Average Indemnity Research Articles

Errors in Endoscopy

Aim: To determine core issues regarding patient safety and endoscopic errors, and to compare the malpractice indemnity of GI's compared to other specialists who also perform endoscopies. Methods: Retrospective analysis of a nationwide endoscopy-related malpractice claims files from Physicians Insurers Association of America (PIAAA) from January 1985 to December 2006. Results: Of 316 closed claims, the most common procedures involved were colonoscopy, ERCP, and sigmoidoscopy with average indemnity of $237,632, $344,297, and $330,000 respectively. Over 98% of closed claims involved physical injury and most were severe - 26% resulted in death, and an additional 40% caused significant or major disability. Claimants were more often female (180 versus 129 closed claims) and over age 50 (205 versus 107). The majority of claims involved either improper performance (for example, perforation from a colonoscopy, 51%) or diagnosis error (17.3%). There were relatively few meritless claims (10%) lacking evidence of error. Among 21 cases involving colon cancers, both right and left sided cancers were equally represented. Table 1 shows the average indemnity comparing the various specialties that perform endoscopies. Colorectal surgeons and family practice physicians who perform endoscopies cost more than GI's in terms of average indemnity per claim. Conclusions: Awards and settlements on alleged injuries resulting from errors in endoscopy differ according to specialty of the endoscopist. Malpractice insurers might use this information to scale their premiums, incentivize simulation training, credentialing, or other regulatory strategies, or even sponsor safety improvement efforts to reduce their exposure.

Malpractice Litigation Involving Iatrogenic Surgical Vocal Fold Paralysis: A Closed-Claims Review with Recommendations for Prevention and Management

We describe the nature of malpractice claims filed involving surgical iatrogenic vocal fold paralysis, review surgical literature for recommendations for prevention of this complication, and suggest management of this complication. Data collection was made regarding any closed claims that involved vocal fold paralysis. The results were then analyzed and categorized. The PubMed literature regarding this complication was reviewed, and recommendations on prevention were compiled. Finally, suggestions regarding management based on the current literature and the senior author's 17-year experience in his laryngeal practice are offered. From 1986 to 2007, 112 closed claims involving vocal fold paralysis were reported by the 16 largest malpractice insurers. More than US $10 million ($18 million adjusted for inflation [AJI]) has been paid thus far. The average indemnity was $285,000 ($513,000 AJI). The surgical physician defendants were from multiple specialties, including general surgery (31%), cardiothoracic surgery (12%), neurosurgery (12%), otolaryngology (10%), and orthopedic surgery (5%). The most common procedures were thyroid and parathyroid surgery (32%), cervical disc procedures (16%), thoracic procedures (12%), endarterectomy (9%), and open neck biopsy (6%). The most common claims cited were improper performance (61%), failure to recognize a complication (36%), and consent issues (19%). Vocal fold paralysis is a complication of many different surgical procedures across multiple specialty lines. Closed-claims analysis can offer a unique glimpse on what went wrong and why patients sue. Modification of techniques and incorporation of new technology may significantly reduce this complication. Preoperative written information on potential complications, and early referral to and management by laryngeal specialists, we believe, may significantly reduce malpractice litigation.

Patient Safety and Telephone Medicine

The telephone can facilitate medical care but also result in adverse outcomes leading to telephone-related malpractice suits. Analyzing claims might identify errors amenable to prevention. The objective of the study was to describe medical errors involving the telephone in patient-clinician encounters that significantly impacted medical care and medico-legal outcomes. The design of the study was a descriptive, retrospective case review of telephone-related closed malpractice claims that included depositions, expert witness testimony, medical records, allegations, injuries, and outcomes. Forty defendants from 32 cases coded specifically as telephone related by a major provider of malpractice insurance. Leading specialists sued: Internists, pediatricians, and obstetricians. Cases were reviewed by a physician experienced in telephone medicine and independently checked by a risk management nurse specialist and discussed by 2 additional risk management analysts before arriving at full agreement. Twenty-four (60%) cases were settled or awarded to the plaintiff. The most common allegation was failed diagnosis (68%), most common injury was death (44%), and most common setting was general medicine ambulatory practice. Leading errors were documentation (88%) and faulty triage (84%). The average indemnity was $518,932, with a total indemnity of $12,454,375. Telephone-related claims were costly; injuries were catastrophic. Poor documentation and faulty triage were major factors influencing care and legal outcome. Telephone errors may represent the tip of the iceberg in patient safety in ambulatory practice; however, these preliminary results need to be confirmed in a larger sample of cases.

