Can defensive medicine ever be stopped?

You may have missed this when it first appeared.

Experts from Harvard and the University of Southern California say assumptions made by some analysts that defensive medicine is not an important facet of the high cost of health care may be wrong.

Those assumptions were based on data showing that malpractice reforms instituted in some states did little to reduce health care spending.

According to the report from the National Center for Policy Analysis about an article in the Wall Street Journal, defensive medicine (“ordering some tests or consultations simply to avoid the appearance of malpractice”) is just as common in states with low as it is in those with high malpractice risk. In fact, about 2/3 of doctors in both the low and high risk states admitted to practicing defensive medicine.

My experience is that the 2/3 figure is probably a very low estimate. Just about every physician I know has ordered a test or consult strictly to “cover his/her ass” if something were to go wrong. I am certain it happens tens of thousands of times per day in the US.

I can cite many examples of defensive medicine. Here are a few.

A young man with chest pain arrives in the ED. After taking a history and examining the patient, the ED MD is 99.99% certain that the patient did not have a heart attack or a pulmonary embolism. But he’s a little short of breath. He remembers a case of a fatal PE with only minimal shortness of breath, orders a blood gas and CT angiogram of the chest.

A young girl comes in with lower abdominal pain, no GI symptoms, no fever. The pain improves over a couple of hours. Could she have appendicitis? Very doubtful, but yes, it is possible. Will she get a CT scan or an ultrasound? Yes. People who get sent home from EDs and return with appendicitis often have complications. Complications = lawsuit (delay in diagnosis).

A surgeon readmits a patient with a wound infection after a colon resection. The wound is opened widely and packed. The culture comes back “E. coli sensitive to every antibiotic.” The surgeon knows that the treatment of a wound infection is drainage without antibiotics unless there are systemic signs of infection (fever, elevated WBC, tachycardia). “Just to be safe” he asks an infectious disease doctor to see the patient.

In my opinion, defensive medicine is ubiquitous and not going to go away soon. Health care costs will continue to rise.

What can be done about it? If you believe the NCPA article, tort reform is not the answer. Then what is the answer?

I think reducing defensive medicine would take a massive culture shift that is unlikely to happen any time soon. Patients would have to be educated about expectations.

For example despite what the so-called “never events” list says, some complications, like infections, are not 100% preventable.

And it would require a whole new generation of physicians with a different outlook, which would not be easy to accomplish either. Students and residents learn defensive medicine from their role models.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • DoubtfulGuest

    I agree the culture shift is necessary. Unlikely to happen anytime soon? Let’s get the ball rolling now, then. Some patients are trying to educate ourselves. Doctors, we need you to recognize this and help us help you.

    In my experience, there’s a very strong psychological and emotional component on the doctors’ end. It has little to do with numbers. The risk of my personally filing a lawsuit against any doctor is zero. If the doctors who misdiagnosed me, harmed me, and deceived me had done their part to have a good relationship with me, they would know that. Fear seemed to be the main driver of decision making for one of my doctors in particular.

    As much as patients try to educate ourselves and develop reasonable expectations, we run up against the tradition of secrecy and lack of transparency in your profession. As I’ve said before, lawyers are a big problem too. We often can’t get the facts when things go wrong, whether or not anyone is to blame. I don’t even know how many lawyers are involved with my situation or who they are, even though they likely have access to my personal information that I shared only for medical reasons.

    We often hear about how doctor comes from the Latin word docere, ‘to teach’? Well, teach us about you, how you think, how you make decisions, what you’re worried about, what you need from us.

    Here’s a concrete example: A few years ago I had major surgery that was done with a newer less invasive technique. I visited with the surgeon just three times; before, after, and of course the day of. Despite the short time, I would describe it as an ideal doctor patient relationship.

    The pre- consultation was long, but my post-surgery checkup was so straightforward it probably balanced out the time investment. The surgeon took initiative to tell me his complication rate and what he had done to address those complications. He told me where there was uncertainty in the situation and why. I made it clear to him that I understood the risk, I would willingly share the risk, and I would do my part to make sure it turned out well. Even as I was going under anesthesia, I stayed calm by thinking “my job now is to be sleeping”. :) This surgeon was confident in his skill, but still let me see that he was human. I trusted him because he was HONEST.

