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Sports-related spinal injuries can be catastrophic in nature. Athletes competing in collision sports (eg, football) may be particularly prone to injury given the high-impact nature of these activities. Due to the oftentimes profound impact of sports-related spinal injuries on health and quality-of-life, they are also associated with a substantial risk of litigation. However, no study to date has assessed litigation risks associated with sports-related spinal injuries. A better understanding of the risk factors surrounding these legal claims may provide insights into injury prevention and other strategies to minimize litigation risks. In addition, it may allow the spine surgeon to better recognize the health, socioeconomic, and legal challenges faced by this patient population. To provide a comprehensive assessment of reported legal claims involving sports-related spinal injuries, including a comparative analysis of legal outcomes between collision and non-collision sports. To discuss strategies to prevent sports-related spinal injuries and minimize litigation risks. Retrospective review. Athletes experiencing spinal injuries during sports. Outcomes included verdict outcome (defendant vs. plaintiff), legal claims, injuries sustained, clinical symptoms, and award payouts. The legal research database Westlaw Edge (Thomson Reuters) was queried for legal claims brought in the United States from 1950 to 2021 involving sports-related spinal injuries. Verdict or settlement outcomes were collected as well as award payouts, time to case closure, case year, and case location. Demographic data, including type of sport (ie collision vs. non-collision sport) and level of play were obtained. Legal claims, spinal injuries sustained, and clinical symptoms were also extracted. Furthermore, the nature of injury, injured spinal region, and treatment pursued were collected. Descriptive statistics were reported for all cases and independent-samples t -tests and chi-square tests were used to compare differences between collision and non-collision sports. Of the 840 cases identified on initial search, 78 met our criteria for in-depth analysis. This yielded 62% (n=48) defendant verdicts, 32% (n=25) plaintiff verdicts, and 6% (n=5) settlements, with a median inflation-adjusted award of $780,000 (range: $5,480–$21,585,000) for all cases. The most common legal claim was negligent supervision (n=38, 46%), followed by premises liability (n=23, 28%), and workers' compensation/no fault litigation (n=10, 12%). The most common injuries sustained were vertebral fractures (n=34, 44%) followed by disc herniation (n=14, 18%). Most cases resulted in catastrophic neurological injury (n=37, 49%), either paraplegia (n=6, 8%) or quadriplegia (n=31, 41%), followed by chronic/refractory pain (n=32, 43%). Non-collision sport cases had a higher percentage of premises liability claims (41% vs. 11%, p=.006) and alleged chronic/refractory pain (53% vs. 28%, p=.04). Conversely, collision sport cases had a higher proportion of workers' compensation/no fault litigation (23% vs. 4%, p=.03) and cases involving disc herniation (29% vs. 9%, respectively; p=.04). Sports-related spinal injuries are associated with multiple and complex health, socioeconomic, and legal consequences, with median inflation-adjusted award payouts nearing $800,000 per case. In our cohort, the most commonly cited legal claims were negligent supervision and premises liability, emphasizing the need for prevention guidelines for safe sports practice, especially in non-professional settings. Cases involving athletes participating in non-collision sports were significantly associated with claims citing chronic/refractory pain, highlighting the importance of long-term care in severely injured athletes. [ABSTRACT FROM AUTHOR]

