Analysis of medical litigation among patients with medical disputes in cosmetic surgery in Taiwan.

Abstract

This study aimed to investigate the key factors in medical disputes (arguments) among female patients after cosmetic surgery in Taiwan and to explore the correlates of medical litigation.
A total of 6,888 patients (3,210 patients from two hospitals and 3,678 patients from two clinics) received cosmetic surgery from January 2001 to December 2009. The inclusion criteria specified female patients with a medical dispute. Chi-square testing and multiple logistic regression analysis were used to analyze the data.
Of the 43 patients who had a medical dispute (hospitals, 0.53%; clinics, 0.73%), 9 plaintiffs eventually filed suit against their plastic surgeons. Such an outcome exhibited a decreasing annual trend. The hospitals and clinics did not differ significantly in terms of patient profiles. The Chi-square test showed that most patients with a medical dispute (p < 0.05) were older than 30 years, were divorced or married, had received operations under general anesthesia, had no economic stress, had a history of medical litigation, and eventually did not sue the surgeons. The test results also showed that the surgeon's seniority and experience significantly influenced the possibility of medical dispute and nonlitigation. Multiple logistical regression analysis further showed that the patients who did decide to enter into litigation had two main related factors: marital stress (odds ratio [OR], 10.67; 95% confidence interval [CI], 1.20-94.73) and an education level below junior college (OR, 9.33; 95% CI, 1.01-86.36).
The study findings suggest that the key characteristics of patients and surgeons should be taken into consideration not only in the search for ways to enhance pre- and postoperative communication but also as useful information for expert testimony in the inquisitorial law system.

Full text

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ORIGINAL ARTICLE
Analysis of Medical Litigation Among Patients with Medical
Disputes in Cosmetic Surgery in Taiwan
Shu-Yu Lyu•Chuh-Kai Liao•Kao-Ping Chang•
Shang-Ta Tsai•Ming-Been Lee•Feng-Chou Tsai
Received: 12 December 2010/Accepted: 11 February 2011/Published online: 17 March 2011
? Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2011
Abstract
Background
factors in medical disputes (arguments) among female
patients after cosmetic surgery in Taiwan and to explore
the correlates of medical litigation.
Methods
A total of 6,888 patients (3,210 patients from
two hospitals and 3,678 patients from two clinics) received
cosmetic surgery from January 2001 to December 2009.
This study aimed to investigate the key
The inclusion criteria specified female patients with a
medical dispute. Chi-square testing and multiple logistic
regression analysis were used to analyze the data.
Results
Of the 43 patients who had a medical dispute
(hospitals, 0.53%; clinics, 0.73%), 9 plaintiffs eventually
filed suit against their plastic surgeons. Such an outcome
exhibited a decreasing annual trend. The hospitals and
clinics did not differ significantly in terms of patient pro-
files. The Chi-square test showed that most patients with a
medical dispute (p\0.05) were older than 30 years, were
divorced or married, had received operations under general
anesthesia, had no economic stress, had a history of med-
ical litigation, and eventually did not sue the surgeons. The
test results also showed that the surgeon’s seniority and
experience significantly influenced the possibility of med-
ical dispute and nonlitigation. Multiple logistical regression
analysis further showed that the patients who did decide to
enter into litigation had two main related factors: marital
stress (odds ratio [OR], 10.67; 95% confidence interval
[CI], 1.20–94.73) and an education level below junior
college (OR, 9.33; 95% CI, 1.01–86.36).
Conclusion
The study findings suggest that the key
characteristics of patients and surgeons should be taken
into consideration not only in the search for ways to
enhance pre- and postoperative communication but also as
useful information for expert testimony in the inquisitorial
law system.
Keywords
Malpractice ? Medical dispute
Cosmetic surgery ? Lawsuits ? Litigation ?