Missed Diagnoses by Urologists Resulting in Malpractice Payment

Missed diagnoses are a patient safety concern and they can result in malpractice allegation. The specialist physician may be liable for missed or delayed diagnoses even if an abnormality in the physician area of expertise is ruled out. We approached this largely unstudied area of medical malpractice in an effort to increase physician awareness and identify opportunities for prevention. Working with the Medical Liability Mutual Insurance Company of New York State, we evaluated malpractice claims in urology that were closed with indemnity payment between 1985 and 2004. We identified all such claims resulting from alleged missed or delayed diagnoses by urologists. Claims were divided into 2 main categories based on whether the missed diagnosis was primarily urological, ie testis torsion, or not urological, ie appendicitis. A total of 75 missed diagnosis claims were identified, representing 15% of claims overall. The total indemnity payment for missed diagnosis claims was $32,591,013, which represented 27% of all indemnity payments for the study period. They were divided into 58 missed urological diagnoses and 17 missed nonurological diagnoses. Cancer represented 71% of missed urological diagnoses and 41% of missed nonurological diagnoses. Urological cancer missed diagnosis claims were associated with the highest average indemnity payment of $526,460. The average indemnity payment for missed diagnosis claims was 92% greater than the average indemnity payment for all other claims ($434,546 vs $226,133). An increase in the frequency of missed diagnosis claims closed with indemnity payment and in the amount of payment for missed diagnosis claims were observed during the 20-year study period. Indemnity payments resulting from missed diagnosis claims represent a disproportionately high percent of total indemnity payments (27%) due to a high average payment for such claims. Liability for the urologist resulted from missed diagnoses not only of urological conditions, but also of nonurological conditions.

Lawsuits against plastic surgeons: Does locale affect incidence of claims?

Physicians continue to practice in a very litigious environment. Some physicians try to mitigate their exposure to lawsuits by avoiding geographical locations known for their high incidence of medical malpractice claims. Not only are certain areas of the United States known to have a higher incidence of litigation, but it is also assumed that certain areas of the hospital incur a greater liability. There seems to be a medicolegal dogma suggesting a higher percentage of malpractice claims coming from patients seen in the emergency room (ER), as well as higher settlements for ER claims. To determine if there is any validity to the dogma that a higher percentage of malpractice claims arise from the ER. An analysis of common plastic surgery consults that result in malpractice claims was performed. The location where the basis for the lawsuit arose - the ER, office (clinic) or the operating room (OR) - was evaluated. The value of the indemnity paid and whether its value increased or decreased based on the location of the misadventure was evaluated. According to the data, which represented 60% of American physicians, there was a larger absolute number of malpractice claims arising from the OR, not the ER. However, the highest average indemnity was paid for cases involving amputations when the misadventure originated in the ER. The dogma that a greater percentage of lawsuits come from incidents arising in the ER is not supported. However, depending on the patient's injury and diagnosis, a lawsuit from the ER can be more costly than one from the OR.

Medical Malpractice in Urology, 1985 to 2004: 469 Consecutive Cases Closed With Indemnity Payment

Malpractice premiums have increased by up to 57% for urologists in the last 3 years, for which the reasons are not clearly reported. We sought to better understand factors contributing to the current medical malpractice crisis in urology. Working with the Medical Liability Mutual Insurance Company of New York State we evaluated malpractice claims in urology that were closed with indemnity payment between 1985 and 2004. Individual claims were assessed for the purported negligent act, the procedure when applicable and the expense incurred. We also evaluated the impact of new technologies, eg laparoscopic nephrectomy, on reported claims. A total of 469 urology malpractice claims were closed with indemnity payment during the period evaluated for a total loss indemnity of Dollars 99,335,431. The number of files closed with indemnity payment yearly remained relatively constant at an average of 22 claims. The average indemnity payment increased each year and after correcting for inflation a 191% increase was observed for the period evaluated. The greatest number of claims was related to postoperative events (total of 101), followed by intraoperative events (96), failure to diagnose a given condition (60), medication administration error (21) and a foreign body left following surgery (20). In the area of new technologies laparoscopic surgery accounted for 4 claims and transurethral needle ablation accounted for 1. Vasectomy accounted for 8 claims. In the current study surgical procedures were the greatest generator of claims with the most common being oncological. Emerging and new technologies, eg laparoscopy and robotics, did not account for the increase in indemnity payments observed to date. Only further investigation will determine whether this is secondary to a lag time in the closure of suits related to these emerging technologies or to a lack of such suits. The actual number of claims closed with indemnity payment yearly remained relatively constant. However, the indemnity payment per claim far outpaced that expected for inflation. The observed increase in indemnity payment per claim would appear to be a significant contributing factor to the current malpractice crisis in urology.

