Background: Variables affecting malpractice rates are important to the medical profession. Empirical data on trends in malpractice payments and settlements from anesthesiologists, surgeons, pediatricians and psychiatrists over an eight-year period are publicly available for analysis. Methods: A literature search of PubMed and Index Medicus was conducted for the years from 1985 to 2013 using the search terms National Practitioner Data Bank, physicians, and malpractice. Data from the National Practitioner Data Bank (NPDB) calculated proxy variables for the different specialties for the years 2004 to 2011 for frequency of malpractice settlements and mean settlement per incident. Results: The literature review revealed both systemic and individual factors related to the incidence of malpractice lawsuits and settlements. Systemic factors included the “fault” system of malpractice and high and low risk specialties. A recurring theme of individual factors was failure to make the correct diagnosis. The NPDB rates of malpractice and payments over the study period declined for all specialties. The trend in improvements differed somewhat by specialty. Conclusions: Although individual factors might be amenable to improvement by the individual physician, systemic factors are beyond the control of the individual practitioner and would need to be managed on a public policy basis.