fuegorama

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After reading the “hatred” thread and following a lecture this week by a guru surgeon, I started thinking about this kidney stone of an education I’m trying to pass and what it will cost me.
You guys should read the hatred thread and make your own judgements.
http://forums.studentdoctor.net/showthread.php?t=185661

The lecture I sat in this week was with a great doctor who was droning about the diagnostic issues surrounding Ischemic Bowel disease. Mid- hour he drops this line, “as physicians you will be the administrator of your patient’s finances”. Really?!! I thought I was being trained to make the best recommendation regarding my patient’s health and her potential pathology.
How did we become responsible for people’s financial issues? Why do we keep doing it? How can responsibility be transferred back to the patient where it belongs?

We are being taught a science and an art that has trust as its foundation. Right now that trust flows in one direction, and it isn’t toward docs.


Some observations:
1. Physicians are no longer the controllers of medicine. There are administrators that demand ‘production’ which is interpreted as minimal testing + maximum patients seen = risk assigned to docs. Lawyers equipped with low-tech retrospectometers have made every diagnostic decision a risk. Patients are web-educated experts that are convinced they have at least as much knowledge about the appropriate interventions they need.
2. We have created a system where the physician assumes all risk and responsibility. You may not be able to pay for that full body CT to rule-out the horribloma, but your doctor better not miss it.
3. Patients demand to have more say in their care.

We are witnessing a collision of ethical, financial, and resource distribution issues.
A suggestion-
In a possible future, everyone will have some form of health-care account. A percentage of this will be government funded. I can hear the teeth gnashing, but get over it. This will happen. The good news is that this account will be finite. Let’s say everyone is given $4,000 to start. If that’s all that’s in your account, no other investment or insurance, when it’s gone it’s gone.
On presentation a patient is given a copy of their financial situation. “Here is your account. Here is what it will pay. Here is the dollar amount for which you are responsible. You can now see your doctor. Your visit will minimally cost $x to cover the physician’s fee. This has already been deducted.”

The physician takes an H&P, performs her exam and steps out to mull over the diff. On returning to the patient, the conversation will be significantly different than the current ‘here’s your diagnosis, let’s hope I’m right’.
Rather, it will sound something like, “Your s/s are likely due to a new onset of migraine headache. However, we must also consider that this could be due to meningitis, sinusitis, a stroke, an arteritis, any autoimmune disorder, a tumor of primary or metastatic nature etc.” This differential will appear on a prepared sheet with percentages assigned to the probability of each diagnosis. The diagnostics required to r/o each of the alternatives will be listed along with their price and potential harm. E.G. Tumor-contrast CT head- ~$950, radiation exposure risk of anaphylaxis. The doc and patient discuss the probabilities and the patient decides the diagnostic pathway. She signs the sheet and leaves with the glow of owning her own healthcare.

The lawyer? What stinking lawyer? The patient has sought expert advice, has received said advice and has made her decision. Will she be suing herself?

Let’s take another example only with an emergent presentation. If EMTALA is still a reality in this future, then EM docs should have a form of “credit” whereby they can apply diagnostics. This would not differ from today except care given under the EMTALA rules will be required to be funded!
(all numbers and tx. are fictional examples from an MSII perspective)
So…a gentleman presents with his nasty anterior MI. The doc paints the big picture and gives the family and patient some alternatives. This is where familiarity with a Chinese menu comes in handy.
A. The full court. NTG drip. Some wondrous anti-platelet potion, a date with a cath cowboy. Two days in the CCU. 30-day mortality without complications =<12%. Cost= $12,000
B. The special. NTG SL, MSO4, ASA, IV Heparin, IV beta blockers, a cheap thrombolytic (when you’re looking at $4,000 as real money, then the difference in $1200 for tPA vs. $2000 for Tenectaplase makes a difference). A day in the CCU. A day on the tele floor. 30-day mortality without complications =<20% Cost=$5500.
C. Lunch menu. NTG SL, MSO4, ASA, LMWH, IV beta blockers. Tele admission for two days. 30-day mortality without complications =<40%. Cost $2500
D. The free mint. NTG SL x 3, ASA. A consultation with clergy of choice is complementary. 30-day mortality without complications =<80%. Cost $200

This suggestion eradicates the need for administration. The production is based on patient decisions. The dollar is not the physician’s to spend.
The risk is shared.
The patient is given the ‘say’ in their care they so vocally demand.
Thoughts? Flames?
 