Background Context: In the U.S., medical malpractice litigation is associated with significant financial costs and often leads to the practice of defensive medicine. Among medical subspecialities, spine surgery is disproportionately impacted by malpractice claims.Purpose: To provide a comprehensive assessment of reported malpractice litigation claims involving elective lumbar spinal fusion (LSF) surgery during the modern era of spine surgery instrumentation in the U.S., to identify factors associated with verdict outcomes, and to compare malpractice claims characteristics between different approaches for LSF.Study Design/setting: A retrospective review.Patient Sample: Patients undergoing elective lumbar spinal fusion surgery.Outcome Measures: The primary outcome measure was verdict outcome (defendant vs. plaintiff verdict). Secondary outcome measures included alleged malpractice, injury/damage claimed, and award payouts.Methods: The Westlaw legal database (Thomson Reuters, New York, NY, USA) was queried for verdict and settlement reports pertaining to elective LSF cases from 1970 to 2021. Data were collected regarding patient demographics, surgeon specialty, fellowship training, state/region, procedure, institutional setting (academic vs. community hospital), alleged malpractice, injury sustained, case outcomes, and monetary award.Results: A total of 310 cases were identified, yielding 67% (n=181) defendant and 24% (n=65) plaintiff verdicts, with 9% (n=26) settlements. Neurosurgeons and orthopedic spine surgeons were equally named as the defendant (45% vs. 51% respectively, p=0.59). When adjusted for inflation, the median final award for plaintiff verdicts was $1,241,286 (95% CI: $884,850-$2,311,706) while the median settlement award was $925,000 (95% CI: $574,800-$1,787,130), with no stastistically significant differences between verdict and reported settlement payouts (p=0.49). The Northeast region displayed significantly higher award payouts compared to other U.S. regions (p=0.02). There were no associations in awards outcomes when comparing alleged malpractice, alleged injuries/damages, institutional setting, surgical procedures, and surgeon specialty or fellowship training. The most common claims were intraoperative error (28%, n=107) followed by failure to obtain informed consent (24%, n=94). In the analyzed cohort, the most common injuries leading to litigation were refractory pain and suffering (37%, n=149) followed by permanent neurological deficits (26%, n=106). There were no differences in alleged malpractice or injury sustained between cases in which the outcome was favorable to defendant versus plaintiff. Anterior lumbar interbody fusion (ALIF) cases were 2.75 times more likely to be cited for excessive or inappropriate surgery (OR: 2.75 [95% CI: 1.14, 6.86], p=0.02) when compared to posterior surgical approaches.Conclusion: The results of our analysis of reported claims suggest that medical malpractice litigation involving elective LSF is associated with jury verdicts over $1 million per case, with the most common alleged malpractice being intraoperative error and failure to obtain informed consent. Surgeon specialty, fellowship training, procedure type, and institution type were not associated with greater litigation risks; however, ALIF surgery had a significantly higher risk of involving claims of excessive or inappropriate surgery compared to posterior approaches for lumbar fusion. In addition, claims were significantly higher in the Northeast compared to other U.S. regions. Efforts to improve patient education through shared-decision making and proactive strategies to avoid, detect, and mitigate intra-operative procedural errors may decrease the risk of litigation in elective LSF. [ABSTRACT FROM AUTHOR]

Thoracic outlet syndrome (TOS) is most often referred to vascular surgeons. However, there is a lack of understanding of the malpractice cases involving TOS. The goal of this study is to better understand the medicolegal landscape related to the care of TOS. The Westlaw Edge AI-powered proprietary system was retrospectively reviewed for malpractice cases involving TOS. A Boolean search strategy was used to identify target cases under the case category of "Jury Verdicts & Settlements" for all state and federal jurisdictions from 1970 to September 2020. The settled case was described but not included in the statistical analysis. Descriptive statistics were used to report our findings, and when appropriate. The P ≤.05 decision rule was established a priori as the null hypothesis rejection criterion to determine associations between jury verdicts outcomes and state's tort reform status. In this study, 39 cases were identified and met the study's inclusion criteria from the entire Westlaw Edge database. Among plaintiffs who disclosed age and/or gender, median age was 35.0 years with a female majority (67.6%). Cases involving TOS were noted to be steadily decreasing since the mid-1990s. The cases were unevenly spread across 18 states, with the highest number of cases (14, 35.9%) from California and the second highest (4, 10.3%) from Pennsylvania. A similar uneven distribution was seen among U.S. census regions, in which the West had the highest cases (39.5%). The study revealed that more cases were brought to trials in tort reform states (26, 68.4%) than in non-tort reform states (12, 31.6%). A total of 24 of 39 (61.5%) plaintiffs had one specific claim, which resulted in their economic and noneconomic damages. Negligent operation and treatment complication represented an overwhelming majority of claims brought by 38 of 39 plaintiffs (97.4%). Misdiagnosis and lack of informed consent were both brought nine times (23.1%) by the group. Intraoperative nerve injury (20 patients, 51.3%) was the most commonly reported complication. Excluding one case with a settlement of $965,000, 30 of 38 (78.9%) cases went to trials and received defense verdicts. Eight cases (20.5%) were found in favor of plaintiffs with a median payout of $725,581. This study highlighted higher than average payouts to plaintiffs and risk factors that may result in malpractice lawsuits for surgeons undertaking TOS treatment. Future studies are needed to further clarify the relationships between tort reform and outcomes of malpractice cases involving TOS. [ABSTRACT FROM AUTHOR]

