Wednesday, December 28, 2005
From the Oswego County Business, The Malpractice Mess: A Consumer's Opinion (emphasis mine):
I submit, and I hear the howls of disagreement already, that physicians are allowed too much leeway in treatment options. I submit that the establishment of detailed protocols for treatment—very detailed protocols—would eliminate a lot of lawsuits. If, for example, the protocols required a brain scan of any middle aged man suddenly presenting with severe headaches, we should see a corresponding decrease in neurology premiums. If detailed treatment protocol were developed, and followed, malpractice rates should drop accordingly.One comment, one question; To my knowledge protocols and standards of care do not seem to prevent lawsuits, and who is going to pay? Also posted at RedStateMoron. O.K. you guys, have at it. Like when Kevin posts. Please...
It would take work. It would take agreement, and consensus. The courts, the insurance industry, the physicians, and their overseer organizations, would have to agree on the standard of care each group of symptoms merited. Someone within this group would have to be responsible for timely updates, as medical advances occurred. Physicians would need to be more responsible in the matter of continuing education, and staying abreast of new developments in their field. But should such protocols be established, and followed, then weeding out lawsuits without merit would be much easier. Plus, healthcare consumers could be assured a minimum standard of quality care, and stop worrying about their physician having a bad day or off moment, that might result in our death. Remarkably, we human lab rats would really, really like that.
Posted by RSM |
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Comments:
Too many objections to count.
The patient who pleads "Can I postpone the scan until after my daughter's wedding?", then at trial says "the doctor never said it could be cancer!"
Or the scan report that reads "cannot rule out ...(anything)", such that the scan reports are generally worthless.
Or the insurance companies who foot the bill, decreeing 'no more scans unless there are neurologic signs' -- signs that can be debated.
With inexpensive co-pays by the patient which encourage frequent doctor visits, do you realize how much "protocol medicine" will cost?
In my primary care lifetime I've seen lots of schemes to improve quality; better records, evermore CME, peer review, protocols, mandatory second opinions, cultural competency, etc.
The best -- and only -- way toward quality care is to attract the best and brightest young people to the profession, and part of that attraction will necessitate that these young doctors forsee that they will maintain their autonomy.
The patient who pleads "Can I postpone the scan until after my daughter's wedding?", then at trial says "the doctor never said it could be cancer!"
Or the scan report that reads "cannot rule out ...(anything)", such that the scan reports are generally worthless.
Or the insurance companies who foot the bill, decreeing 'no more scans unless there are neurologic signs' -- signs that can be debated.
With inexpensive co-pays by the patient which encourage frequent doctor visits, do you realize how much "protocol medicine" will cost?
In my primary care lifetime I've seen lots of schemes to improve quality; better records, evermore CME, peer review, protocols, mandatory second opinions, cultural competency, etc.
The best -- and only -- way toward quality care is to attract the best and brightest young people to the profession, and part of that attraction will necessitate that these young doctors forsee that they will maintain their autonomy.
# posted by 
: 7:23 AM
: 7:23 AM
"In my primary care lifetime I've seen lots of schemes to improve quality"
These schemes are not meant to improve quality; they're meant to improve missing the proverbial "needle in a haystack" that is making lawyers money. Nobody is going to miss a pulmonary embolism in the 60 year old with breast cancer who's short of breath and hypoxic. It's the 25 year old with reproducible low back pain who has lupus that we miss. These would be missed by any protocol too,
These schemes are not meant to improve quality; they're meant to improve missing the proverbial "needle in a haystack" that is making lawyers money. Nobody is going to miss a pulmonary embolism in the 60 year old with breast cancer who's short of breath and hypoxic. It's the 25 year old with reproducible low back pain who has lupus that we miss. These would be missed by any protocol too,
# posted by : 10:59 AM
: 10:59 AM
"In my primary care lifetime....."
Dr John primary care is dead. Ten years from now this will all be done by PA's and NP's with a doc overseeing the flock. One of the reasons I went on to fellowship. It is a dying industry that the government is going to take out into the barnyard and shoot one of these days with it's cuts.
Dr John primary care is dead. Ten years from now this will all be done by PA's and NP's with a doc overseeing the flock. One of the reasons I went on to fellowship. It is a dying industry that the government is going to take out into the barnyard and shoot one of these days with it's cuts.
# posted by : 11:17 AM
: 11:17 AM
"primary care is dead. Ten years from now this will all be done by PA's and NP's with a doc overseeing the flock"
Two errors. "Ten Years from now"? Right now I practice more primary care in my ER in a day then most PCPs do in a week. I see 5 patients an hour. That's the wave of the future. Not NP's, not PA's, ER Docs. And all we do is practice DEFENSE!!. Thank you America, for the job security.
Two errors. "Ten Years from now"? Right now I practice more primary care in my ER in a day then most PCPs do in a week. I see 5 patients an hour. That's the wave of the future. Not NP's, not PA's, ER Docs. And all we do is practice DEFENSE!!. Thank you America, for the job security.
# posted by : 12:15 PM
: 12:15 PM
What many fail to understand is that protocol-driven, "cookbook" medical care fails to prepare the physician for the (surprisingly frequent) unusual case. Protocols strip the physician, and system, from the ability to think on one's feet and make judgements in regards to care. Instead, each patient will be a round peg which must be inserted into one of a series of round holes....unless the patient is actually a square peg, in which case the physician must do some actual thinking. There is no subsitute for experience, and protocols by design take away from the ability to garner experience.
