ self-rated health and life satisfaction. Design Prospective cohort study. Participants Registered doctors practising in Australia who participated in waves 4 to 11 of the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey between 2011 and 2018. Primary and secondary outcome measures Self-rated health and self-rated life satisfaction. Results Of the 15 105 doctors in the study, 885 reported being named in a medical negligence claim. Fixed-effects linear regression analysis showed that both self-rated health and self-rated life satisfaction declined for all doctors over the course of the MABEL survey, with no association between wave and being sued. However, being sued was not associated with any additional declines in self-rated health (coef.=−0.02, 95% CI −0.06 to 0.02, p=0.39) or self-rated life satisfaction (coef.=−0.01, 95% CI −0.08 to 0.07, p=0.91) after controlling for a range of job factors. Instead, we found that working conditions and job satisfaction were the strongest predictors of self-rated health and self-rated life satisfaction in sued doctors. In analyses restricted to doctors who were sued, we observed no changes in self-rated health (p=0.99) or self-rated life satisfaction (p=0.59) in the years immediately following a claim. Conclusions In contrast to prior overseas cross-sectional survey studies, we show that medical negligence claims do not adversely affect the well-being of doctors in Australia when adjusting for time trends and previously established covariates. This may be because: (1) prior studies failed to adequately address issues of causation and confounding; or (2) legal processes governing medical negligence claims in Australia cause less distress compared with those in other jurisdictions. Our findings suggest that the interaction between medical negligence claims and poor doctors’ health is more complex than revealed through previous studies.

clearly presented and the discussion, including strengths and limitations, and conclusions are appropriate. The manuscript should be supplemented in a few places: -the authors do not justify why exactly the items listed were used when asking about the constructs "High job demands, low job control, poor social supports, and work-life imbalance" from the MABEL-Questionnaire and from which survey instruments these items were taken. If a psychometric test of the questionnaire is available that proves the fit of the items to the constructs, this should be cited. Otherwise, this would be cited as a limitation.
-The authors state that a small number of sued physicians might have led to the fact that an existing association could not be detected. Therefore, a power analysis should be added to allow the reader to assess the significance of the nonsignificant associations.
-Last, a better estimate of self-reported data on the frequency of lawsuits could be obtained by comparing the data in the surveys with official statistics from the courts or insurers on the number of physicians sued.

VERSION 1 -AUTHOR RESPONSE
Comments from Dr Ardeshir Sheikhazardi (Reviewer 1) 1. I have published an article in this domain as "A survey of sued physicians' self-reported reactions to malpractice litigation in Iran" in jflm 16 (6) 2009 (301-306). We saw the threat of, or real, legal process can cause psychological changes. But as you know there is much differences between legal process in different countries and a stressful process in some countries can produce psychological changes.
Thank you for drawing our attention to this important prior work. We have already noted in our manuscript that "legal processes and frameworks governing medical negligence claims differ between jurisdictions" and that one reason why our results differ to prior overseas findings is that "processes in Australia may cause less distress than processes overseas".

Comments from Dr Hanna Khan (Reviewer 2)
1. This is a great paper. Yes, this area of research has yet to be covered by other authors.
Thank you for your support for our manuscript.
Comments from Dr Max Geraedts (Reviewer 3) 1. The authors do not justify why exactly the items listed were used when asking about the constructs "High job demands, low job control, poor social supports, and work-life imbalance" from the MABEL-Questionnaire and from which survey instruments these items were taken. If a psychometric test of the questionnaire is available that proves the fit of the items to the constructs, this should be cited. Otherwise, this would be cited as a limitation.
The MABEL survey contained a series of "Job satisfaction" questions that were drawn from the Warr-Cook-Wall Job Satisfaction Scale, a modified version of which was validated for use in the Australian clinical medical workforce. The four variables that we constructed ("High job demands, low job control, poor social supports, and work-life imbalance") were theoretically derived from this existing validated measure of job satisfaction, but were not themselves formally validated. They have nevertheless been employed by others in assessing the relationship between working conditions and self-rated health among Australian doctors.
We have now revised the manuscript to include this information. The text reads (page 7): To adjust for the potential confounding effect of job satisfaction, we constructed four variables which we included in our models: high job demands, low job control, poor social supports, and work-life imbalance. These four variables were derived from the "Job satisfaction" questions contained in the MABEL survey, which themselves were drawn from the Warr-Cook-Wall Job Satisfaction Scale, and have been validated for use in the Australian medical workforce context. Previous research has shown that higher scores on these four variables are associated with higher odds of poorer self-rated health.
2. The authors state that a small number of sued physicians might have led to the fact that an existing association could not be detected. Therefore, a power analysis should be added to allow the reader to assess the significance of the nonsignificant associations.
Our comment about a lack of power intended to signal that this could be an explanation but not one we considered likely. An indicator of a lack of power would be a large effect size with wide confidence intervals crossing zero. That is not what we observed here. Rather, we saw effect sizes that were very close to zero on scales than ran from 0 to 4 (self-rated health) or 1 to 10 (life satisfaction). This pattern is more consistent with there being no association between being sued and self-rated health or life satisfaction. We have now made this point clearer. To respond to the comment, we have done a power calculation, and this shows that we have around 13% power to detect a difference of -0.02 between exposure groups on self-rated health. The text now reads (page 13): Third, as only a small proportion of doctors participating in the survey were sued, we were unable to detect a statistically significant difference in self-rated health and life satisfaction between sued doctors and controls. In a post hoc power calculation, we estimated that we had 13% power to detect the observed difference of -0.02 between sued and non-sued doctors on self-rated health. However, this difference is very close to zero, and the explanation that there is no association between being sued and self-rated health or life-satisfaction after adjustment for time seems more likely than the explanation that the study lacked power. This is because an indication of lack of power would be a large effect size with wide confidence intervals that included the null value; whereas we observed small effect sizes close to zero. A substantially larger sample of doctors who had been sued would be required to detect a difference between groups of this magnitude.
3. Last, a better estimate of self-reported data on the frequency of lawsuits could be obtained by comparing the data in the surveys with official statistics from the courts or insurers on the number of physicians sued.
Thank you for this comment. We had thought of this, but this court information is not publicly available in Australia and insurers do not release this information. Even the US, which has one of the best systems for capturing claims through the National Practitioner Data Bank does not include claims not