Either a reasonable amount of money to compensate me for the risk, or a legally-tested waiver of the right to sue (which would cost the patient $0) would be acceptable to me. It would not have to be your suggested $10K (that seems way high). In this low risk scenario, a straight $250 would be adequate, but the patient could go to an urgent care center for his Rx for a lot less than that.

The patient wanted the convenience but he would have still hold you liable for missing a more serious condition. Plus, once you have a policy you have to be consistent in following that policy.

Why would a physician even consider prescribing anything other than say, birth control, over the phone?

That doesn't sound like defensive medicine, it sounds like common sense.

I stand corrected. I was just curious.

Yeah, how crazy of me to think that prescribing medicine without any kind of examination at all might be a bad idea regardless of the liability issue.

Why do we even need doctors if we can self-diagnose? Maybe we could set up a touch screen at Walgreens where we could all input our symptoms and doctors could input the "If X then Y" info and then we could eliminate office visits altogether?

"Yeah, how crazy of me to think that prescribing medicine without any kind of examination at all might be a bad idea regardless of the liability issue."

As another doc said, you have no clue about this. Lots of medical problems can be treated safely over the phone without a face to face visit but it may not be wise to do so these days with know-it-all lawyers like yourself out there passing judgement on medical practices that they know nothing about.

Any doctor in primary care, probably a lot of specialty care for that matter, does treatment over the phone.

My patients ask me to do it every day.

With liability concerns, I do less and less of it. When I'm on call for the community docs, I do it essentially zero. On-call for myself, by definition they're all people I know; on-call for the community docs, I don't know them. I send it all to the ER or a local walk-in.

And yes, they complain, but that's still another service they lose because of liability.

Something important is happening here. The docs reading this blog are all aware of it, if only at a subconscious level. C-JD is having his consciousness raised, and maybe some others will learn something. The important thing that is happening is that the Standard of Care is beings shifted, out in public, by non-medical personnel, with no medical justification. For you civilians out there, the SOC is a somewhat nebulous legal concept that is defined by the spectrum of interventions that a prudent physician would take in a given clinical situation. A bacterial infection could be treated by any one of a number of antibiotics, all of which would be within the standard of care, but treatment limited to saying a prayer or chanting would be outside the SOC of modern medical practice, and a physician could be legally liable for failure to do more than that. Without a violation of the SOC, there can be no legal malpractice.
I’ll wager that ~99% of practicing physicians in the 1980s would have prescribed that eye medication over the phone in that situation (known patient, same presentation of same disease as before, with known history of good response to a time-tested safe effective remedy). Docs were happy to do that sort of thing, at no charge, as a service to their patients, and a physician who insisted on an office visit for that type of prescribing would have been at the very least viewed as money-grubbing. Today, the poster who declined to do the same thing is viewed as prudent. Note that nothing in the clinical realm has changed. Same patient, same disease, same treatment. Note that the doc’s impulse, to do what he thinks is best for the patient, and call in the Rx, is the same. What has changed is that docs now have a sense of self preservation. Instead of clinical judgment, we have arbitrary rules- “Unfortunately, due to today's liability climate, we have a strict policy of not treating patients over the phone - no matter how small the problem is. If you're not comfortable with this policy, you are welcome to change practices.”
The SOC changes one doctor at a time. It has changed for the posting doctor, and it has changed for me in a similar fashion, and it is gradually changing for the rest of us. Little by little, it will become professionally unacceptable to help patients in this way. Previously, the doc could call the pharmacy, and the patient could pick up his Rx for $10-20 an hour later, and effective treatment would be started. Now, it will require an office visit, $40-100, possibly several hours’ delay, plus the cost of the Rx. If you go to the ER or Urgent Care, they do not know you, and it may be necessary to run additional tests, just to be sure, or even call in an ophthalmologist if you seem the least bit unusual. Nothing different about the ultimate treatment, no improvement in the outcome, just significantly more expense and time wasted.
Note that the SOC was changed by forces outside of medicine. This is actually a fairly trivial example; it would be easy to show how what was formerly a $150 ER visit is now up to $1000 as fewer leave the ER without high tech imaging. Less obvious, but no less costly, is that the OBs in my town will not do high-risk pregnancy management, and the definition of high risk gets lowered every year. I feel sympathy for the 3rd trimester pregnant women who have to drive a couple of hours every week for their OB checkups, and then make the same drive when they go into labor, when we have 5 well trained, board certified OBs in our hospital who could do the exact same job as the folks at the university. It’s that SOC thing again, driven by risk management. You get less. You pay more. It takes longer. But at least you have the right to justice in the legal system.

"It saddens me that victims are the ones who are really hurt (after all, everyone knows someone in their profession they wouldn't dare let treat them or work on their case) by all this "reform""

And just who is responsible for the necessity of this reform? I submit that is the lawyers who have abused the system for so long. You guys have frivolously sued so many times that something had to be done to reel you in. Society will benefit as a whole from reform though a few legitamately hurt patients might not.

Yes I have!

Oops. The link to the article:http://www.medpagetoday.com/tbindex1.cfm?tbid=1130&topicid=61

"How come when my mom had me 30 years ago she felt nothing and
remembered nothing after getting a simple IV in her arm"

IANAO

(I am not an obstetrician, just a psychiatrist) not even an American rather a curious observer from across the Atlantic.

There are many possible explanations.

1) Were you a smaller baby than your child? It is my understanding that babies are getting heavier on average.

2) Was your mother a bigger woman than your wife?

3) Differences in the anatomy of the pelvis between your wife and your mother?

4) Different age and parity status. Was this your wife's first baby and your your mother's 2nd or 3rd? Maternal age at first baby rising in some Western countries.

5) Recall bias. You weren't there (in an observational sense) at your own birth. Your mother's generation probably more stoical than ours. It could have been bloody awful for her. She might not have wanted to make you feel bad.

6) Bad luck. **it happens.

These are a range of alternatives to the implicit "doctors are getting more incompetent" hypothesis you advance. That's not to say your hypothesis is not correct, just that your study design is flawed.

My understanding of the stats in this area (hazy at best) is that, this side of the pond anyway, there has been no steady rise in maternal mortality and morbidity as your hypothesis would predict.

Best wishes

Fionn

In case anyone wants some insight from a partner in medical malpractice defense in NYC...

More than 50% of malpractice is caused by less than 1% of doctors.

Medical malpractice insurance is primarily set to go up or down with the stockmarket because insurance payments are invested. Low stock market = higher insurance rates.

If we could get rid of lousy doctors and have a robust stock market, insurance would certainly be manageable.

That said, defensive medicine certainly has some relationship to insurance rates. The important question is whether this is right. The problem with treating over the phone is that there is always a chance of misdiagnosis. If you think the patient should accept this slim risk, this would lower insurance rates a little bit.

On another note, yes there are many frivilous law suits. They rarely, if ever, succeed. My firm frequently sees them and frequently gets them dismissed. This still costs several thousands $ though and I can understand doctors frustration with this, but to suggest that frivolous lawsuits dominate is a gross exaggeration. I personally can see no better way to do things...

Just my thoughts...