malpractice and such

[TheLesPaul]

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http://www.cnn.com/2008/SHOWBIZ/02/05/ritter.death.ap/

I will only start med school this fall, so I'm not quite sure what to think of this story. It seems like the doctors make a logical decision which had unforeseen consequences. Did the doctors just make a big mistake, or are the lawyers whipping themselves up into a froth over nothing here? Either way, the hospital already paid out some money, but is the lawsuit justified?

And if it wasn't justified yet they lawyers still won, why in the world would you ever treat a celebrity?

 

[LizUMD]

http://www.cnn.com/2008/SHOWBIZ/02/05/ritter.death.ap/

I will only start med school this fall, so I'm not quite sure what to think of this story. It seems like the doctors make a logical decision which had unforeseen consequences. Did the doctors just make a big mistake, or are the lawyers whipping themselves up into a froth over nothing here? Either way, the hospital already paid out some money, but is the lawsuit justified?

And if it wasn't justified yet they lawyers still won, why in the world would you ever treat a celebrity?

My favorite part is his wife's quote "You can't treat my kid's dad for something and kill him in the process. Somebody needs to take responsibility."
GMAB. I've yet to hear of one medical expert reading about the case and concurring that there may even be a chance of serious malpractice here. Do you really think John Ritter would have wanted his family, four years after his death, to be tangled up in a $67 million lawsuit in his name against the doctors who tried to save his life? This wasn't a surgeon operating drunk or leaving a scalpel inside his chest. This was a differential diagnosis by the book that, unfortunately, was an atypical presentation of something far down on the list.

Also interesting that the radiologist alleges that two years before his death Ritter was advised to follow-up with a cardiologist for calcifications in his arteries and high cholesterol but never did.

 

[xanthines]

Without knowing all the facts, it's hard to say whether the doctors made a mistake or not. From what the defense has said, it doesn't sound like it. Then again, that's kind of the job of defense lawyers, isn't it? 🙂

As for why would you treat a celebrity... well, they're people, too and need healthcare like everyone else. As a physician you're not really supposed to treat people based on what their social worth is, be it great or nil. Of course, the cynical answer is that celebrities pay you well without the hassles of insurance reimbursements. 🙂

-X

Did the doctors just make a big mistake...?

And if it wasn't justified yet they lawyers still won, why in the world would you ever treat a celebrity?

 

[coffeebythelake]

My favorite part is his wife's quote "You can't treat my kid's dad for something and kill him in the process. Somebody needs to take responsibility."

I think that is the problem with medical malpractice today. Sometimes things go wrong even when everybody did everything right.

 

[Doctor Bagel]

The thing that particularly bugged me about this lawsuit is that Ritter's wife has said she's bringing the suit to raise awareness, not because of the money. Couldn't she raise awareness in some way that won't be a huge stress for these docs who probably did provide the proper standard of care?

I'm not out there yet, but I agree that it doesn't sound like any gross malpractice happened here.

 

[osli]

I certainly don't know all of the details, but it is possible that the physicians involved did not think of something that they should have based on presentation, or did not properly rule out alternatives even given the limited time. It is highly likelely that some doctor somewhere would have immediately thought of dissection as a distinct possiblity and either done or ordered a quick test to help make the proper diagnosis.

However, would all doctors everywhere be expected to have done such? IMO, this is the grounds for malpractice; not whether the particular physician in question did or did not do something that another somewhere might have done to save the life (or achieve a better outcome), but whether the physician did or did not do something that would be expected of all competent physicians. Did Ritter receive the "standard of care?" I don't think you can expect to always be in the presence of the very best EM doc, surgeon, etc. on his/her very best day every time you need medical care. You do expect to always be provided the standard of care at a competency level equal to that of what would be expected anywhere.

Everyone makes mistakes: IMO, physicians should not be liable for mistakes they make that would reasonably be made by many other physicians under the exact same circumstances, but only for the mistakes which would not be expected of any other competent physician under the circumstances.

