It’s a simple question that has myriad, disparate answers: Why do rates of malpractice claims against hospitalists remain high?

A 2023 report from MedPro showed that while claims won against hospitalists were not financially outrageous, they have the highest claims frequency compared to all other specialties. A 2021 report showed that out of six specialties, including neurosurgery, hospitalist medicine is the sole specialty whose malpractice claims rate continues to climb.

Housed in an enormous nutshell, the reasons for a patient suing, both likely and evidence based, cover everything between seam-ridden lines of communication among hospitalist team members — let alone between staff and patients and their families — to at-odds business goals of administrative and hospital staff. Also, add mistakes made around diagnoses and pharmaceutical related errors.

Possible reasons surrounding the growth of the hospitalist specialty itself and hospital ownership exist. In 2024, 80% of physicians worked for a hospital system or a corporation. Since Farzana Hoque, MD, associate professor of medicine and medical director at Saint Louis University Hospital in St. Louis, joined the Hospital Medicine division about 8 years ago, the number of hospitalists has nearly tripled.

Speaking generally, Hoque said, as hospitalist employment numbers have increased over the years, so have claims.

Has hospital ownership played a role in hospitalist-involved claims? Tough to say.

Private equity (PE)-backed growth in this sector aligns with the growth of the hospitalist specialty. By 2025, PE groups owned 8.5% of private and 22.6% of for-profit hospitals nationwide. That said, if a provable connection exists between ownership and claims made against hospitalists, it is obscure. What data are available involving hospitals and PE-backed ownership concern bankruptcies, patient safety, and the like.

“PE firms use the bankruptcy process to get out of debt and liability against them,” said Matt Parr, communications director, Private Equity Stakeholder Project (PESP). Thirty-seven of the 154 healthcare bankruptcy filings in 2023 and 2024 had PE ownership, according to PESP data. In 2024, PE-backed companies accounted for seven of the eight largest healthcare bankruptcies.

“Generally speaking, yes there are higher proportions of suits now against hospitals that are larger systems,” said Thomas W. Miller, MD, a hospitalist in Longmont, Colorado, and expert witness in malpractice cases involving hospitals. “They are not necessarily private equity, but some are. [Hospital] ownership has shifted so much.”

There are other reasons malpractice claims remain high. For one, patients are sicker — a 2022 study showed that half of the admitted patients had at least three comorbidities. And another, arguably connected reason: Hospitalists are expected to be the jacks and jills of all subspecialty trades. “Hospitalists now tend to be the primary attending on everybody, even surgical cases,” Miller said.

What follows is advice, gleaned in the courtroom and the St. Louis hospitalist program. Other hospitals contacted declined to comment. (The American Investment Council, a PE advocacy group, also declined comment.)

Some Noteworthy Numbers

But first, some data to keep in mind.

A study published in 2014 of more than 52,000 malpractice claims made against many specialties showed that hospitalists had the lowest claims rate, 0.52 claims per 100 physician coverage years. Nonhospitalist internal medicine physicians had the next lowest, at 1.91 claims.

By 2023, that previously mentioned 63% higher claim frequency had been reached, increasing from 46%, pre-pandemic. It wasn’t hospitalists in the ICU and the emergency department (ED) propelling these claims, as 79% of them had origins in the patient’s room. (Combined, the ICU and ED were 17%.)

In the Courtroom

In Miller’s 20-plus years in the witness box, he has witnessed more than a few lawsuits brought that began with a statement that made the patient, including the family, feel diminished, insecure, angry. Phrases like “the patient doesn’t meet the criteria for that procedure” or a nurse telling a patient “I don’t know why a doctor is doing that” or even a patient hearing a complaint like “I have too many patients to see” can start the malpractice ball rolling.

It’s a turn of phrase that slides off the tongue without a whole lot of thought given to how it will be received. He calls it the nub. “It can be very subtle.”

Meeting criteria is medical jargon but think how it could be interpreted by someone from a distressed socioeconomic background, Miller said.

Another important issue: Does everyone know who is ultimately in charge of a patient’s care?

Miller calls this person the captain of the ship, the person who decides when a patient needs evaluation by the surgeon, obstetrician, whomever. If the captain says a patient needs to be evaluated immediately, it has to happen.

