Medical Malpractice Myth
December 18, 2005 7:24 PM Subscribe
Medical Malpractice Myth explores the idea that it's not litigious patients, ambulance chasing lawyers and runaway juries behind the rising costs of medical malpractice insurance. It's the increasing occurrence of medical malpractice that's driving those insurance rates up.
There are definitely many more medical mistakes than the public knows about.the first thing that is needed to lower malpractice insurance rates is for doctors to police their own. This is not currently done. In fact (personal observation, I work in the medical field) much more common is for doctors to cover other doctors mistakes.
There is lots of talk about the heavy burden that “defensive medicine” imposes on health costs, but the research shows this is not true.
Actually defensive is driving up the cost of medicine, but it does little to lower the number of mistakes because many of the doctors don't fully understand what the tests they are ordering can and do show.
posted by ScotchLynx at 7:45 PM on December 18, 2005
There is lots of talk about the heavy burden that “defensive medicine” imposes on health costs, but the research shows this is not true.
Actually defensive is driving up the cost of medicine, but it does little to lower the number of mistakes because many of the doctors don't fully understand what the tests they are ordering can and do show.
posted by ScotchLynx at 7:45 PM on December 18, 2005
Disclaimer: I am the son of doctor and a law student
The major research on the topic is the Harvard Medical Practice Study. Basically, a medical team and a legal team reviewed (medical) cases, analyzed them for malpractice, and then determined whether the case had merit. Then they looked and saw whether the patient actually sued, and if they did, if they actually won.
The main findings were that malpractice is relatively rare, most injured patients do not bring claims, and (this is the biggie, I think) there is no correlation between the existence of malpractice and whether the patient won the suit. In fact, there is some suggestion that it is precisely those cases without merit that win and those with merit that do not.
Personally I don't buy the idea that the reason there are a lot of suits is that there is a lot of malpractice. Generally speaking medical education and certification in America is comparable to that in other countries, yet there are more malpractice suits in the US than the rest of the developed world. So if it's bad here it must be downright awful in the rest of the world. Maybe it is, but I'd like to think it isn't.
ScotchLynx: You're right about the lack of self-policing. Fear of litigation keeps doctors and hospitals from creating effective feedback loops. No one will admit to making mistakes. As regards defensive medicine, there's some evidence that it actually makes things worse. And not just in the 'all those unnecessary CT scans are going to give us cancer' sense (although there's some real concern about that).
posted by jedicus at 7:51 PM on December 18, 2005
The major research on the topic is the Harvard Medical Practice Study. Basically, a medical team and a legal team reviewed (medical) cases, analyzed them for malpractice, and then determined whether the case had merit. Then they looked and saw whether the patient actually sued, and if they did, if they actually won.
The main findings were that malpractice is relatively rare, most injured patients do not bring claims, and (this is the biggie, I think) there is no correlation between the existence of malpractice and whether the patient won the suit. In fact, there is some suggestion that it is precisely those cases without merit that win and those with merit that do not.
Personally I don't buy the idea that the reason there are a lot of suits is that there is a lot of malpractice. Generally speaking medical education and certification in America is comparable to that in other countries, yet there are more malpractice suits in the US than the rest of the developed world. So if it's bad here it must be downright awful in the rest of the world. Maybe it is, but I'd like to think it isn't.
ScotchLynx: You're right about the lack of self-policing. Fear of litigation keeps doctors and hospitals from creating effective feedback loops. No one will admit to making mistakes. As regards defensive medicine, there's some evidence that it actually makes things worse. And not just in the 'all those unnecessary CT scans are going to give us cancer' sense (although there's some real concern about that).
posted by jedicus at 7:51 PM on December 18, 2005
Meta-disclaimer: that is, I'm a law student and my dad's a doctor, not that I'm the son of both.
posted by jedicus at 7:53 PM on December 18, 2005
posted by jedicus at 7:53 PM on December 18, 2005
Quick toss-out: the more doctors there are, the more BAD doctors there are; and the more medicine being practiced (especially elective -- non-critical -- medicine), the more malpractice there'll be.
Med school should be at least as hard to get into as veterinary school. From what I've seen of the graduates of both, I keep wanting to remind the "exotics" vet we use that dammit I'm really just a bald chimp and deserve the same quality care that our ferrets get!
posted by davy at 8:01 PM on December 18, 2005
Med school should be at least as hard to get into as veterinary school. From what I've seen of the graduates of both, I keep wanting to remind the "exotics" vet we use that dammit I'm really just a bald chimp and deserve the same quality care that our ferrets get!
posted by davy at 8:01 PM on December 18, 2005
The main findings were that malpractice is relatively rare, most injured patients do not bring claims
And this study can be spun a different way...
A study of medical malpractice in New York State, conducted by the Harvard Medical School, confirms that the incidence of malpractice is much larger than the incidence of claims.
Can you find the study? Seems as though it looks pretty inconclusive from what I have read.
"More than with most studies, however, the Harvard group’s results are subject to sharply different interpretations and depend heavily on definitions and assumptions with which many will differ. "
posted by j-urb at 8:08 PM on December 18, 2005
And this study can be spun a different way...
A study of medical malpractice in New York State, conducted by the Harvard Medical School, confirms that the incidence of malpractice is much larger than the incidence of claims.
Can you find the study? Seems as though it looks pretty inconclusive from what I have read.
"More than with most studies, however, the Harvard group’s results are subject to sharply different interpretations and depend heavily on definitions and assumptions with which many will differ. "
posted by j-urb at 8:08 PM on December 18, 2005
i'm sure i read somewhere that medical error was the 3rd leading cause of death in the US. shhhh...it's a secret.
posted by brandz at 8:08 PM on December 18, 2005
posted by brandz at 8:08 PM on December 18, 2005
As the most popular Doctor, Tom Baker certainly is qualified to write about matters of medical malpratice.
posted by kindall at 8:10 PM on December 18, 2005
posted by kindall at 8:10 PM on December 18, 2005
j-urb: I looked pretty hard to find the study itself. I couldn't even find a proper citation or a for-pay link. Disconcerting, seeing as how everyone and their dog mentions it.
And I freely admit that the perspective from which I view it is very different from the one that most lawyers view it from.
In all seriousness, I wonder what dios thinks about this guy's thesis.
posted by jedicus at 8:13 PM on December 18, 2005
And I freely admit that the perspective from which I view it is very different from the one that most lawyers view it from.
In all seriousness, I wonder what dios thinks about this guy's thesis.
posted by jedicus at 8:13 PM on December 18, 2005
Doctors commit a great deal of malpractice; patients rarely sue or get compensated at all for the malpractice they endure. Doctors are well paid; doctors in the U.S. net an average of $200K or so, after malpractice insurance and taxes, while in other developed countries it's more like $100K. Try talking to some surgeons at cocktail parties - they treat their profession like woodworking. Chop here, slice here, staple there, got two more scheduled before lunch. Remember: half of all surgeons are below average.
But one of the largest reasons rates are skyrocketing is that the economy has been crap. Insurance - all insurance - works by taking your money now and possibly paying you later. The insurance industry sits on trillions of dollars, and they get the returns from investing it while they wait to possibly pay out, and the investment returns go into the business just like the premiums do. When the stock market is up up up, like it was until 2001, you can stop raising premiums at all, because investment returns are outrageous, and this is in fact what happened. When the stock market is crummy, like it has been since 2001, then the premiums need to go up up up like the stock market used to.
So to a first approximation, the reason that insurance rates are up hugely since 2001 is that the stock market is bad. Nothing more, nothing less.
Going slightly deeper, the US medical insurance system spends about 1/3 of every dollar it receives trying to deny care to people. That's really the main medical insurance line of business - finding healthy people to insure and finding sick people to cut off insuring.
The current system is massively subsidized by the US government, because insurance premiums are not taxed. If you're getting insurance from your employer, you're also getting massive subsidy from the Federal and State governments, whether you're aware of it or not. Overall, the U.S. government pays more per capita (across the whole population) for health care than Canada or any other nation, and yet only manages to get health care to half the population. That's the real shame.
Overall, the U.S. health care system is a failed one. If the government subsidies ended, the whole thing would collapse. You get much less for your tax dollar than citizens of other countries do - in Canada, you can get run over by a truck, spend a month recuperating in intensive care, get an aide to come to your home and do rehab therapy for a year, and be out of pocket exactly $0. For this, the Canadian citizen pays less in taxes than you do - not even counting the money you pay for health insurance, I'm talking about the money that you pay in U.S. taxes that ends up going to health care. The Canadian pays less than you do and gets free health care. For everyone. U.S. citizens are getting the shaft.
[Aside on j-urb's comments above: please don't mistake hackjob commentary from a "thinktank" paid to influence public debate, like that Manhattan Institute, with real scientific commentary. If you have trouble determining, just substitute "paid lairs" for the word "thinktank" and see if that helps.]
posted by jellicle at 8:19 PM on December 18, 2005
But one of the largest reasons rates are skyrocketing is that the economy has been crap. Insurance - all insurance - works by taking your money now and possibly paying you later. The insurance industry sits on trillions of dollars, and they get the returns from investing it while they wait to possibly pay out, and the investment returns go into the business just like the premiums do. When the stock market is up up up, like it was until 2001, you can stop raising premiums at all, because investment returns are outrageous, and this is in fact what happened. When the stock market is crummy, like it has been since 2001, then the premiums need to go up up up like the stock market used to.
So to a first approximation, the reason that insurance rates are up hugely since 2001 is that the stock market is bad. Nothing more, nothing less.
Going slightly deeper, the US medical insurance system spends about 1/3 of every dollar it receives trying to deny care to people. That's really the main medical insurance line of business - finding healthy people to insure and finding sick people to cut off insuring.
The current system is massively subsidized by the US government, because insurance premiums are not taxed. If you're getting insurance from your employer, you're also getting massive subsidy from the Federal and State governments, whether you're aware of it or not. Overall, the U.S. government pays more per capita (across the whole population) for health care than Canada or any other nation, and yet only manages to get health care to half the population. That's the real shame.
Overall, the U.S. health care system is a failed one. If the government subsidies ended, the whole thing would collapse. You get much less for your tax dollar than citizens of other countries do - in Canada, you can get run over by a truck, spend a month recuperating in intensive care, get an aide to come to your home and do rehab therapy for a year, and be out of pocket exactly $0. For this, the Canadian citizen pays less in taxes than you do - not even counting the money you pay for health insurance, I'm talking about the money that you pay in U.S. taxes that ends up going to health care. The Canadian pays less than you do and gets free health care. For everyone. U.S. citizens are getting the shaft.
[Aside on j-urb's comments above: please don't mistake hackjob commentary from a "thinktank" paid to influence public debate, like that Manhattan Institute, with real scientific commentary. If you have trouble determining, just substitute "paid lairs" for the word "thinktank" and see if that helps.]
posted by jellicle at 8:19 PM on December 18, 2005
So if I'm one of Jellicle's woodshop surgeons, practicing in Canada, making a third of my prior income, with little chance of getting sued, exactly why, again, do I give a shit if I leave behind a sponge? Oh, right, because everywhere else in the world doctors are selfless, virtuous, and motivated by altruism.
posted by docpops at 8:31 PM on December 18, 2005
posted by docpops at 8:31 PM on December 18, 2005
So to a first approximation, the reason that insurance rates are up hugely since 2001 is that the stock market is bad. Nothing more, nothing less.
jellicle has this exactly right. Malpractice is most definitely not driving up the price of insurance, to any significant degree.
And he's also spot-on in saying the US health care system is a failed one. We pay more than anyone else, yet we receive slightly inferior to massively inferior care, depending upon where you lie in the system. The average Joe with insurance gets care that is slightly less effective (by several metrics), and pays more for it, IF he is insured, compared to those in other countries of similar wealth. (He pays something like 2-4 times as much).
If you're one of those 45 million uninsured, you care is much, much less than that you would receive in one of those "socialized medicine" countries. Further, a significant chunk of these people do pay for insurance -- it just doesn't go to them. They pay taxes for military, Medicare, and Medicaid insurance. For others. They themselves are uninsured.
Nice system.
For a vanishingly small number of super-rich people, the American system may be the best in the world. For the overwhelming majority, it is not, and it's damn expensive, to boot.
posted by teece at 8:36 PM on December 18, 2005
jellicle has this exactly right. Malpractice is most definitely not driving up the price of insurance, to any significant degree.
And he's also spot-on in saying the US health care system is a failed one. We pay more than anyone else, yet we receive slightly inferior to massively inferior care, depending upon where you lie in the system. The average Joe with insurance gets care that is slightly less effective (by several metrics), and pays more for it, IF he is insured, compared to those in other countries of similar wealth. (He pays something like 2-4 times as much).
If you're one of those 45 million uninsured, you care is much, much less than that you would receive in one of those "socialized medicine" countries. Further, a significant chunk of these people do pay for insurance -- it just doesn't go to them. They pay taxes for military, Medicare, and Medicaid insurance. For others. They themselves are uninsured.
Nice system.
For a vanishingly small number of super-rich people, the American system may be the best in the world. For the overwhelming majority, it is not, and it's damn expensive, to boot.
posted by teece at 8:36 PM on December 18, 2005
There was a very interesting CBC TV program on related subject matter a couple of years ago, Inside the Canadian Medical Protective Association.
There was a discussion on CBC Radio's The Sunday Edition with Dr. Pat Crosskerry (audio file). The intro to that piece claims that medical mistakes are the 4th leading cause of death in Canada.
Finally, I can recall a discussion from a couple of years ago about how lack of sleep effects doctors - not surprising that doctors are effected just like the rest of us. I can't find the link, but here is a recent Scientific American news brief on the subject.
posted by Chuckles at 8:44 PM on December 18, 2005
There was a discussion on CBC Radio's The Sunday Edition with Dr. Pat Crosskerry (audio file). The intro to that piece claims that medical mistakes are the 4th leading cause of death in Canada.
Finally, I can recall a discussion from a couple of years ago about how lack of sleep effects doctors - not surprising that doctors are effected just like the rest of us. I can't find the link, but here is a recent Scientific American news brief on the subject.
posted by Chuckles at 8:44 PM on December 18, 2005
If you're one of those 45 million uninsured
Keep repeating the same lie often enough...
posted by Kwantsar at 8:45 PM on December 18, 2005
Keep repeating the same lie often enough...
posted by Kwantsar at 8:45 PM on December 18, 2005
hmm, Cato, Cato, where have I heard that thinktank in the news lately...
posted by Heywood Mogroot at 8:50 PM on December 18, 2005
posted by Heywood Mogroot at 8:50 PM on December 18, 2005
jellicle: Try talking to some surgeons at cocktail parties - they treat their profession like woodworking. Chop here, slice here, staple there, got two more scheduled before lunch.
When it comes to surgery, you really want the procedure to be absolutely the most routine thing in the world to the people performing it. If it isn't very well understood, and very easy (easy for the practiced professional, that is), it isn't something that should be tried very often.
That doesn't excuse the attitude though, of course. The sleep issue is a great illustration of the problematic culture of doctors...
posted by Chuckles at 8:54 PM on December 18, 2005
When it comes to surgery, you really want the procedure to be absolutely the most routine thing in the world to the people performing it. If it isn't very well understood, and very easy (easy for the practiced professional, that is), it isn't something that should be tried very often.
That doesn't excuse the attitude though, of course. The sleep issue is a great illustration of the problematic culture of doctors...
posted by Chuckles at 8:54 PM on December 18, 2005
Remember: half of all surgeons are below average.
Keep in mind, however, that it is quite difficult for a below-average medical school student to get accepted to a surgical residency program. Half of MIT-educated engineers are below average MIT-educated engineers, but even the below-average ones are pretty damn good.
But, yeah, sometimes a surgeon will screw up in the middle of the procedure, correct his mistake, go back to what he was working on, and sew up the patient, all while the patient is under anaesthesia. How much you want to worry about all the mistakes that surgeons make that you won't even get a chance to notice because the doctor fixed it while you were under is a matter of how much paranoia you're willing to accept.
posted by deanc at 9:04 PM on December 18, 2005
Keep in mind, however, that it is quite difficult for a below-average medical school student to get accepted to a surgical residency program. Half of MIT-educated engineers are below average MIT-educated engineers, but even the below-average ones are pretty damn good.
But, yeah, sometimes a surgeon will screw up in the middle of the procedure, correct his mistake, go back to what he was working on, and sew up the patient, all while the patient is under anaesthesia. How much you want to worry about all the mistakes that surgeons make that you won't even get a chance to notice because the doctor fixed it while you were under is a matter of how much paranoia you're willing to accept.
posted by deanc at 9:04 PM on December 18, 2005
If someone wants to pull it for horrible copyright problems, please do so.....but I post it since it contributes to a basic problem about medical malpractice. It's long and rambling and the copyright problem is at th end. But, I think it's a worth read.
1. It's usually people who are not doctors who make claims like "medical errors kill lots of people." This might be "true" in a very loose causation sense. Yes, some type of event that didn't go perfect or according to textbook ended up in adverse result. But, wow, there's usually a lot more to a story: a patient does not tell you they did indeed have a previous surgery; kidneys just were so shot and were not able to spit out the medicine given; it's an unusually difficult case to begin with and the doctor is just trying to make something work; even in the case of heart and lung transplants as Tom Baker in all his infinite medical wisdome highlights in his article, they're just very difficult to do and 5 year surviving rates are not that high -- especially in children. True, the hospital committed a stupid, terrible error -- but even, in this situation, was it completely the "medical error" that killed the patient, or perhaps, jeez-louise, did the poor child's congenital heart and lung ailment have a teeny bit of something to do with it?