People expect physicians/medicine to be at the very forefront of modern science and technology, and at the same time to be absolutely infallible in their understanding of or use of often very new knowledge or techniques that come from being on that forefront. I don't believe that is a reasonable expectation. There are certainly things that happen that warrant malpractice, but to expect physicians to be exempt from the human condition is absurd.

Again, I don't know about this case specifically, but on the surface it seems to fit the generalization applicable to so many malpractice suits these days.

 

[Bushido416]

Real problem in this case is that the state has not enacted a law like www.mirca.org look at this site. Good many states have put this law into effect. It establishes a statue of limitations in which claims can be pursued. Also puts a limit on non-economic damages like pain and suffering. States like Texas enacted it and doctor's insurance rates went down about 30 percent ish. Anyway they did the best with the information they had. 99% of the time it was what they treated him for. Also they already received 14 million dollars. John Ritter was not an actor in his prime and would not have made that much money. The 67 million is absolutely ridiculous and was an estimate contingent upon well if he signed this hypothetical contract and got this hypothetical job then he would have made this much. It's outrageous that the family feels they are any more entitled than anyone else who has had a legitimate medical judgement call made with the best information and had adverse results. This is just trial lawyers going crazy because they collect large fees. I feel bad for the Ritter family and I don't know what I would do without my dad but I wouldn't sue a competent physician who did the best he could with the information he had. If this were some avg joe who this had happened to there is no way we'd hear of such large settlements and no way a jury wouldn't throw this out as a frivilous case. There is no basis of negligence and cases like this make the cost of health care heavier on everyone's shoulders.

 

[AZhopeful]

MIRCA.org: the MIchigan Roofing Contractors Association, eh Bushido?

May want to call a mulligan on that one...

 

[Doctor Bagel]

Most of the legislation dealing with tort caps only addresses non-economic harm (pain & suffering, etc. . Here, they're suing for economic harm (lost future wages), which is not generally a hot topic for tort reform.

 

[ColinHay]

MIRCA.org -the MIchigan Roofing Contractors Association, eh Bushido?

May want to call a mulligan on that one...

I think that means if you don't like the way things are just find another job - roofing is as good as any.

 

[nogolfinsnow]

I saw this on TV the other day and almost threw up. As much as I want to feel bad for the lady for losing her husband early, I can't. She's being an opportunist. She said she wants to use the 67mil to start a foundation to raise awareness about aortic dissection. What, she couldn't spare any of the original 14 mil to start up a foundation? She's being a greedy POS and I hope she gets exposed for what she is.

 

[coffeebythelake]

I saw this on TV the other day and almost threw up. As much as I want to feel bad for the lady for losing her husband early, I can't. She's being an opportunist. She said she wants to use the 67mil to start a foundation to raise awareness about aortic dissection. What, she couldn't spare any of the original 14 mil to start up a foundation? She's being a greedy POS and I hope she gets exposed for what she is.

It makes it easier to justify one's greed when the they claim it is for a selfless cause. But I agree it is bull.

 

[amherstguy]

wouldnt a troponin, cpk or an EKG clearly distinguish an MI for an AD??

 

[DrMom]

not necesarily. a dissection can lead to cardiac ischemia.

 

[Instatewaiter]

I have no idea if this guy had markers showing ischemia but seriously if EKG showed ischemic changes and troponin was elevated and you didnt put a patient on thrombolytics immediately you'd be up ****'s creek.

I'm curious to know more

 

[Law2Doc]

Either way, the hospital already paid out some money, but is the lawsuit justified?

And if it wasn't justified yet they lawyers still won, why in the world would you ever treat a celebrity?

