An old-timer bemoans the demise of the physical exam, or hyposkillia:

We need teachers who truly comprehend the value of a good medical history, the rewards of a pertinent physical examination, the power of knowing how to think, and the importance of accountability; teachers who first use the stethoscope, not an echocardiogram, to detect valvular heart disease; teachers who first use the ophthalmoscope, not magnetic resonance imaging, to detect intracranial hypertension; teachers who first use their eyes, not a blood gas apparatus, to detect cyanosis; teachers who first use their hands, not computed tomography, to detect splenomegaly; and teachers who always use their brains and their hearts, not a horde of consultants, to manage their patients.

We need teachers who don’t order expensive, state-of-the-art studies when cheaper, conventional tests supply the same information; teachers who don’t administer a slew of medications in an effort to alleviate every possible ill; teachers who appreciate that doing nothing is, at times, doing a lot; and teachers who realize that many patients get well despite what we do, not because of what we do.

Those days are long over, my friend. Readers of this blog know why this is happening: time pressures in a fee-for-service reimbursement system and defensive, objective-based medicine.

I recently discussed this with someone who is completely unapologetic about the demise of old-school, physical exam-based medicine: “I compare it to this – why travel by horse and buggy when you have a car available? The same goes for today’s medicine.” (via Notes from Dr. RW)

Update:
retired doc comments.

Update 2:
Dr. RW addresses some of the comments here.

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  • Anonymous

    This guy needs to learn that the most important teacher in his hospital, who should be giving 50% of the medical school’s lectures, is the hospital’s risk manager. I still don’t understand why med schools don’t have the risk manager give lectures.

  • Anonymous

    Why do I have the feeling this guy never had to see 40 patients a day at 15-minutes per encounter…I bet his physical exams would leave a lot to be desired at that rate.

    While this jag-off is writing bs articles so that he can write MACP (whatever the f*** that is) after his name, the rest of us will keep practicing defense to ward off the sodomites!

  • tflm

    I do believe the old saying that over 90% of diagnoses are made from history alone but I wouldn’t accept a 1 in 10 chance of getting sued.

    It’s a pity everyone’s out for a quick buck, we all lose in the end with protective medicine; patients have to go through more tests, the public pays higher bills (either taxes or insurance premiums) and doctors create more work for themselves. At least the lawyers get paid by every side…

  • Greg P

    He paints with a broad brush indeed.
    And ends up sounding like a disgruntled faculty member, perhaps because he was “overlooked” for advancement.

    In my neurology training almost 30 yrs ago I remember watching our chief methodically examine patients. One thing he did at the bedside was ocular plethysmography — where you apply a pressure-generating gizmo to the side of someone’s eyeball, slowly increasing the pressure while you did an ophthalmoscopic exam watching for the retinal arteries to collapse to get a sense of arterial pressures in the eyes. Yes, a test easily done at the bedside with a good hands-on factor, but these days totally supplanted by better, more useful technology.

  • Anonymous

    I don’t agree that we all lose with defensive medicine…the patients lose, and the public loses, but physicians actually get PAID for defensive medicine…more tests generate more diagnoses (pulmonary nodule, liver cyst, ashd – when someone has an unnecessary cardiac cath and has 1% blocked artery, they have coronary disease! yeah!). So keep up the defense, guys…the patients are trying to screw us, don’t feel bad about it…

  • Anonymous

    Another preacher from the ivory tower. Bet he never spent a day practicing medicine in the real world.

  • Anonymous

    I think Dr. Fred hit the nail on the head.

  • Anonymous

    You think this clown ever had to stand in front of the Powers-that-Be and explain why he didn’t order a Cat Scan on a patient who had a bad outcome: “But I did a Really Good Physical Exam, Really I did!! I thought I heard an S3!

  • Anonymous

    Osler’s dead and he ain’t coming back.

    That said, all the modern docs that can’t diagnosis appendicitis without a spiral CT will be up a creek when oil is $250 a barrel, there’s no transportation between communities because of an avian flu-like illness, or a dirty bomb closes the east coast.

    Could happen sooner than you think.

  • Anirban

    “when oil is $250 a barrel, there’s no transportation between communities because of an avian flu-like illness, or a dirty bomb closes the east coast
    Could happen sooner than you think”

    Perhaps an abridged version has been noticed already in New Orleans and the only factor that came into the way of patient-care
    was liability concerns(anecdotes although). A devastated hospital that had no spiral CT MRI ,still showed professionalism and provided excellent service with means at hand. Absent all these doctors and nurses the nemesis that is hanging loose “could happen sooner than you think”

  • Anirban

    “when oil is $250 a barrel, there’s no transportation between communities because of an avian flu-like illness, or a dirty bomb closes the east coast
    Could happen sooner than you think”

    Perhaps an abridged version has been noticed already in New Orleans and the only factor that came into the way of patient-care
    was liability concerns(anecdotes although). A devastated hospital that had no spiral CT MRI ,still showed professionalism and provided excellent service with means at hand. Absent all these doctors and nurses the nemesis that is hanging loose “could happen sooner than you think”

  • Anirban

    sorry for the repeat post.I apologize.

  • Anonymous

    Professionalism? In the medical industry? Perhaps you anonymice can go observe.

  • Anirban

    We observe and practice it everday but you will need eyes for it. What you don’t see with your eyes, don’t invent with your mouth

  • Anonymous

    You need to read some of these anonymous comments a little closer.

  • Anonymous

    CT scan for a patient who presented with a large zit on the lip. What did this test add to the care of this patient? What medicolegal exposure would have been incurred by NOT ordering this test? Does every patient who has an acute otitis media need followup wiht a specialist?

    Do you all still wonder why the gov’t and insurers taek the attitude that primary care doc’s can be replaced by PA’s and NP’s??

  • Anonymous

    Two sodomites from the same law firm were having lunch when suddenly one of them jumped up and said, “I have to go back to the office – I forgot to lock the safe!”

    The other sodomite replied, “What are you worried about? We’re both here.”

  • Anirban

    With primary care docs gone I would prefer following up from a specialist rather than a PA or NP if my hearing is at stake.The choice is yours where you will put your money and how much.By the way who was the doctor ordered CT for a “zit” on the lip? was it a Squamous Cancer, melanoma? was it biopsied?if indicated it will require CT scan for diagnosing metastasis and follow up. So you see medicolegal concerns are there in appropriate cases.

