This is why doctors practice CYA medicine

[DermViser]

Just saw this article: http://www.kevinmd.com/blog/2014/03/doctors-practice-cover-ass-medicine.html

This should be show to every single liberal, health economist, etc. who says that defensive medicine and malpractice lawsuits are only a small proportion of healthcare costs.

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[notbobtrustme]

The biggest problem is having non-medical people judge medical decisions.

If the doctor followed the standard of care, then any malpractice lawsuit should be thrown out.

 

[deleted500612]

How can we possibly have lay persons judge a case like this? They don't have a clue what viral myocarditis is, or how reasonable it would have been to expect the doctor to accurately diagnose it in those circumstances. All they know about the virus or practicing medicine in general is what the prosecution and defence teams tell them, which of course is going to be a lot of biased BS meant to indict. And of course when given the choice of siding with (from their perspective) a pompous upper-class overpaid ER physician, or the hometown blue-collar Joe they are going to have Joe's back every time. This sort of over-litigation is why American doctors pay up to 10 times the malpractice insurance rates of other western nations, it's frightening and disheartening that this kind of verdict is not even close to unprecedented.

 

[dyspareunia]

We have a professor who says he routinely serves as an "expert witness" in cases like these. He's a med-peds guy with a PhD in one of the basic sciences (trying to remain somewhat anonymous here). Dude says his rate is $800-$1k/hr and the lawyers didn't even bat an eye at that number. Ridiculous.

 

[TooMuchResearch]

We have a professor who says he routinely serves as an "expert witness" in cases like these. He's a med-peds guy with a PhD in one of the basic sciences (trying to remain somewhat anonymous here). Dude says his rate is $800-$1k/hr and the lawyers didn't even bat an eye at that number. Ridiculous.

Is he one of the expert d*cks for the plaintiff? Make sure to tell him how much of a d*ck he is.

 

[TooMuchResearch]

The biggest problem is having non-medical people judge medical decisions.

If the doctor followed the standard of care, then any malpractice lawsuit should be thrown out.

But much of medicine has no standard of care. All it takes is a couple of hack sell-out a**hats claiming there is a standard when none actually exists.

 

[TooMuchResearch]

Ah, there has been discussion on this case in the EM forum for about a week.

 

[Long Way to Go]

This should be show to every single liberal, health economist, etc. who says that defensive medicine and malpractice lawsuits are only a small proportion of healthcare costs.

I mean, malpractice suits suck, but there's a reason why economists work with data and not anecdotes.

Let's take a look at a paper that I'm sure will have at least one author that you have heard of:

Mello MM, Chandra A, Gawande AA, Studdert DM. National costs of the medical liability system. Health Aff (Millwood). 2010 Sep;29(9):1569-77. doi:
10.1377/hlthaff.2009.0807. (http://content.healthaffairs.org/content/29/9/1569.full)

The total monetizable costs of the medical liability system—those that can be quantified and expressed in monetary terms—can be divided into several components. The major categories of costs are indemnity payments, or the amounts that malpractice defendants, typically through their liability insurers, pay out to patients who file malpractice claims against them; administrative expenses, consisting of attorneys’ fees and other legal expenses for both sides, plus insurer overhead; defensive medicine costs, which are the costs of medical services ordered primarily for the purpose of minimizing the physician’s liability risk; and other costs, some of which are difficult or impossible to quantify in economic terms.

So note that this does include their estimates of defensive medicine costs, which they do acknowledge is incredibly difficult to estimate. But it isn't like the authors are totally unfamiliar with the concept--for example, Atul Gawande, the third author, has written about his and colleagues' experiences being sued (http://www.newyorker.com/archive/2005/11/14/051114fa_fact_gawande?currentPage=all) in the popular press.