Justified? The lawyers didn't decide if there was a case here -- they had the record looked at by a physician who told them that "in his expert opinion" as a physician, that there was a mistake here, a deviation from the accepted standard of care. Since such a physician is coming forward and saying another physician made a mistake, there is a suit that legitimately can be heard in court. No judge is going to dismiss such a case because few judges have gone to med school and are going to superimpose their own medical knowledge over that of an expert. So it is not frivolous by any definition. It may not be a winning case, but it certainly can be brought -- whether something prevails isn't determined by whether it is justified or frivolous; it is whether there was an actual dispute as to whether the doctors followed the standard of care expected of physicians in this situation. They may have, but at least one doctor in the world is willing to go on record and disagree, making the case something that gets to court. It will be a battle of physicians and the judge or jury will decide who is right. Without physicians jumping into the expert witness chair, there would be no medmal lawsuits-- this is what gets these cases into court.

But yes, you probably have to be awfully careful when you treat a celebrity, because famous people have better access to the media, and lawyers certainly don't mind the free advertising a high profile case will bring.

 

[MattD]

I'm more interested in how this presentation would have gone down, hypothetically speaking of course. So he comes in with substernal pain, nausea, vomiting. Sounds like MI. No excruciating tearing pain. Doesn't sound like dissection. Even so, it could be other things. So, let's get enzymes, EKG, chest film. I suppose as Dr. Mom stated, a very proximal dissection could block the coronaries and cause ischemic change. My question to you guys is, would a chest film show any indication of an aortic root dissection? I wouldn't imagine it would, but I have no real practical experience in these things, so I defer to you guys 🙂 If not, is there any situation in which a patient presenting with probable MI would be sent to CT before treatment was started, where the dissection may have been picked up? Also, would a dissection that proximal have produced a murmur they should have heard on exam?


Finally, out of curiosity, how would thrombolytics have hastened his death? Is there some protective benefit to generating a clot at the site of dissection?

 

[Jolie South]

This is talked to death in the EM physicians forum. You might get more answers about the medical technicalities there.

I'm not going to pretend I know anything, but what I read over there was that they didn't think the physician was at fault.

 

[dilated]

The lawyers didn't decide if there was a case here -- they had the record looked at by a physician who told them that "in his expert opinion" as a physician, that there was a mistake here, a deviation from the accepted standard of care. Since such a physician is coming forward and saying another physician made a mistake, there is a suit that legitimately can be heard in court.

You can't be saying this with a straight face, can you? The idea that somehow you can't find a physician willing to say anything you want in exchange for $$$ is hilarious. Have you heard of the case the "neurosurgeons" who did nothing but testify in neurosurgery malpractice cases for a living and were then kicked out of the AANS after it was found that they would say totally absurd things if the lawyer told them to? If you're willing to spend money, the "expert" certification is a joke.

The pressure to settle is based on the odds of success... and the cost of losing. Even if it's a crappy case, grieving widow + potential 67 million dollar loss = 2 or 3 million to go away doesn't seem so bad.

 

[coffeebythelake]

The pressure to settle is based on the odds of success... and the cost of losing. Even if it's a crappy case, grieving widow + potential 67 million dollar loss = 2 or 3 million to go away doesn't seem so bad.

Jurors are partial to sob stories.

 

[Law2Doc]

The idea that somehow you can't find a physician willing to say anything you want in exchange for $$$ is hilarious. Have you heard of the case the "neurosurgeons" who did nothing but testify in neurosurgery malpractice cases for a living and were then kicked out of the AANS after it was found that they would say totally absurd things if the lawyer told them to? If you're willing to spend money, the "expert" certification is a joke.