Human rights and democracy in Taiwan have greatly
improved since the end of martial law was declared in
1987. The increasing trend in medical malpractice lawsuits
S.-Y. Lyu
School of Public Health, Taipei Medical University,
250 Wu-Hsing Street, Taipei 11031, Taiwan
e-mail: sylyu@tmu.edu.tw
C.-K. Liao
Department of Family Medicine, Taipei Municipal Wan Fang
Hospital, Taipei, Taiwan
e-mail: m013089004@tmu.edu.tw
K.-P. Chang
Division of Plastic Surgery, Department of Surgery, Chung-Ho
Memorial Hospital, Kaohsiung Medical University, Kaohsiung,
Taiwan
e-mail: kapich@kmu.edu.tw
S.-T. Tsai
Division of General Surgery, Department of Surgery,
Taiwan Adventist Hospital, Taipei, Taiwan
e-mail: Shang_Ta@tmu.edu.tw
M.-B. Lee
Department of Psychiatry, National Taiwan University Hospital,
7, Chung-Shan South Road, Taipei, Taiwan
e-mail: mingbeen@ntu.edu.tw
F.-C. Tsai (&)
Division of Plastic Surgery, Department of Surgery, Center
for Mathematical Biology, Taipei Medical University Hospital,
Taipei Medical University, 252, Wu-Hsing Street, Taipei 11031,
Taiwan
e-mail: biopattern@gmail.com
123
Aesth Plast Surg (2011) 35:764–772
DOI 10.1007/s00266-011-9684-1

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reflects how people have gradually begun to pursue their
rights. The court system in Taiwan is an inquisitorial sys-
tem enacted in 1967 based on the continental German
system and not an adversarial (accusatorial) system with
trial by jury. Studies indicate that approximately 44% of
physicians faced medical litigation in 2009 [1, 2]
Taiwanhas the following
characteristics:
specificmedicolegal
1. Medical malpractice law is under the authority of the
central government in Taiwan [3].
Physicians practicing in Taiwan rarely carry medical
malpractice insurance for two reasons: (1) Taiwanese
insurance companies consider surgeons to be in a high-
risk career for lawsuits. (2) Surgeons themselves have
limited understanding of medical malpractice.
Plastic surgeons in Taiwan are not permitted to
practice in both a hospital and a clinic at the same
time.
2.
3.
These advantages can be used to analyze the differences
in medical disputes and litigation among different institu-
tions and clinical practice styles because this specific
medicolegal group in Taiwan has more uniformity, limited
variability, and less confounding bias.
The definition of various terms must be clarified first [4]
Medical malpractice is defined as any act or error by a
physician during treatment of a patient that deviates from
the accepted norms of practice in the medical community
and causes injury to the patient. This is judged by the court
or an official medical committee. Medical dispute (argu-
ment) is defined as a patient proposal in return for the
argument (any form of request such as a threat, apology, or
reimbursement), which may or may not correlate with
medical malpractice. Medical litigation occurs when the
patient files a lawsuit against the physician over a medical
dispute.
Medical dispute or malpractice does not necessarily lead
to medical litigation. The process of medical litigation
does, however, involve a medical dispute, as shown in
Fig. 1. For example, plastic surgery generally does not
result in medical malpractice, but subjective dissatisfaction
with the aesthetic outcome often leads to a medical dispute.
Due to the nature of the specialty, patients approach plastic
surgeons for aesthetic needs rather than medical diseases
[5]. Unfortunately, the literature provides little information
for improving the understanding of medical disputes (not
only malpractice) or of references for expert testimony
(witness) in cases of alleged medical malpractice in plastic
surgery [6–8]. Physicians may be put in a difficult position
during future lawsuits if no references can be cited. To our
knowledge, this study was the first to broaden the scope of
discussion to include medical disputes and to analyze
which factors increase the likelihood of medical disputes
and the subsequent shift to medical litigation.