Estimates Of National Costs Of The Medical Liability System

Component Estimated cost (billions of 2008 dollars)
Indemnity payments $5.72
 Economic damages $3.15
 Noneconomic damages $2.40
 Punitive damages $0.17
Administrative expenses $4.13
 Plaintiff legal expenses $2.00
 Defendant legal expenses $1.09
 Other overhead expenses $3.04
Defensive medicine costs $45.59
 Hospital services $38.79
 Physician/clinical services $6.80
Other costs
 Lost clinician work time $0.20
 Price effects –
 Reputational/emotional harm –
Total$55.64

So $56 billion dollars. That's a lot. And the bulk of the costs are defensive medicine costs, which are high. But right now, the total cost of malpractice is less than how much the U.S. spends on Medicare Part D (http://www.cbo.gov/sites/default/files/cbofiles/attachments/12-01-MedicarePartD.pdf). Even if this is underestimated by a factor of five, it's not the end of the world.

Anecdotes vs. Evidence-based research. There's a reason one is more emotionally powerful than the other, but what profession are you planning on entering?

 

[GadRads]

So what is your point?

I mean, malpractice suits suck, but there's a reason why economists work with data and not anecdotes.

Let's take a look at a paper that I'm sure will have at least one author that you have heard of:

Mello MM, Chandra A, Gawande AA, Studdert DM. National costs of the medical liability system. Health Aff (Millwood). 2010 Sep;29(9):1569-77. doi:
10.1377/hlthaff.2009.0807. (http://content.healthaffairs.org/content/29/9/1569.full)



So note that this does include their estimates of defensive medicine costs, which they do acknowledge is incredibly difficult to estimate. But it isn't like the authors are totally unfamiliar with the concept--for example, Atul Gawande, the third author, has written about his and colleagues' experiences being sued (http://www.newyorker.com/archive/2005/11/14/051114fa_fact_gawande?currentPage=all) in the popular press.



So $56 billion dollars. That's a lot. And the bulk of the costs are defensive medicine costs, which are high. But right now, the total cost of malpractice is less than how much the U.S. spends on Medicare Part D (http://www.cbo.gov/sites/default/files/cbofiles/attachments/12-01-MedicarePartD.pdf). Even if this is underestimated by a factor of five, it's not the end of the world.

Anecdotes vs. Evidence-based research. There's a reason one is more emotionally powerful than the other, but what profession are you planning on entering?

 

[DermViser]

I mean, malpractice suits suck, but there's a reason why economists work with data and not anecdotes.

Let's take a look at a paper that I'm sure will have at least one author that you have heard of:

Mello MM, Chandra A, Gawande AA, Studdert DM. National costs of the medical liability system. Health Aff (Millwood). 2010 Sep;29(9):1569-77. doi:
10.1377/hlthaff.2009.0807. (http://content.healthaffairs.org/content/29/9/1569.full)



So note that this does include their estimates of defensive medicine costs, which they do acknowledge is incredibly difficult to estimate. But it isn't like the authors are totally unfamiliar with the concept--for example, Atul Gawande, the third author, has written about his and colleagues' experiences being sued (http://www.newyorker.com/archive/2005/11/14/051114fa_fact_gawande?currentPage=all) in the popular press.



So $56 billion dollars. That's a lot. And the bulk of the costs are defensive medicine costs, which are high. But right now, the total cost of malpractice is less than how much the U.S. spends on Medicare Part D (http://www.cbo.gov/sites/default/files/cbofiles/attachments/12-01-MedicarePartD.pdf). Even if this is underestimated by a factor of five, it's not the end of the world.

Anecdotes vs. Evidence-based research. There's a reason one is more emotionally powerful than the other, but what profession are you planning on entering?

I'm already a resident in the profession, pre-med. I am not talking about absolute costs from malpractice lawsuits, or the cost of malpractice insurance. I am talking about the effect of the fear of a lawsuit on physician behavior when it comes to ordering something whether that be a lab/imaging/medication/procedure. No doctor can write in their chart - I am ordering this test/procedure to avoid getting a lawsuit. So knowing when something was ordered due to medical necessity vs. whether it was ordered to avoid a lawsuit, is not black and white. I am talking about the affect on downstream behavior on all patients.

 

[Long Way to Go]

So what is your point?