  • Anonymous

    The zit CT was on a healthy young man who presented to the ED with pain , swelling, and redness of the lip. You have to be a collosal moron to think you’re dealing with a melanoma in this setting. Again, what does the CT add to this patient’s care??

    And to the other poster, what makes you think your hearing is at risk after an isolated episode of acute otitis media? Your concern will make audiologists allover this conuntyr jump for joy.

  • Anonymous

    The “zit” on the lip could possibly be an external manifestation of an oral infection that has spread to the deep planes of the neck, AKA Ludwigs Angina. I would probab;ly concur with this ER doc and do a neck CT scan “just in case”. Remember, if you miss a Ludwig’s Angina you will be called on the carpet for missing such an easy diagnosis, in retrospect.

  • Anonymous

    With respect to htis article posted. the whole point is that a properly trained physician will recognize a Ludwig’s Angina on the spot and won’t need a damn CT scan to tell him what his eyes (a grossly underrated organ in these sad times) could in a second. Why not get a CT for every acute otitis media, since you can’t trust your eyeballs? The analogy is totally apropos.

  • Anonymous

    What kind of idiot would go to the er for a swollen lip is the question that should be asked…

  • Anirban

    “The zit CT was on a healthy young man who presented to the ED with pain , swelling, and redness of the lip.”

    You never said these before.Presentation like this doesn’t make him ‘healthy’ either because he wouldnt be in an ER in the first place but it does make you a “collosal moron”.encerta dictionary says Zit is a slang word for a pimple or blemish

    “Again, what does the CT add to this patient’s care”

    Same moronic behavior.what CT it was a head CT or Neck CT? Both may be indicated .Neck CT as my fellow gentleman has pointed out to exclude ludwig’s angina or any neck space infection.To add my two cents the lip anatomically is the dangerous area of the face from where the infection through the venous radicles is carried to the intracranial venous sinuses in the form of emboli leading to sinus thrombosis.It can happen suddenly and be life-threatening. In 2 to 3 out of every 10 cases it can be fatal.Doing a Head CT scan was definitely medicolegally practical.However I don’t know if you are still hiding anything

    “after an “isolated” episode of acute otitis media”

    Similar moronic omission in the first post. Are you in a position to advise me where from i get my follow-ups

    “a properly trained physician will recognize a Ludwig’s Angina on the spot and won’t need a damn CT scan to tell him what his eyes (a grossly underrated organ in these sad times) could in a second”

    There will be hundreads of (im)properly trained lawyers searching for a “properly trained physician” like this ,to sue “in a second”. In your words ,”will make them allover this “conuntyr” jump for joy”

    Stop being a jack of all trades.

  • Anonymous

    Why are you guys arguing with this moron…you guys are physicians, he is some loser who only wishes he could be called doctor…God knows what kind of low-skill job he has (if any…)

    Don’t debase yourselves…you shouldn’t breathe the same air as that guy let alone converse with him…go back and practice some defense…

  • Anonymous

    Seriously, you guys are better than everyone. You shouldn’t have to be accountable to the commoners now that you have medical degrees.

  • Anirban

    “Why are you guys arguing with this moron”

    Just to know how his thought process operates. It is enjoyable

    “Don’t debase yourselves”

    No way ,all this conversation lets you peep into the relms of human nature like this.

    “You shouldn’t have to be accountable to the commoners now that you have medical degrees”

    you don’t have to.Be truithful to the “commoners” you accept as patient.
    Accepting the difference of knowledge between a layman and professional I must say each person is unique in his/her own way.The word “comonner” is a slander to those you’re trying to represent.Just we all need to recognize our boundaries.

  • Anonymous

    yeah, you’re right…the thought process of the litigious patient is useful to know about…it will be another tool we can use to defend ourselves…thanks for setting me straight.

  • Anonymous

    So you’ll still CT scan a healthy guy with a lip zit eh? YOU’RE the moron who’s bankrupting the medical system. Didn’t you learn ANYTHING in medical school? The point of the article is the unbelievable lack of physical examination skills and accompanying logical thought processes that foollwo form mastery of those skills. You’re clearly demonstrating this. Your lack of clinical skills is no excuse for managing a patient no better than the average nurse or first year medical student. Nothing about what I was “hiding” changes any of the points I made. Remember that when your job is taken by a PA in a few years.

  • Anonymous

    who’s the bigger moron: the person who orders the ct with a flick of a pen or a few keystrokes, or the doofus who agrees to it and gets irradiated?

  • Anonymous

    I have never ordered a CT for zit of the lip, but I have ordered a CT scan and MRI for zit on the nose and found a cavernous sinus thrombosis — a life threatening emergency. Venous nasal drainage can go to central venous drainage.

    DEFENSE. DEFENSE. Order CT/MRI for any zit on the nose. Don’t let a lawyer with a retrospectoscope tell what a moron you were.

  • Anonymous

    All I can say is…good catch. But seriously, was there something that led you to order the ct, or are you just the king of defense…tell me more.

  • Anonymous

    It’s very sad to see what kind of guys are now part of the medical profession. It would do every one of you good to pay attention to what the retired Doc. is trying to tell you.

    You have cheapened your profession to the point that it won’t be long until the general public is “on to you”..You order CTs for patients and then call them (pts) morons for allowing it to be done. In fact you are calling yourself a moron because you are the only one who realizes how you practice medicine. the patient still believes in you. So who is the REAL mnoron?

    I guess you can enjoy this lazy, disgraceful, uneducated way of practicing medicine for awhile. But, one day when we all figure out what you are doing it will be a different story. I guess we can just look up our own symptoms and then call the hospital, lab or whatever and order our own tests. You know, maybe cut you right out of the mix..Get the reports sent directly to us and if need be just take ourselves off to a specialist.

    Walk into the ER and fill out a form that says headache, back pains, abdominal pains, etc….check here..Then there could be multiple choice tests or procedures that MIGHT show something. We can pick and choose what we like… No need for you at all, if you arent going to be a REAL physician.