2. Why do I talk about the above? Well, because this talk of "errors" and criticizing hospitals for having less verification procedures than "Starbucks" is just not fair to health care providers and is why Tom Baker just needs to not be listened to here. To begin with, the vast, vast, vast, vast majority of doctors simply are not in the business of committing errors of true, true negligence -- the very thing the tort system was designed to handle. Believe it or not, most of them want to help people. What's wrong with the tort system is that it focuses way too much on blame in order to get even larger and larger jury rewards and, really, in the vast majority of malpractice cases -- blame is a questionable thing. For instance, the bread and butter of scum sucking lawyers -- err, sorry, lawyers who sue doctors is the kid with cerebral palsy. They seriously have driven many, many obstetricians out of business to the point where it's a relatively easy residency to get because American medical students are scared shitless of having to deal with lawyer scum their whole careers. At any rate, it's led to an incredible amount of C-sections on the basis that lawyers link the deprivation of oxygen during a prolonged vaginal delivery to some brain impairment that occured in the kid later. This C-Section phenomenon happened in the mid 80s. It was (and has been) a freaking astronimical rise of C-sections to the point where thousands of mothers are getting cut up (and exposed to the risks of post-operative infection and inappropriate scar healing) just because obstetricians are worried that a prolonged or troubled delivery = lawsuit. Well, guess what's happend to the per capita rate of cerebral palsy since then? It absolutely has not changed. It's a needless set of events brought about by a crummy way we ensure against malpractice: blaming doctors. Just ask John Edwards who fed his family off stuff like this. (He's lately, after pocketing millions and millions just buy showing a retarted/mentally challenged cerebral palsy kid's picture to a jury of highly discerning and medically knowledgable North Carolinians, said perhaps his arguments might have been bogus.) Listen, it could very well be that some crappily managed deliveries led to mental retardation in a child. BUT, we'll never know with the system the way it nowadays. And, moreover, the right patients have less of chance to get rewarded -- it depends more on the skill of the lawyer than whether inappropriate medicine was given. Edwards did have his charms you know. You can probably think of a handful (nay, countryful) of lawyers who lack such abilities.
3. I bring up all this stuff because, when victims are not getting properly compensated, when blame is used as a weapon of litigation to increase verdicts and settlements instead of to ferret out bad doctors and hospitals, and when some victims are not being told of the mistake because of this atmosphere of blame -- such a system sucks and needs to changed -- namely, as the Harvard Schools of Law, Medicine, Public Health, and Economics have indicated -- to a NO FAULT MEDICAL MALPRACTICE SYSTEM -- where panels comprised of people who know whether errors happened and systems are designed solely to compensate victims without passing blame upon the doctors -- works for everyone, except, well, you know who ------ people of Mr. Baker's ilk. This system would absolutely rock and works very well in other countries where you get doctors and hospitals more ready to admit mistakes and victims more appropriately and quickly compensated -- just see how stable and successful no fault is in auto and divorce areas.
4. Despite the amazing progress of medicine, there's a boatload doctors, who train for the minimum of seven years in the stuff, will never know. A famous phrase my medical school dean told me was that the dean of a medical school once said that, "We can only teach you 10% of what is known." ---- and he said that in 1915. A system built upon blaming doctors for their mistakes is not going to cut it. So, let's not go about quoting a lawyer and some dubious studies that claim the real medical malpractice myth is "a lot more medical malpractice happens than you'd believe".
5. Would it not be nice to have a system that simply states: "You know, they told you were going to have a less congested heart and, now, due to whatever in the world (after they gave you a drug, operation, or managed you) your heart's worse off than it is if they just left you alone." Let's compensate you.
That's it. Nothing more.
6. In today's system, the scum lawyers get to make a big deal about how an "expert" would have handled it differently and then drag in family, friends, and doe eyed kids to talk about daddy can't run with them anymore and how they cry about it. The use of expert testimony is a whole other bugaboo -- and, usually, they are experts who are well credentialed academics who have no sense of the economic, business, and political pressures everyday/normal doctors face and for a nice $2000-$4000/hour fee will easily state another doctor fucked up real bad in all their 20/20 hindsight glory. (And, it's this stuff that causes just about every person that enters an ER to get a defensive medicine CAT-SCAN with all the glorious radiation and questionable diagnoses that entails).
Ok that being said, Baker is talking about maintaing lots of the status quo and has a distrust for the medical profession that is alarming to anyone who really wants to find a way to help victims of medical malpractice.
Finally, I'll end by saying that just because doctors win such trials a lot or that most cases settle -- does not mean the system works. Lawyers sue everybody and see what sticks. The process of subpoenas and adversial discovery rules only throw coal on the fire of animosity that exists between doctors and lawyers. And, moreover, doctors are freaking busy people, who, despite their high salary, go through much more (longer) poorly paid training than most people and would rather not be bothered by how litigation is going. They'd rather be seeing patients.
Read this pNew Yorker iece by Atul Gawande (a doctor) in the New Yorker and you'll see, much better than I can state, how the truth is a lot more difficult to entertain than one might imagine.
SECTION: FACT; Annals Of Medicine; Pg. 63
LENGTH: 7542 words
HEADLINE: THE MALPRACTICE MESS;
Who pays the price when patients sue doctors?
BYLINE: ATUL GAWANDE
BODY:
It was an ordinary Monday at the Middlesex County Superior Court in Cambridge, Massachusetts. Fifty-two criminal cases and a hundred and forty-seven civil cases were in session. In Courtroom 6A, Daniel Kachoul was on trial for three counts of rape and three counts of assault. In Courtroom 10B, David Santiago was on trial for cocaine trafficking and illegal possession of a deadly weapon. In Courtroom 7B, a scheduling conference was being held for Minihan v. Wallinger, a civil claim of motor-vehicle negligence. And next door, in Courtroom 7A, Dr. Kenneth Reed faced charges of medical malpractice.
Reed was a Harvard-trained dermatologist with twenty-one years of experience, and he had never been sued for malpractice before. That day, he was being questioned about two office visits and a phone call that had taken place almost nine years earlier. Barbara Stanley, a fifty-eight-year-old woman, had come to see him in the summer of 1996 about a dark warty nodule a quarter-inch wide on her left thigh. In the office, under local anesthesia, Reed shaved off the top for a biopsy. The pathologist's report came back a few days later, with a near-certain diagnosis of skin cancer-a malignant melanoma. At a follow-up appointment, Reed told Stanley that the growth would have to be completely removed. This would require taking a two-centimetre margin-almost an inch-of healthy skin beyond the lesion. He was worried about metastasis, and recommended that the procedure be done immediately, but she balked. The excision that he outlined on her leg would have been three inches across, and she couldn't believe that a procedure so disfiguring was necessary. She said that she had a friend who had been given a diagnosis of cancer erroneously, and underwent unnecessary surgery. Reed pressed, though, and by the end of their discussion she allowed him to remove the visible tumor that remained on her thigh, only a half-inch excision, for a second biopsy. He, in turn, agreed to have another pathologist look at all the tissue and provide a second opinion.
To Reed's surprise, the new tissue specimen was found to contain no sign of cancer. And when the second pathologist, Dr. Wallace Clark, an eminent authority on melanoma, examined the first specimen he concluded that the initial cancer diagnosis was wrong. "I doubt if this is melanoma, but I cannot completely rule it out," his report said. Reed and Stanley spoke by phone on August 10, 1996, to go over the new findings.
None of this is under dispute; what's under dispute is what happened afterward. According to Barbara Stanley, Reed told her that she did not have a melanoma after all-the second opinion on the original biopsy "was negative"-and that no further surgery was required. That's not how Reed recalled the phone conversation. "I indicated to Barbara Stanley . . . that Dr. Wallace Clark felt that this was a benign lesion called a Spitz nevus, and that he could not be a hundred per cent sure it was not a melanoma," he testified. "I also explained to her that in Dr. Clark's opinion this lesion had been adequately treated, that follow-up would be necessary, and that Dr. Clark did not feel that further surgery was critical. I also explained to Barbara Stanley that this was in conflict with the previous pathology report, and that the most cautious way to approach this would be to allow me to [remove additional skin] for a two-centimetre margin." She told him, he said, that she didn't want more surgery. "At that point, I reemphasized to Barbara Stanley that at least she should come in for regular follow-up." Unhappy with the care she received, she didn't return.
After two years, the growth reappeared. Stanley went to another doctor, and the pathology report came back with a clear diagnosis: a deeply invasive malignant melanoma. A complete excision, she was told, should probably have been done the first time around. When she finally did undergo the more radical procedure, the cancer had spread to lymph nodes in her groin. She was started on a yearlong course of chemotherapy. Five months later, she suffered a seizure. The cancer was now in her brain and her left lung. She had a course of brain and lung radiation. A few weeks after that, Barbara Stanley died.
But not before she had called a lawyer from her hospital bed. She found a full-page ad in the Yellow Pages for an attorney named Barry Lang, a specialist in medical-malpractice cases, and he visited her at her bedside that very day. She told him that she wanted to sue Kenneth Reed. Lang took the case. Six years later, on behalf of Barbara Stanley's children, he stood up in a Cambridge courtroom and called Reed as his first witness.
Malpractice suits are a feared, often infuriating, and common event in a doctor's life. (I have not faced a bona-fide malpractice suit, but I know to expect one.) The average doctor in a high-risk practice like surgery or obstetrics is sued about once every six years. Seventy per cent of the time, the suit is either dropped by the plaintiff or won in court. But the cost of defense is high, and when doctors lose, the average jury verdict is half a million dollars. General surgeons pay anywhere from thirty thousand to two hundred thousand dollars a year in malpractice-insurance premiums, depending on the litigation climate of the state they work in; neurosurgeons and obstetricians pay upward of fifty per cent more.
Every doctor, it seems, has a crazy-lawsuit story. My mother, a pediatrician, was once sued after a healthy two-month-old she had seen for a routine checkup died of sudden infant death syndrome a week later. The lawsuit alleged that she should have prevented the death, even though a defining characteristic of SIDS is that it occurs without warning. One of my colleagues performed lifesaving surgery to remove a woman's pancreatic cancer only to be sued years later because she developed a chronic pain in her arm; the patient blamed it, implausibly, on potassium that she received by I.V. during recovery from the surgery. I have a crazy-lawsuit story of my own. In 1990, while I was in medical school, I was at a crowded Cambridge bus stop and an elderly woman tripped on my foot and broke her shoulder. I gave her my phone number, hoping that she would call me and let me know how she was doing. She gave the number to a lawyer, and when he found out that it was a medical-school exchange he tried to sue me for malpractice, alleging that I had failed to diagnose the woman's broken shoulder when I was trying to help her. (A marshal served me with a subpoena in physiology class.) When it became apparent that I was just a first-week medical student and hadn't been treating the woman, the court disallowed the case. The lawyer then sued me for half a million dollars, alleging that I'd run his client over with a bike. I didn't even have a bike, but it took a year and a half-and fifteen thousand dollars in legal fees-to prove it.
My trial had taken place in the same courtroom as Reed's trial, and a shudder went through me when I recognized it. Not all Americans, however, see the system the way doctors do, and I had come in an attempt to understand that gap in perspectives. In the courtroom gallery, I took a seat next to Ernie Browe, the son of Barbara Stanley. He was weary, he told me, after six years of excruciating delays. He works for a chemistry lab in Washington State and has had to take vacation time and money out of his savings to pay for hotels and flights-including for two trial dates that were postponed as soon as he arrived. "I wouldn't be here unless my mother asked me to, and she did before she died," he said. "She was angry, angry to have lost all those years because of Reed." He was glad that Reed was finally being called to account.
The dermatologist sat straight-backed and still in the witness chair as Lang fired questions at him. He was clearly trying not to get flustered. A friend of mine, a pediatric plastic surgeon who had had a malpractice suit go to trial, told me the instructions that his lawyer had given him for his court appearances: Don't wear anything flashy or expensive. Don't smile or joke or frown. Don't appear angry or uncomfortable, but don't appear overconfident or dismissive, either. How, then, are you supposed to look? Reed seemed to have concluded that the only choice was to look as blank as possible. He parsed every question for traps, but the strenuous effort to avoid mistakes only made him seem anxious and defensive.
"Wouldn't you agree," Lang asked, "that [melanoma] is very curable if it's excised before it has a chance to spread?" If a patient had asked this question, Reed would readily have said yes. But, with Lang asking, he paused, uncertain.
"It's hypothetical," Reed said.
Lang was clearly delighted with this sort of answer. Reed's biggest problem, though, was that he hadn't kept notes on his August 10th phone conversation with Barbara Stanley. He could produce no corroboration for his version of events. And, as Lang often reminded the jury, plaintiffs aren't required to prove beyond a reasonable doubt that the defendant has committed malpractice. Lang needed ten of twelve jurors to think only that it was more likely than not.
"You documented a telephone conversation that you had with Barbara Stanley on August 31st, isn't that correct?" Lang asked.
"That is correct."
"Your assistant documented a discussion that you had with Barbara Stanley on August 1st, right?"
"That is correct."
"You documented a telephone call with Malden Hospital, correct?"
"That is correct."
"You documented a telephone conversation on September 6th, when you gave Barbara Stanley a prescription for an infection, correct?"
"That is correct."
"So you made efforts and you had a habit of documenting patient interactions and telephone conversations, right?"
"That is correct."
Lang began to draw the threads together. "Exactly what Barbara Stanley needed, according to you, [was] a two-centimetre excision, right?"
"Which is what I instructed Ms. Stanley to do . . ."
"Yet you did not tell Dr. Hochman"-Stanley's internist-"that she needed a two-centimetre excision, right?"
"That is correct."
"But you want this jury to believe you told Barbara Stanley?"
"I want this jury to believe the truth-which is that I told Barbara Stanley she needed a two-centimetre excision."
Lang raised his voice. "You should have told Barbara Stanley that . . . isn't that correct?" He all but called Reed a perjurer.
"I did tell Barbara Stanley, repeatedly!" Reed protested. "But she refused." As the examination continued, Reed tried to keep his exasperation in check, and Lang did all he could to discredit him.
"In your entire career, Doctor, how many articles have you published in the literature?" Lang asked at another point.
"Three," Reed said.
Lang lifted his eyebrows, and stood with his mouth agape for two beats. "In twenty years' time, you've published three articles?"
Without documentation, Reed was in a hard spot, and Lang's examination made my skin crawl. I could easily picture myself on the stand being made to defend any number of cases in which things didn't turn out well and I hadn't got every last thing down on paper. Lang was sixty years old, bald, short, and loud. Spittle flew in droplets. He paced constantly, and rolled his eyes at Reed's protestations. He showed no deference and little courtesy. He was almost a stereotype of a malpractice lawyer-except in one respect, and that was the reason I'd come to watch this particular trial.
Barry Lang used to be a doctor. For twenty-three years, he had a successful practice as an orthopedic surgeon, with particular expertise in pediatric orthopedics. He'd even served as an expert witness on behalf of other surgeons. Then, in a turnabout, he went to law school, gave up his medical practice, and embarked on a new career suing doctors. Watching him, I wondered, after all his experience did he understand something that the rest of us didn't?
I went to see Lang at his office in downtown Boston, on the tenth floor of 1 State Street, in the heart of the financial district. He welcomed me warmly, and I found that we spoke more as fellow-doctors than as potential adversaries. I asked why he had quit medicine to become a malpractice attorney. Was it for the money?
He laughed at the idea. Going into law "was a money disaster," he said. Starting out, he had expected at least some rewards. "I figured I'd get some cases, and if they were good the doctors would settle them quickly and get them out of the way. But no. I was incredibly naive. No one ever settles before the actual court date. It doesn't matter how strong your evidence is. They always think they're in the right. Things can also change over time. And, given the choice of paying now or paying later, which would you rather do?"
He entered law practice, he said, because he thought he'd be good at it, because he thought he could help people, and because, after twenty-three years in medicine, he was burning out. "It used to be 'Two hip replacements today-yeah!' " he recalled. "Then it became 'Two hip replacements today-ugh.' "
When I spoke to his wife, Janet, she said that his decision to change careers shocked her. From the day she met him, when they were both undergraduates at Syracuse University, he'd never wanted to be anything other than a doctor. After medical school in Syracuse and an orthopedics residency at Temple University, he had built a busy orthopedics practice in New Bedford, Massachusetts, and had a fulfilling and varied life. Even when he enrolled in night classes at Southern New England School of Law, a few blocks from his office, his wife didn't think anything of it. He was, as she put it, "forever going to school." One year, he took English-literature classes at a local college. Another year, he took classes in Judaism. He took pilot lessons, and before long was entering airplane aerobatics competitions. Law school, too, began as another pastime-"It was just for kicks," he said.
After he finished, though, he took the bar exam and got his license. He was fifty years old. He'd been in orthopedics practice long enough to have saved a lot of money, and law had begun to seem much more interesting than medicine. In July, 1997, he handed his practice over to his startled partners, "and that was the end of it," he said.
He figured that the one thing he could offer was his medical expertise, and he tried to start his legal practice by defending physicians. But, because he had no experience, the major law firms that dealt with malpractice defense wouldn't take him, and the malpractice insurers in the state wouldn't send him cases. So he rented a small office and set up shop as a malpractice attorney for patients. He spent several thousand dollars a month for ads on television and in the phone book, dubbing himself "the Law Doctor." Then the phone calls came. Five years into his new career, his cases finally began going to trial. This is his eighth year as a malpractice attorney, and he has won settlements in at least thirty cases. Eight others went to trial, and he won half of them. Two weeks before the Reed trial, he won a four-hundred-thousand-dollar jury award for a woman whose main bile duct was injured during gallbladder surgery, forcing her to undergo several reconstructive operations. (Lang got more than a third of that award. Under Massachusetts state law, attorneys get no more than forty per cent of the first hundred and fifty thousand dollars, 33.3 per cent of the next hundred and fifty thousand, thirty per cent of the next two hundred thousand, and twenty-five per cent of anything over half a million.) Lang has at least sixty cases pending. If he had any money troubles, they are over.
