Comments on: A cost effectiveness institute

By: Mike

Mike — Thu, 14 Jun 2007 02:15:00 +0000

The sad truth is that so many medical "mistakes" are not mistakes... its just bad luck. Patients never want to hear that, but the woman in the Florida trial who didn't get the fluids, that case literally turned on a dime I imagine. I wonder how many of my patients could just as easily croaked, and I not having done ANYTHING different. If the Merenstein patient had never had prostate cancer, for instance, but even more subtle.

I've heard over and over that when it comes to aseptic technique in the OR you could pee in a wound and no sepsis would occur (I'm not ready to try it, but anyway...) But so much prep and antibiotics are given. How many of those unfortunate infectious complications occured just on bad luck?

Two patients with identical age/sex/diseases/etc can have ENTIRELY different outcomes. Every doctor has seen that one case that was out of the blue! Of all the sicklers who come to hospital and appear fine, but demand tons of opiates. And then you get blindsided by that one who codes in the middle of the night. what made them different??? The sad truth is that most of the time, the answer is... nothing.

Juries aren't qualified to determine the outcome of cases like that. And I suspect that all the EBM in the world wouldn't help either.

By: Anonymous

Anonymous — Wed, 13 Jun 2007 23:11:00 +0000

Anon 11:13, I wrote the original comment and your response sparked something in me.

I'm a medical student (there, I outed myself) but my background is actually in Health Law (admittedly academic, not trial). I really do sympathize with the complaint that dueling experts is no way to establish a meaningful standard of care in med-mal. I also don't think it is quite as simplistic as 'they [MDs] all want immunity to butcher you anyway they please'. What really bugs the docs I talk to is the feeling of the capriciousness of it all. When MDs scream for things like evidence based standards of care, what they're really asking for is arbiters of fact who are competent to the task.

Leaving aside practical matters (I'm an academic, remember?) The real intellectual appeal of health courts isn't that doctors will win more often (they already win the overwhelming majority of the time). The real appeal is that the trier of medical fact is someone who is specially trained in the area and has access to a body of expert opinion; equally importantly (to docs anyway) is the perception that people trained to hear medical cases will not only be competent to understand the testimony but will also be largely immune to appeals to sympathy.

The problem with an EBM database isn't that it doesn't offer enough protection at trial, it is that it isn't a reflection of what a competently trained physician would do in the case at hand. And that, after all, is what med mal is SUPPOSED to be about.

By: Anonymous

Anonymous — Wed, 13 Jun 2007 16:13:00 +0000

” If there ever were a sort of Cochrane that actually held weight in a court of law all you’d get would be complaints from the doctors who (rightly or wrongly) judged their patient to be sufficiently different from those the Cochrane review was based on and deviated from the ’standard’ of care and then ended up in court over a bad outcome.”

Exactly. There’s nothing short of immunity that will satisfy them.

By: N=1

N=1 — Wed, 13 Jun 2007 14:30:00 +0000

Cost control opportunities lie with administrative, claims and insurer/HMO authorization time and documentation -to the tune of up to 40% of all dollars spent on healthcare. Get that down to the Medicare administrative fee overhead of around 3% and then I’ll take the rest of your position more seriously….

By: Anonymous

Anonymous — Wed, 13 Jun 2007 14:22:00 +0000

There has to be an irony somewhere in the same blog that is so consistently anti-socialization/centralization of health care management supporting what amounts to the centralization of clinical decision making. Look I’m as big an EBM cheerleader as the next fellow, but let us be perfectly clear about what EBM is evidence of/for. It is evidence of what works on aggregate. It is most helpful when your patient looks exactly like the patients in the studies the EBM was based on. The reality is that patients each have their own foibles and the more ‘unique’ they get the harder it is to hang your hat on the EBM. If there ever were a sort of Cochrane that actually held weight in a court of law all you’d get would be complaints from the doctors who (rightly or wrongly) judged their patient to be sufficiently different from those the Cochrane review was based on and deviated from the ’standard’ of care and then ended up in court over a bad outcome.