    Yes, maybe we should just do that..No PCP, no ER Docs except maybe one on call for true emergencies. Then he can be paid by the actually work he does instead of seeing all these patients that really don’t need a Dr. at all.

  • Anirban

    “So you’ll still CT scan a healthy guy with a lip zit eh? YOU’RE the moron who’s bankrupting the medical system. Didn’t you learn ANYTHING in medical school?”

    How could we. Great clinicians like you got retired.Couldn’t learn the voodoo medicine you practice.

    “Your lack of clinical skills is no excuse for managing a patient no better than the average nurse or first year medical student”

    nobody has browbeaten you to visit ER or even a doctor.You always have the choice.

    “Nothing about what I was “hiding” changes any of the points I made”

    You have to be a real doctor to understand that. What you don’t see with your eyes, don’t invent with your big mouth.

    “good catch. But seriously, was there something that led you to order the ct”

    Then what is not so serious about this good catch.

    “It would do every one of you good to pay attention to what the retired Doc. is trying to tell you”

    Then understand what people are trying to tell you here. Do Unto Others As You’d Have Done Unto You.

    “You have cheapened your profession to the point that it won’t be long until the general public is “on to you”..”

    Won’t happen in your lifetime not even mine.the face of medicine has changed and people do understand that.

    “In fact you are calling yourself a moron because you are the only one who realizes how you practice medicine. the patient still believes in you. So who is the REAL mnoron?

    Don’t understand what are you trying to say.but name calling started from your side.Why your statemnts are so disorganized. Are you demented?

    “But, one day when we all figure out what you are doing it will be a different story”

    Acc to you you’ve figured it out already.So all the best for your campaign to raise awareness.

    “You know, maybe cut you right out of the mix..Get the reports sent directly to us and if need be just take ourselves off to a specialist”

    You can interpret your test reports,what prevents you to treat yourself.Why even need a specialist .Are you sure he is not “lazy, disgraceful and uneducated ” like a PCP,whom you despise.

    “No ER Docs except maybe one on call for true emergencies”

    Are u a real doc? In which ER you have worked? A million doller question here.

    Amazing to see what a jackass you are

  • Anonymous

    ” Your lack of clinical skills is no excuse for managing a patient no better than the average nurse or first year medical student.”

    What does DEFENSE have to do with my (or anybody’s clinical Skills? It takes me one minute to figure out with 99% certainty what is wrong with a patient. Then I order defensive tests (THOUSANDS OF THEM) to bring my sensitivity as close to 100% as I can. That’s the only way to protect myself from the Sodomites. And I’ll still get sued, I’m in a high risk specialty. Just not as often.

  • Anonymous

    If you ignore the obscene language, there is actually truth in what Anon 112 is saying in this thread.
    – amd

  • Anonymous

    “Yes, maybe we should just do that..No PCP, no ER Docs except maybe one on call for true emergencies. Then he can be paid by the actually work he does instead of seeing all these patients that really don’t need a Dr. at all.”

    I love how this moron thinks he has the power to change the medical system (he’s some retired loser who probably goes to the doc every time he gets a sniffle)…in your dreams pal…we’re going to keep making money of the defensive testing you idiots give us the opportunity to order…enjoy!

  • Anonymous

    “Yes, maybe we should just do that..No PCP, no ER Docs except maybe one on call for true emergencies.”

    OK, then the next time you get a viral URI, your nose is stuffed with Buggers, and you RUSH to the ER and complain about the 3 hour wait because some 14 year old has 14 bullet wounds and is tying up the ER staff (“That’s not my problem, how much longer, i’m really sick”) Whi will prescribe Broad spectrum antibiotics for your cold?

  • Anonymous

    William Osler would be deported back to England if he practiced medicine in the US in the 21st century. How the hell am I supposed to do Histories, physicals, order tests and spend hours documenting in the computer to cover my ASS and see 40 patients in an 8 hour ER shift? SOmething’s got to be left out, abd the only thing I can sacrifice is the H + P. WHen we go to Continuing ED lectures , you think they talk about good physical exam skills? “Interactions that Create/Prevent Malpractice” ….that’s all we hear at lectures. We’re not doctors anymore, we’re Lawyer Avoiders.

  • Anonymous

    I think you are putting too much blame on the lawyers…it takes two to file a suit…a lawyer and a litigious patient. The patients are just getting the kind of care they deserve, what goes around comes around…they just don’t know it. DEFENSE RULES!

  • Anirban

    Unrealistic expectation of the patient and the lawyer’s gaming of the system reinforce each other. With so many law grads churned out the fight for cases, the line of money and power has become quite murky. The selection of the cases has been mostly on the tragic outcomes, regardless of an element of malpractice. Otherwise how can a doctor win 75% of the time, with juries who unequivocally put themselves in the common man’s shoes. Virtually it is a trial of 13 plaintiffs. Sad to see it has been allowed to persist unchallenged until recently.

  • Anonymous

    “I think you are putting too much blame on the lawyers…it takes two to file a suit…a lawyer and a litigious patient.”

    I disagree. The Sodomites advertise on TV when most people are working, late night, and midday, so the unemployed and welfare population they are trying to reach (who are looking for a financial way not to work) are watching and will call. You’re sitting at home, unemployed, you see a commercial for a sodomite who says “did a doctor hurt you?, well hurt him back”, and you think to yourself, “well Uncle Ernie died last year, maybe I’ll call this lawyer and he’ll get me some money from that hospital he died in”.

  • Anonymous

    That’s exactly my point…if the patients had any respect for the doctors helping them, they wouldn’t call…they deserve to be hurt back, not just the lawyers…

  • Anonymous

    I disagree with you…despite what some of the trolls on this website say (CJD and his disciples, Sarah etc.) I actually like the patients I see and I don’t blame them for being sucked in by the opportunity at an easy quick buck at our expense. As for the sodomites, as Mark Twain sorta said, the only good lawyer is a DEAD lawyer.

  • Anonymous

    Don’t forget, one little mistake and all those patients that you love so much will turn on you like a pit bull…just stick to the defense and you won’t get burnt.

  • Anonymous

    “We’re not doctors anymore, we’re Lawyer Avoiders.”

    You may still be a doctor, but you’re clearly not a professional.