Neurosurgeons, especially spine surgeons, have the highest risk of facing a malpractice claim. Average verdicts in spine surgery litigation has been shown to be over USD $1 million/case. This systematic review aimed to clarify the impact of tort reforms on neurosurgical health care environments across the United States, including patient outcomes, practice of defensive medicine, and physician supply aims. A systematic literature search was performed using PubMed, Embase, Cochrane, and Web of Science databases until May 13, 2022. Study quality was assessed using the quality assessment tool for studies reporting prevalence data. Five studies (all rated as good quality) were included. Two studies found that in higher-risk state malpractice environments, risk of postoperative complications was higher and odds of nonhome discharge were larger (odds ratio 1.1169, 95% confidence interval 1.139–1.200). One study found that neurosurgeons reported practice of defensive medicine by ordering more imaging in a higher-risk environment, while this was not shown in a study examining imaging rates in different medicolegal environments. One study observed that noneconomic damage caps were associated with a 3.9% increase of physician supply in high-risk specialties. There was a suggestive association between tort reforms and less practice of defensive medicine among neurosurgeons, improvement in postoperative outcomes in spinal fusion patients, and increase in physician supply. More elaborate studies on the medicolegal environment in neurosurgical practice are needed to give more insight on the current size of the problem that litigation presents in the United States and the effects tort reforms have on neurosurgical health care environments. [ABSTRACT FROM AUTHOR]

Purpose: Defensive medicine, broadly defined as medical practices that protect physicians from malpractice lawsuits without providing benefits to patients, can lead to wasteful use of health care resources and higher cost. Although physicians cite malpractice liability as an important factor driving their decisions to order imaging tests, little research has been done to examine the systematic impact of liability pressure on overall imaging. The authors examined the extent to which radiography use is influenced by malpractice liability pressure among office-based physicians.Methods: Using National Ambulatory Medical Care Survey data from 1999 to 2010, the authors used multivariate difference-in-difference logistic regression to examine the effects of different types of state tort reforms on the probability of radiography orders by primary care physicians (PCPs) and specialists.Results: The probability that a PCP ordered radiography decreased when states enacted permanent caps on noneconomic damages (-1.0%, P < .01), periodic payment reforms (-1.6%, P < .05), and the total number of tort reforms (-0.5%, P < .05). Specialist physicians were responsive to two reforms: caps on punitive damages (-6.1%, P < .01) and the total number of medical tort laws (-1.2%, P < .01). The passage of new indirect reforms was found to reduce radiography orders for PCPs (-1.8%, P < .05), and the repeal of indirect reforms was found to increase radiography orders for specialists (+3.4%, P < .01).Conclusions: State tort reform seems to reduce physicians' ordering of radiography. This analysis also suggests that reforms that make it harder to sue physicians have a stronger impact than reforms that directly reduce physicians' malpractice claim payments. [ABSTRACT FROM AUTHOR]

Does tort reform reduce defensive medicine and thus healthcare spending? Several (though not all) prior studies, using a difference-in-differences (DiD) approach, find lower Medicare spending for hospital care after states adopt caps on non-economic or total damages ("damage caps"), during the "second" reform wave of the mid-1980s. We re-examine this issue in several ways. We study the nine states that adopted caps during the "third reform wave," from 2002 to 2005. We find that damage caps have no significant impact on Medicare Part A spending, but predict roughly 4% higher Medicare Part B spending. We then revisit the 1980s caps, and find no evidence of a post-adoption drop (or rise) in spending for these caps. [ABSTRACT FROM AUTHOR]

The U.S. tort system has experienced various reforms over the last three decades. While there is an extensive literature on the consequences of these reforms, very little is known about their determinants. In this study, we investigate the role of party politics in the reform process across U.S. states. In order to test whether any party effect goes beyond voter preferences, we apply the idea behind regression discontinuity studies based on close electoral outcomes to semi-parametric proportional hazards models. We find that in states with close election outcomes, a narrow Republican majority in the lower house is associated with a 50 to 150% higher risk of tort reform enactment compared to a narrow Democratic majority. Our results indicate that party politics plays a role in tort reforms over and above potential underlying preferences in the constituency. [ABSTRACT FROM AUTHOR]