Pediatrics among specialties with highest payments for closed malpractice claims in 1985-2005

What do neurologists, neurosurgeons, obstetricians/gynecologists and pediatricians have in common? ![Figure][1] Dr. McAbee They are the physician specialties with the highest average indemnity payments for closed malpractice claims from 1985-2005, according to the Physician Insurers

Pediatric Medicolegal Education in the 21st Century

The most recent medical malpractice crisis affecting the nation has underscored the need for improved medicolegal education for pediatric practitioners at all levels of training and experience. Besides issues related to malpractice, the increase in enforcement of state and federal regulatory laws,1 regulations relating to hospital privileges and employment contracts,2 and an evolving and widening oversight by state licensing boards3 has escalated an imperative to expand on current educational efforts. Pediatric educators must support the notion that a sound foundation in medicolegal issues, along with continuing education in these areas, will be as integral to a successful practitioner as is competence in medical diagnosis and management. A solid basis in medicolegal principles is not simply self-serving for the practitioner to reduce the risk of a lawsuit, but good risk management can contribute to improved patient safety and quality of care.4 Each of the periodic surveys on medical liability completed since 1987 by fellows of the American Academy of Pediatrics (AAP) has found that 30% of pediatricians will be sued during their careers, with an average of 1.7 lawsuits per pediatrician.5 Ten percent of pediatricians reported being sued as interns/residents, which can have ramifications for future managed care and hospital credentialing because of the mandatory reporting to the National Practitioner Data Bank. At the end of 2004, there were payment reports in the National Practitioner Data Bank for 1669 allopathic/osteopathic interns and residents.6 Although pediatricians are not sued as frequently as other physicians, they had the fourth highest average malpractice indemnity payout of 28 specialties (behind neurology, neurosurgery, and obstetrics-gynecology) among claims closed in 2004. This payout was 43% higher than the overall average indemnity paid for all physician specialties.7 Despite many malpractice suits being dropped before settlement or trial, the dramatic increase in … Address correspondence to Gary N. McAbee, DO, JD, FAAP, Pediatrics (Neurology), Robert Wood Johnson School of Medicine, 3 Cooper Plaza, Suite 309, Camden, NJ 08103. E-mail: mcabee-gary{at}cooperhealth.edu

Vital Signs: Average Indemnity Payment per Internist Involved in Malpractice Case

Vital Signs: Average Indemnity Payment per Internist Involved in Malpractice Case

Vital Signs: Average Indemnity Payment per General or Family Physician Involved in Malpractice Case

Vital Signs: Average Indemnity Payment per General or Family Physician Involved in Malpractice Case

Communication Errors in Radiology: A Liability Cost Analysis

We evaluated the economic effect on radiologists involved in litigation of failures in communication of results. We examined claims data from the Physicians Insurers Association of America 2002 report on breast cancer and identified malpractice cases in which miscommunication, rather than misdiagnosis, was the primary cause for litigation. The average indemnity payment for primary errors in communication by radiologists was between $228,000 and $236,000, or twice as high as when appropriate communication occurred. As a percentage of total indemnity payments to plaintiffs, such awards were 15 times higher than when communication was effective. Notwithstanding diagnostic accuracy, errors attributable to ineffective communication of results account for high indemnity awards. These errors can be easily resolved in clinical practice.

Quantification and risk analysis of occupational burns: Oregon workers' compensation claims, 1990 to 1997.

This study examined all accepted Oregon workers' compensation claims for occupational burn injuries during the period of 1990 to 1997 (N = 3,158). The Current Population Survey was used to derive employee population baselines for establishing rate estimates. It was estimated that the average occupational burn claim rate was 2.89 per 10,000 workers (95% confidence interval [CI] 2.76, 3.02). The majority of claimants (71.7%) were males, the largest proportion (32.6%) was aged 25 years or less, and almost half (48.7%) had less than 1 year of job tenure. The most frequent burn type cited was heat/scald burns (78.9%) followed by chemical burns (19.3%). Costs averaged over 1.6 million dollars annually. The average indemnity period was 16 days. Higher relative risks were found for evening workers (2.97, 95% CI 2.96, 2.98) and night workers (2.13, 95% CI 2.12, 2.13) compared with dayshift workers. Kitchen workers had the highest burn rate of all occupations, with 62.5 claims per 10,000 workers.

