When I think of all that money you people waste on cya test copays and deductibles I just get this warm and fuzzy feeling all over…

There was a study that came out in a malpractice law journal awhile back showing that the cumulative lawsuit risk of a typical doctor n teh United States over a 20 year time span is about 90%

For 2 lawsuits over 20 years, its about 50%, and 3 lawsuits its about 25%

So it is in fact true that doctors are virtually guaranteed to get sued at least once. No other profession, besides perhaps lawyers, stands such a high risk of lawsuits

There’s a bad apple here, and I’m afraid that by stating his case with such hostility, he is making a mockery of himself and of our lawsuit problem.

But I wanted to address a misconception: giving patients information about risks of diagnostic testing and allowing them to decide if, say, a CT scan is necessary for pain which has, for example, a 4% chance of being appendicitis, simply does not work. The phrase “patient declined CT scan,” does not protect the ER doctor in any way. A signed AMA form is marginally helpful.

The ones “over a barrel” are the doctors, who know that their clinical accumen and training allow for 97% certainty. There was a time when that was sufficient. Now, anything less than 100% certainty is grounds for suit, whether you explained the odds or not. Explaining incidence of disease and risks of tests is just polite, and I routinely engage in such discussions with patients who show an ability to understand, but it doesn’t really have a place in emergency medicine, and doesn’t really affect my practice style.

This is why emergency medicine is so expensive. Armed with only a good history and physical exam, I can often exclude appendicitis with 97% certainty. But there will always be atypical presentations, no matter how good of a clinician I am. For each percentage point of certainty, add about $1000 of tests. Thus, lab tests get me to 98%, CT with contrast to 99%, surgical consult with admission for observation and exploratory laparotomy gets me to 100%. I frequently stop at 99%.

If I were to explain this to more patients, more of them would opt out of the scan. Because I see about 11 cases of abdominal pain per night, this approach would miss appendicitis at least twice a year. Therefore, giving patients the option increases the risk to me, because there is no protection except for 100% perfection. Documenting that there was no right lower quadrant tenderness of rebound does not hold up. We are sued not for deviation from standards, but for bad outcomes.

I really wish there was a better way. For patients who actually try to pay their bills (less that 17% at my institution), I feel especially bad. On the other hand, defensive medicine actually does help prevent that 1-2% extra chance of bad outcomes. Unfortunately taxpayers are picking up the tab (for my patients).

you sound like a nice guy; your story is kind of on a tangent with regards to this discussion except for bringing up another point…the litigiousness seems a characteristic of Americans and not foreigners…

This sounds like one of those car insurance scams they run in Brooklyn…

To Anon 5:00pm – excellent explanation and point of view. One of the best I’ve read. I printed it to save.

To Anon 3:14pm – “Would someone please suggest a solution, …”

Here’s my personal solution for my practice. This is what works for me. It may be unworkable for other physicians.

First, I’m board certified in Ob/Gyn with 17 years of practice. Only Neurosurgeons have higher malpractice risk.

Largely Ob/Gyn’s have a procedure based practice. I choose a current definitive text such as Speroff’s Gynecologic Endocrinology or Gabbe’s Obstetrics. I make my self responsible for knowing it cold. Modified by some, but not a lot, of current literature. With some variance, but not much, the protocols in those commonly accepted definitive texts are the basis for my testing and evaluation/treatment. For instance; rule out ectopic pregnancy, testing for gestational diabetes, rational for ultrasound in pregnancy, abnormal uterine bleeding, indications for hysterectomy, etc. I ask myself, could a put a photocopy in the chart delinating the rational behind that individual test/treatment. I actually put a copy in the chart about twice a week.

Another perspective, mine alone, which might bother some patients.

I have no loyality to patients, per se. My loyality is to what I term “the diagnostic process of medicine,” and to my teachers, mainly my residency faculty, but also colleagues. If I perform the diagnostic process well and do what I was taught, with thinking, the patients will, god willing, automatically do well.

