A Critical Commentary On The Illinois New Physician Workforce Study Report

By Tom Knight[1]

Introduction

A review of the recently published Illinois New Physician Workforce Study Report reveals that the study, which was sponsored by two organizations that strongly advocate for the interests of doctors and hospitals, is not an objective, scientific study.  It is skewed in a way that overemphasizes alleged concerns by young doctors doing their graduate training in Illinois about a claimed hostile medical malpractice liability environment.  The report of the study then misleadingly exaggerates the significance of those biased results and makes unfounded recommendations that are not fairly supported by the results of the study.  And now the two advocacy groups which sponsored it are polemically publicizing the report, and further exaggerating it in order to try to lend credibility to their ongoing effort to make the law more favorable to doctors and hospitals at the grave expense of the rights of patients.

A reality of life in our society today is that well-funded special interest groups have elevated to a form of art the manipulation of the news media in order to garner legislative, judicial and public opinion for their own financial benefit.   A particularly effective tool in such manipulative efforts is to create biased reports of skewed research studies, designed to look scientific, but with the purpose from the outset to bolster the economic interests of the special interest group.  If successful, of course, the report makes false propaganda look more credible.

This scientific study support tactic often is successful because lawmakers, judges and hard-working citizens normally do not have the time to learn the financial interest motives of those who actually are behind the study, or who funded it.  They do not have the time to determine whether the study was performed objectively.  And they do not have the time to analyze whether the data gathered supports the conclusions in the study report.  Thus, they often are left only with the superficial and misleading fact that a report of what looks like a scientific study seems to support the special interest group’s position.

The task of pointing out the lack of credibility of such a report because of the money motives of those who put it out, the biased nature of the study, or the unsupported conclusions, typically falls to those who would be most directly or seriously harmed by the success of the false propaganda campaign, or to those who have the interest of such potential victims at heart.  Admittedly, by definition, the group behind the study report can then argue that those segments of society also are “special interest groups.”  Nonetheless, in the post-Citizens United era, the only recourse for the public and their governmental representatives who are trying to learn the truth, is to maintain a healthy skepticism of alleged scientific study reports and to look to the opposing interests for circumstances which may cast doubt upon the credibility of the report and study.  This commentary is written to discuss some of the circumstances which cast doubt on the credibility of the Illinois New Physician Workforce Study Report as a reliable scientific study report.

The Motives of the Sponsors of the Study

The Illinois New Physician Workforce Study Report (the report) is an unfortunate, illustrative example of the scientific study propaganda technique.  It was done in collaboration with two sponsoring advocacy groups -- the Illinois Hospital Association (IHA) and the Illinois State Medical Society (ISMS) -- which are engaged in a relentless campaign to change the laws that protect people killed or seriously disabled by the negligence of doctors and hospitals.  They are vigorously lobbying the State legislature to limit the ability of patients who are negligently killed or catastrophically injured to get fair compensation for their injury and loss through the civil justice system.  If those sponsors are successful in their campaign to change the justice system, the hospitals, doctors and their insurance companies, all will stand to make much more money. That money motive – greed – has been understood forever as a valid reason to be suspicious of representations made.

The primary representation of the report, immediately and misleadingly publicized by its sponsors, is that a hostile medical malpractice liability environment in Illinois is a major reason why approximately half of the young doctors graduating from residency or fellowship programs in early 2010 are planning to practice outside of Illinois.  Based on that unfounded conclusion, the report strongly urges further efforts to establish “tort reform” (laws which take away crucial rights of negligently killed and catastrophically injured consumers)  in order to make the environment “more friendly” to doctors and hospitals.  So who are the sponsors of this study and report?

The introductory summary of the report acknowledges that it is a product of a collaborative effort by the Northwestern Medical School, the IHA and ISMS.  Indeed, the logos of all three organizations adorn the cover of the report. The grossly exaggerated press release of the report also bears all three logos.

The IHA strongly and openly advocates for changes in the law to benefit hospitals.  It even filed an amicus brief in the Illinois Supreme Court earlier this year, which argued that the Court should sustain a law that would have severely limited the rights of patients to recover fair and reasonable compensation for injuries and death resulting from the carelessness of hospitals and doctors.[2]

The Illinois Supreme Court, however, held the law unconstitutional in Lebron v. Gottlieb Memorial Hospital, 237 Ill.2d 217, 930 N.E.2d 895 (Feb 4, 2010).  The IHA has vociferously criticized the Supreme Court for that decision and continues to push for new laws limiting the rights of patients in cases against hospitals and doctors.

