NY Times – Why doctors get it wrong:
But we still could be doing a lot better. Under the current medical system, doctors, nurses, lab technicians and hospital executives are not actually paid to come up with the right diagnosis. They are paid to perform tests and to do surgery and to dispense drugs.There is no bonus for curing someone and no penalty for failing, except when the mistakes rise to the level of malpractice. So even though doctors can have the best intentions, they have little economic incentive to spend time double-checking their instincts, and hospitals have little incentive to give them the tools to do so.
“You get what you pay for,” Mark B. McClellan, who runs Medicare and Medicaid, told me. “And we ought to be paying for better quality.”
Dr. RW begs to differ:
Although the Times article suggests that pay for performance and penalties for errors might solve the “crisis” the data suggest otherwise. Studies on Pay for Performance to date have failed to demonstrate improved quality. A spate of articles analyzing medical error indicates that promotion of a culture of blame by penalizing doctors for honest mistakes is counter productive.The JAMA perspective is more nuanced: “However, it remains unclear to what extent clinically missed diagnoses represent errors per se, rather than acceptable limits of antemortem diagnosis in the face of atypical clinical presentations. In fact, because the vast majority of autopsy studies come from teaching hospitals, published autopsy series may be enriched for atypical cases.”
Related posts:
- Medical errors: Impact on physicians
- Pay for performance unintended consequences
- Pay for performance follies
- Is reducing medical errors similar to improving transportation safety?
- Does pay-for-performance work, and will it improve health care quality or patient outcomes?
- Working harder won’t reduce medical errors
- Op-ed: Medicare’s mistake
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You’re not really a Doc., are you?
Most things you say go against everything that most of us are told by our real life doctors. They say, don’t mess around with chest pain “GET YE TO THE ER” in case of chest pain.
You imply that if we have any other illness that COULD be responsible for the chest pains then why go to the ER.
So, we can stay at home hoping our pains might be non-coronary related
and run the risk of dying or we can piss you off by going to your ER?
I can’t even think of words to describe you. I really think and hope you aren’t a doc. I know NO Drs. who behave the way you do. If you are one please get help. Or just find a new line of work.
My biggest fear is now that you may be an ER Doc. in the state I live in. The thought of my life being in your hands is more than terrifying!
I think the cynical sarcastic doc above may be overstating things, but I understand his frustration. Every day we see hysterical patients who had a one second “twinge” of chest pain, which we have to admit to the hospital to CYA. Meanwhile, the nurses are having chest pain, the secretary is having chest pain, the EMT’s are having chest pain. Then, like today at work, a patient comes in dead, and it turns out he’s been sitting at home infarcting his heart having excruciating chest pain for a month. I know it’s hard for patients to tell what is cardiac vs. non-cardiac pain, but alot of ER docs get frustrated having to admit the “worried well” because of the litigousness of our society. And yes, I can almost always tell when a patients chest pain is non-cardiac, but I can’t tell them definitively and I have to admit them all due to litigation concerns. (Because I’m not 100% right) I’m sorry I do it.
And after you have admitted them to rule out the MI they never had, many who aren’t the brightest remain under the impression that they had a “mild heart attack” or “almost had one”. they show up to the next ER 10 minuets away in the middle of night for their one second of chest pain. Records can’t be obtained from the other hospital so they go throughthe whole process again because know they have a “cardiac history” that can’t be disproved at the moment.
when would I recommend you go to the er? I guess it depends…if it was you, every time you have chest pain…because you see like a litiginous sob; if it was my family member, I would try to figure out what it is and treat appropriately…
And what exactly in my post made me appear a litiginous sob? You berate patients when they go to an ER for chest pain and it turns out nothing, you berate patients when they don’t and it turns out serious. I seem to see an inconsistency here and I tried to point it out in my post.
It’s a bit hipocritical to say that for your family you’d try to figure it out, IMHO, but those of us who are litiginous sobs should go to the ER. Most of us don’t have doctors in the family. For the record I’ve never sued anybody nor do I see myself suing anybody except for obvious negligence like cutting the wrong limb. Was I rude in my post or called you names? Is insulting patients who post here is some way to vent your frustration with your job?
yeah, when you get the chest pain pull out that flowchart…you doofus….
The only reason I brought up the flowchart is because the doctors here seem to berate patients for going to the ER for chest pain when it turns out to be GERD. But I guess you missed the irony.
Am I doofus? My collegues in a world-renown corporate research lab where I work don’t think so. I have papers published, I also have patents. I don’t think I am any less intelligent than you are. I don’t know your field but that doesn’t make me a doofus.
You gotta love how people think they can rate physicians. I don’t know which is worse, that they think they can judge a physician based on one 10 minute visit or based on what he anonymously posts on a Web Blog site!
