Patients lose if physicians are expected to practice perfect medicine

I discussed whether or not ambulances should be required to add equipment costing $12,000 in order to be able to transport 850 pound patients recently, so I won’t belabor the point here. Providing medical care to morbidly obese patients presents multiple challenges.

Then I read an article in the Florida Sun Sentinel about how some obstetrician-gynecologists in South Florida are refusing to provide medical care to obese women. Fifteen out of 105 Ob/Gyns refuse to treat patients based upon either weight or BMI. Some won’t take any patients who weigh more than 200 lbs.

In the article, other obstetricians without such a policy state that “no doctor should be unable to treat patients just because they are heavy.”

The “ability” to treat patients is only one of the issues involved, though.

Morbidly obese patients are more likely to develop surgical and post-op complications.  One of the physicians in the article mentioned that ultrasounds are more difficult to perform and interpret in obese patients. If a physician misses a critical finding on ultrasound due to a patient’s obesity, a plaintiff’s attorney will argue that the patient should have been referred to someone with more experience under those circumstances.

Malpractice insurance costs in Florida are some of the highest in the country. In fact, the costs are so high that the article states that half of Florida obstetricians go without malpractice insurance.

If physicians want to decrease their risk in managing patients by excluding patients who are at higher risk for complications, shouldn’t they be able to do so?

Many commenters to the article have harsh words for doctors who are unwilling to treat obese patients. The article itself cites physician groups, medical ethics experts and advocates for the obese, all of whom said that refusing to treat patients based on obesity would “violate the spirit of the medical profession.”

Insurers can refuse to provide insurance based upon pre-existing conditions (at least for a few more years) or can jack up premiums so high that the insurance is unaffordable. Good luck getting life insurance or disability insurance if you have a history of cancer. Airlines can refuse to transport people that are deemed an excessive “risk.” Banks can put limitations on those who enter their premises. Try walking inside a bank wearing a ski mask some day. Lawyers can reject any potential client for any reason. I don’t understand why people find it morally reprehensible if some doctors want to try to limit their liability by refusing to care for patients who are a higher risk for adverse outcomes.

This whole situation is a perfect example of the “perfect care” or “available care” paradigm.

The more that physicians who care for higher-risk patients are sued for less than perfect outcomes, the less that those physicians will be willing to treat higher-risk patients.

“WhiteCoat” is an emergency physician who blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly.

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  • Anonymous

    Every bad result, particularly in obstetrics, carries a risk of being sued. Even negligence-free doctors are often sued when a bad result occurs. It only takes a couple of hundred bucks to file suit.  To WIN such a suit, particularly in high-risk patients, is quite something else.   A plaintiff’s lawyer must convince a jury that the doctor was negligent, that is, did or failed to something a reasonably prudent doctor in that field of specialty would have done or not done, AND that negligence has to have caused injury. Those are not easy hurdles to jump over.

    If I were a legislator in Florida, I would require obstetricians to carry malpractice insurance (and I would regulate the insurers to prevent gouging), much like most states require automobile owners to carry liability insurance.  I would also give the docs some relief in the way of tort reform, perhaps a cap on non-economic damages or an overall cap on damage awards in med mal cases.  I would also investigate the insurance carriers to see why the rates are so high relative to other states (if they are). 

    OB’s rarely go through a career without being sued.  If you don’t want to LOSE a lawsuit, don’t practice negligently.

    —A Virginia medical malpractice lawyer

  • Anonymous

    If it’s okay for OB GYNs to “pick and choose” patients based on their  ” high risk” status, why can’t all Doctors do it?
    Do you see where your point is going? When you chose to be a Doctor, did you not want to help people, regardless of their flaws and disabilities?

  • WhiteCoat Rants

    HealthCareProf –
    Nearly all doctors already can “pick and choose” the patients they want to accept. A doctor isn’t “required” to accept you as a patient when you walk into the office. One of the only arenas where doctors can’t “pick and choose” patients is in the emergency department. We emergency physicians serve as a safety net for patients who can’t find another physician to care for them (and those numbers are increasing steadily). If you consider “on call” rosters at hospitals, many specialists are refusing to take call so they can maintain their ability to “pick and choose” patients.
    Your argument that doctors somehow accept the inevitability of being sued by entering medical school is a strawman argument. We should accept the presence of frivolous lawsuits because we allegedly knew about them in medical school? Please.
    If you read more about health care policy, you will see that fear of being sued in medicine is absolutely one of the reasons that doctors refuse care to patient. It happens every day. Surgeons will refuse to accept care in a patient whose surgery turned out poorly – they don’t want to “get caught up in another physician’s mess.” Many doctors will not accept care for a litigious patient or their family. Many doctors won’t provide care to lawyers.
    Imagine that you could be sued for millions of dollars each time that one of your students failed a semester. Would you do anything to mitigate your risk?