  • Anonymous

    We still have a license to do procedures and whatever we want to you…I guess that makes us professionals?

  • Anonymous

    And you wonder why the “profession” of medicine has lost so much respect?

    By the way, do you really think your ISP can’t be figured out and you can’t be traced? These posts will make some compelling reading for 12 people some day.

  • Anonymous

    I hate lawyers. I think they are the scum of the earth, as well as several other planets. If a jury is going to award the lottery to one of you sodomites because I write about how you parasites suck, it reinforces what is wrong with the system.

  • Anonymous

    I think it’s your disdain for your patients that will be your downfall. Wonder how this will play in Peoria:

    “We still have a license to do procedures and whatever we want to you”

    and

    “if the patients had any respect for the doctors helping them, they wouldn’t call…they deserve to be hurt back, not just the lawyers…”

    Better start posting from the public library with all the other psychos.

  • Anirban

    “You may still be a doctor, but you’re clearly not a professional”

    But we don’t choose to be sacrificial lamb for the legal ‘profession’ either. So tough to keep your grubby hand off us.

    “And you wonder why the “profession” of medicine has lost so much respect?”

    Medicine is in a sense a victim of its own success. Transplants of heart, lungs and liver seem so routine that we are surprised when they don’t take. A fetus can be operated on in the womb, and extremely premature babies regularly survive, and so we now view any birth-related injury as someone’s fault. All the time we presume a cure. A bad outcome is a betrayal; lawyers repeat the cliché “it is un-American”. More we become critical of it reinforces the fact that it is effective and is supposed to be.
    Basically this is the reason why medicine is loosing respect I think. But having said that, it is well above how people view the lawyers, especially the trial lawyer variety and most of them don’t bite the hand that cares for them.

    “These posts will make some compelling reading for 12 people some day.”

    Would like to apply a Stanford –Binet test on you. No judge will admit a blog like this as evidence, unless you’ve heavily campaigned for his/her election. Even if it is there it is supposed to be interpreted by a group of my peers who are active and informed.

    Just to refresh your memory, in the first Vioxx trial seven jurors had only high school educations, while two went to college for two years and one for four. The other two didn’t indicate where their education stopped. They could easily be persuaded to believe that the pharmaceutical companies are enemies of the ‘common man’ on the basis of some internal documents and emails. In the second trial Lawyers tried to play the same cards but a group of jurors including a former prosecutor a insurance defense lawyer a retired real estate agent, a bank manager, a casino supervisor, an accountant, a grade-school teacher and an administrative assistant were not that gullible .They didn’t buy the story of email conspiracy. To quote one , Juror Patricia Harley, 44, said the internal emails weren’t a problem for Merck. “If someone peeked through all my emails, forget about it,” .And the rest is history

  • Anonymous

    “Basically this is the reason why medicine is loosing respect I think.”

    Yes, I’m sure the ridiculous levels of arrogance by the anonymous posters has nothing to do with it. The thing is though, that’s probably not even the real reason why. The real reason is likely due to the fact that medicine is not viewed as a right by most voters. Thus, you’re nothing more than highly skilled civil servants, another govt. bureacracy to be endured.

    “especially the trial lawyer variety and most of them don’t bite the hand that cares for them.”

    And yet everyone, including and especially doctors, run to the trial lawyers when things don’t go their way. Strange, huh?

    “No judge will admit a blog like this as evidence, unless you’ve heavily campaigned for his/her election.”

    Yes, because no emails have ever made it into evidence, eh Mr. Skilling?

    “Even if it is there it is supposed to be interpreted by a group of my peers who are active and informed.”

    Your arrogance has caused you to misconstrue the meaning of the word peers in this context.

    What’s more, your knowledge of the Vioxx facts is quite poor, which is surprising considering the way you denigrate the jurors. It was not the same lawyers at all who tried the second case. It’s also impressive how you could take two completely separate cases, both with weeks of testimony each, and distill the difference down to the education of the jurors, people you’ve never met. Do mind reading skills come with a medical degree?

  • Anirban

    “The real reason is likely due to the fact that medicine is not viewed as a right by most voters. Thus, you’re nothing more than highly skilled civil servants, another govt. ‘bureacracy’ to be endured.”

    interesting theory. Doctors work for Government insurance program, private HMOs or as a fulltime salaried employee or a lot others. Sometimes they may act as an extension of the government and the bureaucracy, So are a lot of other people with other profession. Hardly makes a civil servant out of anybody. And the people who views health care as their right,i.ve found them most litigious . Health is never a right, can’t be given to any body. It is an asset that has to be earned and maintained .period. There is no element of truth in your assertion.

    “And yet everyone, including and especially doctors, run to the trial lawyers when things don’t go their way. Strange, huh?”

    The prevailing culture of victim hood and entitlement hits everone .Doctors are no exception. That being said the fundamental question is Even if I hire a hit man for my purpose (doesn’t make me a saint) how much I can trust him and given a questionnaire will rate him for professional work, even though he may be pretty good in his job

    “Your arrogance has caused you to misconstrue the meaning of the word peers in this context.”

    Enlighten me. And face some more arrogant music (if you think it is.)

    “Considering the way you denigrate the jurors”

    It is denigration, are you so thin-skinned? If I had to endure rambling of a Harvard physicist on nanotechnology and nanorobots not for fun but to remember and second-guess later when I find another scientist holding much different opinion and I’m between Scylla and charybdis .”Whom to believe to pass the judgment” I ask from my yawning mouth”

    If anybody tells me that I did a lousy job does it denigrate me as I am a doctor? No my education has not empowered me in that way let’s face the truth. But I see a lawyer so eager to put me in the jury pool. If you can’t convince him better confuse him. Who denigrates me more? Jury system as the way it is, will spark discussion and criticism time to time. Let’s not make it a holy cow.

    “It was not the same lawyers at all who tried the second case”

    And I thought justice is done on the merits of the case not how clever the lawyer was .By the way are you denigrating Chris Seegar ?