Purpose: A widespread concern among physicians is that fear of medical malpractice liability may affect their decisions for diagnostic imaging orders. The purpose of this article is to synthesize evidence regarding the defensive use of imaging services.Methods: A literature search was conducted using a number of databases. The review included peer-reviewed publications that studied the link between physician orders of imaging tests and malpractice liability pressure.Results: We identified 13 peer-reviewed studies conducted in the United States. Five of the studies reported physician assessments of the role of defensive medicine in imaging-order decisions; five assessed the association between physicians' liability risk and imaging ordering, and three assessed the impact of liability risk on imaging ordering at the state level. Although the belief that medical liability risk could influence decisions is highly prevalent among physicians, findings are mixed regarding the impact of liability risk on imaging orders at both the state and physician level.Conclusions: Inconclusive evidence suggests that physician ordering of imaging tests is affected by malpractice liability risk. Further research is needed to disentangle defensive medicine from other reasons for inefficient use of imaging. [ABSTRACT FROM AUTHOR]

This paper analyzes the effect of non-economic damage caps on the treatment intensity of heart attack victims. We focus on whether a patient receives a major intervention in the form of either a coronary artery by-pass or angioplasty. We find strong evidence that treatment intensity declines after a cap on non-economic damages. The probability of receiving a major intervention in the form of either an angioplasty or bypass declines by 1.25–2 percentage points after non-economic damage caps are enacted, and this effect is larger a year or two after reform. However, we also find clear evidence of substitution between major interventions. When doctors have discretion to perform a by-pass and patients have insurance coverage, caps on non-economic damages increase the probability that a by-pass is performed. The effect of non-economic damage caps on costs is not always statistically significant, but in models with state-specific trends, total costs decline by as much as four percent. We conclude that tort reform reduces treatment intensity overall, even though it changes the mix of treatments. Using the Center for Disease Control's Vital Statistics data, we find that tort reform is not associated with an increase in mortality from coronary heart disease; if anything, mortality declines. [ABSTRACT FROM AUTHOR]

Purpose To determine whether chargemaster (a list of prices for common services and procedures set by individual hospitals) rates for diagnostic imaging were lower in states that cap awards for noneconomic damages (NED) than states with unlimited awards for medical negligence.Methods We analyzed 2011 chargemaster data from the Centers for Medicare & Medicaid, pertaining to 6 ambulatory patient classifications specific to imaging. The dataset includes outpatient imaging facilities and hospitals in 49 states and the District of Columbia. The association between caps on NED and chargemaster rates for imaging in a sample of 15,218 data points was analyzed using linear regression and two-sample t tests assuming unequal variances.Results In states that cap NED, the chargemaster rates were higher for the following modalities: Level II Echocardiogram without Contrast (mean charges: $2,015.60 versus $1,884.81, P = .0018); Level II Cardiac Imaging ($4,670.25 versus $4,398.58, P = .002); MRI & Magnetic Resonance Angiography without Contrast ($2,654.31 versus $2,526.74, P = .002); and Level III Diagnostic and Screening Ultrasound ($1,073.31 versus $1,027.32, P = .037). High charge-to-payment ratios were associated with states with the highest charges. There was a positive correlation between number of outpatient centers in the state and the average chargemaster rates for the state (mean chargemaster rate = 1727 + 0.79*Number of Outpatient Centers; R-squared = 0.23, P = .0004).Conclusions Chargemaster rates for select imaging services are not lower in states that have capped NED. [ABSTRACT FROM AUTHOR]

We examine whether caps on noneconomic damages in medical malpractice cases affect in-hospital patient safety. We use Patient Safety Indicators - measures of adverse events - as proxies for safety. In difference-in-differences ("DiD") analyses of five states that adopt caps during 2003-2005, we find that multiple measures of non-fatal patient safety events worsen after cap adoption relative to control states. DiD inference can be unreliable with a small number of treated units. We therefore develop a randomization inference-based test for inference with few treated units but multiple correlated outcomes and confirm the robustness of our results with this nonparametric approach. We also provide evidence that the decline in patient safety is unlikely to be driven by patient selection. [ABSTRACT FROM AUTHOR]

