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.