“You have to be sure that [the people who] are assisting are staying on board and following those issues as needed,” Miller said, who added that he had worked on a few cases in which such assistance didn’t happen. “The hospital system needs to understand this to reduce the number of lawsuits.”

And never assume that a procedure, medication change, or communication took place; assumptions are another growing basis for lawsuits, Miller said. If the hospitalist has a surgical patient and documents that she noticed rebound tenderness and pain, “it is not okay to say, ‘let the surgeon take care of that.’”

And just documenting the observation isn’t enough. There has to be follow through.

And while time clicks away during a shift, it might be tempting to avoid a sit-down with a patient. Do it anyway, Miller said, especially around touchy issues involving risks. “Make sure you aren’t using medical lingo. Ask, ‘does that make sense?’”

In the Hospital

Today, at least 40% of hospitals in this country have a hospitalist program. Yale has an apprenticeship model in which senior residents are paired with hospitalists. Tulane’s program is geared so that resident graduates “have the knowledge, skills, and attitude of a practitioner who already has 6 months of experience.”

At Mount Sinai, hospitalists can get specialized training in oncology, palliative care, and so on. They are all geared toward better patient care. And arguably, these programs are hedges against malpractice suits.

Physicians, Hoque said, do not receive formal training on what things must be done and not be done when a physician is named in malpractice lawsuits. So she created a lecture to inform her peer physicians. She lectures at medical conferences on patient safety and malpractice concerns, a good handful per year.

“Both medical schools and residency training do not educate the trainees on what to do immediately after being named in a lawsuit claim,” Hoque said.

For example, physicians named in a suit should not make any changes in that patient’s electronic medical record. It could be seen as an attempt to hide the truth.

“As the malpractice claims are quite significant in the USA, more than in other countries, physicians need to be educated about this.”

Generally speaking, she said, malpractice claims are high for hospitalists; the median indemnity payment is nearly as high as those awarded neurosurgeons.

Late last year, Hoque co-authored a review that detailed the care hospitalists need to provide to patients with heart failure. St. Louis hospitalists see patients with heart failure frequently.

“We wanted to bring the data into one place,” she said. She concurs the review is to be used as a resource to ensure safe patient care and reduce adverse events, to minimize malpractice suits.

At St. Louis, those efforts include the installation of a transitional care clinic 2 years ago, whose staff is responsible for scheduling follow-up appointments with primary care physicians. All paperwork is sent to the PCP as well.

And lines of communication are in place. Hoque said she discusses key care plans with nurses and advises patients to tell staff if they wish to speak with her. Many times, she said, patients have questions after hospitalists complete rounds.

A critical step in avoiding lawsuits is meeting the standard of care, generally defined as what a reasonably competent hospitalist would do in a similar situation. “An alleged violation of standard of care should always be the reason basis for a complaint; technically the suit could/should be dismissed by the judge if that were not the case,” Miller said.

Knowing when to call in the clinically relevant specialist is often a key factor in questions of standard of care.

Hoque calls it the “tipping point.” Hospitalists, she said, need to have the professional wisdom to call the clinically needed consulting team in a timely manner. Also, she said, it is essential to document clinical reasoning and key discussion points with any requested consulting teams, brought in on an emergency/urgent basis.

“I teach my residents not to practice curbside consulting. If patients need a consult, I advise my trainees to consult per the hospital policy,” she said.

A final word or two on PE in the healthcare sector, specifically on why PE firms find the sector so attractive.

In a podcast hosted by the National Conference of State Legislatures, Zirui Song, MD, associate professor of healthcare policy and medicine, Harvard Medical School, Boston, who has published much on private sector investment in the healthcare system, said the fragmented nature of the delivery system [provides] many opportunities for consolidation and consolidation garners greater market power.

The reaction to PE’s reach for control in healthcare is fragmented as well; some states, like Oregon, Indiana, Massachusetts, Indiana, New Mexico, Washington, have laws looking for disclosure of information, financial oversight, or acquisition activities.

Hoque said bad outcomes do happen, despite the best of intentions, and the best of care. In some way, “[malpractice claims] are eye opening and self-reflecting,” she said. “It is telling us we need to be motivated to sharpen our skills.”

She agreed with Song. “In medicine, it is fragmented, everybody needs each other.”

No disclosures reported.