MAC10

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Your proposal is very interesting. Im still chewing on it and trying to digest it. I still think its flawed and that there is room to be sued. For example take your local University hosptial/va/ heck even private practice patient they dont REALLY understand what Nitro, plavix, cath...etc is,how it works on the body, how its benifical, they dont know what the latest medical journal says about what treatment regime is best. Even if they do read a journal article they dont know the study was well designed and they probably wont understand 75% of the stuff in there. So how could they really make an informed decsion on their own, esp one so important as the ICU managment of someone that just had a massive MI?Some of these people cannot even understand why you are telling them to stop smoking. Some doctors couldnt even do that cause thats not their area of traning(ie pathologist, PM&R, psych etc). Even if THEY make the choice and have bad outcome they will still go after you, the doctor. I just think there is always gonna be someone that gripes about something when they are sick they are still going to run to the doctor. And me personally id rather have a Critcal care doc calling the shots when I have a massive MI, not my uncle bobby
 

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There is also the ever-present

"I didn't know what I was signing" defense.
Otherwise, nice ideas.
 

dry dre

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fuegorama said:
he drops this line, “as physicians you will be the administrator of your patient’s finances”. Really?!! I thought I was being trained to make the best recommendation regarding my patient’s health and her potential pathology. How did we become responsible for people’s financial issues? Why do we keep doing it? How can responsibility be transferred back to the patient where it belongs?
Starting point: in simple economic terms, the US healthcare system operates in a failed market. The consumer is told what to buy (by docs), when to buy it (by docs), and at what price (partially by docs).

In my training why have been heavily leaned on by attendings to know what to order and when as much for financial reasons as for patient outcomes. I don't have a problem with this...this isn't rocket science or additional things you need to study. Do you need a CBC when a H/H will do? Do you really need the tests done daily? Do you need a CT when an x-ray will suffice? Do you need an MRI when it neither sorts out the differential diagnosis or plays into the plan? These issues are much more than "marginal" costs to consumers.

You don't think that as a physician you have a responsibility to practice financially efficient medicine?

I've heard sayings that go like "if residents could keep take home 1% of the cost of the useless tests they order, they're salaries would go up by an ~order of magnitude."

The vast majority of usesless tests/studies that I've considered ordering, or have seen others order, has nothing to do defensive medicine. I agree that defensive medicine exists, but of the things I've missed/seen people miss, it's because the basics (proper H&P, review of chart, lack of medical knowledge) weren't performed, not because full-body scans weren't performed.

As the countdown timer to a govt-wide healthcare system clicks on...
 

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Residents order lots of useless stuff because they practice the most defensive of all medicine. They are not defending against lawsuits. They are defending against being asked the results of a test they didn't order by the attending at morning rounds. Same phenomonon, just more expensive and sillier.
 
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fuegorama

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dry dre said:
Starting point: in simple economic terms, the US healthcare system operates in a failed market. The consumer is told what to buy (by docs), when to buy it (by docs), and at what price (partially by docs)....
This is a big chunk of my point. How can this be a market-driven profession when costs are unknown? The consumer is "purchasing" in a vacuum. Further, most physicians do not know the dollar amount assigned to the tests being ordered. Assigning real dollar value to everything on the front end would be a radical change. I think it would be a move in a positive direction.

dry dre said:
You don't think that as a physician you have a responsibility to practice financially efficient medicine?
I totally agree. We do have that responsibility. Part of the plan outlined above would be presenting patient's with the most cost-effective route to diagnosis.
The difference is, I believe the decision should be shared with the person paying the bills/sharing the risk.

dry dre said:
The vast majority of usesless tests/studies that I've considered ordering, or have seen others order, has nothing to do defensive medicine. I agree that defensive medicine exists, but of the things I've missed/seen people miss, it's because the basics (proper H&P, review of chart, lack of medical knowledge) weren't performed, not because full-body scans weren't performed.
...
And this is where Dr. DryDre will please his patients. By doing that thorough H&P, you can narrow the scope of your diagnostic evaluation and save that "consumer" some change.
 

Febrifuge

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I'd like to see this phenomenon in action at the place that does my car repairs first, and then maybe we can think about applying it to Grandma's care...

I will say that if I were the patient, I wouldn't want my distraught family looking at that 'Chinese Menu' and making decisions. My mom would ask about the bullcrap alternative methods that are "missing," and my brother would assume that the most expensive test must be the one with greatest therapeutic value, no matter what.