    • Bob Alexander

      Scalpel gets the closest that I’ve ever seen to reaching the true underlying point but doesn’t quite get there. Malpractice is about “standard of care”. Standard of care is relative. When every ER doctor gets that CT, it IS malpractice (or at least you are legally on the hook) to not get it even if cold review of evidence suggests it’s not really an effective use of resources.

      “Defensive medicine” has changed the standard of care for every disease in America. The way generations of doctors have taught the doctors after them has ingrained it into the management of EVERYTHING. All you need to do is look at the way basic things are managed in the US vs, say, the UK. It’s so insidious that nobody realizes that the way they were taught was actually defensive medicine. So the doctors treating you don’t even realize that their aggressive workup of cardiac disease in a low risk population (for example) is a poor use of health care resources, simply because that’s what we learned was appropriate.

      And no, I don’t know how to solve this.

      • DoubtfulGuest

        Excellent points…I sometimes lose sight of this because I turned out to have a weird disease for which the standard of care is not so well defined. So, what’s the root cause, do you think? How much of this is technological advances vs. lawyers driving how doctors make decisions?

        • Skeptical Scalpel

          I think it’s a combination of the two plus the fact that role models foster defensive medicine in students and residents.

          • DoubtfulGuest

            Thanks. Do role models foster it for those two reasons or is there more behind it?

          • Skeptical Scalpel

            I think it is just the two factors. I can’t think of another reason. Moist docs don’t make money from ordering lab tests or x-rays, but clearly some do.

    • rbthe4th2

      Agreed, 110%. I think Skeptical got it right also – he’s going down the path of that as part of the problems.
      Randy

  • Thomas D Guastavino

    Can someone explain to me why the trial bar is the only organization involved in health care that has not had to undergo a radical change in their behaviour.? Until that happens defensive medicine will continue.

    • Skeptical Scalpel

      It’s easy. Lawyers make up 90% of all legislatures. Don’t expect any new laws to change the situation.

      • Thomas D Guastavino

        Precisely why defensive medicine will continue

        • rbthe4th2

          That and you’ve got patients out there looking for an easy ticket (you know where I’m going with this). Its some on both sides, but I see more of it on the doc side. I’ve known a number of people that had issues with doctors, when some common sense and listening to the patient would have told the story. Is that being modeled in our medical schools? I don’t think so.

          • DoubtfulGuest

            Yeah, any patient with common sense would acknowledge there are some looking for an easy ticket. Problem is, to an extent we’re all being treated as though we’re doing that. Like being accused of a crime we didn’t commit.

            This one doctor I keep mentioning appeared to be so consumed with those thoughts even as he took my history and examined me, that he missed the boat completely. He would alternate between being really kind, and glaring right up in my face, during the exam. This is only an educated guess on my part, but it came across like “Are YOU looking for an easy ticket? ARE YOU?”. And later he asked me a lot of leading questions that were very suggestive of this thinking. “Well, no sir, and if you’d just let me explain a few things…”

            So, I think it’s best to focus on what happens on the front end, during the clinical encounter. The trial bar association would lose power if fewer patients go running to lawyers. If we could actually trust our doctors, if our doctors would listen, our expectations would more often line up, and there’d be nothing to fight about.

          • Thomas D Guastavino

            Thats not been my experience. Most of the Medmal cases I and others have been involved with have nothing to do with physician competence, common sense , or failure to listen to patients.

        • DoubtfulGuest

          Um, you guys? We don’t just get pulled by vacuum into an attorney’s office the second things go wrong. There are so many steps in decision-making before that might happen. Why aren’t we talking more about the whole process that contributes to defensive medicine?

          Agree with you on the trial bar, and their med mal defense buddies. Feel free to tell us more.

          • Thomas D Guastavino

            Where would you like to start?

          • DoubtfulGuest

            I’ve heard different things about what happens on doctors’ end after a bad outcome (let’s say it *appears* the doctor made mistakes). Do the med mal insurance companies forbid the doctor from talking right away, or only after a claim is filed? I’ve heard different things. Does it depend on the insurance company? I’ve been stonewalled completely even though I filed no claim and have never sought legal counsel. I did tell the doctor quite bluntly in writing that we had a problem. I would have preferred to work it out privately with him (just a conversation, no money). I agree plaintiff’s attorneys are part of the problem, hence my not having one. I’d appreciate anything else you could explain – thanks.