The Illinois State Medical Society (ISMS) similarly represents doctors throughout Illinois.  It too filed a brief in support of the anti-patient rights law which was held unconstitutional in the Lebron case.  Interestingly, on the same day that the Report was released, the ISMS web site posted the lengthy press release -- obviously prepared in advance -- which further exaggerates the already exaggerated conclusion of the report.  The ISMS press release announced that doctors are fleeing Illinois because of the medical liability environment.  ISMS also is closely aligned with ISMIE, the insurer which insures the great majority of doctors in Illinois.

Illinois Hospitals, doctors and their insurers obviously stand to make much more money if they do not have to fully compensate the consumer patients who are catastrophically injured or killed because of the carelessness of a doctor or hospital.  Thus, they have a clear and strong monetary motive to come up with a “study” that supports their ongoing effort to convince the legislature, the courts and the public that there will be a shortage of doctors in Illinois if carelessly injured patients continue to get fair compensation from the Courts.   Any honest scientist would acknowledge that such “investigator bias” can have a dramatic effect upon the objectivity of a study.

Biased Conclusions

In addition to the obvious motives of the sponsors, there are several indications in the way the report was done which tend to reveal that the bias of those behind the report has significantly influenced the conclusions. The Executive Summary actually admits that one of the purposes of the study was to raise awareness of what the authors already had determined to be current physician workforce issues.  One of those, according to the authors, is how the assumed hostile medical malpractice liability climate in Illinois affects doctors’ choices of where to practice.  Then, in an argumentative statement, quite inconsistent with typical scientific presentations, the authors alarmingly and misleadingly forecast that if the workforce issues are not addressed, there is danger that there may not be enough doctors to provide basic care.  It is apparent from even a casual read of the report’s executive summary that the unidentified “executive” authors were not simply summarizing a study; they quite clearly were re-arguing their defense position in the Lebron case: that patients negligently killed and injured by medical malpractice should be prevented from having their fellow citizens award them fair compensation so that doctors can earn more money that will keep them in Illinois![3]

Another revealing indication of bias in the “Executive Summary” section of the report is the inordinate emphasis it places on the medical malpractice liability environment as a reason that doctors plan to leave Illinois.[4] The authors list as their first “key finding” the fact that 49 per cent of those who responded planned to practice outside of Illinois.  As the authors had to acknowledge, the study expressly demonstrated that the number one reason for the young doctors to plan leave Illinois was the overall practice opportunities in their chosen specialty. On average “professional practice opportunities” was ranked as the most important consideration, and by far the largest majority of the respondents found it to be either important or very important.  See table 2, page 14.  But after acknowledging job opportunities as the primary reason for young doctors to leave Illinois, the authors, in an obvious show of bias, inserted, “…but the medical malpractice liability environment is a major consideration for those that plan to leave Illinois to practice.”   Anyone assessing the objectivity of the sponsors should ask the question why they chose to emphasize only that one additional consideration when the study clearly revealed that after overall practice opportunities, there were at least two other considerations deemed more important by more of the young doctors who answered the questionnaire.  For example, the next highest ranked reason for young doctors choosing where to practice, after “job opportunities,” was “proximity to family.”  The third most important reason was “salary/compensation.”  Even “spouse/partner employment opportunities” was ranked as important or very important by more of the respondents than medical liability environment.  See table 2, page 14.[5] See also table 5, page 19.  It should be apparent to any attentive reader that the hospital and doctor advocate authors of the report were not truly interested in accurately summarizing the results of the study.  Rather, they were intent upon misleadingly associating the medical liability environment as strongly as they could to the decision of young doctors to practice elsewhere.[6]

Another indication that the agenda of the sponsors of the report was to link medical liability environment to place of practice choice as strongly as they could is found in the next section of the Executive Summary where the authors set forth their recommendations.  While the objective data (tables 2 & 5) showed that job opportunities, family location and salary/compensation were all more significant considerations for choosing practice location, the second recommendation of the Executive Summary authors (after forming a physician workforce institute) is to urge pursuit of tort reform in order to make the medical liability environment more friendly to doctors.  That, of course, means that they are urging that the rights of patients to recover fair and reasonable compensation when they are killed or injured because of the negligence of hospitals or doctors, should be sacrificed.  Why would an objective summary of the data in the study so inordinately and misleadingly emphasize the medical liability environment consideration?   The most important consideration (job opportunities) reported by young doctors actually is relegated to a lower position on list of recommendations, and is only treated very generally.  Moreover, the recommendation for lobbying in pursuit of tort reform is much more polemic than scientific reports normally are.  For example, one would expect any objective recommendation to at least acknowledge that any changes should nonetheless protect the rights of patients to hold careless doctors accountable for the harm they do; and to provide fair compensation for the deaths and injuries resulting from that carelessness.