I'm saying this is really a problem of the medical profession, not the legal one. Without physicians willing to ***** themselves out, these cases don't exist. Lawyers don't create these cases from thin air. Generally, a family comes to a lawyer (not the other way round, despite the ambulance chasing imagery largely created by the media, but an exception not the norm in reality) and says, "can I sue?" The lawyer, in turn, calls up a physician from his expert witness rolodex and asks the doctor "can they sue?" So it is the doctor who makes this lawsuit happen, is the critical point on the decision tree. Physicians could crack down on this; the point of a profession is that it is a club with rules and self disciplining. They could easilly make a rule that you cannot testify in court for money, or not testify in a case to which you have no professional nexus, or cannot stay licensed if greater than X percent of your income comes from witness fees, etc. But they choose not to. You can't complain against medmal as a profession if so many of your fellow physicians are benefiting from making these suits go forward. Sure it's nice to blame lawyers (it is an age old tradition, even seen in Shakespeare's days), but this is a physician issue.

 

[mjl1717]

Jurors are partial to sob stories.

This my deeper thought!! Maybe in malpractice cases the jury should be made up of medical personnel to add some levity to the situaiton??
Just a thought?
Instead of having "Mary Vanderbuilt" and John Doe using ONLY emotions to reach an unfair settlement...

 

[osli]

I'm saying this is really a problem of the medical profession, not the legal one.

You're right... of course the legal system is completely faultless here. 🙄

Do you not see a problem in the lawyer having a rolodex of scummy physicians on hand? Or the wife having a phone book full of scummy lawyers to call?

Personally, I think there are many parties at fault in cases like this. You can't lay the blame solely on physicians - that's ludicrous. Just because cutting one part of the problem network would offer a solution does not mean that it is solely responsible - cutting another part of the problem network may be equally effective.

 

[Doctor Bagel]

You're right... of course the legal system is completely faultless here. 🙄

Do you not see a problem in the lawyer having a rolodex of scummy physicians on hand? Or the wife having a phone book full of scummy lawyers to call?

Personally, I think there are many parties at fault in cases like this. You can't lay the blame solely on physicians - that's ludicrous. Just because cutting one part of the problem network would offer a solution does not mean that it is solely responsible - cutting another part of the problem network may be equally effective.

But from a practical standpoint, we can do a lot more regulating our own profession than trying to regulate another one. Maybe we should focus on reporting these doctors who do seem willing to testify for whatever cause in exchange for payment?

 

[TheLesPaul]

If the problem was so simple, then why isn't a group like the AMA doing something about it?

 

[dilated]

Physicians could crack down on this; the point of a profession is that it is a club with rules and self disciplining. They could easilly make a rule that you cannot testify in court for money, or not testify in a case to which you have no professional nexus, or cannot stay licensed if greater than X percent of your income comes from witness fees, etc. But they choose not to.

AFAIK, this is wrong. Courts have held that physician associations cannot set punishments for physician members that violate the professional standards of the organization, the most they can do is remove them from the association. And it is outside the scope of state medical boards and would require legislative action to make it affect actual medical licenses (which would never happen). Lawyers have a pretty good system set up.

 

[dilated]

Physicians could crack down on this; the point of a profession is that it is a club with rules and self disciplining. They could easilly make a rule that you cannot testify in court for money, or not testify in a case to which you have no professional nexus, or cannot stay licensed if greater than X percent of your income comes from witness fees, etc. But they choose not to.

AFAIK, this is wrong. Courts have held that physician associations cannot set punishments for physician members that violate the professional standards of the organization, the most they can do is remove them from the association. And it is outside the scope of state medical boards and would require legislative action to make it affect actual medical licenses (which would never happen). But wait, what profession makes up all of the legislature?? Lawyers have a pretty good system set up.

 

[Law2Doc]

But wait, what profession makes up all of the legislature?? Lawyers have a pretty good system set up.

Um, lawyers don't make up legislature. Your elected officials make up legislature. But rules of professional conduct are made up by the respective professions.

Every profession has an ability to make binding rules for its members. The legal profession, for instance, has many rules that prohibit conduct of its members, ranging from what kinds of things may be in their advertising, whose names may be on a firm's letterhead, to whether lawyers can date clients etc. Medicine has the same leeway.

 

[Law2Doc]

If the problem was so simple, then why isn't a group like the AMA doing something about it?