          • Thomas D Guastavino

            First, we all agree that there are clear cut examples of physician incompetence, lies, and other questionable actions that deserve swift action to resolve. Unfortunately, these cases are the exception, not the rule. Our current systems major flaw is the fact that trial attorneys are not punished for filing meritless claims, meaning that we lose, even if we win. We bear the cost of this runaway system with very little recourse since we can’t simply pass this cost onto our “customers”. Our only choice is to avoid being sued in the first place. Defensive medicine is only one consequence. There is avoidance of high risk cases, denial of care as well prolongation of resolution for those patients who have truly been harmed.

          • DoubtfulGuest

            I hate this as much as you do. Not least for the fact that I must have put in writing 20 times now that I’m not going to sue this doctor, but it seems to carry no weight. I watched “The Vanishing Oath”, which does a good job of showing how the system harms everyone. Lots of stuff people don’t think about, like if the doctor goes to court, that means the office is closed and the staff sent home with no pay. Plaintiff’s attorney websites are extremely manipulative…I didn’t catch on right away because of my emotional state when I was searching for information on *alternatives*. It’s insulting and predatory toward patients. Many of us liked our doctors and we get disillusioned when that doesn’t seem to matter anymore.

          • Thomas D Guastavino

            Then we are on the same side. This is what I would to see:
            1) Reasonable limits on non-economic damages
            2) Time limits to resolution. (Three years from filing to deposition, the three years to resolution) Six years should be more then enough.
            3) Loser pays rules. During the investigational phase (Filing, investigation, expert witness, deposition) if the case is dropped or settled, no harm, no foul. However, if it goes to trial and the plaintiff loses then the attorney must pay the legal fees of the defendant.
            I believe such a system would force the trial attorneys to devote their time only to those cases with merit providing swifter justice to those who have been truly harmed. Also, I see no reason why the trial bar should not be asked to give something up the same as the rest of us to achieve reasonable health care reform

          • DoubtfulGuest

            Works for me. Also, those of us who don’t want to sue need options. Many of us just want explanations and apologies. I still ask, what can we fix with our interactions in the exam room? The lawyers do a great job of making themselves appear necessary, but I’d like to show them otherwise.

          • Thomas D Guastavino

            The best quality control has and always will be freedom of choice to find any physician of your choosing. Ironically, current so-called health reform measures will take that away.

          • DoubtfulGuest

            Sure, and I did that, fortunately well ahead of health care reform. But having great doctors now does nothing to resolve the harm I experienced before. My choice not to sue doesn’t make it hurt any less.

          • rbthe4th2

            I agree. I think the other issue is publicizing how the other side acted. When docs act like out, well … I’ve seen a mentally challenged adult who has acted more mature in a tougher circumstance.
            Read ego and attitude need ta go.

          • rbthe4th2

            Finding any physician isn’t going to work when they’re not willing to do their own take on it and maybe do the right thing, not back up their buddy. I found once no one knew of some history with one doctor, it was amazing the care I got.

          • rbthe4th2

            I would like to be able to say I’ve named hemorrhoids after admin and lawyers, but it wouldn’t go over well. I’m sure there are some docs here who would be right beside me on that one.

          • rbthe4th2

            Problem is, damages need to pay for care when a baby has a lifelong problem due to an issue, damaged organs and transplant … that sort of thing. How much are we talking about in terms of limits? Some people would need a lot of counseling, some wouldn’t. There’s where some of the pay off is.

            Problem with time limits: risk managers. Stonewalling on the part of the medical side.

            Loser already pays. Plus you have this: http://www.9news.com/news/article/349310/339/Family-gets-340000-bill-after-losing-medical-malpractice-suit

            “Attorneys for the hospital originally included a $250 fine after one of the nurses named in the lawsuit was caught smoking in a hotel room. That charge was eventually removed from the bill of cost after the Wardens’ attorneys objected to the fine.”

            So here is a good suit that lost.