I guess if you switch “doctors” and “patients” in the last quote, you’ll get it exactly right.
I think an “irony” or an interesting comment, is the difference between the US and Canada. The reason the above ER doc berates patients for showing up at ERs when they have chest pain is because the so-called “standard of care” in the US is to do an expensive workup on any patient that walks through the door with chest pain. If an ER doc in the U.S. sends a patient home with chest pain he is “rolling the dice” taking a litigous chance. In Canada, if you go to the ER with chest pain, they will usually do an EKG, and if it’s normal, send you home (unless you have alot of risk factors) There’s no such thing as the “Chest pain Rule out MI” admission so common in the U.S. In Canada, either you’re having an MI, or “unstable Angine”, or you get discharged. The only difference in the equation is the lawyers.
anon 1:58 says he knows of no docs that act like me…yet he says that his docs tell him “not to mess with chest pain” and go to er…they are COVERING THEIR ASS…it’s just that they don’t say it to your face…I am telling you the truth. i do the same thing every day as a pcp. There may be a 0.001% risk of cardiac etiology of the chest pain but the only downside is your time is wasted waiting to get seen in the er and undergoing unecessary tests…the upside is my ass is covered…that is why every doc tells everyone with chest pain to go to er…
“the only downside is your time is wasted waiting to get seen in the er and undergoing unecessary tests.”
That’s not true. Every day these hospitalized patients are picking up VRE, C-Diff, having reactions to IV DYE, having their kidneys killed by the medications we are forced to give them for diseases they don’t have. We’re probably causing cancer with all the radiology tests we order, “just in case”. All in the name of defensive medicine. I do it every day too, but playing defense has it’s price. We need to kill all the lawyers!
anon 7:28, you’re right with what you say, but all of that corroborates what I am saying…it is a problem for the patients, but I don’t get sued for that stuff happening in the er…if it’s a decision between covering myself and ordering unecessary bs tests and having patients waste 2-3 days on unecesary hosiptalizations, which do you think most docs would pick?
the lawyers run the govt and everything in this country, so until they start getting screwed by the system (which won’t happen because they get VIP healthcare)or enough patients get screwed and understand what is going on here nothing will change…
I’m not disagreeing with you anyway, though when you send the patients to the ER, unless you work in a hospitalist system, you’re still on the hook once the ER doc sends the patient upstairs. For example, I admitted a guy from the ER with small cell lung cancer several years ago with SOB, I did a CYA Cat Scan to rule out PE, the Radiologist misread the CT as negative. While the patient was upstairs, he crumped, the Primary care ordered lasix for his worsening SOB, he died of SVC syndrome. The family sued me, the radiologist, and the primary care. (they got diddly, since svc syndrome is nearly unsurvivable)But you’ll have to lose a week of your life a week in court having a moron lawyer tell everyone what a moron you are just by having your name on a chart. But I agree, keep sending in your patients to CYA.
anon 8:29, that’s a perfect example of what I am talking about…the CYA system worked! the patient was sent to er, admitted, liability was spread to the radiologist, and the family didn’t get anything anyway…but could you imagine what would have happened if the guy wasn’t sent to the er? Then the primary care gets f*****!
I’ve never seen so much arrogance coupled with so much ignorance.
I daresay most of you last few anonymouses wouldn’t survive in a free market for healthcare. You better hop on the government tit now.
WE couldn’t find the “government tit, it is shoved so way up the considerable asses of the law lobby. Stop being jealous that we’re protecting ourselves from your sodomy. There are plenty of “caring” doctors you can sue whose principles disallow them from ordering tests solely to “cover my ass”. You can still extract some blood from them. Me, the only suit you’ll get out of me these days is assault with a deadly radiation weapon: the CT Scan machine.
Anonymous : 9:54 PM
The way the public will get you is when your “quality of care” & outcome statistics will become public record.
This day is closer than you think.
I think a surer bet is the day is coming when you are in a hospital sick getting gang-banged by doctors and ct scans and iv dye,ventilators…or one of your family members is…
The reason the above ER doc berates patients for showing up at ERs when they have chest pain is because the so-called “standard of care” in the US is to do an expensive workup on any patient that walks through the door with chest pain.
But he berates patients for not going to an ER as well; he also ridicules a patient for trying to use some kind of a decision aid like this one
http://www.webmd.com/hw/heart_disease/hw85944.asp
in trying to figure out what to do by this supremely mature, insightful and intelligent comment:
yeah, when you get the chest pain pull out that flowchart…you doofus….
He (or his collegue) calls a person he’s never met in his life a litiginous sob. Simply because this patient dared to explain why people go to the ER and asked a question when we should do it.