    “It’s also impressive how you could take two completely separate cases, both with weeks of testimony each, and distill the difference down to the education of the jurors, people you’ve never met”

    The final nail for Merck’s coffin was those dubious emails and internal documents so vocipherously crowed by Lanier in the 1st trial .Seegar took the same path and got slapped. Hardly it takes time to know the thought process of a person,even you’ve not met him if some one could lap up their identities and statements. Just needed a little googling. How the juries of the 2nd trial felt and issued their statement was avoided by the ATLA website like a flea infested mongrel ,even when you see those of the 1st case burning bright. Do mind you are the only one with internet connection?

  • Anonymous

    “Health is never a right, can’t be given to any body. It is an asset that has to be earned and maintained .period. There is no element of truth in your assertion.”

    Don’t kid yourself. With the nations largest and most wealthy voting bloc now becoming the biggest consumers of healthcare, it’ll be a right before the end of this decade. Not health, healthCARE.

    “Even if I hire a hit man for my purpose (doesn’t make me a saint) how much I can trust him and given a questionnaire will rate him for professional work, even though he may be pretty good in his job”

    Why would you trust a doctor for the same reasons?

    “Enlighten me.”

    Do your own constitutional law research.

    “Jury system as the way it is, will spark discussion and criticism time to time. Let’s not make it a holy cow.”

    I agree wholeheartedly. What I’m referring to is the belief by physicians that they should not have to be judged by anyone but others with a medical degree and the belief that jurors are simpletons who are all easily swayed by emotional pleas.

    ” Just needed a little googling.”

    Yes, because a few quotes in the Wall Street Journal are representative of the evidence of an entire trial, involving two different plaintiffs, with two different medical histories, who took Vioxx for different lengths of time.

    Considering the amount of complaining physicians do about how the media reports medical issues, it’s amazing the faith you have in its ability to accurately report legal ones. You hear what you want to hear, I guess.

    Can I accurately assess your intelligence based on what you’ve written here, which is far more voluminous than any quotes from the Vioxx jurors?

    CJD

  • Anirban

    “With the nation’s largest and most wealthy voting bloc now becoming the biggest consumers of healthcare, it’ll be a right before the end of this decade”

    Does it make it more dangerous or less dangerous, only time will tell. But as an advocate of a free market economy I think we should have choice where I can sell my craft. Be it NHS or Canada style it will bring their own share of woes. It will be over simplistic to hop to the other side of the fence. Having said that, it was my person opinion in context to challenge someone else’s false belief.

    “Why would you trust a doctor for the same reasons?”

    People usually don’t bite the hand that cares for them but some of them have their dentures borrowed from a lawyer- could be another lawyer joke. Going to post on lawyer stink

    “belief by physicians that they should not have to be judged by anyone but others with a medical degree and the belief that jurors are simpletons who are all easily swayed by emotional pleas.”

    Not everyone can judge scientific evidence. I can’t judge evidence on astrophysics but can if it is a C+ programme. I know my limitations so everybody should. After the heavy battle of the expert witness is over, refuting each other what else a jury member can do, not to respond to a Broadway tearjerker. Probably I would have done the same thing.

    “It’s amazing the faith you have in its ability to accurately report legal ones”

    Conscientious issues like law is subject to more introspection and second guessing because it is not science in the first hand , much more ethics logic and philosophy kind where people can talk and talk and nothing comes out. So the opinion gets polarized based on the career political belief and ideologies. But that is what law is.
    Even the mostly hot debated issue in Medicine is not the steps of Lap chole but of legal medicine. So which legal reporting I can believe. If I refute vioxx 1 why not 2 or 3 or vice versa why cant there be a court TV like thing for tort cases as the drama here is no less now a days, because there is so much money involved

    “Can I accurately assess your intelligence based on what you’ve written here, which is far more voluminous than any quotes from the Vioxx jurors?”

    You can’t, but can see how the thought process operates which is only a fraction of the total intelligence

    “Because a few quotes in the Wall Street Journal are representative of the evidence of an entire trial”

    Call it evidence. I call it bottom-line to see what went in their mind .what comes out of their mouth,if it was’nt doctored, is a glimpse of that and that is what a trial is all about.

  • Anonymous

    “After the heavy battle of the expert witness is over, refuting each other what else a jury member can do, not to respond to a Broadway tearjerker. “

    And yet the physician wins 75% of the time. Maybe they are just more strong willed than you are, and less prone to being swayed by emotion?

    “Conscientious issues like law is subject to more introspection and second guessing because it is not science in the first hand , much more ethics logic and philosophy kind where people can talk and talk and nothing comes out.”

    I think you should watch a trial sometime. A trial is not like a debate class where attorneys just get up and muse on various subjects.

    “You can’t, but can see how the thought process operates which is only a fraction of the total intelligence”

    It’s stunning to me that one would think they can understand a person based on a couple of sentences. I think you’re illustrating where a medical education falls short in understanding others.

    “Call it evidence. I call it bottom-line to see what went in their mind .what comes out of their mouth,if it was’nt doctored, is a glimpse of that and that is what a trial is all about.”

    I can’t imagine that the Journal, with its decidedly pro-limited liability for corporation stance, would take a portion of a quote to make a point, can you? I read the Journal every day, and enjoy it immensely, but even when I agree with them I retain my skepticism.

    CJD

  • Anonymous

    Remember OJ CJD?
    This is the FACT. the molecular biology PROVED his blood was at the scene of the crime which means one of two things

    1: He did it

    2: There was a massive conspiracy by the LAPD to set up OJ

    We know what the jury went for. You know better than I WHO you pick for a jury. Quit the BS.

  • Anirban

    “And yet the physician wins 75% of the time. Maybe they are just more strong willed than you are”

    Are you pointing to that fraction? Which shouldn’t be there in the first place . Doctors will win those any way. Despite the treacherous character of a trial. You try those as a jackpot and sometimes prove yourself a jackass.

    “Trial is not like a debate class where attorneys just get up and muse on various subjects”

    Then what it is any way .Attorney does get up, not as often, and muse. In fact they muse everywhere in front and behind the camera in front and back of their client, the judge and juries .they are trained to muse and confuse. Why shouldn’t they.

    “I can’t imagine that the Journal, with its decidedly pro-limited liability for corporation stance, would take a portion of a quote to make a point”

    And you imagine an organization like ATLA or CJD or lots of phony others, with their “pro trial lawyer pocket stance “won’t make a point with their share of quotes. They do. It is up to me to analyze those with the jurors’ background.

