1) The NHS is discovering how ERs are circumventing the mandate that patients be seen within 4-hours. Patients are simply kept in ambulances longer.
My take: Incentives to mandate medical behavior often leads to unintended consequences. Witness our current fee-for-service system where physicians are paid based on the quantity of work they do. It should come as no surprise that the majority American doctors strive to do more and see more, simply because the system rewards such behavior.
It is imperative that physician incentives be carefully thought out. Pay for performance will be an open invitation to treat the number, not the patient. This is not always the best approach, as evidenced by the recent Zetia controversy and ACCORD study findings. Physician “report cards” simply encourage doctors not to see complicated patients that would potentially hurt their “grade”.
Everyone tries to game the system. Doctors are no exception.
2) With the growing popularity of hospitalists, some internists and FPs worry about losing their hospital skills.
My take: This is a legitimate concern, but is it really a problem? There doesn’t seem to be any controversy about hospitalists losing their outpatient skills. Why can’t physicians specialize in outpatient medicine? An “officist” so to speak?
Hospitalists generally provide primary care physicians with a better quality of life. By alleviating hospital rounds and middle of the night admissions, primary care physicians are able to focus on outpatient medicine.
I suspect that the majority of doctors would gladly take quality of life in exchange for the erosion of hospital skills.
3) A patient presented to the emergency room with back pain, and died of a missed aortic dissection. The likelihood of such an occurrence would be about two in 10 million. The doctor was successfully sued.
My take: What is more common, a muscle strain or dissection? In the ER where critical decisions are made in a matter of seconds, physicians have to play the odds. You can’t scan everybody. You can’t cath everybody. No test is 100% accurate, and there will always be missed cases no matter how good the care was. Medicine is all about probabilities.
The public needs to understand this, and stop going after cases of unfortunate outcomes in the context of appropriate medical care. I suspect they won’t, since the uncertainty inherent in medicine feeds into the litigious mentality.
Indeed, the majority of cases are found for the physician. But remember, that doesn’t count the vast number that are settled. Which for the plaintiff is pretty much a win.
Related posts:
- Most hospitalists are good, but some, like these ones, aren’t
- Hospitalists are here to stay, or look how ER physicians are thriving
- Hospitalists assimilate inpatient medicine, is resistance futile?
- Should hospitalists or intensivists manage ICU patients?
- Hospitalists and the importance of the patient-doctor interaction
- Are patients refusing doctors who no longer do hospital work?
- Are hospitalists doing their job too well?
{ 13 comments }
Really, I don’t think its jake to take a nearly factless anecdote about a med mal case, and based on generalties pronounce it the perfect example of litigation gone mad.
I’d certainly want to know whether the patient had Marfans, for example, before assuming her age and sex made her an unlikely candidate for an aortic dissection, abd review her entire history and presentation. There’s probably more to the story, there almost always is.
Regarding observation #2: As a relatively new hospitalist (and board certified FM doc), I appreciate your comments.
I know that hospitalists result in fewer hospital days, which makes insurance folks happy and should trickle down to lower healthcare costs for everybody (still waiting on that).
I wish there were a study that the hospitalist specialty results in keeping people OUT of the hospital. I would imagine that as PCPs are allowed to specialize and focus on outpatient medicine, they can do more to tune up problems before they result in hospitalization. This study would be nearly impossible to do, of course.
Think about where medical students and residents get most of their early clinical training and experience – the hospital. New physicians are poorly prepared and have little motivation to become “officists.” The hospital is where the action is. That being said, I have seen a few experienced but burnt out hospitalists gladly trade their skills for the slower pace and more predictable practice of an “officist.”
#1. I appreciate the new Kevin format of reflection and position statement. While I don’t always agree, you are concise and readable. And I have noted an evolution in your thinking which is, what I believe we all(Patient, physician, policy maker) need.
#2 Hospitalist. I believe in continuity. The hospitalist is another chink in that grand plan. And, the point that the new graduate is not “Office Skilled” is well taken. It can take years to become good at office practice. But the two should not be considered separate specialties. The hospitalization of a patient well known to the physician should be under the care of “the expert” in the patient.