The current culture of medicine with its steep authority
hierarchies and propensity to punish people who err is
detrimental to the willingness of physicians to discuss
medical errors [9]. In a worst-case scenario, physicians
develop a ‘‘defensive medicine’’ approach. Those who
adopt this stance develop diagnostic examinations and
treatment plans with the goal of refusing or transferring
high-risk patients, increasing the number of tests and fol-
low-up visits, and obtaining detailed informed consent to
lower the number of medical malpractice lawsuits. Sys-
tematic studies of defensive medicine have shown that
excessive medical treatment is based on fear of legal lia-
bility rather than the patient’s best interests [10, 11].
Physicians practicing defensive medicine tend to be more
conservative in their choices of treatment [12].
In the past, physicians received little training in medical
malpractice, dispute, and litigation during the long medical
education process. Our study was therefore aimed at
investigating the prevalence of medical disputes in plastic
surgery among female patients in Taiwan and to explore
the factors correlated with medical litigation in the hospital
and the clinic.
Patients and Methods
The target population of the study included all patients
receiving cosmetic surgery at two teaching hospitals
(n = 3,210) and two clinics (private facilities, n = 3678)
in Taiwan from January 2001 to December 2009. Data
were collected from the patients’ medical records, with the
inclusion criteria requiring the study subject to be a female
with a medical dispute (hospital, n = 17; clinic, n = 27).
All 35 plastic surgeons in the study (hospital, n = 20;
clinic, n = 15) were board certified. Three patients and one
surgeon were excluded because of incomplete data. Male
patients with a medical dispute were not included because
the number of cases was relatively small in all target
populations (n = 1). Reports of poor service from medical
personnel, unreasonable medical costs, and an unfavorable
Fig. 1 Relation between medical malpractice, dispute, and litigation
Aesth Plast Surg (2011) 35:764–772 765
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medical environment were included based on the definition
of medical dispute used in this study.
We compared the differences in stratified variables
within and between the medical institutions in the same
medical dispute and litigation event from the viewpoint
of patients’ and surgeons’ characteristics. The patients were
given preoperative explanations and signed informed con-
sents that included the process of procedures, the difficulty,
the recovery time, the possible complications, and so forth.
The design of many variables was aimed at decreasing
the confounding bias in our study. We hoped to clarify
which factors had a major influence on medical dispute and
litigation. The variables were selected according to the
questionnaire opinions of all the plastic surgeons involved
in the study. The variables for analyses included the
following:
Patients’ Characteristics
1. Demographics including age, level of education, and
marital status.
Patient’s help-seeking behaviors2.
a. The reason for choosing a particular physician
(e.g., recommendation by family members and
friends, the physician’s fame, random selection).
Source of medical payment (e.g., loans, borrowed
money, or credit card payment).
Medical dispute records (e.g., any previous record
of medical dispute/litigation or whether the
patients eventually sued their plastic surgeons).
b.
c.
3. Medical history of the patients
a. The types of surgical procedures that caused the
dispute were grouped as general operations (e.g.,
liposuction and augmentation mammaplasty) or
local anesthesia (e.g., blepharoplasty and rhino-
plasty) as a way to reflect the complexity of the
procedure.
The history of plastic surgery detailed whether the
patients had three or more cosmetic operations in
different medical institutions.
The history of psychiatric diagnoses such as
bipolar disorder, borderline personality disorder,
and insomnia was described. The records were
obtained from patients’ self-report of psychiatric
clinic visits or from medical records.
b.
c.
Surgeons’ Characteristics
1. Surgeons’ seniority. A senior surgeon is defined as a
surgeon with surgical experience longer than 5 years.
Surgeons’ previous experience with medical litigation. 2.
3. Whether the surgeons have medical malpractice
insurance or not.
Statistical Analysis
Chi-square testing was used to evaluate the association
between the hospital and patient characteristics. Multiple
logistic regression analysis was used to determine which
patient variables significantly affected the odds of medical
litigation. The odds ratio value was adopted to evaluate the
strength of correlation, and the significance level was set at
0.05.
