These letters highlight the fact that medical malpractice is a complex process where simplistic descriptions or solutions always fall short. Dr. Yaes' concern that the number of claims is too many depends on one's perspective [1]. Malpractice claims vary greatly among specialties [2]. We agree with Dr. Oppenheimer that the fear of malpractice is a powerful force in U.S. medicine. The prevalence of "medical prostitution" and the possible deterrent effect of filing countersuits are unknown.

One aim of our study was to contrast malpractice perceptions with reality based on the experience of a physician-owned insurance company in New Jersey. We explicitly described how the company initially assesses physician defensibility. We concur with Dr. Posner and colleagues that assessing defensibility is difficult and subject to bias. Whether explicit or implicit standards are used for peer review, it must be recognized that some misclassification will occur [3]. Whether misclassification varies with specialty deserves further study. Our hypothesis to explain why 21% of cases initially classified as defensible resulted in payment, namely that these cases were probably misclassified as defensible, is being tested by studying those cases.

The alternative hypotheses proposed by Dr. Lagerquist show the anger that fuels the fires of an already emotionally charged topic. Our work and the work of others clearly show that exorbitant awards are rare [4] and that jury decisions are typically not arbitrary [5]. Furthermore, a physician-owned company will not condone and thereby promote "token settlements." No case can be settled without the written consent of the physician defendant.

One of our conclusions with which all seem to agree is that "neither the patient nor the physician is served by this extremely inefficient and costly process, which results in delayed payments to injured parties and casts a prolonged cloud over physicians." Tort reform is needed and requires knowledge about the strengths and weaknesses of the medical malpractice process. For example, although exorbitant rewards are rare, the financial and emotional impact to the physicians and insurers is profound.

Our article provides the reader with facts. Not surprisingly, proponents of various causes have used the same data to arrive at different conclusions. We believe that the interpretation and application of these facts should generate hypotheses to be carefully evaluated.