Defensive medicine sucks for the patient, for the physician and for society as a whole. I've seen it in practice and I've had it performed on me. But there's no political point to be made here; it's simply not terrible as you're making it out to be.

 

[Long Way to Go]

I'm already a resident in the profession, pre-med. I am not talking about absolute costs from malpractice lawsuits, or the cost of malpractice insurance. I am talking about the effect of the fear of a lawsuit on physician behavior when it comes to ordering something whether that be a lab/imaging/medication/procedure. No doctor can write in their chart - I am ordering this test/procedure to avoid getting a lawsuit. So knowing when something was ordered due to medical necessity vs. whether it was ordered to avoid a lawsuit, is not black and white. I am talking about the affect on downstream behavior on all patients.

Yes. Did you actually read the paper?

 

[dyspareunia]

Is he one of the expert d*cks for the plaintiff? Make sure to tell him how much of a d*ck he is.

No, he says he only does it when he can help the physician.

 

[DermViser]

Ah, there has been discussion on this case in the EM forum for about a week.

The worse part is according to the article: "Viral myocarditis has been recognized as a cause of congestive heart failure for >50 years, but it is still a challenging disease to diagnose and treat. The history and clinical features are often nonspecific, and practical serological markers are not available during the acute phase of the disease. Even after proper diagnosis, no clinically proven treatment exists to inhibit the development of subsequent dilated cardiomyopathy (DCM) and, in some cases, death."

So what is the ED physician supposed to do, and if had been admitted, what would the admitting team have been able to do?

 

[Coffee Machine]

The worse part is according to the article: "Viral myocarditis has been recognized as a cause of congestive heart failure for >50 years, but it is still a challenging disease to diagnose and treat. The history and clinical features are often nonspecific, and practical serological markers are not available during the acute phase of the disease. Even after proper diagnosis, no clinically proven treatment exists to inhibit the development of subsequent dilated cardiomyopathy (DCM) and, in some cases, death."

So what is the ED physician supposed to do, and if had been admitted, what would the admitting team have been able to do?

This is what scares me the most about this case. This isn't a situation where an extremely rare, but preventable outcome occurred because of a diagnostic error. It was an atypical presentation of a rare condition that has been called "one of the most difficult diagnoses in all of cardiology" (per the article) that doesn't have an effective treatment. I mean... Come on. And the plaintiffs were awarded $4.8 million. This is just unbelievable.

And, as one of the comments points out, even if the ED doc had practiced the usual CYA in these circumstances (ie, ordering enzymes, CXR, EKG, etc) there's still a good chance that nothing would've been abnormal. Would that have been "good enough" for the family? Or should MDs just order heart biopsies on all of their twenty-something pts with cough, fever, and chest pains, just to be thorough? And God forbid someone has a bad outcome post-biopsy. Catch-22 if I've ever heard of one.

 

[DermViser]

This is what scares me the most about this case. This isn't a situation where an extremely rare, but preventable outcome occurred because of a diagnostic error. It was an atypical presentation of a rare condition that has been called "one of the most difficult diagnoses in all of cardiology" (per the article) that doesn't have an effective treatment. I mean... Come on. And the plaintiffs were awarded $4.8 million. This is just unbelievable.

And, as one of the comments points out, even if the ED doc had practiced the usual CYA in these circumstances (ie, ordering enzymes, CXR, EKG, etc) there's still a good chance that nothing would've been abnormal. Would that have been "good enough" for the family? Or should MDs just order heart biopsies on all of their twenty-something pts with cough, fever, and chest pains, just to be thorough? And God forbid someone has a bad outcome post-biopsy. Catch-22 if I've ever heard of one.

Yes, I thought one of the comments was telling: "In the medicolegal world "might have" is good enough for medmal. They do not need to show beyond reasonable doubt.
And EKG "might have" picked up viral myocarditis. Of course, if the EKG was normal and the patient died from myocarditis the attorney would spin it another way: can patient with normal EKG still have myocarditis? There's no winning on this. Damned if you do and damned if you don't."