Malpractice claims made against orthopedic and neurosurgical spine surgeons over a 21-year period

Daveed D. Frazier, MD, David Rojer, MD, John Brennan, MDM, Andrew Patterson, MD, New York, NY, USAIntroduction: We live in an increasingly litigious society. As physicians, malpractice claims are considered a simple cost of doing business. If we were more aware of the types and circumstances of cases involved in most malpractice cases, we might be able to avoid such cases in the future. To this end, we looked at data taken from the largest physician-owned professional liability carrier in the United States to determine if certain trends were notable in cases that were filed. We focused on claims related to spine surgery performed by orthopedic and neurosurgeons from a specific region in New York State. The identification of these trends might give us useful information for not only patient education but also for the way in which we practice medicine.Methods: All insurance claims made between 1975 and 1996 at Mutual Liability Medical Insurance Company were reviewed. Those claims made against spine surgeons in the districts of New York City, Long Island and upstate New York were isolated and provided the database for information obtained in this study. Charts on each case were reviewed and the information was tabulated to look for trends in malpractice claims. The information collected included district, insurance type, age of patient, sex of patient, hospital type (ie, teaching versus community), spine surgeon (ie, orthopedic versus neurosurgical), time of injury, anatomic area of injury, insurance company rating of case to be defensible or not defensible, procedure and allegation of wrong doing. This information was compared with national and regional data to provide trends in malpractice claims filed against spine surgeons.Results: There were a total of 176 cases filed against spine surgeons between 1981 and 1997. Of the cases filed, 75 were against orthopedic spine surgeons and 101 were against neurosurgeons. Sixty-two percent of orthopedic surgeons being sued had to give some monetary payout. There was no difference between orthopedic and neurosurgeons (p=.55, Fisher's exact test). If you were a spine surgeon and were sued, the average indemnity was $280,328 (median, $235,000). This indemnity did not differ between orthopedic and neurosurgeons (p=.599). In cases involving the cervical and thoracic spine, there is a trend for neurosurgeons to pay more if they are sued. In the cervical spine neurosurgeons paid $427,511, whereas orthopedic surgeons paid $250,833. In the thoracic spine neurosurgeons paid $511,063, whereas orthopedic surgeons paid $315,027. There is no significant difference in indemnity paid by orthopedic surgeons versus neurosurgeons in cases involving the lumbar spine: orthopedic surgeons paid $254,981, and neurosurgeons paid $239,488. Certain surgical procedures have a higher number of lawsuits filed. For orthopedic surgeons, the overwhelming procedure associated with lawsuits is lumbar laminectomies for discectomies, which accounts for nearly 55% of all cases filed against orthopedic surgeons. This is followed by scoliosis correction, which accounts for 11%. Lumbar laminectomies for discectomies account for 49% of all cases filed against neurosurgeons. This is followed by posterior cervical laminectomies, which account for 13% of cases; and lumbar decompression for stenosis, which accounts for 10% of cases filed against neurosurgeons. Of the cases that were filed, certain procedures are associated with a higher payout. For orthopedic surgeons, suits associated with lumbar laminectomies and fusion on average pay out $332,443, whereas lumbar laminectomies for discectomies on average pay out $260,167. For neurosurgeons, suits associated with posterior cervical laminectomies on average pay out $348,426, whereas lumbar laminectomies for discectomies on average pay out $217,946. More cases led to payout when filed upstate versus in New York City or Long Island: 75.6% versus 58.7% or 53.6% (p=.005). Although cases filed upstate had the highest rate of payout, they had the lowest median payout: $155,000 versus $625,000 or $275,000. Community hospitals had a significantly higher rate of payout versus teaching hospitals: 75.4% versus 48.4% (p=.000). When controlling for location of the hospital, this difference persisted. There is a trend toward lower payouts in community hospitals versus teaching hospitals (p=.098). For both neurosurgeons and orthopedic surgeons, the most common allegations being filed in malpractice cases are chronic pain postoperatively, postoperative infections, nerve damage, incorrect levels and dural tears.Discussion: A number of malpractice claims are associated with events that would typically be included in perioperative consent forms: chronic pain, infection, dural tear, nerve damage. Knowing these areas might help us to provide better informed consent to our patients in the future. Although the amount of indemnity paid in certain claims provides us with a number of different trends, the possible financial loss should not affect the way in which we practice medicine. Ultimately, our goals as physicians should not change: excellent patient care always.