There are some other basic questions about the menu, but I'll let others talk a bit.
 

Febrifuge

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Dang. There are a couple things. Sorry...
fuegorama said:
This is a big chunk of my point. How can this be a market-driven profession when costs are unknown? The consumer is "purchasing" in a vacuum. Further, most physicians do not know the dollar amount assigned to the tests being ordered. Assigning real dollar value to everything on the front end would be a radical change. I think it would be a move in a positive direction.
At the ED where I work, there's a little chart stuck to the wall. It lists the costs for CBC, CT scan, UPT, EKG, and other frequently-ordered tests. We're a county hospital, so many of our patients are un- or under-insured. Not only do expensive tests hit them hard, but those charges are more likely to turn into unpaid (or unpayable) bills.

Even so, I don't think that patients are going to be as open to this idea as fuegorama may think, and that's because I've seen what happens when we try to connect the "delivery of service" to the economic reality. I've seen the triage nurses try to explain that a $600 ED visit for a UPT gets you essentially the same thing that $14 and a trip to Walgreens gets you. I've seen them explain that if you're presently in between herpes outbreaks and have no acute symptoms, an EM doc is not the person you want to see, and there's a strong possibility you'll walk out of here with no meds and, again, a $600 bill, so hey, here's a list of community clinics with sliding-scale charges.

And the response? It's not "wow, thank you so much, I had no idea, this really helps me understand."
 

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Febrifuge said:
I've seen the triage nurses try to explain that a $600 ED visit for a UPT gets you essentially the same thing that $14 and a trip to Walgreens gets you. I've seen them explain that if you're presently in between herpes outbreaks and have no acute symptoms, an EM doc is not the person you want to see, and there's a strong possibility you'll walk out of here with no meds and, again, a $600 bill, so hey, here's a list of community clinics with sliding-scale charges.

And the response? It's not "wow, thank you so much, I had no idea, this really helps me understand."
We are now taking these non-emergent pts and doing a medical screening exam which consists of a full H&P. If they are in fact non-emergent they are told that they can go to a clinic or pay up front. As physicians we don't like this system because it increases liability, patient dissatisfaction and actually takes longer than it would to just see and discharge them. However this is now being done in every hospital in my community and others around the country. It's likely coming soon to your ER whetehr you like it or not.

I started a thread on this a while back. I'll bump it so I don't totally derail the OPs thread.
 
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fuegorama

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Febrifuge said:
Dang. There are a couple things. Sorry...
At the ED where I work, there's a little chart stuck to the wall. It lists the costs for CBC, CT scan, UPT, EKG, and other frequently-ordered tests.
Believe it or not, this is a rarity. (but of course Hennepin does have it together) Is this list only for the docs to appreciate, or are the pts. privy as well?


Febrifuge said:
I've seen what happens when we try to connect the "delivery of service" to the economic reality. I've seen the triage nurses try to explain that a $600 ED visit for a UPT gets you essentially the same thing that $14 and a trip to Walgreens gets you. I've seen them explain that if you're presently in between herpes outbreaks and have no acute symptoms, an EM doc is not the person you want to see, and there's a strong possibility you'll walk out of here with no meds and, again, a $600 bill, so hey, here's a list of community clinics with sliding-scale charges.

And the response? It's not "wow, thank you so much, I had no idea, this really helps me understand."
My years as that triage nurse is part of what is driving this current rant. I have had both the UPT and herpes talks. I can also fill you in on plenty of :eek: :eek: :eek: stories of abuse and ignorance. But of course that's what the TILFMP thread is for ;) .
I have also seen a department almost break down when the administration started to require the clerks to actually collect co-pays from every patient. I was awed by the reluctance to ask people for money for a service they had been provided. In what other BUSINESS would this be an issue? Collection of medical billing is a real crisis. On one hand we have the $500 UPT gal who will never open a bill from the hospital but does have a cell phones to accessorize her entire wardrobe. (you know the frilly pink skirt just GOES with that fuscia US Wireless and Usher ringtone number) on the other hand we have 50% of the bankruptcy claims placed last year based in some part on medical costs.
Both of these groups of people would do well to have up front notice of cost. Will it be hard? Ya betcha! But at present it's only the physician who carries the blame. i say share the joy!