Results
The incidence of medical disputes was 0.53% for the hos-
pitalsand0.73%fortheclinics,andthatofmedicallitigation
was respectively 0.09 and 0.16%. The mean age of the
patientswithmedicaldisputeswas35.76 ± 7.05 yearsatthe
hospitals and 35.29 ± 7.99 years at the clinics. The patients
were mainly in the middle-age group.
The number of medical disputes and litigations showed
a declining trend for both the hospitals and the clinics
(Fig. 2). The occurrence of disputes in the first 5 years of a
surgeon’s practice was 76.2% in the hospitals and 80.3% in
the clinics.
The characteristics of the patients with medical disputes
are listed in Table 1. In general, the Chi-square test showed
that most patients with a medical dispute had the following
characteristics (p\0.05):
Patient factors age older than 30 years, divorce or
marriage status, experience of surgery under general
anesthesia, no money borrowed using credit card or bank
Fig. 2 Number of medical disputes and litigation cases by medical
institution, 2001–2009
766 Aesth Plast Surg (2011) 35:764–772
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Table 1 Characteristics of patients with medical disputes in different medical institutions
VariableHospital
(n = 17)
n (%)
Clinic
(n = 27)
n (%)
p Valuea
Total
(n = 44)
n (%)
p Valueb
Patients’ characteristics
Age (years)0.46
\0.001*
B30
[30
Marital status
3 (17.6)2 (7.4) 5 (11.4)
14 (82.4) 25 (92.6)39 (88.6)
0.72
\0.001*
Divorced6 (35.3) 12 (44.4)18 (40.9)
Married 7 (41.2) 11 (40.7)18 (40.9)
Never married 4 (23.5)4 (14.9)8 (18.2)
Level of education0.12 0.763
Under junior college11 (64.7) 10 (37.1)21 (47.7)
Junior college and above6 (35.3) 17 (62.9)23 (52.3)
Anesthesia type during surgery0.54
\0.001*
Local anesthesia 4 (23.5)5 (18.5) 9 (20.5)
General anesthesia13 (76.5) 22 (81.5)35 (79.5)
History of psychological stress
or psychiatric clinic visit
0.23 0.228
Yes 8 (47.1) 18 (66.7) 26 (59.1)
No 9 (52.9) 9 (33.3)18 (40.9)
Information factor (had heard about
their doctor before seeking
the operation)
0.22 0.303
Yes 10 (58.8)10 (37.1)20 (45.5)
No7 (41.2) 17 (62.9)14 (54.5)
Economic stress (borrowed money
to pay for their surgery)
0.99 0.007*
Yes 5 (29.4) 8 (29.6) 13 (29.5)
No12 (70.6)19 (70.4) 31 (70.5)
History of at least three previous
cosmetic operation experiences
0.20 0.070
Yes 4 (23.5) 12 (44.4)16 (36.4)
No 13 (76.5) 15 (55.6)28 (63.6)
History of medical dispute/litigation0.77
\0.001*
Yes 1 (5.9) 3 (11.1) 4 (9.1)
No16 (94.1) 24 (88.9)40 (90.9)
Finally sued the plastic surgeons 0.57
\0.001*
Yes 3 (17.6)6 (22.2)9 (20.5)
No14 (82.4)21 (77.8)35 (79.5)
Surgeons’ characteristics
Surgeons’ seniority0.74 0.003*
Seniority 4 (23.5) 8 (29.6) 12 (27.3)
No seniority13 (76.5) 19 (70.4) 32 (72.7)
Experience with medical litigation0.46
\0.001*
Yes 2 (11.8)6 (22.2)8 (18.2)
No15 (88.2)21 (77.8)36 (81.8)
Aesth Plast Surg (2011) 35:764–772 767
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loan, a history of medical litigation, and eventually no
suit against the plastic surgeon.
Surgeon factors seniority less than 5 years and no
medical malpractice insurance or experience with med-
ical litigation.
The characteristics in the two medical institution groups
(hospitals and clinics) were statistically matched.