 

[GadRads]

But this story though http://www.cnn.com/2008/HEALTH/01/09/ep.suing.docs/index.html?_s=PM:HEALTH

 

[DermViser]

But this story though http://www.cnn.com/2008/HEALTH/01/09/ep.suing.docs/index.html?_s=PM:HEALTH

Quite telling:

So after weeks of pressure, Christine visited a malpractice attorney recommended by a friend. But he wouldn't take the case. A different lawyer contact by CNN said he wouldn't have either, partly because he wouldn't make much money off it.

"What are her losses -- maybe $50,000? I can't afford to take a case that recovers $50,000," says Wayne Grant, an Atlanta malpractice attorney. "My expenses would likely be more than the recovery. She's out of luck."

 

[snowflakes]

Quite telling:

So after weeks of pressure, Christine visited a malpractice attorney recommended by a friend. But he wouldn't take the case. A different lawyer contact by CNN said he wouldn't have either, partly because he wouldn't make much money off it.

"What are her losses -- maybe $50,000? I can't afford to take a case that recovers $50,000," says Wayne Grant, an Atlanta malpractice attorney. "My expenses would likely be more than the recovery. She's out of luck."

I wonder how common this is. Are the majority of medical malpractice cases based on a contingency fee?

 

[deleted526486]

I wonder how common this is. Are the majority of medical malpractice cases based on a contingency fee?

From what I understand, yes. I came across this podcast recently that discusses this exact issue.

http://soundmedicine.iu.edu/segment/3974/Why-a-medical-malpractice-attorney-might-not-take-your-case

 

[Obnoxious Dad]

This case should serve as a teachable moment for all young physicians. Vote with your feet against states like Massachusetts that feature a wild west malpractice environment. Do not practice in states that have not reformed their medical malpractice laws. Practice in a state with caps on noneconomic damages and low insurance rates.

 

[croak]

Just saw this article: http://www.kevinmd.com/blog/2014/03/doctors-practice-cover-ass-medicine.html

This should be show to every single liberal, health economist, etc. who says that defensive medicine and malpractice lawsuits are only a small proportion of healthcare costs.

Sophisticated uninsured patients who use America's Emergency Departments for primary care probably shouldn't read this. It's not unknown for ED regulars to exaggerate mild conditions: induced vomiting, self-defecation, laying on the floor, etc., to get a thorough work up -- Granted this case is a Zebra, but when you have an over burdened healthcare system with dozens of non-physicians (MBAs, administrators, insurance company minions, etc.), this happens. Medicine ought excise--or at least curtail--the hideously expanding growth in manager-types (at least ten to one businessman: doc), and leave the practice of medicine to physicians. "Managers" banking on docs work should have liability.

 

[FIREitUP]

there's no way in hell 99.99% of ER docs would get this diagnosis, especially considering the amount of volume they have to worry about on a day to day basis. what a shame for the doc

 

[NickNaylor]

there's no way in hell 99.99% of ER docs would get this diagnosis, especially considering the amount of volume they have to worry about on a day to day basis. what a shame for the doc

Yeah - this is just terrible. I can understand the argument for maybe getting an EKG, but I don't think the docs I've worked with would've done anything much different than as it's portrayed in the OP's post.

 

[evilbooyaa]

This reminds me of that Johns Hopkins OB/Gyn case from a while back (where a completely unknown patient showed up after trying to deliver with a midwife for a couple hours, then blamed the OB/Gyn dept at JHU's ER to not have a stat C-section room ready within like 15-30 mins).

All I can say is that this is a completely BS case. The malpractice lawyer must have had an 'expert' witness detailing the 'failure of standard of care' in regards to this 23 year old, right? As a future physician, I want all of these 'expert' witnesses outed so that they can be discredited fully and shown that there are consequences for blatantly lying (and trampling on your own colleagues) for the sake of a couple bucks.

Every bad outcome is not malpractice (and medmal lawyers know this, hence the article about the ER doc who had complications d/t a hysterectomy), but the general public (and therefore juries) don't know that.

Can't win, one way or the other. Dr. Liang is now going to get EKGs and heart biopsy on anyone coming in with a cough and chest pain. Sounds legit.