There needs to be a dramatic paradigm shift in the world of healthcare. Risk, cost, and yep even responsibility must be shared by the patient.
Medicine has undergone enormous change. The physician of 1970 would not recognize the profession and shift in identity that is the role of "doctor" today.
The funny thing is insurance companies, lawyers, hospitals, and patients all recognize the changed role. It's the docs and med students of today who are still fantacising about those halcion days of yore when your opinion was respected, when a bill was delivered with the realistic belief that it would be paid, and when encounters with people needing care didn't have the specter of litigation lurking behind every curtain. We can either keep dreaming, or we can step up and require change on our terms.

(wow! and I thought Spring Break would be about drinking and catching up on some movies)
 

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fuegorama said:
Believe it or not, this is a rarity. (but of course Hennepin does have it together) Is this list only for the docs to appreciate, or are the pts. privy as well?



My years as that triage nurse is part of what is driving this current rant. I have had both the UPT and herpes talks. I can also fill you in on plenty of :eek: :eek: :eek: stories of abuse and ignorance. But of course that's what the TILFMP thread is for ;) .
I have also seen a department almost break down when the administration started to require the clerks to actually collect co-pays from every patient. I was awed by the reluctance to ask people for money for a service they had been provided. In what other BUSINESS would this be an issue? Collection of medical billing is a real crisis. On one hand we have the $500 UPT gal who will never open a bill from the hospital but does have a cell phones to accessorize her entire wardrobe. (you know the frilly pink skirt just GOES with that fuscia US Wireless and Usher ringtone number) on the other hand we have 50% of the bankruptcy claims placed last year based in some part on medical costs.
Both of these groups of people would do well to have up front notice of cost. Will it be hard? Ya betcha! But at present it's only the physician who carries the blame. i say share the joy!

There needs to be a dramatic paradigm shift in the world of healthcare. Risk, cost, and yep even responsibility must be shared by the patient.
Medicine has undergone enormous change. The physician of 1970 would not recognize the profession and shift in identity that is the role of "doctor" today.
The funny thing is insurance companies, lawyers, hospitals, and patients all recognize the changed role. It's the docs and med students of today who are still fantacising about those halcion days of yore when your opinion was respected, when a bill was delivered with the realistic belief that it would be paid, and when encounters with people needing care didn't have the specter of litigation lurking behind every curtain. We can either keep dreaming, or we can step up and require change on our terms.

(wow! and I thought Spring Break would be about drinking and catching up on some movies)
Interesting post with great insight. I agree with everything you say. As a med student I have realized that docs are sorta like babysitters of patients who don't want to be cured and expect the best care available in the world. I have decided that I will not waste the rest of my life trying to care for stupid, moronic people who, not only resent you, but are looking for the chance to sue you. I hate the american mentality that when bad **** happens, it must always be someone else's fault. It makes me puke just to even think about it.
 

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toughlife said:
I have decided that I will not waste the rest of my life trying to care for stupid, moronic people who, not only resent you, but are looking for the chance to sue you.
But what else can you do? This is how medicine is. The only options are leave the US, leave clinical medicine or get used to it.
 

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docB said:
Residents order lots of useless stuff because they practice the most defensive of all medicine. They are not defending against lawsuits. They are defending against being asked the results of a test they didn't order by the attending at morning rounds. Same phenomonon, just more expensive and sillier.
:laugh: :laugh: :laugh:
 
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fuegorama

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docB said:
But what else can you do? This is how medicine is. The only options are leave the US, leave clinical medicine or get used to it.
Or stop taking the crap and demand some change. Medical knowledge is fairly rare and always in demand. If physicians would collectively start threatening to take their toys and go home, I believe some positive reform could happen.

Of course from the lofty height of MSIIdom, every problem looks solveable. :rolleyes:
 

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fuegorama said:
Or stop taking the crap and demand some change. Medical knowledge is fairly rare and always in demand. If physicians would collectively start threatening to take their toys and go home, I believe some positive reform could happen.

Of course from the lofty height of MSIIdom, every problem looks solveable. :rolleyes:
It would be nice if we as a profession would do that but we won't. I'm not trying to be overly negative but there are several facts that show how far we are from unifying. There are "doctors" who testify for plaintiffs in med mal cases. When the subpoenas do fly all the docs start blaming each other. "It wasn't me! It was the PMD, the ER doc, the pathologist and the radiologist that did it." We are barred by law from talking to each other about some things like fees. That's why we can't bargain collectively with HMOs.

I agree with you in spirit but realize that you're not just talking about a little attitude change. Your talking about a full scale paradigm shift and change in laws regarding the profession.
 