  • Anonymous

    “We know what the jury went for. You know better than I WHO you pick for a jury. Quit the BS.”

    Obviously, one jury is representative of the thousands of juries that hear cases every day across the country. Just like one physician is representative of the thousands of physicians across the country, right?

    Excellent analysis.

  • Anonymous

    “Despite the treacherous character of a trial. You try those as a jackpot and sometimes prove yourself a jackass.”

    I’m curious, how many trials have you observed?

    “Attorney does get up, not as often, and muse. In fact they muse everywhere in front and behind the camera in front and back of their client, the judge and juries .they are trained to muse and confuse. Why shouldn’t they.”

    You’re right – it’s just like on TV. Same as medicine. I surrender to your superior experience.

    “And you imagine an organization like ATLA or CJD or lots of phony others, with their “pro trial lawyer pocket stance “won’t make a point with their share of quotes.”

    That’s why I don’t cite ATLA as my source for anything.

    “It is up to me to analyze those with the jurors’ background.”

    God, is that you? Nope, just another physician with a god-complex.

  • Anirban

    “You’re right – it’s just like on TV. Same as medicine. I surrender to your superior experience”

    I think you don’t experience publicity whores babbling on TV to call them for making a fortune. in contrast to those histrionics. Law and order or, Boston legal is a nice watch. Are you pointing to those? A similar thing in Medicine would have been an angelic Santa Claus like Doctor with a Magic Wand in hand promising cure for any Disease – Come to me, see how the road to secret garden opens for you. I scratch my head No I haven’t seen. Any way I’ve seen lots of ‘ER’ or ‘Chicago Hope’

    “God, is that you? Nope, just another physician with a god-complex.”

    Then we are a nation of GODS .Everyone should have the right to think in their way. Because I don’t take your argument lying down, I’ve God complex. Are you just another lawyer with unbridled chutzpah?

  • Anonymous

    No, you have a God complex because you believe you can accurately assess the intelligence and reasoning of a person based on a couple of sentences in a newspaper article. The chutzpah is yours, my friend.

    You’re right though, physicians don’t advertise. The insurers and hospitals supply their customers and reward them handsomely – one of the upsides of not being part of the free market. Surely you’re not going to tell me that hospitals don’t advertise, are you? Or that insurers don’t?

    And scratch your head no more, my friend:

    http://abc.go.com/primetime/miracleworkers/

  • Anirban

    “The insurers and hospitals supply their customers and reward them handsomely – one of the upsides of not being part of the free market”

    Free market is nostalgia for a physician who could charge the way he/she liked and let the market decide that. They are presently tied with rims of paperwork to satisfy a faceless bureaucrat; their reimbursements are slashed and go down year after year and with no leverage for negotiation. If this your handsome reward and the idea of free market for a physician is, Adam Smith must be spinning in his grave.

    Efficiencies of a free-market is well-known and if it works in any sphere so it is medicine, so is law . The problem, however, is that unlike computer industry or the health care industry government mandates the existence of your legal industry. That’s why it neither has competition, nor fear of drying up and go away.

    For starters, there is little benefit to your legal industry to ensure that rewards- which, again, are supposed to make things even, actually find their way to victims. You can debate the specific numbers all day long- amount of work involved in bringing a case,where real dollars actually split in real cases, and the reasoning behind all of these things. The end result is that there is no way for
    a victim to resolve legal conflicts and get justice other than using the lawyers,now so much of them, and the industry itself can only sustain itself
    with money not paid to victims.

    This imbalance, in turn, causes law to be used as a weapon- a first line of defense- more often than a last-resort reaction

    In addition one of the dirty little secrets of the American legal system is that anyone who feels wronged, or wants to feel wronged, for any reason, is protected from any risks you might think exist in bringing a lawsuit against another individual or company.

    So considering our ‘nation of victims’, there are very few situations in which a particularly vengeful person can’t find something to sue for. Sure, such cases may be thrown out fairly quickly- but that’s not the point. The point is you vindicated yourself by forcing your ‘enemy’ to part with quite a bit of money. It’s a scary amount of unchecked power the average citizen has – this is not free market

    If it is that impossible for our legal system to operate not as a money-making industry, but somehow outside of the free market, then the next-best solution would be to “check” it with the risks and rewards of the free market itself.

    In a sense legal industry could be seen as an industry with standard “no risk, money back guarantee.” marketing practice The only differentiator here is who sues who- you only get the no risk guarantee if you decide to sue first Are we just inspiring people to be victims and file suits over more risky free-market based methods This notion that a losing plaintiff never has to pay flies in the face of the entire concept of a justice procedure which supposedly can
    assess a monetary loss caused by any action, and if necessary, require an offending party to compensate the “victimized” party for that loss.

    If someone cannot possibly stamp a physician or any body a victim of a wrongful lawsuit- which is essentially what the legal system is saying- then how can we consider people who suffer property damage, damage to a reputation, or other such things victims who deserve retribution? What is the difference?

    If you ever want the legal system to play in the free market, then the only way to ensure its done fairly is if the same concepts of shared risk are allowed to remain. Bring a lawsuit, be prepared to suffer the consequences of, frankly, wasting everyone’s time.

    See how talking about free market opens up your can of worms.

  • Anonymous

    “Free market is nostalgia for a physician who could charge the way he/she liked and let the market decide that. They are presently tied with rims of paperwork to satisfy a faceless bureaucrat; their reimbursements are slashed and go down year after year and with no leverage for negotiation.”

    And yet physicians are doing it already – plenty of blogs on the subject. If you aren’t, it’s because you choose not to.

    ” The end result is that there is no way for a victim to resolve legal conflicts and get justice other than using the lawyers,now so much of them, and the industry itself can only sustain itself
    with money not paid to victims.”

    If you can think of a cheaper way to get responsible parties to pay for their damages, I’d love to hear it. All services cost money, including legal services.

    “In addition one of the dirty little secrets of the American legal system is that anyone who feels wronged, or wants to feel wronged, for any reason, is protected from any risks you might think exist in bringing a lawsuit against another individual or company.”

    This statement lacks a factual basis.

    “It’s a scary amount of unchecked power the average citizen has – this is not free market”

    The power of the individual citizen is what defines the free market, my friend.