The board certification process in Ob/Gyn consists of two parts. The first part is a very long multiple choice test simply to demonstrate basic fact knowledge. The second part, however, is a live presentation of a year of actual practice to a panel of learned professors and practitioners who query the applicant as to method and rational.

My goal is to manage my patients, so that if they were to be presented to that examining panel, the examiners would nod in approval.

“I choose a current definitive text such as Speroff’s Gynecologic Endocrinology or Gabbe’s Obstetrics. I make my self responsible for knowing it cold.”

In my practice (Int. Medicine), I make a point of memorizing Harrison’s Principle’s of Internal Medicine and rememorizing it everytime a new editions is printed…

“I couldn’t let a lawyer’s comment that all car accident lawsuits are because of negligence.”

What I said, or meant to say since it wasn’t terribly clear, is that the THEORY is negligence. Same theory as med mal.

There’s no doubt there are some frivolous lawsuits. Particularly in the range you’re talking about. My state has a $5000 max for small claims. For a mere $25 in filing fees, and another $25 in service costs, any individual, without a lawyer, can file suit and have their day in small claims court.

What is likely to happen if it’s truly frivolous is just what happened in yours – the judge fines the other side and makes them pay your costs (or your insurer’s costs).

How do we remedy that? What else should we change?

Litigiousness is part of America, because we grant more individual rights than any other country. It’s how we settle our disputes, as opposed to barrel of a gun. We believe that the responsible party should pay for harm they cause, and we have put this system together as the most fair way we can think of to apportion harm and preserve these rights.

Do you know of a country that has a better system?

CJD

Bad shift, I do understand a little better since a couple of you have finally taken the time to exlain, in a little detail, exactly what type unfortunate position you are in. I don’t mean to imply that physicians are bad. Actually, I look up to them and have a great deal of respect. If we were to place all of you in the same category, as the anon Dr. here, that is so full of anger and hate, it would be wrong of us . Its hard to place him in the role of caregiver or healer.

I still don’t like the fact of defensive medicine being used on me, but, I do understand it better.

What will happen when ins. companies stop approving all these tests and it becomes our (the patients) responsibility to pay out of pocket for all this useless testing? Many more people will begin to question “Why do I need this test?” Right now, most people are more than happy to overuse the system (at your insistence) because it is not breaking them personally. Thats going to change, one day. What will happen then?

If patients had to pay a small co-pay (I often say 50 cents)alot of this nonsense would come to an end. A patient with gas pain in their belly will be more likely to “let it pass” then to come to the ER, where they will have to drink contrast and have an abdominal CT, as well as labs. Here’s to the 50 cent co-pay! (I know, some insurances require it already)

Cathy makes a good point – with the advent of the new high deductible consumer-driven health plans, there’s pressure put on patients by their employers, to ask questions about costs and the need for tests and treatments. But seeing how the doctors who’ve posted here are reluctant to discuss their real reasons for ordering so many tests, based on their own economic pressures, this looks like it could lead to another source of conflict between patients and doctors.

Before I ever found this site, I had no idea how much testing was due to defensive medicine. I doubt most patients are aware of this, and I wonder how many employers are aware of this as well.

I’d be interested in knowing if any doctors here have come across patients with these new health plans, and if there were more than the usual questions about costs.

Wow, You attacked that radiologist as if he actually saw patients! By the way “some of the responses that were made to the most mean mouthed arrogant Doctor in history” is probably about 10 different docs who post here, you keep getting your anonymi mixed up. I have respect for the radiologist who wrote that, he got out in time and made some good investments so he doesn’t have to deal with the torture I and my colleagues do on a daily basis. He has written in thepast how his health improved by getting out, how his life is so much better. He reminds me there’s hope for us all. Why don’t you go attack another profession, like politicians?

I have several patients with high-deductible plans or consumer driven health plans and they are in general educated, nice people. And yes, I am very honest with them about the reasons for ordering the test, I document in detail and I have a low volume practice, with close follow-up of all cases. These patients are more reluctant to undergo tests. If I insist, they will go for the test but I’d better be right about the need for the test !

except for sarahW, cathy, RL and CJD, why is everyone ANONYMOUS? I would love to see a cat fight with names and IPs on it! Is it possible in blogging?