    VirginiaAtty –
    Agreed that proof of liability is not an easy hurdle, but when the profit potential for winning one case is easily 6 and possibly 7 figures, many attorneys will take that chance — especially when they can use the power of outcome bias to bolster their arguments to a jury.
    Your intended reforms would have little effect because (a) they don’t address Florida’s “three strikes” law and (b) they don’t address the adverse consequences of reports made to the NPDB.
    “Don’t practice negligently” has got to be one of the most trite, overused and unsubstantiated catchphrases ever used by the plaintiff’s bar. Do tell all of the obstetricians everything that they have to do in order to never lose a lawsuit. I’m betting that you couldn’t even come up with a comprehensive list of ways for malpractice defense attorneys to avoid “practicing negligently”. You know or should know that “negligence” is determined on a case-by-case basis, so to make an overarching statement that doctors just shouldn’t be “negligent” – as if it is some intentional act that everyone can somehow avoid – is misleading. Shame on you.

    • Anonymous

      white coat md-
      “Please”??? Thank you. 
         You can read up on all the health care policy in the world, if that is all you stand behind. I am not sure of the hospital you practice at, but  in my years of being a healthcare professional, I have honestly not seen any Doctor overtly refuse to see a patient based their prejudgements. It’s just  WRONG !   I find it quite disturbing that a future doctor in trainng sees no problem with this. Again, I am not denying that” frivolous” lawsuits exist. I also agree that something major needs to be done to tackle  lawsuits that are indeed  ”frivolous”.  

      • WhiteCoat Rants

        I recommended that you read about health care policy based on the title “prof” in your name, assuming that you were a “professor” and didn’t have the ability to witness the effects of failed policy firsthand. My mistake.
         
        I don’t work at “a” hospital, I work at several hospitals and have probably worked in 10-12 hospitals during my training and my career. Doctors can and do refuse to see patients for various reasons, and it has occurred at every hospital at which I have worked. One of the most common reasons doctors refuse care of patients is a fear of liability. That’s the same reason general practitioners refer relatively routine cases to specialists, the same reason obstetricians refer patients to “high risk” obstetricians, and the same reason that many patients with minor surgical problems get referred from the emergency department to surgeons’ offices. I could go on and on with examples. Plaintiff lawyers think that doctors practice “better” medicine when they fear the bad outcome. This is an unintended consequence of what happens when doctors fear the bad outcome.
        The fact that you haven’t seen these types of things occurring in your “years of being a healthcare professional” tells me that either you haven’t had many “years” in whatever your profession is or that you are an administrator who has no direct interactions with doctors and their reasons for taking or refusing patients into their practices.

        Would it still be so “WRONG” if *you* were forced to perform some task you didn’t feel comfortable performing, knowing that if you performed the task incorrectly, you could be sued for tens of millions of dollars and dragged through a lawsuit for 4-5 years?

        That’s the whole point of the post. If we want to impose multimillion dollar liability on physicians who do their best but don’t have perfect outcomes in every case, that’s fine, but there are going to be less and less physicians willing to provide care to patients deemed to be “high risk.” It is happening commonly all over the country. The obstetricians in Florida are just pushing the envelope. Your failure or refusal to acknowledge it means that you either don’t know where/how to look or you need to take your head out of the sand.

        • Anonymous

             Okay. No need for you to be condescending here.. I will “take my head out of the sand”, if you get over yourself. I work directly with patients just as you do. I could be sued just as you could.  I usually find the white coat rant articles interesting and worthy. As I keep saying here in one way or another, I recognize the huge problem with our “sue happy” society and the problems it creates in medicine. The ONLY point I am trying to make here is that I don’t think it justifies discrimination against patients. It is one thing to refer a patient elsewhere, if they would be better served there. It’s another thing to say “I will not care for you just because you are are obese”. I am by no means obese , but I do know first hand how difficult it can be to provide healthcare to morbidly obese patients. How is this different from refusing care for smokers? homeless people? gay people? women? foreign people? stinky unsanitary people?, etc, etc. One could  argue and find evidence to support that these groups may be  ”high risk”  and could potentially be more likely to sue. 
             There’s no denying that some patients are more desirable to care for than others. My colleagues and I are sometimes less than thrilled to have to care for certain patients, but we still do. We  do our best and hope that a jury would agree that we did our best, if we ever got sued.
            