Lang said that he gets ten to twelve calls a day, mostly from patients or their families, with some referrals from other lawyers who don't do malpractice. He turns most of them away. He wants a good case, and a good case has to have two things, he said. "No. 1, you need the doctor to be negligent. No. 2, you need the doctor to have caused damage." Many of the callers fail on both counts. "I had a call from one guy. He says, 'I was waiting in the emergency room for four hours. People were taken ahead of me, and I was really sick.' I say, 'Well, what happened as a result of that?' 'Nothing, but I shouldn't have to wait for four hours.' Well, that's ridiculous."
Some callers have received negligent care but suffered little harm. In a typical scenario, a woman sees her doctor about a lump in her breast and is told not to worry about it. Still concerned, she sees another doctor, gets a biopsy, and learns that she has cancer. "So she calls me up, and she wants to sue the first doctor," Lang said. "Well, the first doctor was negligent. But what are the damages?" She got a timely diagnosis and treatment. "The damages are nothing."
I asked him how great the prospective damages had to be to make the effort worth his while. "It's a gut thing," he said. His expenses on a case are typically forty to fifty thousand dollars. So he would almost never take, say, a dental case. "Is a jury going to give me fifty thousand dollars for the loss of a tooth? The answer is no." The bigger the damages, the better. As another attorney told me, "I'm looking for a phone number"-damages worth seven figures.
Another consideration is how the plaintiff will come across to jurors. Someone may have a great case on paper, but Lang listens with a jury in mind. Is this person articulate enough? Would he or she seem unreasonable or strange to others? Indeed, a number of malpractice attorneys I spoke to confirmed that the nature of the plaintiff, not just of the injury, was a key factor in the awarding of damages. Vernon Glenn, a highly successful trial attorney from Charleston, South Carolina, told me, "The ideal client is someone who matches the social, political, and cultural template of where you are." He told me about a case he had in Lexington County, South Carolina-a socially conservative, devoutly Christian county that went seventy-two per cent for George W. Bush in the last election and produces juries unsympathetic to malpractice lawyers. But his plaintiff was a white, Christian female in her thirties with three young children who had lost her husband-a hardworking, thirty-nine-year-old truck mechanic who loved NASCAR, had voted Republican for the past twenty years, and had built the addition to their country home himself-to a medical error. During routine abdominal surgery, doctors caused a bowel injury that they failed to notice until, days later, he collapsed and died. The woman was articulate and attractive, but not so good-looking as to put off a jury. She wasn't angry or vengeful, but was visibly grieving and in need of help. If the family hadn't spoken English, if the husband had a long history of mental illness or alcoholism or cigarette smoking, if they'd been involved in previous lawsuits or had a criminal record, Glenn might not have taken the case. As it was, "she was darn close to the perfect client," he said. The day before trial, the defendants settled for $2.4 million.
Out of sixty callers a week, Barry Lang might take the next step with two, and start reviewing the medical records for hard evidence of negligent care. Many law firms have a nurse or a nurse practitioner on staff to do the initial review. Lang himself gathers all the records, arranges them chronologically, and goes through them page by page.
There is a legal definition of negligence ("when a doctor has breached his or her duty of care"), but I wanted to know his practical definition of the term. Lang said that if he finds an error that resulted in harm, and the doctor could have avoided it, then, as far as he is concerned, the doctor was negligent.
To most doctors, this is an alarming definition. Given the difficulty of many cases-unclear diagnoses, delicate operations-we all have serious "complications" that might have been avoided. I told Lang about a few patients of mine: a man with severe bleeding after laparoscopic liver surgery, a patient who was left permanently hoarse after thyroid surgery, a woman whose breast cancer I failed to diagnose for months. All were difficult cases. But, in looking back on them, I also now see ways in which I could have done better. Would he sue me? If he could show a jury how I might have avoided harm, and if the damages were substantial, he said, "I would sue you in a flash." But what if I have a good record among surgeons, with generally excellent outcomes and conscientious care? That wouldn't matter, he said. The only thing that matters is what I did in the case in question.
Lang insists that he is not engaged in a crusade against doctors. He faced three malpractice lawsuits himself when he was a surgeon. One involved an arthroscopy that he performed on a young woman with torn cartilage in her knee from a sports injury. Several years later, he said, she sued because she developed arthritis in the knee-a known, often unavoidable outcome. Against his wishes, the insurer settled with the patient for what Lang called "nuisance money"-five thousand dollars or so-because it was cheaper than fighting the suit in court.
In another case, a manual laborer with a wrist injury that caused numbness in three fingers sued because Lang's attempted repair made the numbness worse and left him unable to work. Lang said that he'd warned the patient that this was a high-risk surgery. When he got in, he found the key nerves encased in a thick scar. Freeing them was exceedingly difficult-"like trying to peel Scotch tape off wallpaper," he said-and some nerve fibres were unavoidably pulled off. But the insurer wasn't certain that it would prevail at trial, and settled for three hundred thousand dollars. Both cases seemed unmerited, and Lang found them as exasperating as any other doctor would.
The third case, however, was the result of a clear error, and although it took place two decades ago, it still bothers him. "I could have done more," he told me. The patient was a man in his sixties whom Lang had scheduled for a knee replacement. A few days before the surgery, the man came to his office complaining of pain in his calf. Lang considered the possibility of a deep-vein thrombosis-a blood clot in the leg-but dismissed it as unlikely and ordered no further testing. The patient did have a D.V.T., though, and when the clot dislodged, two days later, it travelled to his lungs and killed him. Lang's insurer settled the case for about four hundred thousand dollars.
"If I had been on the plaintiff's side, would I have taken that case against me?" he said to me. "Yes."
Being sued was "devastating," Lang recalled. "It's an awful feeling. No physician purposely harms his patient." Yet he insists that, even at the time, he was philosophical about the cases. "Being sued, although it sort of sucks the bottom out of you, you have to understand that it's also the cost of doing business. I mean, everybody at some time in his life is negligent, whether he's a physician, an auto mechanic, or an accountant. Negligence occurs, and that's why you have insurance. If you leave the oven on at home and your house catches fire, you're negligent. It doesn't mean you're a criminal." In his view, the public has a reasonable expectation: if a physician causes someone serious harm from substandard care or an outright mistake, he or she should be held accountable for the consequences.
The cases that Lang faced as a doctor, however, seemed to me to epitomize the malpractice debate. Two of the three lawsuits against him appeared unfounded, and, whatever Lang says now, the cost in money and confidence to our system is nothing to dismiss. Yet one of them concerned a genuine error that cost a man his life. In such cases, what do doctors believe should be done for patients and their families?
Bill Franklin is a physician I know who has practiced at Massachusetts General Hospital, in Boston, for more than forty years. He is an expert in the treatment of severe, life-threatening allergies. He is also a father. Years ago, his son Peter, who was then a second-year student at Boston University School of Medicine, called to say that he was feeling sick. He had sweats, and a cough, and felt exhausted. Bill had him come to his office and looked him over. He didn't find anything, so he had his son get a chest X-ray. Later that day, the radiologist called. "We've got big trouble," he told Bill. The X-rays showed an enormous tumor filling Peter's chest, compressing his lungs from the middle and pushing outward. It was among the largest the radiologist had encountered.
After he had pulled himself together, Bill Franklin called Peter at home to give him and his young wife the frightening news. They had two children and a small house, with a kitchen that they were in the midst of renovating. Their lives came to a halt. Peter was admitted to the hospital and a biopsy showed that he had Hodgkin's lymphoma. He was put on high-dose radiation therapy, with a beam widened to encompass his chest and neck. Still, Peter was determined to return to school. He scheduled his radiation sessions around his coursework, even after they paralyzed his left diaphragm and damaged his left lung, leaving him unable to breathe normally.
The tumor proved too large and extensive for a radiation cure. Portions of it had continued to grow, and it had spread to two lymph nodes in Peter's lower abdomen. The doctors told his father that it was one of the worst cases they had ever seen. Peter was going to need several months of chemotherapy. It would make him sick and leave him infertile, but, they said, it should work.
Bill Franklin couldn't understand how the tumor had got so large under everyone's eyes. Thinking back on Peter's care over the years, he remembered that four years earlier Peter's wisdom teeth had been removed. The surgery had been performed under general anesthesia, with an overnight stay at M.G.H., and a chest X-ray would have been taken.Franklin had one of the radiologists pull the old X-ray and take a second look. The mass was there, the radiologist told him. What's more, the original radiologist who had reviewed Peter's chest X-ray had seen it. "Further evaluation of this is recommended," the four-year-old report said. But the Franklins had never been told. The oral surgeon and the surgical resident had both written in Peter's chart that the X-ray was normal.
If the tumor had been treated then, Peter would almost certainly have been cured with radiation alone, and with considerably less-toxic doses. Now it seemed unlikely that he'd finish medical school, if he survived at all. Bill Franklin was beside himself. How could this have happened-to one of M.G.H.'s own, no less? How would Peter's wife and children be supported?
Thousands of people in similar circumstances file malpractice lawsuits in order to get answers to such questions. That's not what Bill Franklin wanted to do. The doctors involved in his son's case were colleagues and friends, and he was no fan of the malpractice system. He had himself been sued. He'd had a longtime patient with severe asthma whom he had put on steroids to ease her breathing during a bad spell. Her asthma had improved, but the high doses resulted in a prolonged dementia, and she had to be hospitalized. The lawsuit alleged that Franklin had been negligent in putting her on steroids, given the risks of the medication, and that he was therefore financially responsible for the aftermath. Franklin had been outraged. She'd had a life-threatening problem, and he'd given her the best care he could.
Now, as an M.G.H. staff member, he decided to see the hospital director. He asked for a small investigation into how the mistake had been made and how it might be prevented in the future; he also wanted to secure financial support for Peter's family. The director told him that he couldn't talk to him about the matter. He should get a lawyer, he said. Was there no other way, Franklin wanted to know. There wasn't.
Here's where we in medicine have failed. When something bad happens in the course of care and a patient and family want to know whether it was unavoidable or due to a terrible mistake, where are they to turn? Most people turn first to the doctors involved. But what if they aren't very responsive, or their explanations don't sound quite right? People often call an attorney just to get help in finding out what happened.
"Most people aren't sure what they're coming to me for," Vernon Glenn, the South Carolina trial attorney, told me. "The tipoff is often from nurses saying, 'This was just wrong. This should never have happened.' " The families ask him to have a look at the medical files. If the loss or injury is serious, he has an expert review the files. "More often than you would think, we'll say, 'Here's what happened. We don't think it's a case.' And they'll say, 'At least we know what happened now.' "
Malpractice attorneys are hardly the most impartial assessors of care, but medicine has offered no genuine alternative-because physicians are generally unwilling to take financial responsibility for the consequences of their mistakes. Indeed, the one argument that has persuaded many doctors to be more forthright about mistakes is that doing so might make patients less likely to sue.
What would most doctors do if someone close to them was hurt by a medical error? In a recent national survey, physicians and non-physicians were given the following case: A surgeon orders an antibiotic for a sixty-seven-year-old man undergoing surgery, failing to notice that the patient's chart says that he is allergic to the drug. The mistake is not caught until after the antibiotic is given, and, despite every effort, the patient dies as a result. What should be done? Unlike fifty per cent of the public, almost none of the physicians wanted the surgeon to lose his license. Medical care requires that a thousand critical steps go right every day, and none of us would have a license if we were punished every time we faltered. At the same time, fifty-five per cent of the physicians said that they would sue the surgeon for malpractice.
That's what Bill Franklin, with some trepidation, decided to do. Lawyer friends warned him that he might have to leave his position on staff if things didn't go well. He loved the hospital and his practice; Peter's oral surgeon was a friend. But his son had been harmed, and he felt that Peter and his young family were entitled to compensation for all that they had lost and suffered. Peter himself was against suing. He was afraid that a lawsuit might so antagonize his doctors that they would not treat him properly. But he was persuaded to go along with it.
At first, the Franklins were told that no lawyer would take the case. The error had been made four years earlier, and this put it beyond the state's three-year statute of limitations. As in most states at the time, one could not file a civil claim for an action long in the past-never mind that Peter didn't learn about the error until it was too late. Then they found a young Boston trial attorney named Michael Mone, who took the case all the way to the Massachusetts Supreme Court and, in 1980, won a change in the law. Franklin v. Massachusetts General Hospital et al. ruled that such time limits must start with the discovery of harm, and the precedent stands today. The change allowed the case to proceed.
The trial was held in 1983, in the town of Dedham, in the same courthouse where, six decades earlier, the anarchists Sacco and Vanzetti had been convicted of murder. "I don't remember much about the trial-I've blocked it out," Bev Franklin, Peter's mother, says. "But I remember the room. And I remember Michael Mone saying those words we'd been waiting so long to hear: 'Ladies and gentlemen, this young man had a time bomb ticking in his chest. And for four years- four years-the doctors did nothing.' " The trial took four days. The jury found in favor of Peter, and awarded him six hundred thousand dollars.
Bill Franklin says that he never experienced any negative repercussions at the hospital. His colleagues seemed to understand, and Peter's doctors did their very best for him. Peter continued to attend medical school. At the end of that long year, after six full cycles of chemotherapy, the lymph nodes in his chest continued to harbor residual cancer. He was given a new chemotherapy regimen, which so weakened his immune system that he almost died of a viral lung infection. He was in the hospital for weeks, and was finally forced to take a leave from school. The virus left him short of breath whenever he did anything more strenuous than climb half a flight of stairs, and with burning nerve pain in his feet. His marriage slowly disintegrated; a disaster can either draw people together or pull them apart, and this one pulled Peter and his wife apart.
Yet Peter survived. He eventually completed medical school, and decided to go into radiology. To everyone's surprise, he was rejected by his top-choice residency programs. A dean at Boston University called the chairman of radiology at one of the programs to find out why. "This guy's a maverick! He's suing doctors!" was the reply. The dean told the chairman Peter's story and then asked, "If this was your son, what would you do?" Peter got in after that. He chose Boston University's program and, when he finished, he was asked to join the staff there. Soon, he was made a division chief. He remarried and is now a fifty-six-year-old expert on orthopedic imaging, with a brush mustache, a graying thatch of hair, and chronic lung and liver troubles from his chemotherapy. Four years ago, he started a teleradiology group that now interprets scans for a hundred and fifty centers across the country. He is also a specialist for professional sports teams, including the San Diego Chargers and the Chicago Bears.
He says that his ordeal has made him exceedingly careful in his work. He has set up a review committee to find and analyze errors. Nonetheless, the single biggest budget item for his group is malpractice insurance. As it happens, the most common kind of malpractice case in the country involves allegations that doctors have made the kind of error that Peter once faced-a missed or delayed diagnosis. I asked him how he felt about being responsible for a lawsuit that had made it easier to sue for such claims. He winced and paused to consider his answer.
"I think the malpractice system has run amok," he finally said. "I don't think that my little experience has anything to do with it-the system is just so rampant with problems. But, if you're damaged, you're damaged. If we screw up, I think we should eat it." Wasn't he contradicting himself? No, he said; the system was the contradiction. It helps few of the people who deserve compensation. His case was unusual, and even that involved a seven-year struggle before all the appeals and challenges were dismissed. At the same time, too many undeserving patients sue, imposing enormous expense and misery. The system, as he sees it, is fundamentally perverse.
The paradox at the heart of medical care is that it works so well, and yet never well enough. It routinely gives people years of health that they otherwise wouldn't have had. Death rates from heart disease have fallen by almost two-thirds since the nineteen-fifties. The survival rate among cancer patients is now almost seventy per cent. A century ago, ten in a hundred newborns and one in a hundred mothers died; today, just seven in a thousand newborns and fewer than one in ten thousand mothers do. But this has required drugs and machines and operations and, most of all, decisions that can as easily damage people as save them. It's precisely because of our enormous success that people are bound to wonder what went wrong when we fail.
As a surgeon, I will perform about four hundred operations in the next year-everything from emergency repair of strangulated groin hernias to removal of thyroid cancers. For about two per cent of patients-for eight, maybe ten, of them-things will not go well. They will develop life-threatening bleeding. Or I will damage a critical nerve. Or I will make a wrong diagnosis. Whatever Hippocrates may have said, sometimes we do harm. Studies of serious complications find that usually about half are unavoidable; and, in such cases, I might be able to find some small solace in knowing this. But in the other half I will simply have done something wrong, and my mistake may change someone's life forever. Society is still searching for an adequate way to understand these instances. Are doctors villains if we make mistakes? No, because then we all are. But we are tainted by the harm we cause.
I watch a lot of baseball, and I often find myself thinking about the third baseman's job. In a season, a third baseman will have about as many chances to throw a man out as I will to operate on people. The very best (players like Mike Lowell, Hank Blalock, and Bill Mueller) do this perfectly almost every time. But two per cent of the time even they drop the ball or throw it over the first baseman's head. No one playing a full season fails to make stupid errors. When he does, the fans hoot and jeer. If the player's error costs the game, the hooting will turn to yelling. Imagine, though, that if every time Bill Mueller threw and missed it cost or damaged the life of someone you cared about. One error leaves an old man with a tracheostomy; another puts a young woman in a wheelchair; another leaves a child brain-damaged for the rest of her days. His teammates would still commiserate, but the rest of us? Some will want to rush the field howling for Mueller's blood. Others will see all the saves he's made and forgive him his failures. Nobody, though, would see him in quite the same way again. And nobody would be happy to have the game go on as if nothing had happened. We'd want him to show sorrow, to take responsibility. We'd want the people he injured to be helped in a meaningful way.