Not only does the Executive Summary place undue emphasis on the alleged medical liability environment consideration; comments throughout the study repeatedly show that the survey strongly focused the attention of the respondents more on the medical liability environment consideration than on the other considerations.[7] And, just as in the Executive Summary, the medical liability environment consideration is selectively highlighted in comments following the various tables.  See for example, the comment following table 5 on page 19.  Even though that table shows that four other considerations were deemed important by more respondents, the only one specifically mentioned as a major consideration was the medical liability environment.  See also the comments following table 2, on page 15; and the comments following table 7 on page 21.

In summary, not only do the obvious motives of the hospital and doctor group sponsors cast doubt upon the credibility of the New Physician Workforce Study Report, but also, the way the report was written reveals that it was a biased presentation. Rather than objectively summarizing the data results, it polemically and misleadingly distorted them so as to create support for the sponsors’ efforts to achieve passage of more laws to limit the rights of patients.

Conclusions Are Not Supported by the Data

With the apparent ulterior motives of the sponsors, and the cues of a biased presentation, it should come as no surprise that the data results really do not support the key conclusions of the report.  First of all, the report, and the attendant press releases, cast the fact that 49 per cent of the graduates plan to practice outside of Illinois as an alarming figure.  The sponsors even publicize it as evidence that doctors are fleeing Illinois, and that Illinois faces a doctor shortage. Yet nowhere in the report is there any comparative data as to what per cent of graduates of resident/fellowship programs in other states go on to practice elsewhere.[8] Without that information, the 49 per cent number is essentially meaningless.  For all anyone knows, based on the study, that may be the norm with graduates from similar programs throughout the states.

Not only is there no comparative data from other states; there also is no comparative data as to the percentage of young doctors in Illinois who went to other states to practice at times before the alleged hostile medical liability environment which the sponsors contend to be driving doctors out of Illinois.  If there were such data, it would tend to show whether the recent medical liability environment is associated with a significant increase in the percentage of Illinois residents and fellows who leave the state to practice.

Traditionally, truly scientific studies do look for comparative data from other studies.  And they almost always research and comment upon earlier studies which have dealt with the same subject.   This study, however, for some reason, failed to comment upon, or even acknowledge the existence of a large-scale 1995 nationwide study of the percentage of doctors who leave to practice in a state other than the one where they did their residency or fellowship.  The report of that study was entitled, “Graduate Medical Education and Practice Location, Implications for Physician Workforce Policy.”  It was published in the prestigious Journal of the American Medical Association (JAMA), September 6, 1995 (Vol. 274, No.9).  It should not have been very hard for the researchers at the Northwestern Medical School to find that study report.

The JAMA study was very comprehensive, surveying hundreds of thousands of doctors from every state in the Country about where they practiced after leaving their residencies and fellowships.  That study found that on average, throughout the States, 51 per cent of physicians went on to practice in same state where they did their residencies or fellowships and, of course, 49 per cent did not.  If those numbers sound familiar it is because they just happen to be identical to the percentages in the current Illinois New Physician Workforce Study Report.  In other words, the same numbers which the IHA and ISMS now claim to be proof that doctors are fleeing Illinois because of a hostile medical liability environment here, actually had been found to be the norm across the country years earlier!  Equally striking is the fact that that JAMA study report also found that, in 1993, long before the argued hostile medical liability environment, the specific percentage of Illinois doctors who had done their residency or fellowship in Illinois was exactly the same as it is in the current study – 51 per cent.  If the Illinois New Physician Workforce Study Report were truly an objective, scientific study report, how could it neglect to discuss, or even acknowledge the JAMA study report?  That study dealt with the same issue and reported results which seem to cast doubt on the primary conclusion of the current report that a recent hostile medical malpractice liability environment is a major contributing factor to the fact that “only” 51 per cent of graduating residents or fellows in Illinois are planning to practice in Illinois.  At the very least, the JAMA study should have been addressed.