           

          • WhiteCoat Rants

            It seems that we disagree on two issues:

            1. Risk avoidance via patient selection is not pervasive in medicine.
            I say it is, you say that you’ve never seen it before. I gave you some examples. Do you deny that those refusals of care occur? What about transplant programs that refuse to provide livers to people who still drink or lungs to people who still smoke? Insurance companies may refuse to insure smokers because of their higher risk of health problems. Is that decision similarly “wrong”? Doctors may not want to provide care to a homeless person because there is no way to verify the person’s identity. Is that a morally incorrect decision? Neurosurgeons drop hospital privileges for head and neck surgery because those are high-risk malpractice areas. Are they devoid of morals? There are a plethora of examples of decisions being made to treat/insure based on patient demographics. I make the “head in the sand” comment because I just can’t imagine someone practicing medicine that doesn’t see these types of things happening every day. Or maybe you see them and don’t recognize them for what they are. But planting a seed in the public’s head that these events don’t occur is just inappropriate – at least to me.
            I guarantee that risk avoidance in the future will get worse and not better – especially with millions of new “insured” patients entering the system in the near future. As I said before, these obstetricians are just pushing the envelope.

            2. Doctors who choose not to provide care to all patients are morally wrong.
            We are supposed to have freedom to contract in this society. Patients can refuse to see me as a physician for any reason. Maybe women don’t want a male doctor performing a pelvic exam. Maybe they don’t like my looks. Maybe they’ve read my blog and think I’m too full of myself. Is it “WRONG” for them to discriminate against me for my gender, appearance or values? I don’t think so. They have the freedom to see whatever physician that they want. I don’t begrudge them that choice.
            Now you’re suggesting that physicians shouldn’t be able to risk stratify and should be forced to see any patients that want their services because it is morally wrong to refuse care? I just don’t agree with that logic. Physicians aren’t saying “I’m not going to treat you because you’re obese.” They’re saying that “I’m not going to treat you because your [obesity/smoking/alcohol abuse/drug abuse/other relevant demographic] leads to higher complication rates, diagnostic difficulties, and malpractice risk that I am not personally willing to accept. Perhaps other doctors will accept those risks, but I am risk-averse and do not.” You want to force doctors to accept risk that they are uncomfortable accepting, and I do not believe that forced contracts for medical care are appropriate.
            That’s the public policy issue at the heart of this debate and we’re going to have to agree to disagree on it.

            I’m not going to argue it further. Readers can choose whose views they believe hold more water.
            Thanks for responding.

          • Anonymous

            The last word is yours. You are welcome.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    An obstetrician in South Florida just lost a malpractice case and the plaintiff was awarded 4.5 million in punitive damages for his failure to detect abnormalities in her fetus limbs with pre birth ultrasounds. She claims that if she knew that the child had limb deformities she would have terminated the pregnancy. 
    Ob-Gyn is not my area of expertise and I certainly do not know what is reasonable to detect on a ultrasound in utero but this is an example of why physicians do not want high risk patients and why they practice cover your butt defensive medicine.

    • http://ClinicalPosters.com ClinicalPosters

      The fact that extra care is required cannot be denied. However, the words that stand out to me in your post are: malpractice, punitive and abnormalities. Evidently, it was proven in court that there was some neglect and consequential damages. The neglect could have been omitting proper precautions or failing to properly inform the patient of potential risks.

      Charging extra for obesity might be required. Referring to a specialist may be warranted. But telling a pregnant mother that she cannot receive any care appears a bit extreme.

      If a physician lacks experience with certain patient conditions or there are equipment limitations, perhaps it should be posted or explained during the initial consult, something like: “This ultrasound equipment is designed to detect abnormalities in individuals within a specific BMI range. There is a high probability that your results may be inaccurate.” Then have the patient sign a liability waver.

      http://www.acr.org/SecondaryMainMenuCategories/NewsPublications/FeaturedCategories/CurrentHealthCareNews/More/ImagingtheMorbidlyObese.aspx

  • http://ClinicalPosters.com ClinicalPosters

    Patients lose if physicians expect all patients to be perfect.

    Obstetricians? Really? We all know that women gain weight during pregnancy, right? 

    Malpractice insurance fees notwithstanding, the do-no-harm oath seems to suggest a moral obligation to care for all patients. Physicians treat ill patients. Those who are morbidly obese often have increased health problems. If they are fortunate enough to have insurance, they pay a steep premium. It would, therefore, seem unconscionable to refuse treatment to someone who is obese. In effect, the message conveyed, is that the physician only treats “healthy” ill patients.