            I’d ask for:

            1) medical boards that actually protect the public and not doctors

            2) JCAHO become meaningful

            3) doctors’ office notes vetted by patient before becoming part of the record

            4) audio/video recording of doctor/patient encounters for those who want it, unedited copies to go to both sides

            5) doctors have to document what exact specific items cause them to label someone with a “mental” diagnosis

            6) any appearance of blacklisting is published on a CNN type area, where people can check this

            7) MPDB is open

            8) lose license in one state must be cleared by a panel of patients before they can practice in another

            9) USMLE’s made useful/meaningful

            10) admin can’t earn more than the highest paid doctor

            11) nutrition and the like emphasized, healthy diets, vitamin panels, etc. checked. Same for exercise.

            12) docs required to do some family touchy feely time … they need to get in touch with themselves and their family. Note – if a doc marries a doc, they need to do outside of medicine things so that they know what the poor people live like.

            13) Start judging the patient, not the lab values. Lab ranges might work for some people and not for others.

            14) Before you dump a patient, 3rd party mediation. Same goes for a doc.

            15) “A panel of experts convened in 2007 by the prestigious Institute of Medicine estimated that “well below half” of the procedures doctors perform and the decisions they make about surgeries, drugs, and tests have been adequately investigated and shown to be effective. The rest are based on a combination of guesswork, theory, and tradition, with a strong dose of marketing by drug and device companies.” Explain the theory behind what you’re doing to the patient.
            16) PAY THE NURSING STAFF.
            17) If a patient wants answers and an apology, 6 months are given where the doctor/admin has to answer them. After that, $50K fine for the first 6 months, $100K fine the next 6 months and after until the questions get answered.
            18) If you screw up then you fix it, absorb the cost of doing so, apologize (the Japanese way is the apology comes from the CEO in the front with him bowing before the patient, since HONOR means something, you bet they do everything to avoid this), and then show us how its going to be fixed so it doesn’t happen to any one else in the future.
            19) Forget the no compete agreements.
            20) Students have to learn to think critically. Get a computer to memorize facts. Teach med students how to use their noodles.
            21) RD’s are covered services, as are ND’s
            22) Cover doctors for phone calls and telemed visits. I asked an admin why someone couldn’t bill the insurance for a phone call because it lasted 15 min. I was told it was illegal. I said that’s stupid. I think the admin needed oxygen.
            23) Docs have to undergo some sort of training to bring them back to humanity and not think and act like they are superheroes. They’re not. They’re graduate degree professionals. Do your doggone best to not screw up, if you do, live by your ethics code.

          • Thomas D Guastavino

            A babies lifelong medical care expenses are actual damages, not the non-economic damages that would be limited. A judge can easily determine whether there is stonewalling involved. As stated, six years is more then enough. I had a case that was dropped after 17 years, all the while having to pay for an open case on the books. The loser pays rules are designed to focus attorneys attention on cases that have merit, not the blind shotgun approach we have now where attorneys shoot at everything hoping to hit something. It is a sick spectacle watching a plaintiffs attorney arguing with a MedMal insurance company to settle for no other reason other then it would be cheaper to settle then defend, a game that we docs pay for through the nose. As far as your other ideas–WOW!!. You think good doctors are a rarity? Try non-existent because no doc in their right mind would tolerate the type of tactics you are proposing.

          • rbthe4th2

            I went thru everything and so far I don’t see where you are proposing things that look out for the patients (and protect doctors from people who are looking to “frame” them). Some of the items you list also are already here (loser pays rules). I can show stats on how it is often the patient who loses, if you like.

            http://www.cnn.com/2013/05/30/opinion/elliott-health-care-risk-management/ “The most jaw-dropping revelation to emerge from Charles Graeber’s alarming new book, “The Good Nurse,” is that in hospital after hospital, officials either knew or strongly suspected that Cullen was murdering patients, but instead of taking measures to stop the killing, they acted to protect the reputation of their institutions.

            According to “The Good Nurse,” one hospital offered to give Cullen neutral references if he would resign. At another, a risk manager stonewalled police for months as they investigated suspicious hospital deaths, during which time Cullen dispatched several more victims.

            For 16 years, hospital officials at one institution after another chose to keep their suspicions secret and let Cullen move quietly on to his next job, where he often escalated the killings.”