Introduction: Texas implemented comprehensive tort reform in 2003. We hypothesized that tort reform was followed by a significant increase of physicians practicing in Texas. Methods: To test this hypothesis, we compared the rate of physician growth prior to and following tort reform, and the number of licensed physicians and physicians per 100,000. Results: Comparing before and after tort reform, the rate of increase in Texas physicians per 100,000 population increased significantly ( p < 0.01). From 2002 to 2012, the Texas population increased 21 %. The number of actively practicing Texas physicians increased by 15,611 a 44 % increase (46 % metro areas vs. 9 % non-metro areas), an increase of 30 physicians per 100,000 population ( p < 0.01). Non-metropolitan Texas had a net increase of 215 physicians; however, there was no change in the number of physicians per 100,000. Examining the data by trauma service areas (TSAs), 20 of 22 TSAs had an increase in both number of physicians and physicians per capita, five greater than 50 %. Conclusions: The post-tort reform period in Texas was associated with a significantly increased growth rate of physicians relative to the Texas population. Tort reform, as implemented in Texas, provides a needed framework for improving access to health care. [ABSTRACT FROM AUTHOR]

Radiology liability claims data are reviewed to explore the risk for suit and adverse judgments or settlements among radiologists, assess high-risk imaging conditions, and identify high-risk practice issues. Possible medical malpractice tort reform options are reviewed. [ABSTRACT FROM AUTHOR]

Abstract: Background: Emergency medicine, with its limited time for patient encounters, unpredictable flow, and lack of a continuing patient-physician relationship, is a particularly high-risk field with regards to the issue of medical liability. There have been limited studies on the financial and time exposure emergency physicians face when confronted with a liability suit. Objectives: Provide practicing physicians with guidance as to what can be expected if they are confronted with a medical malpractice claim, and contribute to the literature as the issue of tort reform is debated. Methods: Retrospective study of all closed malpractice claims involving emergency physicians insured by the Illinois State Medical Inter-insurance Exchange covering the 10-year period 1995 to 2004. Results: Of 450 claims, there were 200 cases served. The median incident-to-close time was 45.5 months (interquartile range [IQR] 30.6–69.9). The median expense per claim served was $14,091 (IQR $3448–$44,363); 19.5% of cases resulted in an indemnity with a median of $220,000 (IQR $117,500–$700,000). Cases in which an indemnity was eventually made tended to be filed 7.7 months faster ( p = 0.065) and took 14.1 months longer to close ( p < 0.05). In cases with a payout of ≥ $1,000,000, 80% were in the ≤ 1-year age group. Conclusion: In this study, emergency physicians with malpractice suits can expect resolution of the case to take over 45 months after an alleged incident, and their malpractice insurer will incur over $14,000 in expenses regardless of the suit outcome. Cases involving patients aged ≤ 1 year may incur higher indemnity payments. [Copyright &y& Elsevier]

For nursing home residents with advanced dementia, very little evidence is available to show clinical benefit from enteral tube feeding. Although no randomized clinical trials have been done, considerable evidence from studies of weaker design strongly suggest that tube feeding does not reduce the risks of death, aspiration pneumonia, pressure ulcers, other infections, or poor functional outcome. Nationally, however, utilization is high and highly variable. System-wide incentives favor use of tube feeding, and may influence substitute decision-makers, bedside clinicians, gastroenterologists, and administrators regardless of patient preferences or putative medical indications. Underlying the widespread use of this marginally effective therapy is a basic misunderstanding about malnutrition and about aspiration pneumonia. The face value of tube feeding is strong indeed. In addition to the general faith in intervention, the impulse to “do something” when things are going poorly, financial incentives favor tube feeding for gastroenterologists, hospitals, and nursing homes. The desire to avoid regulatory sanctions, bad publicity, and liability exposure creates a further incentive for nursing homes to provide tube feeding. Rational, evidence-based use of tube feeding in advanced dementia will depend fundamentally on improved education. Reimbursement schemes require significant modification to limit the irrational use of tube feeding. Nursing home regulations based more securely on scientific evidence would likely reduce nonbeneficial tube feeding, as would evidence-based tort reform. Quality improvement initiatives could create positive incentives. Realigning incentives in these ways could, we believe, improve the quality of care, quality of life, and safety of these vulnerable individuals, likely with reduced costs of care. [Copyright &y& Elsevier]

Patients, physicians, insurance companies, and legislators are expressing mounting concern in the area of malpractice insurance costs and its effect on the availability of health care. In 1986, the highest award in the history of medical-legal claims. $1,200,000, was paid. By 2001, the average award had increased to $3,500,000. In the late 1970s the California's Medical Injury Compensation Reform Act (MICRA) was passed. This article discusses the elements of this important legislation and its effects on the cost of medical malpractice in California. the anatomy and pathophysiology of a medical-legal claim, and the characteristics of excellent expert witnesses and suggests some important elements of a redesigned system of medical-jurisprudence. [ABSTRACT FROM AUTHOR]