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docB said:
But what else can you do? This is how medicine is. The only options are leave the US, leave clinical medicine or get used to it.

You do rads, anesthesia or path. Granted you are not immune to being sued but at least you don't have to put up with all the paperwork and other garbage associated with practicing medicine.
I totally agree with the post about unionizing and bargaining collectively. I think doctors are dumb for letting the CEO's and attorneys dictate how they will practice medicine. I say we all need to follow the example of those orthopods at University Hospital in Las Vegas who just walked out of the job and the hospital had to turn patients away to AZ and CA cuz they had no orthopods to do the job. This happened as a protest against NV's malpractice environment. The state legislature immediately went into emergency session and passed legislation to fix the situation. Now, if we could do that to pressure insurance companies and to pursuade states to pass torn reform, then we would be in business. I am a supporter of diplomatic efforts to fix the problem, but if nothing happens then it is time to play hardball!
All MDs and DOs should say "**** it for a week and see what happens". I, for one, would love to see that happen.


just my 0.02 cents.
 

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toughlife said:
You do rads, anesthesia or path. Granted you are not immune to being sued but at least you don't have to put up with all the paperwork and other garbage associated with practicing medicine.
I totally agree with the post about unionizing and bargaining collectively. I think doctors are dumb for letting the CEO's and attorneys dictate how they will practice medicine. I say we all need to follow the example of those orthopods at University Hospital in Las Vegas who just walked out of the job and the hospital had to turn patients away to AZ and CA cuz they had no orthopods to do the job. This happened as a protest against NV's malpractice environment. The state legislature immediately went into emergency session and passed legislation to fix the situation. Now, if we could do that to pressure insurance companies and to pursuade states to pass torn reform, then we would be in business. I am a supporter of diplomatic efforts to fix the problem, but if nothing happens then it is time to play hardball!
All MDs and DOs should say "**** it for a week and see what happens". I, for one, would love to see that happen.


just my 0.02 cents.
are there any good reports (on the net or elsewhere) on the whole nevada orthopod walkout thing? i've been very interested by this collective action on their part, as i think the same thing is going to be requried by neurosurgeons and others in the near future... has anyone talked to those orthopods and seen what worked and what didn't, and written about it? or just written a nice piece on the whole crisis from beginning to end?
 

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What a refreshing post! Seriously!

Maybe it's my location, but I'm sick of hearing medical students and residents talking like medicine isn't facing some serious problems. I realize that most of them have not actually seen how medicine works in the real world.

We have the most education, the most responsibility, the most debt and the most sacrifice of basically any other field and yet we are now among the most regulated, most restricted and most sued. Our salaries have continued to drop in relation to the cost of living for years despite an increase in the number of hours worked. We can't even order a CBC without justifying it to the insurance companies. Every day that you work you are faced with the real treat of losing everything you have because of a predatory lawsuit filed by a lawyer who advertises in every page of your local phone book.

I'm really glad that other people see this too and at least have thoughts of reformation. Medicine is nothing like it used to be. Physicians have done a dismal job of fighting for their interests and their patients interests.
 

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stuck_in_boston said:
are there any good reports (on the net or elsewhere) on the whole nevada orthopod walkout thing? i've been very interested by this collective action on their part, as i think the same thing is going to be requried by neurosurgeons and others in the near future... has anyone talked to those orthopods and seen what worked and what didn't, and written about it? or just written a nice piece on the whole crisis from beginning to end?
I don't know of any good synopsis reports. That doesn't mean they don't exist. I suggest checking out the Las Vegas Review Journal site. They have all the old articles posted and they're interesting although they don't have much behind the scenes stuff. I got here just after the trauma center crisis so I wasn't in on any of the back room deals. I thought one of the most interesting things was when the state insurance comissioner told the press that he viewed the whole thing as an illegal strike. The head of the NV Med Society replied that it was not a strike, those docs just quit. They weren't trying to bargain, they just decided to persue different things because the system was so crappy. I think that's the tone we need to take.
 

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stuck_in_boston said:
are there any good reports (on the net or elsewhere) on the whole nevada orthopod walkout thing? i've been very interested by this collective action on their part, as i think the same thing is going to be requried by neurosurgeons and others in the near future... has anyone talked to those orthopods and seen what worked and what didn't, and written about it? or just written a nice piece on the whole crisis from beginning to end?
Malpractice insurance crisis closes
Las Vegas trauma center for 10 days
As has happened in other states, malpractice insurance rates have soared in Nevada.
Some physicians, including those with spotless records, have seen their premiums increase as much as fivefold, or have been unable to find malpractice insurance at all, as companies stop doing business there.
The most recent casualty of the crisis was the trauma center at the University Medical Center --- the only trauma center in Las Vegas.
The governor and lawmakers have just met in Carson City to apparently arrange a compromise.
Here is the story of the dramatic shutdown.