This is our situation in medicine, and litigation has proved to be a singularly unsatisfactory solution. It is expensive, drawn-out, and painfully adversarial. It also helps very few people. Ninety-eight per cent of families that are hurt by medical errors don't sue. They are unable to find lawyers who think they would make good plaintiffs, or they are simply too daunted. Of those who do sue, most will lose. In the end, fewer than one in a hundred deserving families receive any money. The rest get nothing: no help, not even an apology.
There is an alternative approach, which was developed for people who have been injured by vaccines. Vaccines protect tens of millions of children, but every year one in ten thousand or so is harmed by side effects. Between 1980 and 1986, personal-injury lawyers filed damage claims valued at more than $3.5 billion against doctors and manufacturers. When they began to win, vaccine prices jumped and some manufacturers got out of the business. Vaccine stockpiles dwindled. Shortages appeared. So Congress stepped in. Vaccines now carry a seventy-five-cent surcharge (about fifteen per cent of total costs), which goes into a fund for children who are injured by them. The program does not waste effort trying to sort those who are injured through negligence from those who are injured through bad luck. An expert panel has enumerated the known injuries from vaccines, and, if you have one, the fund provides compensation for medical and other expenses. If you're not satisfied, you can sue in court. But few have. Since 1988, the program has paid out a total of $1.5 billion to injured patients. Because these costs are predictable and evenly distributed, vaccine manufacturers have not only returned to the market but produced new vaccines, including ones against hepatitis and chicken pox. The program also makes the data on manufacturers public-whereas legal settlements in medical cases are virtually always sealed from view. The system has flaws, but it has helped far more people than the courts would have.
The central problem with any system remotely as fair and efficient as this one is that, applied more broadly, it would be overwhelmed with cases. Even if each doctor had just one injured and deserving patient a year (a highly optimistic assumption), complete compensation would exceed the cost of providing universal health coverage in America. To be practical, the system would have to have firm and perhaps arbitrary-seeming limits on eligibility as well as on compensation. New Zealand has settled for a system like this. It has offered compensation for medical injuries that are rare (occurring in less than one per cent of cases) and severe (resulting in death or prolonged disability). As with America's vaccine fund, there is now no attempt to sort the victims of error from the victims of bad luck. For those who qualify, the program pays for lost income, medical needs, and, if there's a permanent disability, an additional lump sum for the suffering endured. Payouts are made within nine months of filing. There are no mammoth, random windfalls, as there are in our system, but the public sees the amounts as reasonable, and there's no clamor to send these cases back to the courts.
The one defense of our malpractice system is that it has civilized the passions that arise when a doctor has done a devastating wrong. It may not be a rational system, but it does give people with the most heartbreaking injuries a means to fight. Every once in a while, it extracts enough money from a doctor to provide not just compensation but the satisfaction of a resounding punishment, fair or not. And although it does nothing for most plaintiffs, people whose loved ones have suffered complications do not then riot in hospital hallways, as clans have done in some countries.
We are in the midst of a flurry of efforts to "reform" our malpractice system. More than half of the states have enacted limits on the amount of money that juries can award someone who has been injured by a doctor, and Congress is considering a federal cap of two hundred and fifty thousand dollars on non-economic damage awards. But none of this will make the system fairer or less frustrating for either doctors or patients. It simply puts an arbitrary limit on payments so that doctors' insurance premiums might, at least temporarily, be more affordable.
Whether a cap is enacted or not, I will pay at least half a million dollars in premiums in the next ten years. I would much rather see that money placed in an insurance fund for my patients who suffer complications from my care, even if the fund cannot be as generous as we'd like it to be. There's no real chance of this happening, though. Instead, we're forced to make do with what we have.
In Courtroom 7A of the Edward J. Sullivan Courthouse in Cambridge, after seven years of litigation; more than twenty thousand dollars in payments to medical experts; the procurement of bailiffs, court reporters, a judge, and two-hundred-and-fifty-dollar-an-hour defense attorneys; time on an overloaded court schedule; and the commandeered lives of fourteen jurors for almost two weeks, Barry Lang stood behind a lectern to make his closing argument on behalf of the estate of Barbara Stanley. "Dr. Reed is not a criminal," he told the jury. "But he was negligent, and his negligence was a key factor in causing Barbara Stanley's death."
It was not an open-and-shut case. Even in Lang's account, Reed was faced with a difficult medical problem: pathologists who contradicted each other about whether the first biopsy showed skin cancer; a second biopsy that failed to settle the issue; a distrusting patient who was angry with him, first for doing too much and then for doing too little. But, for the first time during the trial, Lang stopped his constant pacing. He spoke slowly and plainly. The story he told seemed lucid and coherent. In that fateful telephone conversation, he argued, Reed failed to offer Stanley the option of a more radical skin excision that might have saved her life.
Judge Kenneth Fishman then gave the jury its instructions. Stanley's son, Ernie Browe, sat in the front row of the gallery on one side, and Kenneth Reed sat a row back on the other. Both looked drained. When the judge finished, it was late in the afternoon, and everyone was dismissed for the day.
The next morning, the jury began its deliberations. Just before noon, the court officer announced that a verdict had been reached: Dr. Kenneth Reed was not negligent in his care of Barbara Stanley. Stanley's son slumped in his seat, looked down at the floor, and did not move for a long while. Barry Lang promptly stood up to put away his papers. "It was a tough case," he said. Reed was not there to hear the verdict. He had been seeing patients in his office all morning.
posted by narebuc at 9:13 PM on December 18, 2005
1. It's usually people who are not doctors who make claims like "medical errors kill lots of people." This might be "true" in a very loose causation sense. Yes, some type of event that didn't go perfect or according to textbook ended up in adverse result. But, wow, there's usually a lot more to a story: a patient does not tell you they did indeed have a previous surgery; kidneys just were so shot and were not able to spit out the medicine given; it's an unusually difficult case to begin with and the doctor is just trying to make something work; even in the case of heart and lung transplants as Tom Baker in all his infinite medical wisdome highlights in his article, they're just very difficult to do and 5 year surviving rates are not that high -- especially in children. True, the hospital committed a stupid, terrible error -- but even, in this situation, was it completely the "medical error" that killed the patient, or perhaps, jeez-louise, did the poor child's congenital heart and lung ailment have a teeny bit of something to do with it?
2. Why do I talk about the above? Well, because this talk of "errors" and criticizing hospitals for having less verification procedures than "Starbucks" is just not fair to health care providers and is why Tom Baker just needs to not be listened to here. To begin with, the vast, vast, vast, vast majority of doctors simply are not in the business of committing errors of true, true negligence -- the very thing the tort system was designed to handle. Believe it or not, most of them want to help people. What's wrong with the tort system is that it focuses way too much on blame in order to get even larger and larger jury rewards and, really, in the vast majority of malpractice cases -- blame is a questionable thing. For instance, the bread and butter of scum sucking lawyers -- err, sorry, lawyers who sue doctors is the kid with cerebral palsy. They seriously have driven many, many obstetricians out of business to the point where it's a relatively easy residency to get because American medical students are scared shitless of having to deal with lawyer scum their whole careers. At any rate, it's led to an incredible amount of C-sections on the basis that lawyers link the deprivation of oxygen during a prolonged vaginal delivery to some brain impairment that occured in the kid later. This C-Section phenomenon happened in the mid 80s. It was (and has been) a freaking astronimical rise of C-sections to the point where thousands of mothers are getting cut up (and exposed to the risks of post-operative infection and inappropriate scar healing) just because obstetricians are worried that a prolonged or troubled delivery = lawsuit. Well, guess what's happend to the per capita rate of cerebral palsy since then? It absolutely has not changed. It's a needless set of events brought about by a crummy way we ensure against malpractice: blaming doctors. Just ask John Edwards who fed his family off stuff like this. (He's lately, after pocketing millions and millions just buy showing a retarted/mentally challenged cerebral palsy kid's picture to a jury of highly discerning and medically knowledgable North Carolinians, said perhaps his arguments might have been bogus.) Listen, it could very well be that some crappily managed deliveries led to mental retardation in a child. BUT, we'll never know with the system the way it nowadays. And, moreover, the right patients have less of chance to get rewarded -- it depends more on the skill of the lawyer than whether inappropriate medicine was given. Edwards did have his charms you know. You can probably think of a handful (nay, countryful) of lawyers who lack such abilities.
3. I bring up all this stuff because, when victims are not getting properly compensated, when blame is used as a weapon of litigation to increase verdicts and settlements instead of to ferret out bad doctors and hospitals, and when some victims are not being told of the mistake because of this atmosphere of blame -- such a system sucks and needs to changed -- namely, as the Harvard Schools of Law, Medicine, Public Health, and Economics have indicated -- to a NO FAULT MEDICAL MALPRACTICE SYSTEM -- where panels comprised of people who know whether errors happened and systems are designed solely to compensate victims without passing blame upon the doctors -- works for everyone, except, well, you know who ------ people of Mr. Baker's ilk. This system would absolutely rock and works very well in other countries where you get doctors and hospitals more ready to admit mistakes and victims more appropriately and quickly compensated -- just see how stable and successful no fault is in auto and divorce areas.
4. Despite the amazing progress of medicine, there's a boatload doctors, who train for the minimum of seven years in the stuff, will never know. A famous phrase my medical school dean told me was that the dean of a medical school once said that, "We can only teach you 10% of what is known." ---- and he said that in 1915. A system built upon blaming doctors for their mistakes is not going to cut it. So, let's not go about quoting a lawyer and some dubious studies that claim the real medical malpractice myth is "a lot more medical malpractice happens than you'd believe".
5. Would it not be nice to have a system that simply states: "You know, they told you were going to have a less congested heart and, now, due to whatever in the world (after they gave you a drug, operation, or managed you) your heart's worse off than it is if they just left you alone." Let's compensate you.
That's it. Nothing more.
6. In today's system, the scum lawyers get to make a big deal about how an "expert" would have handled it differently and then drag in family, friends, and doe eyed kids to talk about daddy can't run with them anymore and how they cry about it. The use of expert testimony is a whole other bugaboo -- and, usually, they are experts who are well credentialed academics who have no sense of the economic, business, and political pressures everyday/normal doctors face and for a nice $2000-$4000/hour fee will easily state another doctor fucked up real bad in all their 20/20 hindsight glory. (And, it's this stuff that causes just about every person that enters an ER to get a defensive medicine CAT-SCAN with all the glorious radiation and questionable diagnoses that entails).
Ok that being said, Baker is talking about maintaing lots of the status quo and has a distrust for the medical profession that is alarming to anyone who really wants to find a way to help victims of medical malpractice.
Finally, I'll end by saying that just because doctors win such trials a lot or that most cases settle -- does not mean the system works. Lawyers sue everybody and see what sticks. The process of subpoenas and adversial discovery rules only throw coal on the fire of animosity that exists between doctors and lawyers. And, moreover, doctors are freaking busy people, who, despite their high salary, go through much more (longer) poorly paid training than most people and would rather not be bothered by how litigation is going. They'd rather be seeing patients.
Read this pNew Yorker iece by Atul Gawande (a doctor) in the New Yorker and you'll see, much better than I can state, how the truth is a lot more difficult to entertain than one might imagine.
SECTION: FACT; Annals Of Medicine; Pg. 63
LENGTH: 7542 words
HEADLINE: THE MALPRACTICE MESS;
Who pays the price when patients sue doctors?
BYLINE: ATUL GAWANDE
BODY:
It was an ordinary Monday at the Middlesex County Superior Court in Cambridge, Massachusetts. Fifty-two criminal cases and a hundred and forty-seven civil cases were in session. In Courtroom 6A, Daniel Kachoul was on trial for three counts of rape and three counts of assault. In Courtroom 10B, David Santiago was on trial for cocaine trafficking and illegal possession of a deadly weapon. In Courtroom 7B, a scheduling conference was being held for Minihan v. Wallinger, a civil claim of motor-vehicle negligence. And next door, in Courtroom 7A, Dr. Kenneth Reed faced charges of medical malpractice.
Reed was a Harvard-trained dermatologist with twenty-one years of experience, and he had never been sued for malpractice before. That day, he was being questioned about two office visits and a phone call that had taken place almost nine years earlier. Barbara Stanley, a fifty-eight-year-old woman, had come to see him in the summer of 1996 about a dark warty nodule a quarter-inch wide on her left thigh. In the office, under local anesthesia, Reed shaved off the top for a biopsy. The pathologist's report came back a few days later, with a near-certain diagnosis of skin cancer-a malignant melanoma. At a follow-up appointment, Reed told Stanley that the growth would have to be completely removed. This would require taking a two-centimetre margin-almost an inch-of healthy skin beyond the lesion. He was worried about metastasis, and recommended that the procedure be done immediately, but she balked. The excision that he outlined on her leg would have been three inches across, and she couldn't believe that a procedure so disfiguring was necessary. She said that she had a friend who had been given a diagnosis of cancer erroneously, and underwent unnecessary surgery. Reed pressed, though, and by the end of their discussion she allowed him to remove the visible tumor that remained on her thigh, only a half-inch excision, for a second biopsy. He, in turn, agreed to have another pathologist look at all the tissue and provide a second opinion.
To Reed's surprise, the new tissue specimen was found to contain no sign of cancer. And when the second pathologist, Dr. Wallace Clark, an eminent authority on melanoma, examined the first specimen he concluded that the initial cancer diagnosis was wrong. "I doubt if this is melanoma, but I cannot completely rule it out," his report said. Reed and Stanley spoke by phone on August 10, 1996, to go over the new findings.
None of this is under dispute; what's under dispute is what happened afterward. According to Barbara Stanley, Reed told her that she did not have a melanoma after all-the second opinion on the original biopsy "was negative"-and that no further surgery was required. That's not how Reed recalled the phone conversation. "I indicated to Barbara Stanley . . . that Dr. Wallace Clark felt that this was a benign lesion called a Spitz nevus, and that he could not be a hundred per cent sure it was not a melanoma," he testified. "I also explained to her that in Dr. Clark's opinion this lesion had been adequately treated, that follow-up would be necessary, and that Dr. Clark did not feel that further surgery was critical. I also explained to Barbara Stanley that this was in conflict with the previous pathology report, and that the most cautious way to approach this would be to allow me to [remove additional skin] for a two-centimetre margin." She told him, he said, that she didn't want more surgery. "At that point, I reemphasized to Barbara Stanley that at least she should come in for regular follow-up." Unhappy with the care she received, she didn't return.
After two years, the growth reappeared. Stanley went to another doctor, and the pathology report came back with a clear diagnosis: a deeply invasive malignant melanoma. A complete excision, she was told, should probably have been done the first time around. When she finally did undergo the more radical procedure, the cancer had spread to lymph nodes in her groin. She was started on a yearlong course of chemotherapy. Five months later, she suffered a seizure. The cancer was now in her brain and her left lung. She had a course of brain and lung radiation. A few weeks after that, Barbara Stanley died.
But not before she had called a lawyer from her hospital bed. She found a full-page ad in the Yellow Pages for an attorney named Barry Lang, a specialist in medical-malpractice cases, and he visited her at her bedside that very day. She told him that she wanted to sue Kenneth Reed. Lang took the case. Six years later, on behalf of Barbara Stanley's children, he stood up in a Cambridge courtroom and called Reed as his first witness.
Malpractice suits are a feared, often infuriating, and common event in a doctor's life. (I have not faced a bona-fide malpractice suit, but I know to expect one.) The average doctor in a high-risk practice like surgery or obstetrics is sued about once every six years. Seventy per cent of the time, the suit is either dropped by the plaintiff or won in court. But the cost of defense is high, and when doctors lose, the average jury verdict is half a million dollars. General surgeons pay anywhere from thirty thousand to two hundred thousand dollars a year in malpractice-insurance premiums, depending on the litigation climate of the state they work in; neurosurgeons and obstetricians pay upward of fifty per cent more.
Every doctor, it seems, has a crazy-lawsuit story. My mother, a pediatrician, was once sued after a healthy two-month-old she had seen for a routine checkup died of sudden infant death syndrome a week later. The lawsuit alleged that she should have prevented the death, even though a defining characteristic of SIDS is that it occurs without warning. One of my colleagues performed lifesaving surgery to remove a woman's pancreatic cancer only to be sued years later because she developed a chronic pain in her arm; the patient blamed it, implausibly, on potassium that she received by I.V. during recovery from the surgery. I have a crazy-lawsuit story of my own. In 1990, while I was in medical school, I was at a crowded Cambridge bus stop and an elderly woman tripped on my foot and broke her shoulder. I gave her my phone number, hoping that she would call me and let me know how she was doing. She gave the number to a lawyer, and when he found out that it was a medical-school exchange he tried to sue me for malpractice, alleging that I had failed to diagnose the woman's broken shoulder when I was trying to help her. (A marshal served me with a subpoena in physiology class.) When it became apparent that I was just a first-week medical student and hadn't been treating the woman, the court disallowed the case. The lawyer then sued me for half a million dollars, alleging that I'd run his client over with a bike. I didn't even have a bike, but it took a year and a half-and fifteen thousand dollars in legal fees-to prove it.
