Dealing with malpractice risks One of the biggest reasons doctors cite for giving up nursing home practice is the fear of malpractice suits and the increasing cost of coverage. In a number of states—Texas and Florida are among the hardest hit—liability insurers have raised rates for nursing homes sharply, or even stopped writing policies. That has put pressure on nursing home medical directors, many of whom have traditionally been covered by the facilities' policies.

In a recent survey of its members, AMDA found that 25 percent reported difficulty obtaining or renewing their malpractice coverage in 2004. Of those, 42 percent complained that their premiums had risen too high, 31 percent said they'd been refused coverage, and 26 percent said that malpractice carriers in their area had stopped writing nursing home policies. As a result, some homes are now self-insured; others have gone bare.

Because of these coverage problems, 31 percent of medical directors claim they had to change the nature of their practice last year. Of those, 38 percent said they'd stopped providing some services; 37 percent had limited the number of patients they care for; 36 percent said they were more likely to refer complex cases in order to reduce their risk; and 14 percent had quit working as medical director of at least one home.

Another source of malpractice claims is the unreasonable expectations and demands of patients' families. "They'll show up maybe three or four times a year, typically on holidays," says Williams, "and they'll be distraught that Mom or Dad has declined, and somehow it's my fault."

Doctors who treat nursing home patients also face the risk of a suit alleging "elder abuse." If the patient's in pain, for example, a doctor who's overly cautious or overly generous about prescribing pain medication could be charged with elder abuse. "Every day," says Reznick, "we see newspaper or TV ads by plaintiffs' attorneys seeking cases of nursing home neglect or abuse."

Compared to malpractice suits, elder abuse claims can present greater legal dangers: While state laws vary, such claims may not be limited by caps on non-economic damages; they're more likely to result in punitive damages; and, worst of all, they may not be covered by your malpractice policy.

Despite such risks, there are ways to protect against liability claims for nursing home patients. As with any good office practice, the best defense is to carefully document all visits, treatments, tests, consultations, and medications. Richard Waltman is careful to avoid treating conditions he's not comfortable with. When a facility pushes for an intervention he considers unreasonable or unwarranted, he asks the staff to fax him their reasons for the treatment, including its benefits, risks, and cost. As he explains, "Writing that up forces them to think it through carefully."

Then there are all the phone calls Many doctors cite excessive phone calls as a major problem with nursing home practice. In addition to consuming a great deal of time, they're often unnecessary or about trivial matters—and they're not reimbursable. Richard Sagall, an FP who gave up private practice in Maine for an occupational medicine post in Philadelphia a few years ago, recalls the "seemingly endless phone calls" he used to get from nursing homes. "Those calls were driving me crazy until I came up with a plan for dealing with them," he says. It's a variation on Waltman's fax request.