The studies show the opposite. Wide variability in care (Dartmouth and Stanford studies) yield no discernible difference in outcomes, but huge differences in expense. More doctors don't improve outcomes. "Defesive medicine" does not improve outcomes and, more importantly, for this discussion does not decrease risk of malpractice. The only way to reduce malpractice risk is to improve outcomes. I'm sorry RSM, but I was under the impression that protocols did improve outcomes. It's why Kaiser and VA are so good. They actually do worse in short-term acute care, but in long-term morbidity and mortality. My understanding is that was because they more closely followed established protocols. Here's the first hit on a google search using search terms "protocols" and "improve outcomes"
http://www.dartmouth.edu/~cardio/Home/news/acutmi.html
Variability in care is a huge cost in our system and, quite possibly, a killer as well, but doctors really hate any impingement on their perogatives.
http://www.dartmouth.edu/~cardio/Home/news/acutmi.html
Variability in care is a huge cost in our system and, quite possibly, a killer as well, but doctors really hate any impingement on their perogatives.
The more detailed the protocol, the more possibility for eroneously not following the protocol to the letter. Lawyers love protocols because they become the bulk of the testamony for the plaintif if not exactly followed.
Plus, the more detailed the protocol then the more absurd the decision making will become. The 39 and 364 day old comming in at 5 minutes before midnight with chest pain might not require a (and therefore won't be paid by the insurer) an EKG and cardiac enzymes, but would if he had arived just a few minutes later.
Care will be driven by absolutely meaningless data that can be plugged into some bean counter generated algorithm.
Plus, the more detailed the protocol then the more absurd the decision making will become. The 39 and 364 day old comming in at 5 minutes before midnight with chest pain might not require a (and therefore won't be paid by the insurer) an EKG and cardiac enzymes, but would if he had arived just a few minutes later.
Care will be driven by absolutely meaningless data that can be plugged into some bean counter generated algorithm.
# posted by : 1:14 PM
: 1:14 PM
"Defensive medicine" does not improve outcomes and, more importantly, for this discussion does not decrease risk of malpractice."
Four years and MILLIONS of dollars of testing later, and I'm pitching a no-hitter (Knock wood, though I know it's going to come to an end soemtime soon)I can list at least 10 instances where nurses and/or colleagues looked at me in horror as I ordered a defensive test looking for that "needle in a haystack" that found that needle, and saved my ass. I've probably caused more cancer my CT scanning everybody than the rare save, but that's not what counts in this game. Defensive medicine is the only way we can try to be 100% right 100% of the time.
Four years and MILLIONS of dollars of testing later, and I'm pitching a no-hitter (Knock wood, though I know it's going to come to an end soemtime soon)I can list at least 10 instances where nurses and/or colleagues looked at me in horror as I ordered a defensive test looking for that "needle in a haystack" that found that needle, and saved my ass. I've probably caused more cancer my CT scanning everybody than the rare save, but that's not what counts in this game. Defensive medicine is the only way we can try to be 100% right 100% of the time.
# posted by : 2:09 PM
: 2:09 PM
agree with the above. "deviating from the protocol" and ordering a "defensive" "off the wall" test on an intuitive hunch has uncovered the "needle in the haystack" time and time again. No protocol would have ever contemplated it. On the other hand, many "hunches" and fishing expiditions come up empty handed. But I will keep pusuing those "hunches" regardless of what any protocol says because the bottom line is that my goal is to keep my ass out of the courtroom.
# posted by : 2:37 PM
: 2:37 PM
The usual data free discussion of anecdotes (prompted by a pretty data free article). Doctors claiming that (fill in the balnk) will just help the lawyers. The doctors who have never been sued suggest it's because they practice defensive medicine rather than other factors. The ones who have been sued, but not lost (yet to make an appearance) argue that defensive medicine is the only thing that kept them from having the judgement going against them. At least he thread has remained civil in deference to the guests.
Healthcare costs $2 trillion in this country and that number is growing. We spend more money per capita than other country and have no better outcomes and poorer access. This means that healthcare delivery is going to radically change and those changes may include tort reform, but that will be a minor part of the package.
Stein's Law: Anything that can't go on forever, won't.
Healthcare costs $2 trillion in this country and that number is growing. We spend more money per capita than other country and have no better outcomes and poorer access. This means that healthcare delivery is going to radically change and those changes may include tort reform, but that will be a minor part of the package.
Stein's Law: Anything that can't go on forever, won't.
Anecdote? 4 Years, Approximately 25,000 patients (not to mention 4 years of residency, for a total of 50,000 patients)of ordering Ultrasounds on people who just want work notes, admitting 21 year olds with chest pain, doing head CT's and LP's on Migraines. And my colleagues with lawsuits which they could have been avoided if they just covered their asses (The patients' bad outcome would have still been avoided, but they would have passed the responsibility on to some other poor schmuck). Thats' not just anecdotal. Show me the study that shows Defensive Medicine DOESN"T work.
P.S. I'm not bragging, because I know it's just a matter of time before you or your brethren catch up with me. I'm Due.
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P.S. I'm not bragging, because I know it's just a matter of time before you or your brethren catch up with me. I'm Due.
# posted by : 1:46 AM
: 1:46 AM