3. Malpractice fear is the community physician’s displaced fear of authority, like the medical student’s fear of the chief resident and the resident’s fear of the attending. I always believed these fear based teaching situations were to help us learn who “WE”, the physician was, not to inculcate a persistent fear of authority…But alas…
1. The part everyone seems to forget with incentives is that you will get exactly what you design to an extreme…often to the detriment of things not incentivized. The key question when designing incentives is to ask “What are we not incentivizing, and are we comfortable with the consequences of ignoring those things?” The other thing to do (something we’ve done) is to ask people what they’d do to “game the system” (anonymously) when presented with a particular model.
Actually, in process/quality improvement, this is one of the reasons why E. Deming opposed “management by objective” approaches.
2. Hospitalists rock. We need to share incentives (share risk?) in some fashion to motivate the behaviors that fat doctor refers to (preventing unnecessary hospitalizations).
3. Liability caps are needed.
Just as there will always be mistakes, and doctors play probabilities, there will always be lawyers waiting around to make their money off of that uncertainty – I don’t think it’s the medical system gone wrong, I think it’s the legal system. There must be a higher burden of proof for cases like this, where it’s precisely the doc’s judgement that they are paid for… isn’t it hypocritical to train, hire and retain docs specifically for their judgement and then sue them when they use it?
Outcome bias is the tendency, even in experts, to seek to find blame as an outcome is horrible.
http://en.wikipedia.org/wiki/Outcome_bias
The Supreme Court has held that civil defendants have procedural due process rights. One of them is a right to a fair hearing. The outcome bias of scapegoating plaintiffs and plaintiff experts violates such a right.
The second holding of the Court is that clinical decisions require deference and a presumption of correctness.
The aortic dissection case should be appealed as a violation of Supreme Court holdings.
It would be nice if people would stop using the ER as a Dr’s office for every ache and pain. No your headache..menstrual cramps, runnynose is not an Emergency!!
Donna G RDH
“There must be a higher burden of proof for cases like this, where it’s precisely the doc’s judgement that they are paid for…”
Cases like what? You know literally nothing about this case but one person who wasn’t involved’s take. This is how you make policy?
Jocelyn, pick a better anecdote to make that argument. No way is there enough info to make a judgement call on that case, and there *are* circumstances possible which would make sending that pt home without even recommending and x-ray, inexcusable, even in a female under 45
A couple of points about the dissection case –
you wrote “A patient presented to the emergency room with back pain, and died of a missed aortic dissection. The likelihood of such an occurrence would be about two in 10 million. “
Even the unnamed son-in-law noted that the severe back pain raised the liklihood from the general “females of a certain age” statistic he threw out (with little to support it)
And at least one other risk factor was present – the deceased in question had a blood pressure of 208/89.
A few more details are available which would not color the case in the doctor’s favor.
But that statistic does not really apply at all to the (deceased) patient in question.
If you can’t scan everyone, you can probably check a patient with sudden onset tearing pain in the middle of the body and dramatically elevated blood pressure, for asymmetric blood pressure.
Find that, and it’s a scanning…. and that’s a cheap and side-effect free way of boosting the chances of catching a dissection.
The doomed patient had her vitals taken once on intake, by a tech. There were never taken by the physician, addressed in any way, nor ordered to be taken again, and no opposite arm reading was ever taken.
I am a senior resident in a surgical specialty, I like what I do, but honestly if I could go back in time there is no way I would go into medicine knowing what I know now.
The lawyers are more an indicator of a problem rather than the problem itself. The way I see it, the problem is that the patients don’t seem to appreciate our work, they rarely show any gratitude, and the smallest misstep on the physician’s part will be used against him without fail.
In the end such experiences and the surgical training produce excellent surgeon-technicians, but cynical and noncaring human beings. It is a struggle trying to stay engaged and caring. This is a situation that makes me very uncomfortable, makes me want to leave the US and go work somewhere in a 3rd world country.
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