I’ll post next time, I enjoy reading this.

ANONYMOUS TOO

Anonymous 11:01, I have been sued once. Well, twice if you count small claims by a tenant.

CJD

“If I insist, they will go for the test but I’d better be right about the need for the test !”

You sound kind of clueless…a physician can almost always justify the need for a test…the insurance companies just put up these hurdles, like you have to call “1-800-dildo” or whatever, and press a whole lot of numbers in succession, then you get to some high school graduate who asks you asks you questions off a computer template for whatever test you’re ordering. If you say the patient has chest pain, you think they won’t allow a stress test? Or if you say rule out appendicitis, you think a cat scan wouldn’t be approved? Every test I have ever ordered has been approved, you just have to put up with the nonsense of wasting time on the call.

Litigiousness is part of America, because we grant more individual rights than any other country. It’s how we settle our disputes, as opposed to barrel of a gun. We believe that the responsible party should pay for harm they cause, and we have put this system together as the most fair way we can think of to apportion harm and preserve these rights.
Unfortunately, this is not the only reason for lawsuits in the US. A few lawsuits are legitimate, more are driven by greed, most malpractice lawsuits are probably driven by pain, anger and ignorance.
In fact, I believe ignorance drives most malpractice lawsuits – patients truly believe they were wronged because of what they saw on TV or heard on the radio or what their “expert” doctor told them. Unfortunately, in the majority of cases this is not the case. A lot of us don’t realize that tests are not risk-free, even fewer understand how ambiguous the results of biopsy may be and how difficult a diagnosis often is. I only understood it recently, and I don’t believe I am stupid.

Another reason for lawsuits that I think is specific to America is that many people don’t take responsibility for their own actions. If I didn’t get test results in the mail, it is my responsibility to call and to check. Even if somebody promised to call. I might be upset that they didn’t do as promised, but it shouldn’t be grounds for lawsuit IMHO because I know how to use the phone. If I refused a test/prescription it is my responsibility to live with consequences. Just like if I decided to swim far in the ocean and drowned. It’s great if a lifeguard saves me, but if not it is my fault. But for some reason here in America people don’t like to blame themselves. Not all Americans, maybe even the minority, but enough to make life worse for all of us.

My cancer was not diagnosed, despite alot of symptoms, including 35 pound weight loss – tumor that was present throughout the weight loss was ignored, then when I finally got them to biopsy– the node was misread as benign. The doctors, who granted did lots of tests, missed what was going on–but– the mailman in my office was spreading rumors that I had cancer because of the drastic weightloss and how awful I looked. It was obvious to the mailman that something big time was wrong.

I did not sue when I was finally diagnossed several years later, at a later stage. I was less angry at the pathologist, who made a flagrant error, than the internist who decided I was a hypochondriac and treated me as such, although prior to the these symptoms, Id been rather doctor avoidant. Had I sued, she would have been my target. Better to say “we dont know” and treat the patient with respect, than to blame the patient for failure to diagnose.

And, supposedly, I didnt go to bad Drs– all were on the so called “best of” lists”

All physican’s are human just like the patient. Rad Doc’s read over 100 to 150 films a day. It’s bad that in this life bad things happen to good people. My husbands been a Rad Doc for 14 years. He has felt bad when he’s missed something. The problem is the money can never replace what was lost on both ends. Most Doctor’s that I know don’t get up in the morning and say to themselves let’s miss diagnose someone today. They have families and the government doesn’t make it easy for the patient or the doctor anymore. Patient’s some of the times have grave news and it’s bad. They get angry and up set at the out come. I’ve personally been missed diagnosed and so has my husband. Requirements are getting harder and more patients come in that need more help. It’s said but lawyers don’t care. I’ve seen them laugh and know they were going to get a Doctor for everything. I’ve seen lawyers that think it’s funny that they run the country. Look at capitol Hill. Both the patient and the Doctor loss.