Solution sought for years

The Nevada malpractice crisis had been brewing for years, and came to a head in June and July when many physicians' insurance policies came up for renewal.
A number of doctors, particularly the orthopedic surgeons, decided they could no longer take the risk to perform services for the University Medical Center's trauma center.

Some doctors requested leaves of absence. Others resigned. The trauma center was forced to close.
Seriously injured patients had to be taken to the emergency rooms at other hospitals in the area. If the necessary specialists were not available, the closest trauma centers were an 80-minute helicopter flight away in Phoenix and Southern California. The local news media began a death watch --- waiting for the first patient to die who might have been saved had the trauma center been open.

Physicians recruited PR help

Long before the crisis peaked --- trying to avoid the worst --- a group of physicians turned to a full-service public relations firm in Las Vegas.
The doctors wanted to raise public awareness and organize a grass roots campaign to stimulate the state lawmakers to bring about change.
"The severity of the issue hadn't been impressed on the public as a whole --- ever. This is an issue that affects everyone --- mom and dad, grandma, and the kids. Anyone who knows someone who goes to the doctor has been affected by this issue," says Chris Ferrari, of Brown & Partners.

The Nevada Medical Liability Physicians' Task Force, was formed at the beginning of the year. The group includes the major medical associations and the physician specialty organizations in the state.
Ferrari was brought in as the Issues and Political Affairs Manager of the task force to lobby on behalf of the doctors.
"They recognized the need to unify the medical community as one voice," he explains.

Their main goal was to convince the state legislators that there had to be change.
They were most interested in a cap on the non-economic damages, believing it was the huge jury awards that was driving the insurance crisis.

"It was an educational campaign to let people know that unless something happens soon, we are virtually on the verge of the collapse of the healthcare system."
Chris Ferrari
Brown & Partners

The physicians' prime opposition has been the Nevada Trial Lawyers Association. The attorneys have been very politically active in the state for the last several decades.
"As a whole, the doctors (in Nevada) really have not participated politically, or raised dollars toward political efforts, so they were really new to the process. One of our greatest challenges was getting doctors on the radar politically," says Ferrari.

Physicians' campaign was multi-faceted

The educational campaign that was conducted through the spring and into the summer (in the months before the closing) included:

Paid media.
The paid media was designed to educate people about what the physicians saw as the positive outcome that healthcare reform has had in California, and how it could be applied to Nevada.
"California is known as a very litigious state, and yet the premium paid by an OB/GYN in California is one-third of what is paid in Nevada!" says Ferrari.

One ad featured a female OB/GYN who had a perfect track record. She was shutting her doors and trying to find other OBs to refer her patients to. She was leaving the state. Dr. Gloria Martin had three patients due July fourth, but felt that because her insurance was expiring, she couldn't deliver the babies.
"To date, there are 150 physicians rumored to be leaving --- 50 of whom have actually left, 80 who are contemplating leaving, and 20 who are in the process of shutting their offices," says Ferrari.

The trial lawyers tried to spin the doctor's paid media campaign as a negative.
One attorney told reporters, "Victims of medical malpractice will continue to stand up for their rights. But unfortunately the victims don't have a million dollars to launch a public relations campaign."

Personal stories.
The doctors told their individual stories. They didn't need to be media coached to talk about something that was threatening their livelihood.

Patient Political Action Kit.
This was distributed to hundreds of doctors' offices. It included an information sheet on California's reform. The sheet explains the group's efforts. It gave phone numbers and e-mail address for the legislative leadership in Nevada.
Postcards with the theme "Help Me Keep My Doctor" could be filled out and sent to elected officials.
"This is something that from an elected official perspective, and from a public perspective, has become an every day issue. It's in the paper every day and people are being turned down by their doctors every day," says Ferrari.

Voter registration materials.

Closing notice. A tent card said, "Notice to all patients: This office may be closed indefinitely ..." It explained the office might be closed unless "excessive litigation and jury awards are reduced."