    “This notion that a losing plaintiff never has to pay flies in the face of the entire concept of a justice procedure which supposedly can assess a monetary loss caused by any action, and if necessary, require an offending party to compensate the “victimized” party for that loss.”

    Ahh, I see the problem – you don’t understand the economics of the plaintiff’s case – someone does pay – namely the lawyer. And in business torts, the plaintiff themselves. So it is not by any stretch of the imagination (beyond small claims court) a free shot. What’s more, almost every state does have a version of loser pays.

    The other problem with your logic is that we have already paid for the defense in the terms of premiums for our insurance. The insurer understood this risk and weighed it against the profit potential of utilizing your premium in the interim when it set the price and collected your money.

    Most of the awards in law, be it contracts, tort, individual or corporate parties, are about burden shifting. Rarely is their a net benefit. Take your average malpractice case – the bulk of the award ends up in the hands of medical providers or the plaintiff’s insurer. Another large chunk will reimburse the plaintiff for lost wages. These are all costs that would be incurred regardless to society, we are just putting them on the responsible party.

    The only can of worms we’ve opened up is an illustration of your lack of knowledge of how the law and the legal system work. Exactly how many trials have you observed? How many cases have you been involved in?

  • Anirban

    “Plenty of blogs on the subject. If you aren’t, it’s because you choose not to”

    These are for venting day to day frustration and have a sense of bonding like another worker in a high-risk job. Leverage for negotiation only comes from lobbying,collective bargaining and lastly the notorious industrial action stance. Physicians are poor in those ‘because they aren’t trained. I don’t see medical schools waking up to reality in near future.

    “All services cost money, including legal services.”

    And the unique thing is that it is mandated by the government. There is a reason it cost hundreds of thousands of dollars to go to law school. There is a reason our legal statutes are the size of libraries (but constitution is only few pages long). There is a reason very few people actually understand the minutia of most court cases- even those involving simple Subjects.

    The complexity of laws and legal proceedings keep lawyers in business. Although I’m not a conspiracy theorist but it seems the whole system was devised to benefit the lawyers, mandated by government. So probably what is needed is a somewhat DEMYSTIFICATION and DE-COMPLEXIFICATION OF LAW

    “This statement lacks a factual basis”

    What is the downside of bringing the lawsuit for the plaintiff?

    “The power of the individual citizen is what defines the free market “

    Then common sense tells us that it is to be extended to both the parties in a lawsuit, if fairness isn’t a hollow word. if a rule is allowed to be a precedent, to line some one’s pocket (govt. mandated remember) and making the defendant eat humble pie, is not a free market, if not a scary conspiracy.

    “Almost every state does have a version of loser pays”

    No state has it in the European style and what is there is an eye wash. And when I’m the defendant and I win I give a shit where your money comes from plaintiffs or lawyers ‘cause you dragged me to court for no reason.

    “The other problem with your logic is that we have already paid for the defense in the terms of premiums for our insurance. The insurer understood this risk and weighed it against the profit potential of utilizing your premium in the interim when it set the price and collected your money.”

    That big premium came from a physicians sweat and labor and extra hours of work. May be he wouldn’t work that hard or use it for his own (nothing selfish about it) rather than squander it on your whims. Defending even a bogus case cost my insurer money that is passed on everybody, artificially raising premiums. Not with tort reform but with a proper loser pay system premiums can go down significantly

    Your can of worms still open.

  • Anonymous

    “Physicians are poor in those ‘because they aren’t trained.”

    They don’t have to be trained in it. They simply need to hire the people who are. That’s what every other group does.

    “There is a reason it cost hundreds of thousands of dollars to go to law school.”

    It doesn’t cost hundreds of thousands at most state schools.

    “There is a reason very few people actually understand the minutia of most court cases- even those involving simple Subjects.”

    Yeah, because they’ve never read them. How many actual cases on, say, a contracts dispute between a homeowner and builder have you ever read and could not understand? I’d venture to say none, because you’ve never read any. You’re just assuming.

    “What is the downside of bringing the lawsuit for the plaintiff?”

    Depends on the case. The expense, the time involved, etc. If it’s a contingency fee case, it’s the lawyer who has the downside.

    “No state has it in the European style and what is there is an eye wash.”

    I bet you can’t even tell me what we have here, much less how it works in Europe. In fact, I’m almost certain that you’ve not looked at one statute from any country in Europe, much less any state in America, which explains it.

    “And when I’m the defendant and I win I give a shit where your money comes from plaintiffs or lawyers ‘cause you dragged me to court for no reason.”

    Do you really believe every defendant who is sued did absolutely nothing? That literally every case is frivolous? I’m sure those health insurers who were sued by 900,000 physicians would agree with you.

    ” May be he wouldn’t work that hard or use it for his own (nothing selfish about it) rather than squander it on your whims.”

    So if you had loser pays you wouldn’t carry insurance? Do you really believe you are incapable of negligence of any form? Impressive!

    “Defending even a bogus case cost my insurer money that is passed on everybody, artificially raising premiums.”

    Why is it artificial? Do you not think the insurer analyzed the risk? Do you even know how much your premiums went up as a direct result of that cost? I’d bet you have literally no clue as to how your premiums are determined.

    “Your can of worms still open.”

    The analogy died a couple of posts ago.

  • Anirban

    “They don’t have to be trained in it. They simply need to hire the people who are. That’s what every other group does”

    Be it physicians themselves or any people they hire, even the idea of lobbying, collective bargaining and not to mention industrial action flies off in the face of the hard core ethics the medical school tries to drill in their students. This imposed altruism is a perfect recipe for disaster .The ivory tower of medical ethics is so high; the sound never reaches the ordinary physician like us. it dies down in the middle. Training is a mindset that medical schools failed to impart in the changing world

    That is the point.

    “I bet you can’t even tell me what we have here, much less how it works in Europe”

    Chutzpah once again. My dear friend just follow this link and educate yourself . It will take a good no. of posts to sum up what is given here.

    http://www.overlawyered.com/loser_pays/

    “Do you really believe every defendant who is sued did absolutely nothing? That literally every case is frivolous?”