Some people go to an ER without good reason – maybe some of them have relatives or friends who died of a heart attack and maybe they are just hypochondics. Some may stay home in spite of a very severe pain and end up having a heart attack. Most fall in-between. They have a chest pain, try to decide using your own best judgement and past experience if it is an emergency, if it can wait till for a regular doctor’s visit or simply ignored. Since we are not doctors, we often get it wrong.
Most of us don’t sue. Honestly, what is the proportion of people who do? Based on your own experience, the number of patients you have and the lawsuits. Among those who do sue, the majority honestly believes that they were wronged. In few cases they are right, in many cases they are wrong. Very few of us understand the difficulty of making the right diagnosis and the potential harms of unnecessary testing.
For the record, I don’t believe in P4P. I do believe that some of you need to look at this whole argument from an average patient’s perspectives. After all some of your collegues are not above suing their doctor (remember a case when a doctor sued her doctor for late diagnosis of breast cancer – Kevin posted it some months ago).
I am tired of arguing this one out with you people…but the bottom line is this…physicians are in a bad situation but I am trying to point out whenever I can how they can protect themselves…this is all we can do for now…
The patients that read about this get upset because they know they are getting screwed by this defensive medicine…but it seems like you all deserve it!
but it seems like you all deserve it!
You know, I do understand everything you said in your post and I don’t particularly like the American national sport of suing each other either, but this point was really uncalled for. In my humble and completely ignorant opinion.
Just out of curiosity – would you mind pointing out what I’ve ever said that make you seem I deserve it? I thought I’ve been reasonable. But I guess just the fact I am a patient means I deserve anything I get. Including name-calling. As if your collegues never sue each other and your other collegues don’t lie on the stand for money when called as “expert witnesses”.
To be honest I don’t see how you came up to this conclusion from other patients’ posts either. It seems it mostly the doctors who resort to name-calling, deliberately misinterpreting posts or using words out-of-context. A sure sign of the strength of one’s argument.
I absolutely agree with the above post. I have carefully read all these comments and the conclusion is that it is the Physicians who have done all the name calling.
You have lowered your selves and your profession in many of our eyes. Noone has said anything in these posts that would make you believe we deserve being screwed over.
You have taken what most of us believe to be a profession that deserves respect and made yourselves look anything but respectable. Actually you appear to be quite childish with your name calling and such.
I use to smack my children in the mouth for using dirty language. Some of you could use some parental disipline!
I think the last comment pools all physicians together unfairly. The reason I am so upset as a physician that I have to order un-needed tests to cover my Butt is that you patients don’t deserve it. I really did get into this to help people and I always feel I am appeasing lawyers and hurting patients when I order all these stupid tests. I would love to just see patients and treat them with empathy but instead we have this lawyer-created anatgonism, where every day I have to tell patients “if you don’t do this test you could die and I need you to sign out AMA” when I know (and I tell the patient) there’s a 1% possibility the test will be positive.
anon 5:09, don’t apologize to these people…you need more than just a lawyer to sue…you need a patient or family members who agree to sue. That is why I said that they get what they reap…other than death and taxes, one thing I can say with almost absolute certitude is that each and everyone of these people is going to deal with a defensive healthcare system and unecessary testing. It may happen tomorrow, a year from now, or on their death bed when the critical care people are sticking feeding tubes/central lines/wires in every one of their orifices so they can do “everything possible”…
Anon 5:09, What if I have been your PT.for a long time and I trust in you completely and one day I say to you..
“Doc. I know what’s going on with all this defensive medicine in this country. I don’t want you to practice that with me”. I know that first response would be similar to “I have to protect myself so you have to receive defensive medicine.” But, can’t you and I have something like a legal agreement on it? Couldn’t YOUR Lawyer draw up papers that your patients could sign? Papers that would release you from legal ramifications? Is this an option that could work? Is this a way that many of us who have never sued anyone in our lives could side with our Physicians against the legal community?
If not, then give us some options. Tell us what we, as patients, can do to help end this disaster.
you need a patient or family members who agree to sue.
and an expert witness…
and of course, doctors themselves never sue other doctors or anybody else – as we’ve seen on this board
and of course, everyone can and shall be judged by the group they belong to – be it patients or doctors or … (I don’t want to go further here)
After reading all this and hearing how many Doctor’s complain about people showing up in their ERs when they really don’t need to be there leads me to one statement.
If the only people who ever showed up were the ones who were truly having an MI or something equally as devastating. How many ERs would there be for you to be practicing in? Surely if only the deathly ill came to the ER you probably wouldn’t have your job..”Now you understand!!!”
ok…you got me on that one…i’ve met my match…
Yes doctors themselves never sue other doctors or anybody else only patients sue.
- Prakash Arige
Health Value Travel
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