How Much Labor Is in a Labor Epidural? Manpower Cost and Reimbursement for an Obstetric Analgesia Service in a Teaching Institution

Background: Some anesthesiologists avoid provision of obstetric analgesia services (OAS) because of low reimbursement rates for the work involved. This study defines the manpower costs of operating an OAS in a tertiary referral center and examines reimbursement for this cost. Methods: The time spent providing OAS in a total of 55 parturients was studied prospectively using a modification of classic time and motion studies. Results: Mean duration of OAS in our population was 412 ± 313 min. Mean bedside anesthesia staff time was 90 ± 40 min, and mean number of visits to each patient’s bedside was 6.3 ± 2.0 visits. Assuming staffing on demand for service (intermittent staffing), a minimum of 2.5 full-time equivalent (FTE) attending anesthesiologists was required to meet demand. With intermittent staffing, labor cost was $325 per patient. Actual practice at Duke University Medical Center is around-the-clock (dedicated) staffing, which requires 4.4 FTEs at a cost of $728 per patient. Neither average indemnity reimbursement ($299) nor Medicaid reimbursement ($204) covered the cost per OAS patient. Breaking even is possible under indemnity reimbursement because operating room reimbursement subsidizes OAS costs. Breaking even cannot occur with Medicaid reimbursement under any circumstances. Conclusions: Obstetric analgesia services requires a minimum of 2.5 FTE attending anesthesiologists at Duke University Medical Center. With the current payer mix, positive-margin operating room activities associated with the obstetric service are not sufficient to compensate for the losses incurred by an OAS. Around-the-clock dedicated obstetric staffing (4.4 FTEs) cannot operate profitably under any reasonable circumstances at our institution.

Malpractice occurrence in Emergency Medicine: Does residency training make a difference?

We evaluated the effects of Emergency Medicine (EM) residency training, EM board certification, and physician experience on the occurrence of malpractice claims and indemnity payments. This was a retrospective review of closed malpractice claims from a single insurer. Outcome measures included the occurrence of claims resulting in indemnity, indemnity amounts, and defense costs. Differences in the outcome measures were compared based on: EM residency training, EM board certification, EM residency training versus other residency training, and physician experience using both univariate and multivariate analyses. There were 428 closed EM claims with indemnity paid in 81 (18.9%). Indemnity was paid in 22.4% of closed claims against non-EM residency-trained physicians, and in only 13.3% against EM residency-trained physicians ( p = 0.04). The total indemnity was $6,214,475. Non-EM trained physicians accounted for $4,440,951 (71.5%), EM residency-trained physicians accounted for $1,773,524 (28.5%). The average indemnity was $76,721 and the average defense cost was $17,775. There were no significant differences in the mean indemnity paid per closed claim or the mean cost to defend a closed claim when comparing EM-trained and non-EM residency-trained physicians. The total cost (indemnity + defense costs) per physician-year of malpractice coverage was $4,905 for non-EM residency-trained physicians and $2,212 for EM residency-trained physicians. EM residency-trained physicians account for significantly less malpractice indemnity than non-EM residency-trained physicians. This difference is not due to differences in the average indemnity but is due to significantly fewer closed claims against EM residency-trained physicians with indemnity paid. This results in a cost per physician-year of malpractice coverage for non-EM residency-trained physicians that is over twice that of EM residency-trained physicians.

Physicians' cognitive errors and their liability consequences.

Diagnostic errors account for one-fifth of lawsuits against hospitals and physicians. Of greatest concern is the rising severity of lawsuits alleging diagnostic errors--over a 12-year period the average indemnity for these claims has risen by 258%. The hospital departments most affected are the emergency room, obstetrics, radiology and pathology. This article probes the structure of diagnostic errors and makes recommendations how to reduce the frequency and severity of these claims.

Occupational upper extremity disorders in the federal workforce. Prevalence, health care expenditures, and patterns of work disability.