My trial had taken place in the same courtroom as Reed's trial, and a shudder went through me when I recognized it. Not all Americans, however, see the system the way doctors do, and I had come in an attempt to understand that gap in perspectives. In the courtroom gallery, I took a seat next to Ernie Browe, the son of Barbara Stanley. He was weary, he told me, after six years of excruciating delays. He works for a chemistry lab in Washington State and has had to take vacation time and money out of his savings to pay for hotels and flights-including for two trial dates that were postponed as soon as he arrived. "I wouldn't be here unless my mother asked me to, and she did before she died," he said. "She was angry, angry to have lost all those years because of Reed." He was glad that Reed was finally being called to account.
The dermatologist sat straight-backed and still in the witness chair as Lang fired questions at him. He was clearly trying not to get flustered. A friend of mine, a pediatric plastic surgeon who had had a malpractice suit go to trial, told me the instructions that his lawyer had given him for his court appearances: Don't wear anything flashy or expensive. Don't smile or joke or frown. Don't appear angry or uncomfortable, but don't appear overconfident or dismissive, either. How, then, are you supposed to look? Reed seemed to have concluded that the only choice was to look as blank as possible. He parsed every question for traps, but the strenuous effort to avoid mistakes only made him seem anxious and defensive.
"Wouldn't you agree," Lang asked, "that [melanoma] is very curable if it's excised before it has a chance to spread?" If a patient had asked this question, Reed would readily have said yes. But, with Lang asking, he paused, uncertain.
"It's hypothetical," Reed said.
Lang was clearly delighted with this sort of answer. Reed's biggest problem, though, was that he hadn't kept notes on his August 10th phone conversation with Barbara Stanley. He could produce no corroboration for his version of events. And, as Lang often reminded the jury, plaintiffs aren't required to prove beyond a reasonable doubt that the defendant has committed malpractice. Lang needed ten of twelve jurors to think only that it was more likely than not.
"You documented a telephone conversation that you had with Barbara Stanley on August 31st, isn't that correct?" Lang asked.
"That is correct."
"Your assistant documented a discussion that you had with Barbara Stanley on August 1st, right?"
"That is correct."
"You documented a telephone call with Malden Hospital, correct?"
"That is correct."
"You documented a telephone conversation on September 6th, when you gave Barbara Stanley a prescription for an infection, correct?"
"That is correct."
"So you made efforts and you had a habit of documenting patient interactions and telephone conversations, right?"
"That is correct."
Lang began to draw the threads together. "Exactly what Barbara Stanley needed, according to you, [was] a two-centimetre excision, right?"
"Which is what I instructed Ms. Stanley to do . . ."
"Yet you did not tell Dr. Hochman"-Stanley's internist-"that she needed a two-centimetre excision, right?"
"That is correct."
"But you want this jury to believe you told Barbara Stanley?"
"I want this jury to believe the truth-which is that I told Barbara Stanley she needed a two-centimetre excision."
Lang raised his voice. "You should have told Barbara Stanley that . . . isn't that correct?" He all but called Reed a perjurer.
"I did tell Barbara Stanley, repeatedly!" Reed protested. "But she refused." As the examination continued, Reed tried to keep his exasperation in check, and Lang did all he could to discredit him.
"In your entire career, Doctor, how many articles have you published in the literature?" Lang asked at another point.
"Three," Reed said.
Lang lifted his eyebrows, and stood with his mouth agape for two beats. "In twenty years' time, you've published three articles?"
Without documentation, Reed was in a hard spot, and Lang's examination made my skin crawl. I could easily picture myself on the stand being made to defend any number of cases in which things didn't turn out well and I hadn't got every last thing down on paper. Lang was sixty years old, bald, short, and loud. Spittle flew in droplets. He paced constantly, and rolled his eyes at Reed's protestations. He showed no deference and little courtesy. He was almost a stereotype of a malpractice lawyer-except in one respect, and that was the reason I'd come to watch this particular trial.
Barry Lang used to be a doctor. For twenty-three years, he had a successful practice as an orthopedic surgeon, with particular expertise in pediatric orthopedics. He'd even served as an expert witness on behalf of other surgeons. Then, in a turnabout, he went to law school, gave up his medical practice, and embarked on a new career suing doctors. Watching him, I wondered, after all his experience did he understand something that the rest of us didn't?
I went to see Lang at his office in downtown Boston, on the tenth floor of 1 State Street, in the heart of the financial district. He welcomed me warmly, and I found that we spoke more as fellow-doctors than as potential adversaries. I asked why he had quit medicine to become a malpractice attorney. Was it for the money?
He laughed at the idea. Going into law "was a money disaster," he said. Starting out, he had expected at least some rewards. "I figured I'd get some cases, and if they were good the doctors would settle them quickly and get them out of the way. But no. I was incredibly naive. No one ever settles before the actual court date. It doesn't matter how strong your evidence is. They always think they're in the right. Things can also change over time. And, given the choice of paying now or paying later, which would you rather do?"
He entered law practice, he said, because he thought he'd be good at it, because he thought he could help people, and because, after twenty-three years in medicine, he was burning out. "It used to be 'Two hip replacements today-yeah!' " he recalled. "Then it became 'Two hip replacements today-ugh.' "
When I spoke to his wife, Janet, she said that his decision to change careers shocked her. From the day she met him, when they were both undergraduates at Syracuse University, he'd never wanted to be anything other than a doctor. After medical school in Syracuse and an orthopedics residency at Temple University, he had built a busy orthopedics practice in New Bedford, Massachusetts, and had a fulfilling and varied life. Even when he enrolled in night classes at Southern New England School of Law, a few blocks from his office, his wife didn't think anything of it. He was, as she put it, "forever going to school." One year, he took English-literature classes at a local college. Another year, he took classes in Judaism. He took pilot lessons, and before long was entering airplane aerobatics competitions. Law school, too, began as another pastime-"It was just for kicks," he said.
After he finished, though, he took the bar exam and got his license. He was fifty years old. He'd been in orthopedics practice long enough to have saved a lot of money, and law had begun to seem much more interesting than medicine. In July, 1997, he handed his practice over to his startled partners, "and that was the end of it," he said.
He figured that the one thing he could offer was his medical expertise, and he tried to start his legal practice by defending physicians. But, because he had no experience, the major law firms that dealt with malpractice defense wouldn't take him, and the malpractice insurers in the state wouldn't send him cases. So he rented a small office and set up shop as a malpractice attorney for patients. He spent several thousand dollars a month for ads on television and in the phone book, dubbing himself "the Law Doctor." Then the phone calls came. Five years into his new career, his cases finally began going to trial. This is his eighth year as a malpractice attorney, and he has won settlements in at least thirty cases. Eight others went to trial, and he won half of them. Two weeks before the Reed trial, he won a four-hundred-thousand-dollar jury award for a woman whose main bile duct was injured during gallbladder surgery, forcing her to undergo several reconstructive operations. (Lang got more than a third of that award. Under Massachusetts state law, attorneys get no more than forty per cent of the first hundred and fifty thousand dollars, 33.3 per cent of the next hundred and fifty thousand, thirty per cent of the next two hundred thousand, and twenty-five per cent of anything over half a million.) Lang has at least sixty cases pending. If he had any money troubles, they are over.
Lang said that he gets ten to twelve calls a day, mostly from patients or their families, with some referrals from other lawyers who don't do malpractice. He turns most of them away. He wants a good case, and a good case has to have two things, he said. "No. 1, you need the doctor to be negligent. No. 2, you need the doctor to have caused damage." Many of the callers fail on both counts. "I had a call from one guy. He says, 'I was waiting in the emergency room for four hours. People were taken ahead of me, and I was really sick.' I say, 'Well, what happened as a result of that?' 'Nothing, but I shouldn't have to wait for four hours.' Well, that's ridiculous."
Some callers have received negligent care but suffered little harm. In a typical scenario, a woman sees her doctor about a lump in her breast and is told not to worry about it. Still concerned, she sees another doctor, gets a biopsy, and learns that she has cancer. "So she calls me up, and she wants to sue the first doctor," Lang said. "Well, the first doctor was negligent. But what are the damages?" She got a timely diagnosis and treatment. "The damages are nothing."
I asked him how great the prospective damages had to be to make the effort worth his while. "It's a gut thing," he said. His expenses on a case are typically forty to fifty thousand dollars. So he would almost never take, say, a dental case. "Is a jury going to give me fifty thousand dollars for the loss of a tooth? The answer is no." The bigger the damages, the better. As another attorney told me, "I'm looking for a phone number"-damages worth seven figures.
Another consideration is how the plaintiff will come across to jurors. Someone may have a great case on paper, but Lang listens with a jury in mind. Is this person articulate enough? Would he or she seem unreasonable or strange to others? Indeed, a number of malpractice attorneys I spoke to confirmed that the nature of the plaintiff, not just of the injury, was a key factor in the awarding of damages. Vernon Glenn, a highly successful trial attorney from Charleston, South Carolina, told me, "The ideal client is someone who matches the social, political, and cultural template of where you are." He told me about a case he had in Lexington County, South Carolina-a socially conservative, devoutly Christian county that went seventy-two per cent for George W. Bush in the last election and produces juries unsympathetic to malpractice lawyers. But his plaintiff was a white, Christian female in her thirties with three young children who had lost her husband-a hardworking, thirty-nine-year-old truck mechanic who loved NASCAR, had voted Republican for the past twenty years, and had built the addition to their country home himself-to a medical error. During routine abdominal surgery, doctors caused a bowel injury that they failed to notice until, days later, he collapsed and died. The woman was articulate and attractive, but not so good-looking as to put off a jury. She wasn't angry or vengeful, but was visibly grieving and in need of help. If the family hadn't spoken English, if the husband had a long history of mental illness or alcoholism or cigarette smoking, if they'd been involved in previous lawsuits or had a criminal record, Glenn might not have taken the case. As it was, "she was darn close to the perfect client," he said. The day before trial, the defendants settled for $2.4 million.
Out of sixty callers a week, Barry Lang might take the next step with two, and start reviewing the medical records for hard evidence of negligent care. Many law firms have a nurse or a nurse practitioner on staff to do the initial review. Lang himself gathers all the records, arranges them chronologically, and goes through them page by page.
There is a legal definition of negligence ("when a doctor has breached his or her duty of care"), but I wanted to know his practical definition of the term. Lang said that if he finds an error that resulted in harm, and the doctor could have avoided it, then, as far as he is concerned, the doctor was negligent.
To most doctors, this is an alarming definition. Given the difficulty of many cases-unclear diagnoses, delicate operations-we all have serious "complications" that might have been avoided. I told Lang about a few patients of mine: a man with severe bleeding after laparoscopic liver surgery, a patient who was left permanently hoarse after thyroid surgery, a woman whose breast cancer I failed to diagnose for months. All were difficult cases. But, in looking back on them, I also now see ways in which I could have done better. Would he sue me? If he could show a jury how I might have avoided harm, and if the damages were substantial, he said, "I would sue you in a flash." But what if I have a good record among surgeons, with generally excellent outcomes and conscientious care? That wouldn't matter, he said. The only thing that matters is what I did in the case in question.
Lang insists that he is not engaged in a crusade against doctors. He faced three malpractice lawsuits himself when he was a surgeon. One involved an arthroscopy that he performed on a young woman with torn cartilage in her knee from a sports injury. Several years later, he said, she sued because she developed arthritis in the knee-a known, often unavoidable outcome. Against his wishes, the insurer settled with the patient for what Lang called "nuisance money"-five thousand dollars or so-because it was cheaper than fighting the suit in court.
In another case, a manual laborer with a wrist injury that caused numbness in three fingers sued because Lang's attempted repair made the numbness worse and left him unable to work. Lang said that he'd warned the patient that this was a high-risk surgery. When he got in, he found the key nerves encased in a thick scar. Freeing them was exceedingly difficult-"like trying to peel Scotch tape off wallpaper," he said-and some nerve fibres were unavoidably pulled off. But the insurer wasn't certain that it would prevail at trial, and settled for three hundred thousand dollars. Both cases seemed unmerited, and Lang found them as exasperating as any other doctor would.
The third case, however, was the result of a clear error, and although it took place two decades ago, it still bothers him. "I could have done more," he told me. The patient was a man in his sixties whom Lang had scheduled for a knee replacement. A few days before the surgery, the man came to his office complaining of pain in his calf. Lang considered the possibility of a deep-vein thrombosis-a blood clot in the leg-but dismissed it as unlikely and ordered no further testing. The patient did have a D.V.T., though, and when the clot dislodged, two days later, it travelled to his lungs and killed him. Lang's insurer settled the case for about four hundred thousand dollars.
"If I had been on the plaintiff's side, would I have taken that case against me?" he said to me. "Yes."
Being sued was "devastating," Lang recalled. "It's an awful feeling. No physician purposely harms his patient." Yet he insists that, even at the time, he was philosophical about the cases. "Being sued, although it sort of sucks the bottom out of you, you have to understand that it's also the cost of doing business. I mean, everybody at some time in his life is negligent, whether he's a physician, an auto mechanic, or an accountant. Negligence occurs, and that's why you have insurance. If you leave the oven on at home and your house catches fire, you're negligent. It doesn't mean you're a criminal." In his view, the public has a reasonable expectation: if a physician causes someone serious harm from substandard care or an outright mistake, he or she should be held accountable for the consequences.
The cases that Lang faced as a doctor, however, seemed to me to epitomize the malpractice debate. Two of the three lawsuits against him appeared unfounded, and, whatever Lang says now, the cost in money and confidence to our system is nothing to dismiss. Yet one of them concerned a genuine error that cost a man his life. In such cases, what do doctors believe should be done for patients and their families?
Bill Franklin is a physician I know who has practiced at Massachusetts General Hospital, in Boston, for more than forty years. He is an expert in the treatment of severe, life-threatening allergies. He is also a father. Years ago, his son Peter, who was then a second-year student at Boston University School of Medicine, called to say that he was feeling sick. He had sweats, and a cough, and felt exhausted. Bill had him come to his office and looked him over. He didn't find anything, so he had his son get a chest X-ray. Later that day, the radiologist called. "We've got big trouble," he told Bill. The X-rays showed an enormous tumor filling Peter's chest, compressing his lungs from the middle and pushing outward. It was among the largest the radiologist had encountered.
After he had pulled himself together, Bill Franklin called Peter at home to give him and his young wife the frightening news. They had two children and a small house, with a kitchen that they were in the midst of renovating. Their lives came to a halt. Peter was admitted to the hospital and a biopsy showed that he had Hodgkin's lymphoma. He was put on high-dose radiation therapy, with a beam widened to encompass his chest and neck. Still, Peter was determined to return to school. He scheduled his radiation sessions around his coursework, even after they paralyzed his left diaphragm and damaged his left lung, leaving him unable to breathe normally.
The tumor proved too large and extensive for a radiation cure. Portions of it had continued to grow, and it had spread to two lymph nodes in Peter's lower abdomen. The doctors told his father that it was one of the worst cases they had ever seen. Peter was going to need several months of chemotherapy. It would make him sick and leave him infertile, but, they said, it should work.
Bill Franklin couldn't understand how the tumor had got so large under everyone's eyes. Thinking back on Peter's care over the years, he remembered that four years earlier Peter's wisdom teeth had been removed. The surgery had been performed under general anesthesia, with an overnight stay at M.G.H., and a chest X-ray would have been taken.Franklin had one of the radiologists pull the old X-ray and take a second look. The mass was there, the radiologist told him. What's more, the original radiologist who had reviewed Peter's chest X-ray had seen it. "Further evaluation of this is recommended," the four-year-old report said. But the Franklins had never been told. The oral surgeon and the surgical resident had both written in Peter's chart that the X-ray was normal.
If the tumor had been treated then, Peter would almost certainly have been cured with radiation alone, and with considerably less-toxic doses. Now it seemed unlikely that he'd finish medical school, if he survived at all. Bill Franklin was beside himself. How could this have happened-to one of M.G.H.'s own, no less? How would Peter's wife and children be supported?
Thousands of people in similar circumstances file malpractice lawsuits in order to get answers to such questions. That's not what Bill Franklin wanted to do. The doctors involved in his son's case were colleagues and friends, and he was no fan of the malpractice system. He had himself been sued. He'd had a longtime patient with severe asthma whom he had put on steroids to ease her breathing during a bad spell. Her asthma had improved, but the high doses resulted in a prolonged dementia, and she had to be hospitalized. The lawsuit alleged that Franklin had been negligent in putting her on steroids, given the risks of the medication, and that he was therefore financially responsible for the aftermath. Franklin had been outraged. She'd had a life-threatening problem, and he'd given her the best care he could.
Now, as an M.G.H. staff member, he decided to see the hospital director. He asked for a small investigation into how the mistake had been made and how it might be prevented in the future; he also wanted to secure financial support for Peter's family. The director told him that he couldn't talk to him about the matter. He should get a lawyer, he said. Was there no other way, Franklin wanted to know. There wasn't.
Here's where we in medicine have failed. When something bad happens in the course of care and a patient and family want to know whether it was unavoidable or due to a terrible mistake, where are they to turn? Most people turn first to the doctors involved. But what if they aren't very responsive, or their explanations don't sound quite right? People often call an attorney just to get help in finding out what happened.
"Most people aren't sure what they're coming to me for," Vernon Glenn, the South Carolina trial attorney, told me. "The tipoff is often from nurses saying, 'This was just wrong. This should never have happened.' " The families ask him to have a look at the medical files. If the loss or injury is serious, he has an expert review the files. "More often than you would think, we'll say, 'Here's what happened. We don't think it's a case.' And they'll say, 'At least we know what happened now.' "
Malpractice attorneys are hardly the most impartial assessors of care, but medicine has offered no genuine alternative-because physicians are generally unwilling to take financial responsibility for the consequences of their mistakes. Indeed, the one argument that has persuaded many doctors to be more forthright about mistakes is that doing so might make patients less likely to sue.