Public may not relate to physicians' dilemma

Medical professionals and hospital administrators understand the malpractice issue, but for the general public, it can be hard to find sympathy for the doctors.
"There is a misconception that every doctor has a mansion and a Mercedes. The fact that it actually costs doctors additional dollars in premiums to serve at the UMC Trauma Center is not widely understood. The compensation is insignificant, and they each take a call shift as a service to the community," says Ferrari.

Trauma center closed amid widespread coverage

With insurance policies expiring, unavailable or unaffordable, more than 50 orthopedic surgeons resigned.
The trauma center at UMC closed just before the July Fourth weekend. Las Vegas was the only major city in the United States without trauma care.

Newscasts featured stories on the crisis, and showed the trauma equipment being packed up and carted away.

The closure of the trauma center resulted from decisions individual physicians made.
"It was a personal decision that each agonized over. They were put in a spot where continuing their privileges at the trauma center would put their families at risk," Ferrari says.
One surgeon told a network reporter that if he continued to practice at the trauma center, he could lose his home, his life savings, his child's college fund --- everything. He feared he could find himself in a situation where he had to "start all over."

Ferrari says it is important to remember that although the physicians weren't serving at the trauma center, they continued to practice at ERs at every hospital in the county, and they served patients there.
"Through their continued practice in the emergency rooms, they were able to keep the emergency healthcare system viable," he adds.
 

toughlife

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Closure was a PR setback

The doctors were criticized by some powerful people.
They were characterized as "strikers" who were putting the public at risk.
The Speaker of the state Assembly said, "We don't let police officers or firefighters go on strike and leave the public at risk."

The trial lawyers attacked.
One Las Vegas attorney claimed:
--- No emergency justifies doctors walking off.
--- It was a calculated game designed to improve their finances.
--- The resignations were similar to a strike by casino restaurant workers who wanted higher wages.

The trial lawyers used print ads at times to get their message out.
Ferrari says, "One ad was offensive to just about anyone who read it. It compared the doctors to terrorists. The copy said that President Bush had warned there could be a terrorist attack over the July Fourth holiday, and went on to say, 'Little did we know it would be come in the form of our doctors leaving the trauma center.' It was really in bad taste, and to some extent, it backfired on them."

Some members of the public were dismayed the physicians had resigned.
"People realized we had to do something to solve the problem, so that everyone could get medical care. When the trauma center closed, the community felt a little bit betrayed," he adds.

From a public relations standpoint, the closure of the trauma center hurt the efforts of the task force, according to Ferrari.
"The community had been on the doctors' side until that point," he says. There was some feeling that people had supported the doctors, and then the doctors walked out on them.
"From a PR perspective, that was the first glitch in our efforts, and it set us back several weeks," says Ferrari.

Media focused on possible deaths attributable to closing

There was substantial news interest in whether closing the trauma center that hopefully saves lives, would result in deaths.

Here are several stories the Las Vegas Review Journal did:

Police: Homicide deaths will increase if trauma center closes.
Before the closing, a Review-Journal writer interviewed the sheriff and a police lieutenant. They expected more shooting and assault victims would die.
The officer gave as an example a recent night when there were four gunshot victims. Two died. Two "were saved" by the trauma experts.

Trauma victim first to die since unit shut doors.
Two days after the closing, a sport utility vehicle slammed into a car near the airport. The car driver subsequently died about 90 minutes after arriving at an emergency room.
The man's adult daughters told the Review-Journal that they wondered if their dad's life could've been saved if the trauma unit physicians were on duty.
Hospital, police and coroner's officials declined to say whether they believed the life would have been saved if the center was open.
"There's no way anyone, a physician or anyone else, can say whether it would have made any difference ... There are too many variables. It's so dependent on the man's medical history and the severity of the accident," said Mike Tymczyn, a spokesman for Desert Springs Hospital, where the man was taken.
Accident victims grateful to be alive
The Sunday paper ran a long piece profiling four survivors (with their pictures).
A girl had lost a leg in a car crash. A man almost burned to death when hit head-on by a truck. Another man was almost killed in a car wreck. Surgeons worked seven hours to help save a motorcyclist hit by a car.
"All say it was the work of specialists at University Medical Center's Trauma Center that kept them alive," wrote reporter Richard Lake.

Temporary deal paved way for re-opening

The hospital is operated by the county.
In Nevada, a governmental employee is covered by a $50,000 liability cap. Staff physicians, who are employed by the hospital, are covered by the sovereign immunity cap. However, most of the specialists are in private practice, and rotate the on-call duty at the trauma center.