Divorced patients accounted for 35.5% of the hospital
patients and 44.4 % of the clinic patients. Relatively few
patients were single. The anesthesia type was mainly
general: 76.5% of the anesthesia at the hospitals and 81.5%
of the anesthesia at the clinics (Fig. 3). Patients with psy-
chological problems comprised 47.1% of the hospital
patients and 66.7% of the clinic patients, with insomnia
as the most common problem. The education level was
mainly below junior college (64.7% of the hospital
patients). Before the procedure, 41.2% of the hospital
patients and 62.9% of the clinic patients had never heard of
their physicians. Most of the patients did obtain loans or
borrowed money to cover their medical expenses: 70.6% of
the hospital patients and 70.4% of the clinic patients.
Only 24.5% of the hospital patients had a rich history of
cosmetic operations, whereas 55.6% of clinic patients had
an extensive cosmetic surgery history. According to the
records, almost all of the patients had no history of medical
disputes: 94.1% of the hospital patients and 88.9% for the
clinic patients. Among the hospital patients 17.6% even-
tually sued their plastic surgeons, whereas 22.2% of the
clinic patients eventually did the same.
Furthermore, the results of multiple regression analysis
showed that divorce (odds ratio [OR], 10.67; 95% confi-
dence interval [CI], 1.20–94.73) and an education level
below junior college (OR, 9.33; 95% CI, 1.01–86.36) were
two factors significantly associated with patients entering
into litigation. In contrast, there was no statistical corre-
lation between surgeon factors and medical litigation
(Table 2).
Discussion
Writings on medical responsibility can be traced to 2030
B.C. in the Code of Hammurabi [13, 14]. Ancient wisdom
emphasized specialization by physicians, who were them-
selves to blame if an error was made. Scientific analyses
however have shown that 37% of closed malpractice
claims did not involve medical errors [15]. Another study
also showed that only 17% of the patients who filed claims
actually experienced an injury due to negligence [16].
Despite the advances in modern medicine, medical
malpractice cases under the transparency and complexities
of medicolegal systems have shown no signs of decreasing,
not only in Taiwan but also worldwide. The high-risk
specialties in Taiwan are obstetrics and gynecology,
anesthesiology, and surgery [1, 2, 17]. Plastic surgery
ranked fourth in medical malpractice cases, at approxi-
mately 9.6%. Physicians in these specialties have respon-
ded by refusing or avoiding high-risk patients, by retiring
early, and by eliminating high-risk operations [18–21].
Medical disputes obviously outnumber medical mal-
practice lawsuits in plastic surgery. The medical disputes
generally fall into the following categories compared with
other specialties: (1) claims related primarily to surgery,
not diagnosis, (2) claims related to the subjective outcome,
and (3) claims related to the medical service and attitude.
In rare cases, the claims relate to adverse reactions to
Fig. 3 Distribution of operation type related to medical litigation in
the hospital and the clinic
Table 1 continued
Variable Hospital
(n = 17)
n (%)
Clinic
(n = 27)
n (%)
p Valuea
Total
(n = 44)
n (%)
p Valueb
Medical insurance 0.52
\0.001*
Yes 0 (0)2 (7.4) 2 (4.5)
No 17 (100) 25 (92.6)42 (95.5)
aComparison of the characteristics of patients in the two medical institutions
bStatistical analysis of the specific factor in whole population
* p\0.05
768 Aesth Plast Surg (2011) 35:764–772
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anesthesia, injuries at the operation site, or lack of
informed consent [22]. With people gradually starting to
claim that their medical rights are similar to their consumer
rights, all medical specialties should pay more attention to
medical disputes in plastic surgery instead of looking only
at medical malpractice, as in the past.