What would most doctors do if someone close to them was hurt by a medical error? In a recent national survey, physicians and non-physicians were given the following case: A surgeon orders an antibiotic for a sixty-seven-year-old man undergoing surgery, failing to notice that the patient's chart says that he is allergic to the drug. The mistake is not caught until after the antibiotic is given, and, despite every effort, the patient dies as a result. What should be done? Unlike fifty per cent of the public, almost none of the physicians wanted the surgeon to lose his license. Medical care requires that a thousand critical steps go right every day, and none of us would have a license if we were punished every time we faltered. At the same time, fifty-five per cent of the physicians said that they would sue the surgeon for malpractice.
That's what Bill Franklin, with some trepidation, decided to do. Lawyer friends warned him that he might have to leave his position on staff if things didn't go well. He loved the hospital and his practice; Peter's oral surgeon was a friend. But his son had been harmed, and he felt that Peter and his young family were entitled to compensation for all that they had lost and suffered. Peter himself was against suing. He was afraid that a lawsuit might so antagonize his doctors that they would not treat him properly. But he was persuaded to go along with it.
At first, the Franklins were told that no lawyer would take the case. The error had been made four years earlier, and this put it beyond the state's three-year statute of limitations. As in most states at the time, one could not file a civil claim for an action long in the past-never mind that Peter didn't learn about the error until it was too late. Then they found a young Boston trial attorney named Michael Mone, who took the case all the way to the Massachusetts Supreme Court and, in 1980, won a change in the law. Franklin v. Massachusetts General Hospital et al. ruled that such time limits must start with the discovery of harm, and the precedent stands today. The change allowed the case to proceed.
The trial was held in 1983, in the town of Dedham, in the same courthouse where, six decades earlier, the anarchists Sacco and Vanzetti had been convicted of murder. "I don't remember much about the trial-I've blocked it out," Bev Franklin, Peter's mother, says. "But I remember the room. And I remember Michael Mone saying those words we'd been waiting so long to hear: 'Ladies and gentlemen, this young man had a time bomb ticking in his chest. And for four years- four years-the doctors did nothing.' " The trial took four days. The jury found in favor of Peter, and awarded him six hundred thousand dollars.
Bill Franklin says that he never experienced any negative repercussions at the hospital. His colleagues seemed to understand, and Peter's doctors did their very best for him. Peter continued to attend medical school. At the end of that long year, after six full cycles of chemotherapy, the lymph nodes in his chest continued to harbor residual cancer. He was given a new chemotherapy regimen, which so weakened his immune system that he almost died of a viral lung infection. He was in the hospital for weeks, and was finally forced to take a leave from school. The virus left him short of breath whenever he did anything more strenuous than climb half a flight of stairs, and with burning nerve pain in his feet. His marriage slowly disintegrated; a disaster can either draw people together or pull them apart, and this one pulled Peter and his wife apart.
Yet Peter survived. He eventually completed medical school, and decided to go into radiology. To everyone's surprise, he was rejected by his top-choice residency programs. A dean at Boston University called the chairman of radiology at one of the programs to find out why. "This guy's a maverick! He's suing doctors!" was the reply. The dean told the chairman Peter's story and then asked, "If this was your son, what would you do?" Peter got in after that. He chose Boston University's program and, when he finished, he was asked to join the staff there. Soon, he was made a division chief. He remarried and is now a fifty-six-year-old expert on orthopedic imaging, with a brush mustache, a graying thatch of hair, and chronic lung and liver troubles from his chemotherapy. Four years ago, he started a teleradiology group that now interprets scans for a hundred and fifty centers across the country. He is also a specialist for professional sports teams, including the San Diego Chargers and the Chicago Bears.
He says that his ordeal has made him exceedingly careful in his work. He has set up a review committee to find and analyze errors. Nonetheless, the single biggest budget item for his group is malpractice insurance. As it happens, the most common kind of malpractice case in the country involves allegations that doctors have made the kind of error that Peter once faced-a missed or delayed diagnosis. I asked him how he felt about being responsible for a lawsuit that had made it easier to sue for such claims. He winced and paused to consider his answer.
"I think the malpractice system has run amok," he finally said. "I don't think that my little experience has anything to do with it-the system is just so rampant with problems. But, if you're damaged, you're damaged. If we screw up, I think we should eat it." Wasn't he contradicting himself? No, he said; the system was the contradiction. It helps few of the people who deserve compensation. His case was unusual, and even that involved a seven-year struggle before all the appeals and challenges were dismissed. At the same time, too many undeserving patients sue, imposing enormous expense and misery. The system, as he sees it, is fundamentally perverse.
The paradox at the heart of medical care is that it works so well, and yet never well enough. It routinely gives people years of health that they otherwise wouldn't have had. Death rates from heart disease have fallen by almost two-thirds since the nineteen-fifties. The survival rate among cancer patients is now almost seventy per cent. A century ago, ten in a hundred newborns and one in a hundred mothers died; today, just seven in a thousand newborns and fewer than one in ten thousand mothers do. But this has required drugs and machines and operations and, most of all, decisions that can as easily damage people as save them. It's precisely because of our enormous success that people are bound to wonder what went wrong when we fail.
As a surgeon, I will perform about four hundred operations in the next year-everything from emergency repair of strangulated groin hernias to removal of thyroid cancers. For about two per cent of patients-for eight, maybe ten, of them-things will not go well. They will develop life-threatening bleeding. Or I will damage a critical nerve. Or I will make a wrong diagnosis. Whatever Hippocrates may have said, sometimes we do harm. Studies of serious complications find that usually about half are unavoidable; and, in such cases, I might be able to find some small solace in knowing this. But in the other half I will simply have done something wrong, and my mistake may change someone's life forever. Society is still searching for an adequate way to understand these instances. Are doctors villains if we make mistakes? No, because then we all are. But we are tainted by the harm we cause.
I watch a lot of baseball, and I often find myself thinking about the third baseman's job. In a season, a third baseman will have about as many chances to throw a man out as I will to operate on people. The very best (players like Mike Lowell, Hank Blalock, and Bill Mueller) do this perfectly almost every time. But two per cent of the time even they drop the ball or throw it over the first baseman's head. No one playing a full season fails to make stupid errors. When he does, the fans hoot and jeer. If the player's error costs the game, the hooting will turn to yelling. Imagine, though, that if every time Bill Mueller threw and missed it cost or damaged the life of someone you cared about. One error leaves an old man with a tracheostomy; another puts a young woman in a wheelchair; another leaves a child brain-damaged for the rest of her days. His teammates would still commiserate, but the rest of us? Some will want to rush the field howling for Mueller's blood. Others will see all the saves he's made and forgive him his failures. Nobody, though, would see him in quite the same way again. And nobody would be happy to have the game go on as if nothing had happened. We'd want him to show sorrow, to take responsibility. We'd want the people he injured to be helped in a meaningful way.
This is our situation in medicine, and litigation has proved to be a singularly unsatisfactory solution. It is expensive, drawn-out, and painfully adversarial. It also helps very few people. Ninety-eight per cent of families that are hurt by medical errors don't sue. They are unable to find lawyers who think they would make good plaintiffs, or they are simply too daunted. Of those who do sue, most will lose. In the end, fewer than one in a hundred deserving families receive any money. The rest get nothing: no help, not even an apology.
There is an alternative approach, which was developed for people who have been injured by vaccines. Vaccines protect tens of millions of children, but every year one in ten thousand or so is harmed by side effects. Between 1980 and 1986, personal-injury lawyers filed damage claims valued at more than $3.5 billion against doctors and manufacturers. When they began to win, vaccine prices jumped and some manufacturers got out of the business. Vaccine stockpiles dwindled. Shortages appeared. So Congress stepped in. Vaccines now carry a seventy-five-cent surcharge (about fifteen per cent of total costs), which goes into a fund for children who are injured by them. The program does not waste effort trying to sort those who are injured through negligence from those who are injured through bad luck. An expert panel has enumerated the known injuries from vaccines, and, if you have one, the fund provides compensation for medical and other expenses. If you're not satisfied, you can sue in court. But few have. Since 1988, the program has paid out a total of $1.5 billion to injured patients. Because these costs are predictable and evenly distributed, vaccine manufacturers have not only returned to the market but produced new vaccines, including ones against hepatitis and chicken pox. The program also makes the data on manufacturers public-whereas legal settlements in medical cases are virtually always sealed from view. The system has flaws, but it has helped far more people than the courts would have.
The central problem with any system remotely as fair and efficient as this one is that, applied more broadly, it would be overwhelmed with cases. Even if each doctor had just one injured and deserving patient a year (a highly optimistic assumption), complete compensation would exceed the cost of providing universal health coverage in America. To be practical, the system would have to have firm and perhaps arbitrary-seeming limits on eligibility as well as on compensation. New Zealand has settled for a system like this. It has offered compensation for medical injuries that are rare (occurring in less than one per cent of cases) and severe (resulting in death or prolonged disability). As with America's vaccine fund, there is now no attempt to sort the victims of error from the victims of bad luck. For those who qualify, the program pays for lost income, medical needs, and, if there's a permanent disability, an additional lump sum for the suffering endured. Payouts are made within nine months of filing. There are no mammoth, random windfalls, as there are in our system, but the public sees the amounts as reasonable, and there's no clamor to send these cases back to the courts.
The one defense of our malpractice system is that it has civilized the passions that arise when a doctor has done a devastating wrong. It may not be a rational system, but it does give people with the most heartbreaking injuries a means to fight. Every once in a while, it extracts enough money from a doctor to provide not just compensation but the satisfaction of a resounding punishment, fair or not. And although it does nothing for most plaintiffs, people whose loved ones have suffered complications do not then riot in hospital hallways, as clans have done in some countries.
We are in the midst of a flurry of efforts to "reform" our malpractice system. More than half of the states have enacted limits on the amount of money that juries can award someone who has been injured by a doctor, and Congress is considering a federal cap of two hundred and fifty thousand dollars on non-economic damage awards. But none of this will make the system fairer or less frustrating for either doctors or patients. It simply puts an arbitrary limit on payments so that doctors' insurance premiums might, at least temporarily, be more affordable.
Whether a cap is enacted or not, I will pay at least half a million dollars in premiums in the next ten years. I would much rather see that money placed in an insurance fund for my patients who suffer complications from my care, even if the fund cannot be as generous as we'd like it to be. There's no real chance of this happening, though. Instead, we're forced to make do with what we have.
In Courtroom 7A of the Edward J. Sullivan Courthouse in Cambridge, after seven years of litigation; more than twenty thousand dollars in payments to medical experts; the procurement of bailiffs, court reporters, a judge, and two-hundred-and-fifty-dollar-an-hour defense attorneys; time on an overloaded court schedule; and the commandeered lives of fourteen jurors for almost two weeks, Barry Lang stood behind a lectern to make his closing argument on behalf of the estate of Barbara Stanley. "Dr. Reed is not a criminal," he told the jury. "But he was negligent, and his negligence was a key factor in causing Barbara Stanley's death."
It was not an open-and-shut case. Even in Lang's account, Reed was faced with a difficult medical problem: pathologists who contradicted each other about whether the first biopsy showed skin cancer; a second biopsy that failed to settle the issue; a distrusting patient who was angry with him, first for doing too much and then for doing too little. But, for the first time during the trial, Lang stopped his constant pacing. He spoke slowly and plainly. The story he told seemed lucid and coherent. In that fateful telephone conversation, he argued, Reed failed to offer Stanley the option of a more radical skin excision that might have saved her life.
Judge Kenneth Fishman then gave the jury its instructions. Stanley's son, Ernie Browe, sat in the front row of the gallery on one side, and Kenneth Reed sat a row back on the other. Both looked drained. When the judge finished, it was late in the afternoon, and everyone was dismissed for the day.
The next morning, the jury began its deliberations. Just before noon, the court officer announced that a verdict had been reached: Dr. Kenneth Reed was not negligent in his care of Barbara Stanley. Stanley's son slumped in his seat, looked down at the floor, and did not move for a long while. Barry Lang promptly stood up to put away his papers. "It was a tough case," he said. Reed was not there to hear the verdict. He had been seeing patients in his office all morning.
posted by narebuc at 9:13 PM on December 18, 2005
Try talking to some surgeons at cocktail parties - they treat their profession like woodworking. Chop here, slice here, staple there, got two more scheduled before lunch.
Oh please! They perform the same procedured day in and day out. Do you really think that your case is so damn special?
posted by c13 at 9:16 PM on December 18, 2005
Oh please! They perform the same procedured day in and day out. Do you really think that your case is so damn special?
posted by c13 at 9:16 PM on December 18, 2005
Q: What do they call the person that graduates last in their class at med-school?
A: Doctor.
posted by tozturk at 9:19 PM on December 18, 2005
A: Doctor.
posted by tozturk at 9:19 PM on December 18, 2005
If you're linking to cato.org about some factual matter, you've already lost. Remember: replace "thinktank" with "paid liars".
The Census Bureau states pretty comprehensively that 15.7% of the U.S. population - 45 million people - had no health insurance for any part of the year 2004. Or you could believe the Cato Institute, who are paid to influence public opinion via lying. Your choice.
About 27% of the U.S. population is covered directly by the government. So you already have one-quarter of universal health care, you just need to work on the other 3/4.
People are commenting on my description of surgeons. I mean only to demystify what surgeons and all doctors do, not to denigrate them. It's a job. It has a great deal in common with automobile assembly. Patients come at you on an assembly line, you perform your technique on them, and they're gone to the next guy down the line. Depending on the factory, the assembly line may be run fast or may be run slow, you might get breaks or not, you might take pride in your work or you might not, you might be concentrating on the job or thinking about what to have for lunch when you're treating any given patient, etc. etc. People treat doctors as some sort of mythic authority figures when they really shouldn't. Not that all doctors are hacks, but rather that those doctors who are hacks can easily get away with it by parading around in a white coat with a stethoscope.
Hmmm. The NY Times has a story summing up the experience of sick people in America - you get a job, you have great health insurance, you get sick, you lose your job, you lose your health insurance because you lost your job, you go bankrupt.
Yossarian was moved very deeply by the absolute simplicity of this clause of Catch-22 and let out a respectful whistle.
"That's some catch, that Catch-22," he observed.
"It's the best there is," Doc Daneeka agreed.
posted by jellicle at 9:24 PM on December 18, 2005
The Census Bureau states pretty comprehensively that 15.7% of the U.S. population - 45 million people - had no health insurance for any part of the year 2004. Or you could believe the Cato Institute, who are paid to influence public opinion via lying. Your choice.
About 27% of the U.S. population is covered directly by the government. So you already have one-quarter of universal health care, you just need to work on the other 3/4.
People are commenting on my description of surgeons. I mean only to demystify what surgeons and all doctors do, not to denigrate them. It's a job. It has a great deal in common with automobile assembly. Patients come at you on an assembly line, you perform your technique on them, and they're gone to the next guy down the line. Depending on the factory, the assembly line may be run fast or may be run slow, you might get breaks or not, you might take pride in your work or you might not, you might be concentrating on the job or thinking about what to have for lunch when you're treating any given patient, etc. etc. People treat doctors as some sort of mythic authority figures when they really shouldn't. Not that all doctors are hacks, but rather that those doctors who are hacks can easily get away with it by parading around in a white coat with a stethoscope.
Hmmm. The NY Times has a story summing up the experience of sick people in America - you get a job, you have great health insurance, you get sick, you lose your job, you lose your health insurance because you lost your job, you go bankrupt.
Yossarian was moved very deeply by the absolute simplicity of this clause of Catch-22 and let out a respectful whistle.
"That's some catch, that Catch-22," he observed.
"It's the best there is," Doc Daneeka agreed.
posted by jellicle at 9:24 PM on December 18, 2005
Fact: The typical family practice doctor in the United States makes $120k. This number has not changed in ten years.
Fact: Most medical malpractice policies have a maximum payout of $1M per incident. This renders "megaverdicts" and "pain and suffering" damages a non-issue for the insurer. Damage caps are a red herring.
Fact: Doctors have no control over how much they will pay for malpractice insurance. In many cases, he has a choice between 2-6 companies that offer it in his state, and depending on his scope of practice some of them will not cover him for any price. Some states have seen double digit rate increases in each of the last five years.
Does the author really mean to say that the incidence of malpractice has gone up that much in the last rive years? You might not want to get me started on this issue.
posted by ilsa at 9:25 PM on December 18, 2005
Fact: Most medical malpractice policies have a maximum payout of $1M per incident. This renders "megaverdicts" and "pain and suffering" damages a non-issue for the insurer. Damage caps are a red herring.
Fact: Doctors have no control over how much they will pay for malpractice insurance. In many cases, he has a choice between 2-6 companies that offer it in his state, and depending on his scope of practice some of them will not cover him for any price. Some states have seen double digit rate increases in each of the last five years.
Does the author really mean to say that the incidence of malpractice has gone up that much in the last rive years? You might not want to get me started on this issue.
posted by ilsa at 9:25 PM on December 18, 2005
no, but he plays one on TV...
posted by Heywood Mogroot at 9:34 PM on December 18, 2005
posted by Heywood Mogroot at 9:34 PM on December 18, 2005
Read this pNew Yorker iece by Atul Gawande (a doctor) in the New Yorker and you'll see, much better than I can state, how the truth is a lot more difficult to entertain than one might imagine.TAG OFF!