Upper extremity disorders (UEDs) account for a significant number of work-related illnesses in the US workforce. Little information exists on the distribution of UEDs, their associated health care and indemnity costs, or patterns of work disability. The study presented is an analysis of upper extremity claims within the federal workforce. In this study, the universe consisted of all claims accepted by the US Department of Labor, Office of Workers' Compensation Programs (OWCP), from October 1, 1993, through September 30, 1994. A total of 185,927 claims of notices of injury were processed during the study period, and of these, 8,147 or 4.4% had an UED diagnosis coded according to the International Classification of Diseases, Clinical Modification (ICD-9-CM). 5,844 claims involved a single UED diagnosis and were the only claims field by these employees between October 1, 1990, and September 30, 1994. These single claims with single diagnoses comprised the sample for further analysis. Mononeuritis and enthesopathies of the upper limb were the most common diagnoses, accounting for 43% and 31% of the claims, respectively. Women had a higher proportion of carpal tunnel syndrome, "unspecified" mononeuritis, and "unspecified" enthesopathies. The majority of claimants for both the mononeuritis- and enthesopathy-related diagnoses were between 31 and 50 years of age, received only health care benefits, and did not incur wage loss. Health care costs for mononeuritis and enthesopathy claims were $12,228,755 (M = $2,849). Carpal tunnel syndrome (CTS) and enthesopathy of the elbow were the most costly diagnoses, accounting for 57% and 16% of the total, respectively. Surgical services represented the highest expenditures in CTS claims. Physical therapy accounted for the majority of health care costs for enthesopathy cases. The mean number of workdays lost for CTS and enthesopathy claims were 84 and 79, and the average indemnity costs were $4,941 and $4,477, respectively. These findings indicate that while UEDs represent a relatively small percentage of all workers' compensation cases, the health care and indemnity costs are considerable. Also mean duration and pattern of work disability revealed that these disorders can result in chronic work disability similar to that observed in low back pain. The results highlight the need to determine whether interventions that account for the majority of costs significantly impact long-term outcomes. There is also a need to identify risk factors for prolonged disability in those who experience problems with delayed recovery.

Massachusetts emergency medicine closed malpractice claims: 1988–1990

To describe the characteristics of malpractice claims against emergency physicians and to identify causes and potential preventability of such claims. Malpractice claims closed in 1988, 1989, and 1990 against emergency physicians insured by the Massachusetts Joint Underwriters Association were compared with claims closed from 1980 to 1987 as investigated in our previous study. Retrospective review of malpractice claim files by board-certified emergency physicians. The average indemnity and expense per claim were higher in the current study population than in our previous study population (P = .05). Claims in eight high-risk diagnostic areas (chest pain, abdominal pain, fractures, wounds, pediatric fever/meningitis, subarachnoid hemorrhage, aortic aneurysm, and epiglottitis) accounted for 50.8% of claims in this study and 55.5% of total monetary losses. Four claims in this study were related to two instances of failure of an emergency department radiograph follow-up system. The evaluation of patients who were intoxicated contributed to major monetary losses, especially in cases of fractures and head injury. Emergency physicians must have a particular awareness of their great risk exposure for missed myocardial infarction. Addition of dictation or voice-activated record generation systems, departmental protocols for radiograph follow-ups, and holding and re-evaluation of the intoxicated patient will help provide systems supports for reducing the liability of individual emergency physicians.

MALPRACTICE IN PHYSICAL MEDICINE AND REHABILITATION

Malpractice issues are a concern for physiatrists, but little information specific to the field is readily available. Medical, legal and economic literature provide profiles of physicians involved in malpractice claims and the types of clinical situations in which suits are brought in general but no specifics on physiatry before 1973. Nine malpractice studies were examined to characterize malpractice claims in the field. The physiatrist's risk relative to other specialties could be studied specifically in three studies of 197,230 claims reported from 182 liability carriers. The number of claims brought was one-third of that predicted relative to the size of the specialty. The number of paid claims was one-fourth of that predicted, and the total dollar indemnity was one-fifth of that predicted. The average indemnity per claim rose 770% over a decade, from $12,000 in 1978 to $92,000 by 1988. Dollar losses were significantly lower than expected compared with other specialties classified by insurance carriers to be of similar risk such as neurology, pediatrics and general/family practice and one specialty considered to be very low, dermatology. Losses for physiatry were more similar to that of the very low risk category specialties such as psychiatry and pathology. One-fourth of successful claims resulting in one-third of the total dollar losses were associated with physical therapy. Cases involving femoral fracture comprised 14% of paid claims accounting for 34% of the total losses. Conditions of the vertebral column accounted for 35% of monetary losses and medication error accounted for 14% of monetary losses. The claim incidence was very low as one study of 71,130 claims identified none against physiatrists, with no more than 110 claims in any single study.