The ACR Board of Chancellors commissioned a task force to investigate the issue of needed reforms in medical liability as it relates to the specialty of radiology. This article relates the task force deliberations and recommendations. [Copyright &y& Elsevier]

As described in the previous article in this series, the United States is in the midst of a medical liability insurance crisis. Research conducted in the wake of similar previous insurance environments has shown that only a fraction of patient injury as a result of negligent medical care is addressed by today’s tort malpractice system. This large reservoir of potential malpractice cases, coupled with the inevitable cycles of the economy and insurance markets, means that current action is mandatory to prevent another, even more serious crisis in the future. A variety of potential solutions have been proposed, including reform of the existing tort malpractice system, a no-fault compensation system, and so-called hybrid systems that combine tort and no-fault. These mechanisms should be evaluated in terms of three key factors: (1) the adequacy of compensation to injured patients, (2) the prevention of future medical injury, and (3) their overall cost and administrative feasibility. Whatever reform mechanism or combination of mechanisms is pursued should represent an improvement on today’s existing tort malpractice system. [Copyright &y& Elsevier]

Most medical malpractice cases are tried under the civil tort of negligence and are often triggered by adverse outcomes. These proceedings are aimed primarily at determining whether the conduct of a health care provider was reasonable. Such legal actions have mostly been subject to state jurisdiction. Increasingly, a number of factors are converging that are threatening the continued practice of medicine in some states and hence patients’ access to care. These include higher amounts of monetary damages awarded to successful plaintiffs, consequent rising malpractice premiums, and the threatened economic insolvency of medical liability insurance carriers as a result of the broader economic downturn. The result is a serious public health dilemma. The national scope of the problem has been considered a crisis, which has prompted unprecedented federal legislative proposals directed toward providing new and preemptive parameters for capitated noneconomic damages, restrictions on certain civil procedures affecting lawsuit outcomes, and methods for attorney compensation, which some states have either not previously addressed or found unconstitutional. A survey of different states’ problems and common issues should assist the reader in understanding the nature of the crisis and proposed solutions. [Copyright &y& Elsevier]

We analyze the tobacco industry's "tort reform" campaign in Louisiana, which marked its first takeover of a state tort reform coalition, and interpret the strategies using the Policy Dystopia Model. We searched internal tobacco industry documents in the UCSF Truth Tobacco Industry Documents Library and searched news archives of state and local periodicals between 1985 and 2000. Using alliances, the tobacco industry clandestinely secured legislation in 1988 limiting manufacturer liability for inherently dangerous products. The industry took over a coalition in 1992 to defend its gains, minimize its publicly visible role, and pursue policies it likely could not directly advocate for after Louisiana's government became more hostile to tort reform. The industry defended gains but failed to secure legislation eliminating liability for inherently dangerous products after its involvement was exposed. This case study expands the applicability of the Policy Dystopia Model. The industry passes laws harmful to the public interest by cloaking its involvement and motivations behind allies, front groups and generalized messaging. Exposing the industry's role can help public health advocates protect against pro-industry legislation. [ABSTRACT FROM AUTHOR]

Few issues elicit more emotion from physicians than medical malpractice. The very word “malpractice” implies guilt and immediately places the involved physician on the defensive. Defensive medicine adds 5% to 9% to the cost of medical care. Numerous solutions have been proposed, but special interests have blocked the implementation of these solutions in most states. Tort reform is necessary to control the escalation of medical costs. [Copyright &y& Elsevier]

We explore whether the composition of the physician workforce is impacted by the clinical standards imposed on physicians under medical liability rules. Specifically, we explore whether the proportion of non-surgeons practicing in a region decreases-and thus whether the proportion of surgeons increases-when liability standards are modified so as to expect that physicians practice more intensively. For these purposes, we draw on a quasi-experiment made possible by states shifting from local to national customs as the basis for setting liability standards. Using data from the Area Health Resource File from 1977 to 2005, we find that the rate of non-surgeons among practicing physicians decreases by 2-2.4 log points (or by 1.4-1.7 percentage points) following the adoption of national-standard laws in initially low surgery-rate regions-i.e., following a change in the law that effectively expects physicians to increase their use of surgical approaches. [ABSTRACT FROM AUTHOR]