If only there were some way to mark text in such a way that clicking on a phrase of text would link one to a longer article that expands on the text that the user clicked on, instead of simply being forced to read the entire article on the same page it was referenced.
posted by deanc at 9:41 PM on December 18, 2005
If only there were some way to mark text in such a way that clicking on a phrase of text would link one to a longer article that expands on the text that the user clicked on, instead of simply being forced to read the entire article on the same page it was referenced.
posted by deanc at 9:41 PM on December 18, 2005
narebuc: It's usually people who are not doctors who make claims like "medical errors kill lots of people." This might be "true" in a very loose causation sense. Yes, some type of event that didn't go perfect or according to textbook ended up in adverse result. But, wow, there's usually a lot more to a story: ...
In the CBC discussion I linked they say that 5% of errors are due to negligence. Personally, I don't care why the errors occur, the error rate needs to be reduced, period.
And... Your "if your not a doctor you can't talk about this subject" bit is not helpful.
What's wrong with the tort system is that it focuses way too much on blame in order to get even larger and larger jury rewards and, really, in the vast majority of malpractice cases -- blame is a questionable thing.
I doubt it... However, Tom Baker's idea seems to be that tort is an effective check against malpractice. I doubt that too...
I think that civil engineering and civil aviation have a lot to teach in this area. It is my impression that both fields have done a masterful job of improving error rates over time, the medical profession doesn't seem to have followed suit.
I don't think tort had anything much to do with the improvements made in civil aviation and civil engineering safety records. I think the improvement came about because the public demanded better performance, and industry decided it would be good for business to spend a lot of money/time/effort learning how to do better.
Of course there is a big difference between the different industries. A plane crash effects tens to hundreds of people, which justifies spending huge amounts of money on investigation. Also, people tend to distrust aviation, and many just wouldn't fly if they didn't know how seriously safety is taken. A medical error normally effects one person, and people have a tendency to trust, even deify, doctors.
Of course that is just a personal theory...
posted by Chuckles at 9:44 PM on December 18, 2005
In the CBC discussion I linked they say that 5% of errors are due to negligence. Personally, I don't care why the errors occur, the error rate needs to be reduced, period.
And... Your "if your not a doctor you can't talk about this subject" bit is not helpful.
What's wrong with the tort system is that it focuses way too much on blame in order to get even larger and larger jury rewards and, really, in the vast majority of malpractice cases -- blame is a questionable thing.
I doubt it... However, Tom Baker's idea seems to be that tort is an effective check against malpractice. I doubt that too...
I think that civil engineering and civil aviation have a lot to teach in this area. It is my impression that both fields have done a masterful job of improving error rates over time, the medical profession doesn't seem to have followed suit.
I don't think tort had anything much to do with the improvements made in civil aviation and civil engineering safety records. I think the improvement came about because the public demanded better performance, and industry decided it would be good for business to spend a lot of money/time/effort learning how to do better.
Of course there is a big difference between the different industries. A plane crash effects tens to hundreds of people, which justifies spending huge amounts of money on investigation. Also, people tend to distrust aviation, and many just wouldn't fly if they didn't know how seriously safety is taken. A medical error normally effects one person, and people have a tendency to trust, even deify, doctors.
Of course that is just a personal theory...
posted by Chuckles at 9:44 PM on December 18, 2005
So to a first approximation, the reason that insurance rates are up hugely since 2001 is that the stock market is bad. Nothing more, nothing less.
Going slightly deeper, the US medical insurance system spends about 1/3 of every dollar it receives trying to deny care to people. That's really the main medical insurance line of business - finding healthy people to insure and finding sick people to cut off insuring.
Good points and I think they are legitimate. I probably should not have posted a think tank link, however, my point was that without me actually being able to read the Harvard data the study is inconclusive and I can not make any objective decision toward it.
posted by j-urb at 9:46 PM on December 18, 2005
Going slightly deeper, the US medical insurance system spends about 1/3 of every dollar it receives trying to deny care to people. That's really the main medical insurance line of business - finding healthy people to insure and finding sick people to cut off insuring.
Good points and I think they are legitimate. I probably should not have posted a think tank link, however, my point was that without me actually being able to read the Harvard data the study is inconclusive and I can not make any objective decision toward it.
posted by j-urb at 9:46 PM on December 18, 2005
Q: What do they call the person that graduates last in their class at med-school?
A: Someone who's still more intelligent and hardworking than 99% of the general population that could never even dream of making it that far.
posted by drpynchon at 9:48 PM on December 18, 2005
A: Someone who's still more intelligent and hardworking than 99% of the general population that could never even dream of making it that far.
posted by drpynchon at 9:48 PM on December 18, 2005
Jellicle,
Unless you are a doctor, and apparently one with a pretty low opinion of yourself, you're talking out your ass anytime you claim to know what the life and practice of a physician is like.
Stick to making points that don't have the validity of three-dollar Gucci wallets.
posted by docpops at 9:49 PM on December 18, 2005
Unless you are a doctor, and apparently one with a pretty low opinion of yourself, you're talking out your ass anytime you claim to know what the life and practice of a physician is like.
Stick to making points that don't have the validity of three-dollar Gucci wallets.
posted by docpops at 9:49 PM on December 18, 2005
hmm, Cato, Cato, where have I heard that thinktank in the news lately...
If you're linking to cato.org about some factual matter, you've already lost
You can either debunk or go all Ad Hominem. Laziness is your prerogative.
posted by Kwantsar at 9:49 PM on December 18, 2005
If you're linking to cato.org about some factual matter, you've already lost
You can either debunk or go all Ad Hominem. Laziness is your prerogative.
posted by Kwantsar at 9:49 PM on December 18, 2005
So a human being is as simple of a mechanism as a bridge or an airplane? Is that also a part of your personal theory?
Do you also mean to say that there is no difference between making a choice between flying or taking a train and between having a broken bone set, or a tumor taken out, and not doing it?
posted by c13 at 9:54 PM on December 18, 2005
Do you also mean to say that there is no difference between making a choice between flying or taking a train and between having a broken bone set, or a tumor taken out, and not doing it?
posted by c13 at 9:54 PM on December 18, 2005
Kwantsar: from the cato report you link to
The Congressional Budget Office shot holes in that statistic last May when it reported the correct figure is between 21 million and 31 million.
I guess 21-31 million people without any type of insurance is just fine and dandy with you.
posted by Freen at 9:59 PM on December 18, 2005
The Congressional Budget Office shot holes in that statistic last May when it reported the correct figure is between 21 million and 31 million.
I guess 21-31 million people without any type of insurance is just fine and dandy with you.
posted by Freen at 9:59 PM on December 18, 2005
Is there are reason you need to be in attack mode c13?
Indeed, biological systems are more complex than human designed systems. That should probably teach us to tread more lightly in those areas...
Or do you prefer attack mode? Then tell me again why 80 hour work weeks are acceptable for resident's when 60 hours is considered the limit for truck drivers?
posted by Chuckles at 10:02 PM on December 18, 2005
Indeed, biological systems are more complex than human designed systems. That should probably teach us to tread more lightly in those areas...
Or do you prefer attack mode? Then tell me again why 80 hour work weeks are acceptable for resident's when 60 hours is considered the limit for truck drivers?
posted by Chuckles at 10:02 PM on December 18, 2005
Do you also mean to say that there is no difference between making a choice between flying or taking a train and between having a broken bone set, or a tumor taken out, and not doing it?
For some procedures, there is an actual choice between, say, surgery and extra drugs or the use of one procedure versus another.... or attempting a risky surgery versus not doing anything at all. Choices and opportunity costs exist in medicine as well as transportation.
posted by deanc at 10:02 PM on December 18, 2005
For some procedures, there is an actual choice between, say, surgery and extra drugs or the use of one procedure versus another.... or attempting a risky surgery versus not doing anything at all. Choices and opportunity costs exist in medicine as well as transportation.
posted by deanc at 10:02 PM on December 18, 2005
being in a professional field (computer science) I've noticed that most of the people in comp sci are actually idiots. I assume the same is true of doctors and lawyers and so on, and it's rather frightening.
posted by delmoi at 10:05 PM on December 18, 2005
posted by delmoi at 10:05 PM on December 18, 2005
Chuckles, I'm not saying you have to be a doctor at all. I'd just like something more than a purely legal "blame/negligence/pain and suffering, etc." way of looking at it. Anyone who wants to apply real scientific rationales and robust critical thought is welcome. Its just that anyone who says -- too much malpractice is the problem is lost from the beginning.
I'm too lazy to post the links here -- but do a search for civilian aviation and medical errors and, yes, the health care industry is taking a huge cue from that area. It's slow in coming, and you're spot on about the differences, but in terms of simple things like repeating back an order: a la: Doctor: "I need 0.5 mg of ceftriaxone" Nurse: "Ok, you asked for 0.5 mg of ceftriaxone" instead of "Ok" -- it's already happening at my hospital. The differences have also been discussed -- and, please, I hate to get back to hit but the human body is a lot harder to understand than an airplane.
Dean -- I went to the newyorker.com and it was not being released to the public. So, I got it from another source for which the link (I thought) was not publically available. At least I italicized it -- so sue me. Ok, bad joke right here. :)
posted by narebuc at 10:06 PM on December 18, 2005
I'm too lazy to post the links here -- but do a search for civilian aviation and medical errors and, yes, the health care industry is taking a huge cue from that area. It's slow in coming, and you're spot on about the differences, but in terms of simple things like repeating back an order: a la: Doctor: "I need 0.5 mg of ceftriaxone" Nurse: "Ok, you asked for 0.5 mg of ceftriaxone" instead of "Ok" -- it's already happening at my hospital. The differences have also been discussed -- and, please, I hate to get back to hit but the human body is a lot harder to understand than an airplane.
Dean -- I went to the newyorker.com and it was not being released to the public. So, I got it from another source for which the link (I thought) was not publically available. At least I italicized it -- so sue me. Ok, bad joke right here. :)
posted by narebuc at 10:06 PM on December 18, 2005
Anyway, the real problem with medical costs is that the baby boomers are getting old, and old people incur a lot of medical costs.
Solution: Kill all the boomers. They're so annoyingly self-centered anyway, so no big loss.
posted by delmoi at 10:08 PM on December 18, 2005
Solution: Kill all the boomers. They're so annoyingly self-centered anyway, so no big loss.
posted by delmoi at 10:08 PM on December 18, 2005
c13 your analogy is false sir. He was refering to the technicians perspective. Not the perspective of a passanger or something that is being manipulated. Of course this is a difference betweeen choosing what vehicle you going to a passenger in and wheter or not the ohave surgery on you body. I will not deny that both relate to earthy conveyance. The rhetoric however is still deceptive.
posted by Rubbstone at 10:09 PM on December 18, 2005
posted by Rubbstone at 10:09 PM on December 18, 2005
Remember: half of all surgeons are below average.
Actually, it could be a lot more then that. If only half of all people can be surgeons, then the number of below-median doctors would be closer to 7/8th then 1/2...
posted by delmoi at 10:14 PM on December 18, 2005
Actually, it could be a lot more then that. If only half of all people can be surgeons, then the number of below-median doctors would be closer to 7/8th then 1/2...
posted by delmoi at 10:14 PM on December 18, 2005
Ergh. Malpractice is horrifying in that if something goes wrong during a medical procedure, there are many, many reasons why that may have happened- physician's error, pre-existing conditions, pure bad luck. My father's a physician, and told me once that, as a doctor, you really just have to make the best decision you can, the absolute safest bet, and then stick by it, because if something goes wrong and you weren't 100% sure about that something, it's going to dig at you forever, even if you weren't at fault. And patients need to realize this- when the doctor tell you possible side effects of a procedure, and they mention death, it might be just to cover their ass, or it might not. For almost all serious medical procedures, there is a chance that you might die, and you need to be fully aware of that.
On another note, the most obvious case of malpractice my father ever saw was...well...if you're having a procedure done, and the doctor accidentally cuts another organ, they will often quickly cauterize it. The largest exception to this rule is if the physician accidentally ruptures an un-prepped colon, because an un-prepped colon is filled with combustible gases, and when you cauterize that... My dad knew of two times that this had happened locally in the last 25 years, and both times the patients died on the table because they suddenly found themselves with large, smoking holes where their lower GI tract should have been. Remember, kids, virtually all operating room fires ignite on or in the patient!
posted by 235w103 at 10:34 PM on December 18, 2005
On another note, the most obvious case of malpractice my father ever saw was...well...if you're having a procedure done, and the doctor accidentally cuts another organ, they will often quickly cauterize it. The largest exception to this rule is if the physician accidentally ruptures an un-prepped colon, because an un-prepped colon is filled with combustible gases, and when you cauterize that... My dad knew of two times that this had happened locally in the last 25 years, and both times the patients died on the table because they suddenly found themselves with large, smoking holes where their lower GI tract should have been. Remember, kids, virtually all operating room fires ignite on or in the patient!
posted by 235w103 at 10:34 PM on December 18, 2005
Deanc, there is a difference between your argument and mine. I say that, if you don't trust one mode of transportation, use a different one. You're, on the other hand, talking about surgery vs drugs. But both the surgery and the durgs require you to go see a doctor. If you'd rather go see you local yoga master when you have an acute appendicitis, then you're really talking about choices.
Rubbstone, allow me to clarify: we (as in humans) know exactly how an airplane operates, we know everything about all of it's parts -- their functions, dimensions, materials they are made out of, etc. We can predict exactly what will happen in response to a certain input. Therefore we know exactly what we should and should not be doing when operating an airplane.
But we don't know much at all about how a human body operates or how it will respond to a particular treatment. That's why the error rate is higher.
Remember, we still have a 100% mortality rate.
And finally, Chuckles, it bothers me when people criticize things they don't know a low about. And especially when they try to offer suggestions. It is not specific to the topic at hand. I would be just as irratated if docpops, for example, posted about how a steel industry is full of incomeptent hacks and if only they did things the way they do it in the cheese industry, things would be so much better.
posted by c13 at 10:35 PM on December 18, 2005
Rubbstone, allow me to clarify: we (as in humans) know exactly how an airplane operates, we know everything about all of it's parts -- their functions, dimensions, materials they are made out of, etc. We can predict exactly what will happen in response to a certain input. Therefore we know exactly what we should and should not be doing when operating an airplane.
But we don't know much at all about how a human body operates or how it will respond to a particular treatment. That's why the error rate is higher.
Remember, we still have a 100% mortality rate.
And finally, Chuckles, it bothers me when people criticize things they don't know a low about. And especially when they try to offer suggestions. It is not specific to the topic at hand. I would be just as irratated if docpops, for example, posted about how a steel industry is full of incomeptent hacks and if only they did things the way they do it in the cheese industry, things would be so much better.
posted by c13 at 10:35 PM on December 18, 2005
You can either debunk or go all Ad Hominem. Laziness is your prerogative.
bringing the ideologues of Cato in this is just retarded. Sorry. Cato, like Heritage, AEI, and Manhattan, are in fact paid liars when it comes to anything smacking of socialism, so bringing them & their op-eds up is just a side-track.
In two seconds of googling I see a recent Kaiser org study showing 30-40M under-65 uninsured, with pretty charts and shit.
There is also a CDC study with similar numbers. Calling the 45M number 'a lie' is adding more heat than light to the issue.
posted by Heywood Mogroot at 10:38 PM on December 18, 2005
bringing the ideologues of Cato in this is just retarded. Sorry. Cato, like Heritage, AEI, and Manhattan, are in fact paid liars when it comes to anything smacking of socialism, so bringing them & their op-eds up is just a side-track.
In two seconds of googling I see a recent Kaiser org study showing 30-40M under-65 uninsured, with pretty charts and shit.
There is also a CDC study with similar numbers. Calling the 45M number 'a lie' is adding more heat than light to the issue.
posted by Heywood Mogroot at 10:38 PM on December 18, 2005
hmm, Cato, Cato, where have I heard that thinktank in the news lately...
I have a soft spot for Cato, FWIW, They oppose the war on drugs and oppsed the Iraq war(!).
posted by delmoi at 10:38 PM on December 18, 2005
I have a soft spot for Cato, FWIW, They oppose the war on drugs and oppsed the Iraq war(!).
posted by delmoi at 10:38 PM on December 18, 2005
c13: That's why the error rate is higher.
I never intended to compare the raw error rates, not even the magnitude of the incremental improvements, only the direction of the change in error rate over time.
posted by Chuckles at 10:50 PM on December 18, 2005
I never intended to compare the raw error rates, not even the magnitude of the incremental improvements, only the direction of the change in error rate over time.
posted by Chuckles at 10:50 PM on December 18, 2005
A: Someone who's still more intelligent and hardworking than 99% of the general population that could never even dream of making it that far.
Well, if you multiply Intelegence and hardworking ness maybe, the problem with working hard is that even a complete idiot can work hard. It tells you nothing about a person's competence.
I don't want a "hard working" doctor. I want one who can take one look at me and know exactly what's wrong and how to fix it.
posted by delmoi at 10:55 PM on December 18, 2005
Well, if you multiply Intelegence and hardworking ness maybe, the problem with working hard is that even a complete idiot can work hard. It tells you nothing about a person's competence.
I don't want a "hard working" doctor. I want one who can take one look at me and know exactly what's wrong and how to fix it.
posted by delmoi at 10:55 PM on December 18, 2005
There is also a CDC study with similar numbers. Calling the 45M number 'a lie' is adding more heat than light to the issue.
Er, isn't heat what you want?
posted by delmoi at 10:57 PM on December 18, 2005
Er, isn't heat what you want?
posted by delmoi at 10:57 PM on December 18, 2005
Bringing the nanny-statists of the Kaiser Family Foundation into this is just retarded. Sorry, Kaiser, like Rockefeller, Pew, and Johnson are in fact tax-exempt ideologues when it comes to anything smacking of personal responsibility or free markets, so bringing them & their studies up is just a side-track.
posted by Kwantsar at 10:58 PM on December 18, 2005
posted by Kwantsar at 10:58 PM on December 18, 2005
so bringing them & their studies up is just a side-track.