            So a nurse who gave me the wrong dosage of an injectable medication (verified on the same sheet the doctors’ orders were and she signed the dosage that she gave me) should get off without anything at all happening to her? Which is what happened and I suffered for it. You agree with that, and that is correct by you?

            So where are you proposing any protections from us from behaviors on the medical establishments’ side? I’m more than happy to show evidence they don’t work, nor do they protect good doctors.

          • rbthe4th2

            Here is another: http://www.texasmonthly.com/content/dr-evil

            “Houston orthopedic surgeon ERIC SCHEFFEY has been sued 78 times. He’s paid out some $13 million to settle malpractice cases. At least five of his patients have died, and hundreds more have been seriously injured. So why did it take 24 years for state regulators—and his colleagues in the medical community—to stop him? Yet what makes his story even more startling is that all were done with the explicit consent of a vast medical, insurance, and governmental bureaucracy, which, even after he became notorious for injuring patients, approved and funded every unnecessary surgery he did.”

            I don’t hear anything from the medical community here on these things.

          • Thomas D Guastavino

            Patient benefits of malpractice reform:
            1) More rapid resolution of legitimate disputes
            2) Greater access to health care as the fear of providing high risk care lessons
            3) Less defensive medicine ( The point of this post)
            4) Lowering of health care costs in general

          • rbthe4th2

            None of which addresses the below:

            http://www.washingtonpost.com/national/health-science/misdiagnosis-is-more-common-than-drug-errors-or-wrong-site-surgery/2013/05/03/5d71a374-9af4-11e2-a941-a19bce7af755_story.html

            “Until it happened to him, Itzhak Brook, a pediatric infectious disease specialist at Georgetown University School of Medicine, didn’t think much about the problem of misdiagnosis. … A physician for 40 years, Brook said he was “really shocked” by his misdiagnosis.

            But patient safety experts say Brook’s experience is far from rare. Diagnoses that are missed, incorrect or delayed are believed to affect 10 to 20 percent of cases, far exceeding drug errors and surgery on the wrong patient or body part, both of which have received considerably more attention.

            Recent studies underscore the extent and potential impact of such errors.

            Misdiagnosis “happens all the time,” said David Newman-Toker, who studies diagnostic errors and helped organize the recent international conference. “This is an enormous problem, the hidden part of the iceberg of medical errors that dwarfs” other kinds of mistakes,

            Studies repeatedly have found that diagnostic errors, which are more common in primary-care settings, typically result from flawed ways of thinking, sometimes coupled with negligence, and not because a disease is rare or exotic.

            Despite their prevalence and impact, such mistakes have been largely ignored, Newman-Toker and others say. They were mentioned only twice in the Institute of Medicine’s landmark 1999 report on medical errors, an omission some patient safety experts attribute to difficulties measuring such mistakes, the lack of obvious solutions and generalized resistance to addressing the problem.

            In the past few years, a confluence of factors has elevated the long-overlooked issue. In his 2007 bestseller, “How Doctors Think,” Boston hematologist-oncologist Jerome Groopman vividly deconstructed the flawed thought processes that underlie many diagnostic errors, including several he made during his long career.

            More recently, an influential cadre of medical leaders has been pushing for greater attention to the problem. They cite concerns about the growing complexity of medicine and increasing fragmentation of the health-care system, as well as relentless time pressures squeezing doctors and the overuse of expensive, high-tech tests that have supplanted traditional hands-on skills of physical diagnosis.

            But doctors often don’t know when they’ve gotten it wrong. Some patients affected by misdiagnosis simply find a new doctor; unless the mistake results in a lawsuit, the original physician is unlikely to learn that he blew it — particularly if the discovery is delayed. While diagnostic errors are a leading cause of malpractice litigation, the vast majority do not result in legal action.

            There is another reason such mistakes have been long ignored: They are regarded as an unusually personal failure in a profession where diagnostic acumen is considered the gold standard.

            “This really gets to who we are as clinicians,” said internist Robert Trowbridge

            “Overconfidence in our abilities is a major part of the problem,” said Graber, who believes doctors have gotten a pass for too long when it comes to diagnostic accuracy. “Physicians don’t know how error-prone they are.”

            Many, he noted, wrongly believe that the problem is “the other guy” and that they don’t make mistakes. A 2011 survey of more than 6,000 physicians found that 96 percent felt that diagnostic errors are preventable; nearly half said they encountered them at least once a month.