    If you believe the jury system then without second-guessing, a person exonerated did absolutely nothing. Out of this A fraction is definitely frivolous.. The suspicion rises when the rate of exoneration is rising up to 75-80 %. To prove it is frivolous a physician has to counter-sue, which are rarely allowed to proceed (I’ve heard only a couple of successful ones), and expenses are not borne by insurance (except by some phony Medical Justice), and no lawyer will work on contingency fee especially against another lawyer. So to legally prove the case was frivolous is more difficult than to prove malpractice.

    “So if you had loser pays you wouldn’t carry insurance? Do you really believe you are incapable of negligence of any form? Impressive!”

    You’re putting your words in my mouth. Mishaps happen and so there is the insurance .
    But these are for compensating actual victims, not for defending false claims Since mistake is inevitable , a rational approach should be to share the burden between Doctors and their patients ,from a common pool . Loser pays doesn’t eliminate insurance, just streamline that and make it realistic.

    “Do you not think the insurer analyzed the risk? Do you even know how much your premiums went up as a direct result of that cost?”

    If an insurer has to analyze the risk of bogus claims then the gaming of the system is in full swing. It sounds more like Vito Corleoni making an offer the company can’t refuse and will go on coughing out protection money so a crack-pot lawyer can play jackpot

    “”Your can of worms still open.”

    The analogy died a couple of posts ago”

    You buried it ,but the stench is reprehensible

  • Anonymous

    “Be it physicians themselves or any people they hire, even the idea of lobbying, collective bargaining and not to mention industrial action flies off in the face of the hard core ethics the medical school tries to drill in their students.”

    Stop the madness with this nonsense. Physicians have no problem hopping into bed with insurance companies to make a buck, or suing them to make another. All the sudden you’ve got an aversion to lobbying for your bottom line? How sweet.

    “Chutzpah once again. My dear friend just follow this link and educate yourself . It will take a good no. of posts to sum up what is given here.”

    Your link doesn’t explain how the current system of loser pays work. I think I’ve pretty clearly illustrated that you don’t know what you’re talking about on this issue, whether it’s in this country or abroad. I’ll tell you again, though – almost every state in the Union already has a version of loser pays.

    But hey, you’ve read Overlawyered so you have the insurer’s position down. You’re halfway to understanding.

    “no lawyer will work on contingency fee especially against another lawyer.”

    You must be drinking with this statement. I know plenty of lawyers who, if there are sufficient damages, will take a contingency fee case against another lawyer.

    “But these are for compensating actual victims, not for defending false claims”

    So then a claim must always be false or true, correct? There is no room for honest disagreement on, say, the standard of care? Have you never had a disagreement w/ another physician on proper care?

    “a rational approach should be to share the burden between Doctors and their patients ,from a common pool.”

    What are you proposing here? A tax on doctors earnings and patients earnings to pay for physicians’ negligence?

    “If an insurer has to analyze the risk of bogus claims then the gaming of the system is in full swing.”

    I think it’s also pretty clear you have no concept of how insurers work. Seriously, read the Buffett letter to get a start.

  • Anirban

    “All the sudden you’ve got an aversion to lobbying for your bottom line? How sweet”

    Who said so . I am all for it. But many actions that seems quite natural for other people , are not tenable for us ‘cause you lose public support very soon. And it does cause “harm” in the short term. So the answer is still blowing in the wind.

    “I’ll tell you again, though – almost every state in the Union already has a version of loser pays.”

    Then link me something,

    “You must be drinking with this statement. I know plenty of lawyers who, if there are sufficient damages, will take a contingency fee case against another lawyer”

    Then all successful physicain will plan a countersuit at the drop of a hat (about 75% of them) . Doesn’t seem to happen.

    “There is no room for honest disagreement on, say, the standard of care? Have you never had a disagreement w/ another physician on proper care?”

    Oh my God. Those honest disagreeing physicians don’t debate with me in the court room costing my time and money. And if there are so much of honest disagreement
    Some Expert witness will agree and some won’t .the plaintiff s lawyer will search for someone to agree. Then we all have honest agreements and disagreements, and medicine will go to hell. If medicine is so subjective a thing, it should have been immune to law suits.

    “A tax on doctor’s earnings and patients earnings to pay for physicians’ negligence?”

    Why not? if physician is not negligent patient will have his own share and in a case of negligence’ pt would have both. That’s better than applying for medical bankruptcy because this system won’t give a dime, if he can’t prove. You can make it more interesting if some tax from the lawyer’s income can enrich this pool, if they chose to represent the plaintiffs. No contingency fee just standard hourly fees. Difficult, but nonetheless possible.

    “I think it’s also pretty clear you have no concept of how insurers work. Seriously, read the Buffett letter to get a start.”

    What is that ?

  • Anonymous

    “But many actions that seems quite natural for other people , are not tenable for us ‘cause you lose public support very soon. And it does cause “harm” in the short term.”

    What are you talking about? You already have a massive lobbying arm in the AMA, it’s just not very effective. No one is going to lose respect for you if you lobby for higher Medicare reimbursements. You’re already bitching about it incessantly as a profession, what do you have to lose by actually trying to change it?

    “Then link me something,”

    Do your own research Google any state’s statutes and then search within them for “offer of judgment”. It essentially works like this: A defendant or plaintiff can make an offer, and if the other side rejects the offer and continues with the case and the ultimate verdict is not within x% of the offer, either high side or low side depending on the party, then the party who offered pays the costs.

    “Then all successful physicain will plan a countersuit at the drop of a hat (about 75% of them).”

    You’re equating a losing case with a frivolous case. Every case has a loser, but that doesn’t mean every case is frivolous.

    “the plaintiff s lawyer will search for someone to agree.”

    And you know this from your extensive experience within a law office? Have you ever even spoken with a plaintiff’s lawyer regarding how they select their cases? Or are you reading minds?

    “Difficult, but nonetheless possible.”

    Absolutely – so propose it legislatively.

    “What is that ?”

    Berkshirehathaway.com. Letter to Shareholders, February ’05. Insurance part starts on about 3rd page I think.

  • Anirban

    No pun Intended Frankly anonymous you seem quite nice to me. Are you a woman ?

  • Anonymous

    Ahh the anonymice must be CJD lite