In our study, the characteristics of most patients
engaging in medical disputes, which occur mainly in the
first 5 years of a surgeon’s practice, were age older than
30 years, divorce or marriage status, experience of surgery
under general anesthesia, no economic stress, history of
medical litigation, and no eventual suit against the sur-
geons. First, patients with medical disputes tended to be
female patients 30–40 years of age in both the hospitals
and the clinics. Middle-aged females who are not single
evidently know how to assert their rights. Age older than
Table 2 Multiple logistic
regression analysis of patients
entering medical litigation
(lawsuits)
* p\0.05
Variable OR (95% CI)
p Value
Medical institution type0.72
Hospital1
Clinic 1.33 (0.29–6.23)
Age (years) 0.82
B30
[30
Marital status
1
3.99 (0.41–39.17)
0.58
Divorced1 0.04*
Married 2.29 (0.12–41.99)
Never married 9.33 (1.01–86.36)
Level of education0.03*
Under junior college1
Junior college and above10.67 (1.20–97.74)
Anesthesia type during surgery0.92
Local anesthesia1
General anesthesia0.15 (0.06–21.95)
History of psychological stress or
psychiatric clinic visit
0.07
Yes1
No7.56 (0.85–66.97)
Information factor (had heard about their
doctor before seeking the operation)
0.13
Yes1
No 0.27 (0.05–1.49)
Economic stress (borrowed money
to pay for their surgery)
0.78
Yes1
No 1.25 (0.26–5.99)
History of at least three previous cosmetic
operation experiences
0.57
Yes1
No0.65 (0.15–2.89)
Surgeons’ seniority0.65
Seniority1
No seniority1.44 (0.29–7.01)
Experience with medical litigation0.73
Yes1
No 0.72 (0.12–4.38)
Medical insurance0.91
Yes1
No1.42 (3.16–23.5)
Aesth Plast Surg (2011) 35:764–772769
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30 years was the main feature of patients for medical dis-
pute (p\0.001) but not litigation (OR, 3.99; 95% CI,
0.41–39.17). Good communication or other efforts may
halt the transition from medical dispute to litigation.
Second, as demonstrated by Fig. 2, the number of
medical disputes decreased significantly as time increased.
The chances of medical litigation remained low with good
control. It is encouraging to find that medical disputes
experienced by surgeons themselves or learning from other
colleagues can decrease the possibility of medical disputes.
Our study showed that the nationwide trend toward
increased medical malpractice cases may be reversible if
preventive efforts are drafted correctly in the future.
Third, the characteristics of the hospital and clinic
patients with medical disputes all matched without any
statistically significant difference. Patients in different
medical institutions therefore shared similar traits regard-
less of location, medical institution type, or practice style.
Even for the patients who eventually entered into lawsuits,
no significant difference between the hospitals and the
clinics was found (OR, 1.33; 95% CI, 0.29–6.23). Pre-
ventive strategies may therefore work equally well in both
types of medical institutions.
Fourth, for medical disputes, there was no statistically
significant difference between whether the patient had
heard about their plastic surgeons before seeking the
operation or not (p = 0.303). Our result meant that to date,
the information factor has not contributed significantly to
medical disputes. Clinic patients may thus have no
knowledge of the physicians before entering the clinic.
They may be following a more aggressive marketing policy
through advertisements or other channels. The reasons may
be good preoperative communication, detailed informed
consent, and the service provided by the clinic [23].
Fifth, our study analyzed the influence of stress on the
patients originating from psychological or marital status,
operation, and economic problems. Of those who entered
medical litigation, only patients with divorced marital
status had statistical significance (OR, 9.33; 95% CI,
1.01–86.36). Divorced or married status also was a key
feature of patients with medical disputes. Marital stress
therefore appeared to have a significant influence on the
female patients. Psychological stress, however, did not
significantly induce medical disputes (p = 0.228) or liti-
gations (OR, 7.56; 95% CI, 0.85–66.97), although a high
percentage of patients in medical litigations had a history
of psychological stress. Previous studies focused mainly on
how to increase patient safety and care by the physicians to
decrease medical malpractice lawsuits but concluded that
this was insufficient [24]. If the patient cannot deal with the
stress after the surgery, then when this is combined with the
hardship of a difficult relationship, divorce, or other psy-
chological issues, the odds of an unfavorable cosmetic
operation turning into a medical dispute become relatively
high [25]. Logically speaking, patients with bipolar disor-
der, borderline personality disorder, and particularly,
insomnia may project their emotional stressors onto their
appearance and seek treatment through plastic surgery.