            In the Texas VA study, more than 80 percent of cases lacked a differential diagnosis, in which a doctor not only declares what he believes is ailing the patient but also lists other potential causes of the problem based on symptoms, test results and a physical exam.

            “A differential helps people to cognitively focus,” said Hardeep Singh, director of the Houston VA Patient Safety Center of Inquiry.

            At Maine Medical Center, Trowbridge spearheaded a pilot program launched in 2010 to persuade doctors to anonymously report diagnostic errors, which would then undergo comprehensive analysis. He said he had to “hound” his colleagues to report mistakes. During the first six months, 36 errors that would otherwise have gone unreported were identified; most were deemed to have caused moderate to severe harm.

            While second opinions are one strategy believed to reduce misdiagnosis, the original error may be the basis of a cascade of mistakes.”

            and read about Holliman later here – and tell me why she wouldn’t win.

            So far I’ve not seen any evidence that I can’t refute that getting appropriate, accurate, prompt, diagnoses would not do more to dump defensive medicine than any tort/legal reform.

            Randy

          • DoubtfulGuest

            You raise some great points here, especially about the “cascade of mistakes”. In my case, the defensive testing I underwent actually contributed to the delay — A LOT.

          • DoubtfulGuest

            17 years is crazy…we appear to be at opposite corners of the same situation. Like you say, we’re on the same side in terms of the underlying problem. It IS sick, the way attorneys bully innocent doctors to settle…it’s extortion.

            I suspect the main doctor who harmed me had been through a similar ordeal or watched a colleague go through it. I think he’s mostly a good doctor, certainly not one for the “horror story” list. Unfortunately, I’m paying the price of his rage and cynicism. I’m never going to accept that. I’m actually trying to help him (and help his future patients), by trying to get him to talk with me *instead of * suing. A lot of time has passed…I’d think it’s too late to file anyway, but he won’t budge…yet…

          • rbthe4th2

            I am surprised about #1, 5, 10 (that has to do with doctor pay, you all don’t think lowering admin pay and boosting yours is a good idea?), 11, 12 (saying you need to spend time with your family is wrong?), 15, 16 (paying the nursing staff is wrong), 18 – note not one mention of a lawsuit because lawsuits aren’t really needed but examination of why things went wrong is & so problems are corrected so I’m not sure how that doesn’t benefit docs and patients, 19 gives you the ability to go where ever you want to practice so why would you object to that?, 20 (so medical students don’t learn how to puzzle solve), 21 with RD visits covered the nutrition part of the obesity coverage would make more sense and since docs say its not covered in medical school how can this be a problem, and 22, you are serious you wouldn’t agree to phone calls and the other getting covered by insurance? Every other doc I know wants them covered for free. What’s the scoop on that?
            I’d say there were things in there that would benefits docs and not just patients, unless you can explain why. I’d sure like to see why you are the only doc I know who wouldn’t be interested in getting a salary boost and paid for the phone calls.
            Randy

          • rbthe4th2

            Yeah its like ok, I’m a doc and there’s not a lot of us, so if I don’t like you, I’ll treat you like dirt, and everyone else I’ll do different. I tell people about these doctors. If that’s how they practice medicine, do you really know they’ll be good to you?

          • DoubtfulGuest

            What I experienced was more like schoolyard bullying than anything based in science.

          • rbthe4th2

            “Unfortunately, these cases are the exception, not the rule.” Nope, I’ve seen some massive screw-ups and the medical boards, JCAHO, risk managers, rather than trying to talk things out, they push people to attempting to file lawsuits. I’ve seen docs with egos so big they can’t admit they missed the boat. Rather than working with a patient to educate themselves, they dump them. You may not see it because you are an MD and no one will treat you like that (its the frat) and second because the medical profession refuses to admit it has a problem. Witness the boatloads of articles we see on screw-ups. We, patients, would like to have a dialogue on that and how we can work together to a solution. Docs hiding their heads in the sand won’t help. Lawsuits don’t get doctors into really fixing the problem of learning how to diagnose and test appropriately, listen to patients. It just throws money at the situation and as we all throw money at the government, we’ve seen how well that works out.
            Btw, I would say even when I’ve confronted docs with OBVIOUS and I mean blatant record screw ups, you should see the responses. If you can’t take responsibility, what does that say about you and the profession? That is why the lawyers are taking you all to the cleaners. Instead of working together, trial lawyers are having a field day. If we had doctors or admin who actually approached us and we could show some simple screw ups that are common sense mess-ups on the doctors part, get them to work out that ego, we could lose a good part of trial lawyers silly lawsuits.

