Oncology fellows about to enter clinical practice face a shifting landscape, as solo practitioners and small group practices are being supplanted by large group practices. Small practices will have several challenges related to malpractice coverage. Interviews with 2 experts in the field highlighted several current trends that will affect malpractice.

Fellows should be aware of the available types of malpractice insurance, which include 2 types of professional liability insurance: occurrence or claims-made.1 Although medical oncologists are less likely to be under litigation than physicians in other specialties and traditionally have enjoyed relatively low malpractice premiums similar to those of nonprocedural internists, being sued is still a possibility. Potential areas of litigation in oncology include delay in diagnosis, errors in chemotherapy dosing, pain control, and informed consent.2

Oncology Fellow Advisor spoke with Patricia Legant, MD, PhD, a solo practitioner in medical oncology in Salt Lake City, who emphasized trends in medicine that are likely to affect malpractice coverage. The first is a large increase in the number of cancer patients, both newly diagnosed and survivors, at the same time that the oncology workforce is decreasing.3

“These trends may lead to longer waiting times for patients and an increasing number of patients seen by midlevel providers such as nurse practitioners and physician assistants, as well as an increasing volume of patients for the remaining physicians to oversee and manage. These factors could lead to errors and lower levels of patient satisfaction and to less patient loyalty to a particular provider,” Dr. Legant said.

Another major trend is employment of physicians by larger entities, including hospitals, health care systems (eg, Kaiser Permanente, Geisinger, Christiana), and large group practices groups (eg, US Oncology). A potential upside of this trend is improved quality of care to the extent that care is driven by evidence-based guidelines, but there are several downsides, Dr. Legant continued. The new employment arrangement may offer more plaintiff targets for lawsuits due to their “deeper pockets.” Dr. Legant offered potential tips to avoid litigation in Table 2.4

Table 2. Dr. Legant’s Tips on Avoiding Malpractice Suits and Decreasing Liability 
Avoid burnout by caring sincerely for patients and maintaining a sense of humor.
Offer quality care and good patient-physician communication.
Keep accurate medical records.
Tie up all loose ends and use tracking systems for follow-up.
Don’t criticize your colleagues.
Adapted from referemce 4.

These arrangements may jeopardize the future of several physician-run medical malpractice companies, because large groups tend to be self-insured. Commercial interests of these larger groups may not be as sympathetic to individual physicians’ interests as current physician-run insurers.

“We may see consolidation of physician-run enterprises across many states, which will be driven by the exit of physicians from the independent market,” Dr. Legant said.

According to Marge Beazley, practice administrator for Cancer Care of Western North Carolina (WNC) and upcoming president of the North Carolina Oncology Management Society, “The pool of insurers is shrinking. Now states have to choose between 3 or 4 carriers, whereas in the past there was more of a choice. Fellows going into practice may find it difficult to get the coverage they need, and it is going to be more expensive.”

The third trend Dr. Legant cited is the progression toward the adoption of electronic health record (EHR) systems, with unrestricted patient access to these records. EHR systems help coordinate patient care with less fragmentation of services, but in her view, they have several potential disadvantages. “Adopting electronic records raises the issues of confidentiality and breach of privacy, as well as the difficulty of maintaining a delicate balance of candor and accuracy of records relative to patient satisfaction and anxiety. Cancer care in particular is fraught with patient anxiety, yet the record must contain truthful information about prognosis, and also medically important topics like multiple missed appointments and drug and alcohol abuse,” she noted.

Also, once records are online, patients can offer them to their lawyers. Doctors will become liable for their statements that perhaps could be discussed with the patient in person in a more nuanced way, Dr. Legant said.

The issue of quality of care versus the amount of reimbursement insurance companies are willing to pay will become an even more important issue that will affect the malpractice environment in the future, predicted Ms. Beazley.

“Although insurance companies may want to acknowledge quality practices that fulfill the American Society of Clinical Oncology’s QOPI [Quality Oncology Practice Initiative], the same companies want to pay for a generic equivalent, which has not been validated in the approved clinical trials. Insurance companies are striving to find a mechanism to treat patients according to [The National Comprehensive Cancer Network] guidelines and preserve the health care dollar at the same time,” she said.

“We’ve run up against this and negotiate with carriers and often come to an agreement,” she added.

Another thing oncology fellows should be aware of is that premiums vary by state and are based on frequency of claims, amount of awards, the legal climate, and whether a cap for pain and suffering exists. When a fellow is deciding whether to enter a practice, the premiums in that state are a factor to consider. Premiums for oncologists are generally similar to those for other internists who do not perform surgical procedures.

Ms. Beazley described her experience with malpractice premiums. “In Western North Carolina, we have a wonderful carrier that may hold/freeze premiums if the practice has not incurred any claims. As time with the company grows and the liability record remains clear, premiums are at a low risk for increasing. We have one oncologist who has practiced for 25 years without an incident, and his premium is now $7,000 per year; this is very low compared with other physicians who are at higher risk,” she said.

Ms. Beazley is “aghast” at some premiums across the United States, some of which are up to 75% higher than what practitioners at WNC are paying. She declined to provide an actual figure for premiums in the practice she administers, but said that states that are more densely populated have increased fraud and abuse and higher liability premiums; examples are New York and Florida.

Ms. Beazley offered this advice: “Find a strong group in an area that allows you to practice the type of oncology you prefer: for example, urban area, hospital, but gives you the most protection—an umbrella of protection. Look at the number of doctors within that group who do not have blemishes on their records, and consult with them on your cases. I tell new oncologists to also review the state medical board regarding medical liability claims of the partners in the practice you are considering joining and ask the partners directly about any past liability claims. I find that most new fellows do not ask that question.”


  1. Wormley JM. Malpractice insurance: what you need to know. J Oncol Pract. 2007;3(5):274-277.
  2. Legant P. Oncologists and medical malpractice. J Oncol Pract. 2006;2(4):164-169.
  3. Shulman LN, Jacobs LA, Greenfield S, et al. Cancer care and cancer survivorship care in the United States: will we be able to care for these patients in the future? J Oncol Pract. 2009;5(3):119-123.
  4. Legant P. Oncologists and medical malpractice. J Oncol Pract. 2006;2(4):164-169.

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