As the JAMA study explained, and as common experience would suggest, young doctors tend to scatter across the country in metropolitan areas for residencies and fellowships in places other than their home or site of medical school. Thus, in the absence of comparative data showing a significant variance between Illinois and other states as to physician retention, or showing a significant difference since the alleged hostile medical liability climate, it should not be surprising if nearly half of them have no intent of staying in the state where they do their residency or fellowship, and instead go to some other state to practice.  See discussion of the “home state” factor below. In any event, it should be clear that the 49 per cent figure does not warrant the alarmist treatment given to it by the report and the exaggerated publicity put out by the sponsors.

Not only do common sense and the Jama study raise serious doubt about the primary conclusion of the Illinois New Physician Workforce Study Report; the report itself actually suggests that a 49 per cent figure for Illinois residents and fellows going out of state to practice is quite understandable without hypothesizing that young doctors are fleeing Illinois because of a hostile medical liability environment.  The study acknowledges at page 17 that a young doctor’s concept of his or her “home state” is an important factor in the choice as to where to begin medical practice; and that it may be a very important factor in this study.  The study proceeded on the premise that where a resident or fellow went to high school correlates well with what he or she regards as his or her home state.  63.1 per cent of the respondents in the study went to high school in another state (their home state), and 63.2 per cent of that group (or about 39.9 per cent over-all) account for most of the 49 per cent planning to practice out-of-state.[9]

That leaves only 9.1 of that 49 per cent to account for.  And the study shows that there are many potential reasons, other than the medical liability environment, for doctors to choose some other state.  Table 5 lists them.  In addition to job opportunities, family proximity and salary/compensation, even climate and cost of living are numerically significant reasons for many of that 9.1 per cent of the respondents to go to another state.   The 49 per cent figure for those going out-of-state simply should not be seen as an alarming statistic.

It already has been pointed out that the objective data in the study does not support the emphasis of the report on the alleged hostile medical liability environment as a major reason why young doctors are planning to practice in other states.  Job opportunities, family location and salary/compensation were of greater importance and important to more of the respondents than the medical liability environment (tables 2 and 5).[10] The emphasis on medical liability environment ignores that very meaningful context.

However, Table 6, on page 14 also contains objective data which calls into question the conclusion of the report that the alleged medical liability environment of Illinois is as big a factor as the report and its sponsors make of it.  That table shows the per cent responses of the survey respondents to questions about their intentions with respect to practicing in Illinois.

• 26.2 percent said that they have never planned to practice in Illinois, and do not plan to now.  Presumably those respondents were not driven to their planned location by the alleged current Illinois medical liability environment.   Indeed, when they started their residency or fellowship programs the law in Illinois included caps on damages and other pro-doctor provisions (Lebron was not decided until February 4, 2010).
• 20.5 per cent said that they would like to practice in Illinois, but cannot find a job here.  Obviously the medical liability environment in Illinois has not deterred them.
• 22.9 per cent have always planned to practice in Illinois and still do.  So they too have not been deterred by the so-called medical liability environment here.
• 21.1 per cent have only recently made the decision to practice in Illinois. Therefore, it can be assumed that the alleged medical environment here has not deterred them either.

Adding those percentages together, the table suggests quite strongly that 90.7 per cent of the respondents did not make their decisions as to where they would like to practice because of the medical liability environment here in Illinois.  The only remaining category of respondents is the 9.3 per cent who said that they had planned to practice in Illinois, but recently changed their mind.  There is no breakdown as to the specific reasons those respondents changed their minds; but we know from table 5 that job opportunities was important or very important to more of the respondents planning to go elsewhere than anything else was (76.2 %).  And salary/compensation and family proximity were important to a slightly greater percentage than medical liability environment (68.8, 68.4 & 67.6 respectively).  So even if the perception they had of the medical liability environment here significantly influenced half of that group – a generous estimate -- it would only indicate that about 4.5 per cent of the respondents were influenced by a perception of the medical liability environment.

Table 6 of the study contains another very clear indication that there is no problem of doctors fleeing Illinois as the Illinois Hospital Association and Illinois State Medical Society sponsors contend.  As noted above, 20.5 per cent of the graduating residents and fellows this year would like to work in Illinois, but cannot find a job here.  If doctors were fleeing Illinois in significant numbers, then there would be a shortage of doctors here.  How is it then, that more than 20 per cent of the graduates cannot find a job here?