          • DoubtfulGuest

            Yes! I think they are the exception, I’ve had enough good doctors now that I can believe it…but less of a minority than many docs would like to think. Mistakes are common and do not equal incompetence. Part of the problem is doctors projecting ANY sense of failure onto the “others”, whether that be patients or *other* doctors far away.

          • rbthe4th2

            I’ve seen enough screw ups I can believe it, but good docs are a rarity. Once they label you, that’s it, the medical profession wants nothing to do with you. That’s without lawsuits too. That is what people see now: the “I don’t wanna be bothered to fix my mistakes” or “don’t help any one because a fellow doc in the frat messed up” attitude.
            We all know docs aren’t perfect. I’d like to see KevinMD put together a patient panel and doc panel, we list our grievances and see what we can do to help each other get them worked out. Even specific examples, we could ask each other how can we solve or what needs to be changed so that we can solve these things without overpaid suits and lawyers.
            I thought docs were bad, wait until you are stuck with admin. Or admin lawyers.

          • DoubtfulGuest

            I think good docs are a majority BUT they need to ask themselves, why would I go to school for so long, only to behave like a lemming afterwards? All kinds of things can happen that could cause one doctor to mislabel a patient — it shouldn’t have a snowball effect on the patient’s care. I finally found one to think independently…he and his colleagues have made me much healthier although it took a few years to really make progress. This doctor is confident enough in himself to really take a fresh look. That should be their default approach, not the exception. There’s a lot of literature out there telling doctors, in most unscientific fashion, that if they feel dislike of any sort for the patient, that may mean the patient has a personality disorder. These papers mostly ignore the time constraints, the fact that the patient may be nervous and not at their best, and, you know, the chance of personality issues in the doctor. But that is where some of the persistent labeling comes from.

          • rbthe4th2

            That is why medicine has a reputation of blacklisting and as a frat where everyone sticks up for the doc (right or wrong) vs. checking the patient. That’s one of the main reasons doctors no longer get respect: they earned that.
            What they don’t like about me is I know how to read blood work tests and have been proven right more times than not. What it tells me is that a docs’ ego is more important than the patient. I could care less who scores, its “Team Randy” that wins.
            Not something taught in medical school.

  • Skeptical Scalpel

    Good ideas but tort reform is tough to accomplish. As I said above, “Lawyers make up 90% of all legislatures. Don’t expect any new laws to change the situation.”

  • DoubtfulGuest

    What about patients wanting only tests that the doctor actually thinks are necessary? How many people even know that CT scan to rule out a PE is often for butt coverage? If we’re not fully informed, it comes across as “The doctor cares and wants to make sure I don’t die even though there’s only a small chance”. How many patients even know about the decline and document option? I’ve seen the anger and loss of respect ramp up on the doctors’ side when I ignorantly agreed to a bunch of CYA tests. It seems like a Catch-22.

    • Skeptical Scalpel

      If a patient declines to undergo a test and later it turns out that the test would have prevented a bad outcome, the patient could still sue. All he has to do is find a lawyer who will tell him to say he did not understand how important the test was and what the implications for not having it were because the doctor didn’t explain it well enough.

      • rbthe4th2

        From the stats I’ve seen, that is unlikely to happen. I started doing some investigation around here, as a good friend is a criminal lawyer and should know. No lawyer will take on the “big” medical groups because of the lawyers they employ, and unless you are killed or incapacitated from the neck down, will they even consider taking on your case.
        Btw, read my post on Dr. Evil. Any commenters from the medical professions as to why this was allowed to go on for years?
        Randy

        • Skeptical Scalpel

          Medical groups don’t employ lawyers to defend malpractice cases. Lawyers are hired by the doctors’ liability insurance companies.

          The “I didn’t understand” ploy is often used by plaintiffs and their attorneys.