After the trauma center was closed for several days, a temporary solution was devised.
The surgeons would be covered as government employees. The state attorney general issued an opinion saying the doctors were covered under the $50,000 liability cap.
This was a temporary solution.

Ten days after it closed, the trauma center re-opened.

Poll: Most support caps on jury awards

The doctors' educational campaign seemed to connect with the public. The newspaper commissioned a wide-ranging survey on many issues at the time the trauma center's closure and reopening was making front-page headlines.

By nearly a 4 to 1 margin (66%-17%), Nevadans supported placing caps on jury awards for pain and suffering in medical malpractice cases. "The doctors certainly made a point by walking off the job. They got plenty of attention," said Brad Coker, managing director of Mason- Dixon Polling & Research.

Question: Do you support or oppose the state of Nevada placing a cap on awards for non-economic damages, such as pain and suffering, in medical malpractice lawsuits?

State Men Women

Support 66% 68% 64%

Oppose 17% 16% 18%

Undecided 17% 16% 18%

Support for caps was widespread across gender and geographical areas.


Nevada Malpractice Crisis Timeline

Fall, 2001 Rate hikes
Insurance rates boosted. Malpractice insurance rates triple and quadruple. S ome physicians limit services, stop taking new patients. Others make plans to move or retire. Pregnant women search for prenatal care.

March 4 State hearing showdown
Hundreds of doctors, lawyers and insurance officials attend a state hearing on the issue. The medical people ask for relief. The trauma center almost had to go to part-time status.

June 15 Ad campaign launches
Physicians begin paid media, including profiles of doctors who are leaving Nevada.

June 18 Doctors' request rejected
County commissioners deny 21 doctors' requests for leaves of absence.

June 21 Doctors prepare to leave
17 doctors say they will quit. Physicians were contacted by the reporter, and they reacted to the "no leaves" policy.

July 2 Medical community gets ready
Other hospitals brace for influx of trauma patients.

July 3 Center shuts down
Trauma Center closes after dozens of doctors resign.

July 6 Media deathwatch begins
Headline: Trauma victim first to die since unit shut doors.

July 7 Doctors criticized
Review-Journal columnist John L. Smith writes a blistering piece attacking the physicians. Smith: "I expect insensitive insurance companies to act like insensitive insurance companies. I expect trial lawyers to act like trial lawyers. But until now, I naively expected doctors to act like doctors ... To use the trauma center as political leverage was a low blow. It scared the wrong people, the ones the doctors took an oath never to harm."

July 9 County liability cap
Attorney General issues opinion supporting temporary extension of the county liability cap to include the UMC Trauma Center doctors.

July 11 Doctors study proposal
State Orthopedic Society president agrees to work, others consider it. The leader said his lawyer had reviewed the attorney general's opinion. Others worried that despite that opinion, it might still be overturned in the courts.

July 12 Doctors prepare to come back
Several surgeons agree to return. They will work temporarily as part-time county employees. Elected state officials are promising a special session of the legislature to deal with the issue late in the month.

July 13 Trauma center re-opens
Review-Journal: During closure, there were 150 trauma patients. Six died. UMC officials said there was no way to know whether any of them could've been saved by the trauma experts.

July Lawyers' ad campaign
Malpractice victims are featured in emotional television commercials generated by trial lawyers. Typical: A widow lost her husband because of a botched needle biopsy. A woman with a kidney stone ended up a double amputee.

July 29 Apparent compromise reached
Lawmakers reach apparent compromise. The governor and legislative leaders announce a package with a $350,000 cap on damages for pain, suffering and other noneconomic factors. But, the deal also provides for several exemptions (e.g. cases involving death, brain damage, etc.) where the cap could be avoided. This seems to leave the door open for many high priced awards, as in the past.

July 30 Agreement in danger
The deal stalls. Eventually a compromise went forward






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docB

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I'd say that overall the trauma center closure helped us in Nevada. There was some short term bad blood but by November of 2004 we had enough public opinion on our side that we soundly passed our ballot measure and defeated the two lawyer backed measures.

Some of the arguments about the closure were truly scary. Let me point out again that the docs resigned. They didn't strike for a bargaining position. They quit saying that working conditions to so bad they were willing to go find work elsewhere. The lawyers were arguing that they couldn't do that. Essentially the lawyers were arguing for an environment in which docs are slaves bound to a permanent duty to act no matter how bad working conditions are.