The question arises as to how the results in tables 2 & 5 fit with the results in table 6.  The logical reconciliation is that while tables 2 and 5 attempt to identify considerations thought to be important to the respondents, table 6 tells us that perception of the medical liability environment was not a determining factor for the overwhelming majority of the young doctors leaving Illinois residency and fellowship programs in early 2010.

Even more evidence that the medical liability environment in Illinois is not driving young doctors away is found in table 3 on page 17.  As noted above, the study report acknowledges that home state is an important factor driving choice of where to practice, and may have been a very important one for the respondents in this study.  74.4 per cent of the respondents who went to high school in Illinois, intend to practice in Illinois.  So, at least about three out of every four Illinois home-staters have not been driven away by the local medical liability environment.  And many other factors could have driven the plan for the remaining one out of every four.  Equally significant is the fact that, despite the importance of home-state attraction, 36.8 per cent of those who went to high school in other states still intend to practice in Illinois, well more than one out of every three of those respondents.  The medical liability environment obviously did not deter them from rejecting their home state and planning to practice in Illinois.

Conclusion

What the study results actually seem to show is that the young doctor respondents, when led by the survey and by interviews to believe that there was a hostile medical liability environment in Illinois, agreed that it was one of many important considerations for them.  But it was not a factor which drove their decision as to where they intend to practice.  That just makes sense.  Those young doctors intend to give good, quality care to their patients.  Like most of us, they trust that, as long as they are reasonably careful, the justice system will protect them from unfounded lawsuits.  So in choosing where they want to practice, they are not about to let worries about being sued in one state versus another outweigh other considerations like job opportunities, salary/compensation, family proximity and the plans of their spouses.

Undoubtedly, there have been relatively isolated instances when doctors have left this state for “greener pastures” after having had settlements or awards against them in Illinois.  But the ones who actually leave for that reason likely are a very small percentage of that subset, and even a much smaller percentage of  Illinois doctors overall, given the  relatively small percentage of doctors who actually get judgments or settlements entered against them.

Certainly, most doctors do not enjoy having to worry about being sued.  Who does?   But, as many as 100,000 patients a year die because of doctor and hospital negligence.  That is almost three times the number killed on the highways last year.  And many more patients must suffer the rest of their life because of permanent and serious disability from medical negligence.  Death and serious injury from medical negligence is a genuine societal crisis.

Most doctors and hospitals realize that other than their own sense of personal and professional obligation to their patients, the risk of being sued if they are careless is the only effective incentive for doctors and hospitals to strive to be reasonably careful at all times.  Good doctors and hospitals trust that as long as they are reasonably careful, the civil justice system will work to protect them from being successfully sued.  In Illinois, for many years now, a medical negligence lawsuit cannot even be filed unless a qualified physician certifies that the case has merit.  So the only real risk that they must worry about is that, if they carelessly and seriously injure a patient, they might have to be held accountable. And that is why they carry liability insurance, just as the rest of us must do when we take the risk of carelessly driving our cars.  Any doctor or hospital that cannot live with that risk and keep it in perspective probably should practice elsewhere for the good of the patients in Illinois.

For the reasons discussed above, the Report of the Illinois New Physician Workforce Study should be seen, not as an objective scientific study report, but as a biased, self-serving propaganda technique employed by the IHA and ISMS to provide ammunition for their never-ending effort to achieve what they call “tort reform.”   It is important to understand, however, that that euphemism really means taking away from patients many of their historically honored rights within the justice system, including the most valued right to have a jury of their peers decide what fair compensation should be when they are carelessly injured by another.  And it is important to keep in mind that success in the tort reform campaign by IHA, ISMS and the insurance companies means that doctors and hospitals, and their insurers, will eliminate much of  their financial accountability to those they carelessly kill and maim – and thus make more money.  The taxpayers will then be left to support the victims.

It is hoped that whenever any legislator, journalist, jurist or member of the public seeks to evaluate the Report of the Illinois New Physician Workforce Study, they also will be linked to this commentary.  They may not have the time to discover the motives of the sponsors and to comb through the study data as this author has; but hopefully, they will have the time to read and consider these points before deciding whether the Report is credible and whether it, and the press releases publicizing it, fairly and accurately, interpret the data.

By:  Thomas L Knight

© November 17, 2010