Based on our results, insomnia is the most prevalent
problem among patients with medical disputes.
Sixth, economic stress did not significantly influence
the occurrence of medical litigation (OR, 1.25; 95% CI,
0.26–5.99). Interestingly, most patients with medical dis-
putes had not borrowed money or taken out a loan
(p = 0.007). Economic stress is not a strong factor in
medical disputes or litigation. Moreover, the patients
receiving major operations under general anesthesia were
significantly more likely to have a medical dispute
(p = 0.001) but not medical litigation (OR, 0.15; 95% CI,
0.06–21.95). Economic and operation stress factors there-
fore have no significant influence on the occurrence of
medical litigation.
Seventh, the level of education did not have a significant
influence on medical disputes (p = 0.763) but was a sta-
tistically significant factor for litigation (OR, 10.67; 95%
CI, 1.20–97.74). This serves as a reminder to us that we
should make more efforts to improve pre- and postopera-
tive communication for people with a relatively low level
of education.
Finally, we looked at the factors related to the experi-
ence in both the patients and the surgeons. Our results
showed that medical disputes normally occur during the
first few years of a physician’s practice, when the physician
still is relatively young in the field. The seniority of phy-
sicians had a significant influence on patients with medical
disputes (p = 0.001) but not on the probability of lawsuits
(OR, 1.44, 95% CI, 0.29–7.01). This fact means that it still
is difficult to avoid having a ‘‘specific’’ part of the popu-
lation with medical disputes sue the surgeon despite the
best efforts. Young physicians may have inadequate sur-
gical skills, ineffective communication strategies (espe-
cially during a medical dispute), no experience with
medical litigation, and insufficient skill in identifying
appropriate patients. All these make medical disputes more
likely [26].
Interestingly, almost all the surgeons with medical dis-
putes in Taiwan have no medical malpractice insurance. A
relatively low final lawsuit rate was noted in this study, and
this may be why surgeons elect not to have insurance.
Surgeons in Taiwan should begin to value the importance
of medical malpractice insurance because 51.9% of plastic
surgeons older than 50 years in the United States have
considered rising malpractice costs as a key factor in their
decision to retire [27]. On the other hand, patients with no
history of medical dispute or litigation still may become
involved in a medical dispute (p = 0.001) but not litigation
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(OR, 0.72; 95% CI, 0.12–4.38). Patients who have received
numerous cosmetic operations also may have the chance to
become involved in medical disputes and litigation.
Some limitations of this study should be taken into
consideration. A larger sample should be used in future
studies to provide a look at the characteristics of patients
who have not produced a medical dispute. In the future, we
should consider the factors related to management meth-
ods. Whenever a medical dispute occurs, the correct
response is to deal with it immediately instead of running
away from it. The priority should be on improving the
physician–patient relationship and patient safety. Physi-
cians should maintain their professionalism and sincerity
and respect their patients’ final decision even when faced
with complaints or arguments [28]. Medical institutions
should establish a standard contingency plan to lower their
incidence or hopefully prevent them from occurring alto-
gether (Fig. 4). Senior physicians also should share their
experiences to educate younger colleagues and decrease
the incidence of medical disputes in the system because a
student’s choice of surgical career depends heavily on his
or her role model [29].
In conclusion, it may be possible to prevent lawsuits
from occurring if preoperative communication is adequate
and key factors related to patient safety and characteristics
are identified and handled properly. Our study also pro-
vides several key factors for expert testimony to use in
countries with an inquisitorial law system. Plastic surgeons
working toward minimizing medical disputes and litigation
can take our results into account.
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