          The so-called “Dr. Evil” case has nothing to do with defensive medicine. I have written about a similar case (Dr. Duntsch, the Texas neurosurgeon) and explained why he was able to create so much havoc. Here’s the link http://bit.ly/1fLkyU8.

      • DoubtfulGuest

        Thanks for the link below…I do see what you’re saying. So, what are we supposed to do then? If there’s really no “choice”, I can’t understand why many doctors get mad at us when we agree to defensive testing and it turns out normal? Often, these tests are only tangentially related to our complaints. We only have the disease we actually have, and can’t be expected to show positive results for everything else?

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I have a slightly irreverent question: How much of that extra ordering is done while actually thinking about a lawsuit, and how much is done due to genuine self doubt and desire for a definitive answer?

    • DoubtfulGuest

      That’s not irrelevant at all. The more we understand about Drs.’ thought processes, the better. I expect there are lots of conscious and unconscious factors at play.

  • DoubtfulGuest

    This sounds bad…I hope you will be okay? Did you cut off contact with the doctor, or the other way around? It amazes me how adept they can be at externalizing blame. I have not seen any other grown up people maintain that stance for so long. It’s not the mistakes that bother me, it’s how they refuse to stop the downward spiral even as they see the patient’s been hurt.

    • JennaSM

      I cut off contact with her then elected not to have the problem fixed. It’s something I’ll live with.

      I saw a different group for a different problem this year and received two incorrect diagnoses by first a NP and then a PA despite agreeing to every test they’d recommended. Fortunately, after living with this problem for two months with no improvement, one of my friends urged me to see a physical therapist, who can’t diagnose but did treat the problem correctly, confirmed by the MD I finally saw. I won’t waste my time with NPs or PAs again unless it’s really basic (which this problem was…).

      This profession is filled with people with poor physical exam and diagnostic skills who rely heavily upon referrals and tests, which maximizes income of everyone in the system, spreads the blame in case someone (inevitably) makes a mistake, and keeps the patient running around off-balance.

  • DoubtfulGuest

    I don’t even need to be first, but…somewhere on the radar of priority? LOL — “dead last and we don’t care what happens to you” was not what I thought I was signing up for. Gotta read the fine print…

    • rbthe4th2

      I’d say where we are on the radar and the fine print timeline was made when they moderated my comments. It’s pretty telling when several of us say we’re not here to sue but we do need you to fix problems in your system. Those problems would do more than tort reform to drop defensive medicine.

      • DoubtfulGuest

        “It’s pretty telling when several of us say we’re not here to sue but we do need you to fix problems in your system.”

        Yes. I am pro-tort reform, at least to some extent, because I think to solve big problems, we have to attack from multiple sides. I agree with Dr. Guastavino that the legal profession should have to give up something, too. And those few patients who try to, shouldn’t be able to take everybody to the cleaners.

        However, I also notice the ethical issues we raise are swept under the rug, in favor of, well, let’s do tort reform (first? only?). If you’re harmed very badly, just find another doctor.

        This was the advice of some of my friends and family, too, upon hearing what had happened with my care. “WELL! You CERTAINLY would be justified in taking your business ELSEWHERE!” (and they say this with the little turned-up nose gesture and everything!) hahahahahah Seriously? Like the doctor would give a rats? There’s no shortage of sick people. Ooh, so empowering to find a new doctor. That changes — what exactly?

        • rbthe4th2

          That’s the point we’re trying to make that I think is getting missed or is just getting ignored (like our problems). Finding a new doc isn’t always an option. Fixing the system so that it functions better for everyone does.
          I also want to see bite into whistleblower retaliation. When I have heard several docs state about the onus was on them for bringing it up, that’s wrong. These people care and they’re shot for it? These people are trying to do the right thing and help everyone involved (except risk managers’ jobs, and the money saved from hiring the lawyers can go to hiring doctors and nurses.)

          Can someone say a boost in pay for FP’s, GP’s, internists that are PCP’s, ob/gyn’s, and peds?

  • rbthe4th2

    What about patients being individuals? If you deviate because patient X has disease Y, but patient A has disease B, C and a family history of D and E, that should make a difference. Yes, you do want standard of care, but there needs to be a checkbox for patient uniqueness.
    Alex

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