The AMA isn't a single cohesive group, and doesn't do this kind of stuff on its own initiative. It takes fees from the docs who serve as experts just like any other doctor. It would take a groundswell of physicians wanting to fix this to make the AMA do anything.

 

[HomerSD]

The CNN story is scant on details, but the lack of a CXR on presentation is moderately disturbing. Per our protocol at my residency for ST segment elevation AMI, a CXR is always ordered specifically to rule out aortic dissection prior to giving heparin and a IIb/IIIa inhibitor. I'm just guessing, but I think John Ritter probably got anti-coagulation and subsequently ruptured his aneurysm. Because AMI and AD can present so closely clinically, I suppose this is why we had a mandate to quickly image first, even though it held up transport to cath lab by 5-10min.

 

[BostonEMT]

"Ritter's second wife, Amy Yasbeck, and his four children have already received a reported $14 million in settlements with nine other medical entities, including the hospital where he was treated."

How typically American: a wealthy celebrity dies of an event with a mortality of ~80% (with rapid, optimal care conditions), celebrity's wife -- who has no training whatsoever in medicine or even an undergraduate science education -- contacts lawyers alleging that the only way her husband's life could possibly have ended is by professional negligence, "medical entities" award family $14 million and yet they...still...need...more...money. *sigh*

My father died at 31 of an aortic dissection. Life sucks sometimes; perhaps I should have thought to sue all of the qualified and extremely educated doctors for not recognizing that he was, in fact, immortal.

 

[dilated]

Um, lawyers don't make up legislature. Your elected officials make up legislature. But rules of professional conduct are made up by the respective professions.

But more than half of Congress is lawyers. Compared to less than 1% physicians. It's not terribly surprising that the legislature then tends to be more favorable towards lawyer's interests.

The AMA isn't a single cohesive group, and doesn't do this kind of stuff on its own initiative. It takes fees from the docs who serve as experts just like any other doctor. It would take a groundswell of physicians wanting to fix this to make the AMA do anything.

I'm confused about what you expect the AMA to do. You talk of "binding" rules, but what if you don't follow these rules? They can't affect their ability to practice medicine. The most they can do is remove them from the organization.

 

[Bushido416]

sorry my link was broken above. http://micra.org/about-micra/micra-history.html
That one should work it's California's 1975 legislation capping the amount of non-economic damages to 250,000 dollars and limits the percentage of that money that can be charged by the lawyers. Interesting legislation. I won't be practicing in a state that has not enacted this kind of liability reform. The best section on the website are the news articles from the different states that have adopted it. A national reform of medical liability failed to pass by 3 votes...and those 3 were conveniently absent on the day of the vote.

 

[Law2Doc]

But more than half of Congress is lawyers. ... It's not terribly surprising that the legislature then tends to be more favorable towards lawyer's interests.

Nah, they stopped being lawyers the second they ran for office. They merely have degrees. Quite a few never even practiced. Legislature tends to be favorable toward groups that know how to lobby effectively. The ABA does this well, the AMA is maybe the least effective I have seen.

 

[Law2Doc]

The most they can do is remove them from the organization.

We aren't talking about the AMA itself, we are talking about it as a proxy for the profession. Organized professions can create rules binding on members of that profession. Law has done it. If you violate these rules of conduct, you go before a disciplinary committee with power to suspend or revoke your license. Most states have a Board for Professional Medical Conduct, where physicians sit in judgment of other physicians. If you do a google search, you will find that these boards "serve patients by ensuring that, in order to be licensed, physicians meet minimum standards of training and competence. They are also required to discipline physicians who commit offenses such as incompetence, negligence, sexual misconduct, and violations of criminal laws." So there are codes of professional conduct under which physicians already have to abide. It isn't much of a hurdle to add a provision on what is or isn't permissible with respect to serving as an expert witness, if the profession were so motivated.