Follow the money, buddy.
posted by Heywood Mogroot at 11:01 PM on December 18, 2005
Follow the money, buddy.
posted by Heywood Mogroot at 11:01 PM on December 18, 2005
"You can either debunk or go all Ad Hominem. Laziness is your prerogative."
"And a little Non Sequitur."
Or you can italicize and capitalize all your Latin phrases, as if to say, "Gentlemen, gentlemen, please: I'd just like you all to note that I've invoked Latin. A learnéd man am I. As you were."
You have probably never won an argument. As you were.
posted by electric_counterpoint at 11:10 PM on December 18, 2005
"And a little Non Sequitur."
Or you can italicize and capitalize all your Latin phrases, as if to say, "Gentlemen, gentlemen, please: I'd just like you all to note that I've invoked Latin. A learnéd man am I. As you were."
You have probably never won an argument. As you were.
posted by electric_counterpoint at 11:10 PM on December 18, 2005
Oh, and Kwantstar, while I've got you here:
You can either debunk, or ... ah, you know.
posted by electric_counterpoint at 11:12 PM on December 18, 2005
You can either debunk, or ... ah, you know.
posted by electric_counterpoint at 11:12 PM on December 18, 2005
Er, isn't heat what you want?
No, getting into a pissing match as to exactly how many millions of Americans cannot gain affordable health insurance is rather besides the point. No sane person given a choice, under Rawl's "veil of ignorance" as to original position, would choose the present US model over any other G7 democracy's.
But this is a malpractice thread so I'll leave all the argumentum from me there.
posted by Heywood Mogroot at 11:15 PM on December 18, 2005
No, getting into a pissing match as to exactly how many millions of Americans cannot gain affordable health insurance is rather besides the point. No sane person given a choice, under Rawl's "veil of ignorance" as to original position, would choose the present US model over any other G7 democracy's.
But this is a malpractice thread so I'll leave all the argumentum from me there.
posted by Heywood Mogroot at 11:15 PM on December 18, 2005
I never intended to compare the raw error rates, not even the magnitude of the incremental improvements, only the direction of the change in error rate over time.
Then compare the patient conditions and the outcome of medical procedures done in Civil War (or early 1900's, or 1950's) hospitals with the modern ones. I think you will be satisfied with the direction.
posted by c13 at 11:17 PM on December 18, 2005
Then compare the patient conditions and the outcome of medical procedures done in Civil War (or early 1900's, or 1950's) hospitals with the modern ones. I think you will be satisfied with the direction.
posted by c13 at 11:17 PM on December 18, 2005
And counterpoint, it was pretty obvious that I was throwing Mogroot's rhetoric back at him. Nice latin troll, too. GFY.
posted by Kwantsar at 11:23 PM on December 18, 2005
posted by Kwantsar at 11:23 PM on December 18, 2005
PS, Heywood, You're doing it again. Not even Kaiser claims that all the people in its study couldn't afford health insurance. In fact, over 1/3 of those cited were over 200% of the federal poverty line.
In 2003, I was one of those uninsured, and it was voluntary.
posted by Kwantsar at 11:26 PM on December 18, 2005
In 2003, I was one of those uninsured, and it was voluntary.
posted by Kwantsar at 11:26 PM on December 18, 2005
I was one of those uninsured, and it was voluntary.
Because you felt not paying the premium was worth the risk.
The Canadian system is eminently affordable in such situations, as was the Japanese 80-20 system when I lived there. People, regardless of ability to pay, get first-class, well, not the shitty treatment the uninsured get here.
Like I said, getting into a pissing match as to the exact number of millions of people not served by this lurching market failure we call a health insurance segment is besides the point, and is horribly off-topic besides:
the original point you called a lie:
If you're one of those 45 million uninsured, you care is much, much less than that you would receive in one of those "socialized medicine" countries
is still true regardless whether going naked was a lifestyle choice or not.
posted by Heywood Mogroot at 11:38 PM on December 18, 2005
Because you felt not paying the premium was worth the risk.
The Canadian system is eminently affordable in such situations, as was the Japanese 80-20 system when I lived there. People, regardless of ability to pay, get first-class, well, not the shitty treatment the uninsured get here.
Like I said, getting into a pissing match as to the exact number of millions of people not served by this lurching market failure we call a health insurance segment is besides the point, and is horribly off-topic besides:
the original point you called a lie:
If you're one of those 45 million uninsured, you care is much, much less than that you would receive in one of those "socialized medicine" countries
is still true regardless whether going naked was a lifestyle choice or not.
posted by Heywood Mogroot at 11:38 PM on December 18, 2005
...unless one is independently wealthy, then of course standards of care are the best here. Hence Heritage, AEI, Manhattan, and Cato barking their masters' tunes wrt single payer.
posted by Heywood Mogroot at 11:40 PM on December 18, 2005
posted by Heywood Mogroot at 11:40 PM on December 18, 2005
Kwantsar, if your going to go all high and mighty with your Latin terms ...
How's about you justify the bullshit rhetorical grenade you threw, eh? So, a disagreement about a hard to pin down number is "a lie." And conveniently, you choose the number you don't like as the "lie."
Census Bureau vs. Cato, hmm...
I know the Census Bureau hires statisticians and such, and comes up with such numbers for a living. I know that Cato makes a living making the data fit a particular world view. Gee, should I debunk Cato? Or should I pick the lint from my belly button?
Maybe you could refrain from lecturing people about ad hominem when you pull transparent bullshit like that?
If you were actually interested in reasoned debate, you wouldn't have called the number a lie -- because it isn't, and you know it. And of course, even if the number is only 20 million, you still made an outstanding addition to the discussion by calling the other number a lie, right?
So you don't even know me, you call me a repeater of lies with zero justification, and you lecture people about ad hominem? What's the Latin term for that? Trollus Assholus?
posted by teece at 11:47 PM on December 18, 2005
How's about you justify the bullshit rhetorical grenade you threw, eh? So, a disagreement about a hard to pin down number is "a lie." And conveniently, you choose the number you don't like as the "lie."
Census Bureau vs. Cato, hmm...
I know the Census Bureau hires statisticians and such, and comes up with such numbers for a living. I know that Cato makes a living making the data fit a particular world view. Gee, should I debunk Cato? Or should I pick the lint from my belly button?
Maybe you could refrain from lecturing people about ad hominem when you pull transparent bullshit like that?
If you were actually interested in reasoned debate, you wouldn't have called the number a lie -- because it isn't, and you know it. And of course, even if the number is only 20 million, you still made an outstanding addition to the discussion by calling the other number a lie, right?
So you don't even know me, you call me a repeater of lies with zero justification, and you lecture people about ad hominem? What's the Latin term for that? Trollus Assholus?
posted by teece at 11:47 PM on December 18, 2005
Well, if you multiply Intelegence and hardworking ness maybe, the problem with working hard is that even a complete idiot can work hard. It tells you nothing about a person's competence.
I don't want a "hard working" doctor. I want one who can take one look at me and know exactly what's wrong and how to fix it.
Rare are the disease processes that can be diagnosed by taking one look at a patient, and far more complex are the decisions about how to intervene in most cases than you suspect them to be.
You assume that doctors can just get by on hard work and seem to think that medicine is like other 'professional' fields when that simply isn't the case. I know it's easy for me to say, but until you've studied for and passed the countless exams required, from the MCAT to the USMLE to the frequent recertifications, you can't really appreciate the massive fund of knowledge required to even get a medical license (let alone be a 'good' doctor). What's more, in medicine far more so than any other business, you need to retrieve that information from memory spontaneously and under difficult circumstances. Perhaps the obvious is overlooked -- place yourself in the position of being responsible for someone who may be dying in front of you, sometimes rapidly, and having to make split-second decisions which in restrospect are dependent on libraries full of literature. Next time you think that guy in the ER is just some hardworking dumbass, try putting yourself in his shoes. Also consider the risks he is taking and the difficult decisions he is making countless times on a daily basis.
That said, to get back on topic, the reality is that even the very best physician is human and has to make a ton of judgment calls which can often have grave consequences. In light of that, medical errors (however you wish to define them) are a statistical certainty over any doctor's career. I submit that the physician who is a repeat offender or who demonstrates a dubious track record is certainly a problem, but in general, such physicians are exceptions to the rule. So while malpractice serves some theoretical purpose, the real solution is developing flexible systems with appropriate failsafes in healthcare. As countless studies have shown there is absolutely no correlation between the merits and the outcomes of malpractice cases in the United States, which if you ask me, is enough to indict that whole process as it stands.
posted by drpynchon at 11:48 PM on December 18, 2005
I don't want a "hard working" doctor. I want one who can take one look at me and know exactly what's wrong and how to fix it.
Rare are the disease processes that can be diagnosed by taking one look at a patient, and far more complex are the decisions about how to intervene in most cases than you suspect them to be.
You assume that doctors can just get by on hard work and seem to think that medicine is like other 'professional' fields when that simply isn't the case. I know it's easy for me to say, but until you've studied for and passed the countless exams required, from the MCAT to the USMLE to the frequent recertifications, you can't really appreciate the massive fund of knowledge required to even get a medical license (let alone be a 'good' doctor). What's more, in medicine far more so than any other business, you need to retrieve that information from memory spontaneously and under difficult circumstances. Perhaps the obvious is overlooked -- place yourself in the position of being responsible for someone who may be dying in front of you, sometimes rapidly, and having to make split-second decisions which in restrospect are dependent on libraries full of literature. Next time you think that guy in the ER is just some hardworking dumbass, try putting yourself in his shoes. Also consider the risks he is taking and the difficult decisions he is making countless times on a daily basis.
That said, to get back on topic, the reality is that even the very best physician is human and has to make a ton of judgment calls which can often have grave consequences. In light of that, medical errors (however you wish to define them) are a statistical certainty over any doctor's career. I submit that the physician who is a repeat offender or who demonstrates a dubious track record is certainly a problem, but in general, such physicians are exceptions to the rule. So while malpractice serves some theoretical purpose, the real solution is developing flexible systems with appropriate failsafes in healthcare. As countless studies have shown there is absolutely no correlation between the merits and the outcomes of malpractice cases in the United States, which if you ask me, is enough to indict that whole process as it stands.
posted by drpynchon at 11:48 PM on December 18, 2005
^^
posted by Heywood Mogroot at 12:05 AM on December 19, 2005
posted by Heywood Mogroot at 12:05 AM on December 19, 2005
Lots of emotion here.
I'm either going to be ignored or flamed, but has anyone done an analysis on the relative pay for physicians compared to the general population/skilled workers and the rate of malpractice (or just plain "whoopsies?").
eg - physicians in the United States tend to draw a far higher salary (gross/net) compared to physicians in the UK/Canada.
Is there an increased percentage of people who are willing to slug it through med school & internship just to make bigger bucks as a doctor (as opposed to being an impecunious scientist) whereas, in other countries physicians are paid well, but not so loftily compared to the rest of the population as is the case in the United States?
In other words, is the (perceived?) disparately high income of medical doctors causing the "wrong" type of people to pursue careers as physicians? anecdotally, from medical doctors, for sure - but these are just "bad apples," I guess
posted by PurplePorpoise at 12:12 AM on December 19, 2005
I'm either going to be ignored or flamed, but has anyone done an analysis on the relative pay for physicians compared to the general population/skilled workers and the rate of malpractice (or just plain "whoopsies?").
eg - physicians in the United States tend to draw a far higher salary (gross/net) compared to physicians in the UK/Canada.
Is there an increased percentage of people who are willing to slug it through med school & internship just to make bigger bucks as a doctor (as opposed to being an impecunious scientist) whereas, in other countries physicians are paid well, but not so loftily compared to the rest of the population as is the case in the United States?
In other words, is the (perceived?) disparately high income of medical doctors causing the "wrong" type of people to pursue careers as physicians? anecdotally, from medical doctors, for sure - but these are just "bad apples," I guess
posted by PurplePorpoise at 12:12 AM on December 19, 2005
So the fact that doctors kill more people than cars, jobs, and terrorism combined is swept under the rug as a footnote to a summary study that is not widely circulated.
We all like to think that the fundamentals of healthcare are so much different than in previous centuries. The medical industry is just more efficient in leveraging its successes to engineer the mass-scale perception that the medical industry is nearly all-knowing and benevolent. We have forgotten what once was common knowledge:
"I often say a great doctor kills more people than a great general."
--G.W. Leibniz
posted by archae at 12:13 AM on December 19, 2005
We all like to think that the fundamentals of healthcare are so much different than in previous centuries. The medical industry is just more efficient in leveraging its successes to engineer the mass-scale perception that the medical industry is nearly all-knowing and benevolent. We have forgotten what once was common knowledge:
"I often say a great doctor kills more people than a great general."
--G.W. Leibniz
posted by archae at 12:13 AM on December 19, 2005
We all like to think that the fundamentals of healthcare are so much different than in previous centuries. The medical industry is just more efficient in leveraging its successes to engineer the mass-scale perception that the medical industry is nearly all-knowing and benevolent.
"I often say a great doctor kills more people than a great general."
--G.W. Leibniz
Tell that to a child whose mother's cancer is in complete remission or someone who is ten years into a heart transplant, or for that matter, anyone who has survived an appendicitis, etc.
Of course, Leibniz was an incredibly brilliant fellow, but he didn't have such people around at the time. You do, but then, you seem to lack his observation skills.
posted by drpynchon at 12:37 AM on December 19, 2005
"I often say a great doctor kills more people than a great general."
--G.W. Leibniz
Tell that to a child whose mother's cancer is in complete remission or someone who is ten years into a heart transplant, or for that matter, anyone who has survived an appendicitis, etc.
Of course, Leibniz was an incredibly brilliant fellow, but he didn't have such people around at the time. You do, but then, you seem to lack his observation skills.
posted by drpynchon at 12:37 AM on December 19, 2005
Oh, right, because everywhere else in the world doctors are selfless, virtuous, and motivated by altruism.
Hey docpops. I understand you can make extra money and gifts by setting up your own webcam.
posted by PeterMcDermott at 12:44 AM on December 19, 2005
Hey docpops. I understand you can make extra money and gifts by setting up your own webcam.
posted by PeterMcDermott at 12:44 AM on December 19, 2005
My dad knew of two times that this had happened locally in the last 25 years, and both times the patients died on the table because they suddenly found themselves with large, smoking holes where their lower GI tract should have been.
My wife trained as a nurse and there were a couple of incidents that made her leave the profession. One of them was just such an incident. Unfortunately though, when the patient's stomach burst into flames, the doctor reached for one of those kidney bowls full of water to douse the flames.
Unfortunately, it wasn't water, it was alcohol.
The other incident was when she worked on men's surgical. The ward was the province of two doctors -- a senior registrar and a consultant. After the op, the senior registrar would stay behind to supervise sewing the patient up, whereas the consultant would just piss off and leave the job to his students. The registrar's patients would all heal nicely, whereas the consultant's patients would have to have progressively more of their limbs removed as gangrene or infections continued to spread. (This was in the 70's, before doctors published league tables, etc.)
All of the nursing staff and the junior doctors were concerned about the state of affairs, but in those days, consultants were equivalent to God, and consultant surgeons more so, so nobody ever raised the issue.
All that said though, she later trained as a lawyer, but refuses to take on medical negligence cases as she believes that far too much of what passes for negligence is nothing of the sort -- simply the outcome of an inexact science that doesn't always have the desired outcome, and so she wasn't prepared to subject people's lives and professional reputations to that kind of scrutiny when the bulk of them will inevitably be doing their absolute best.
posted by PeterMcDermott at 1:16 AM on December 19, 2005
My wife trained as a nurse and there were a couple of incidents that made her leave the profession. One of them was just such an incident. Unfortunately though, when the patient's stomach burst into flames, the doctor reached for one of those kidney bowls full of water to douse the flames.
Unfortunately, it wasn't water, it was alcohol.
The other incident was when she worked on men's surgical. The ward was the province of two doctors -- a senior registrar and a consultant. After the op, the senior registrar would stay behind to supervise sewing the patient up, whereas the consultant would just piss off and leave the job to his students. The registrar's patients would all heal nicely, whereas the consultant's patients would have to have progressively more of their limbs removed as gangrene or infections continued to spread. (This was in the 70's, before doctors published league tables, etc.)
All of the nursing staff and the junior doctors were concerned about the state of affairs, but in those days, consultants were equivalent to God, and consultant surgeons more so, so nobody ever raised the issue.
All that said though, she later trained as a lawyer, but refuses to take on medical negligence cases as she believes that far too much of what passes for negligence is nothing of the sort -- simply the outcome of an inexact science that doesn't always have the desired outcome, and so she wasn't prepared to subject people's lives and professional reputations to that kind of scrutiny when the bulk of them will inevitably be doing their absolute best.
posted by PeterMcDermott at 1:16 AM on December 19, 2005
Ahhh the CATO instititue have some good spinners
Originally, "40-something-million-uninsured" meant the persistently uninsured, i.e., those who lacked health insurance for the entire year. The Congressional Budget Office shot holes in that statistic last May when it reported the correct figure is between 21 million and 31 million.
Ahh the goddamn CBO ! Let's concentrate on the fact that the CBO..ihihihi ..made a 10 million error. They must be nuts, these republican librulz ! Ok ok it's ONLY 30 million..relax ! That's just 1 out of 10 in U.S. population, it's not like there's still
an huge problem. Nothing to see, move on.
he CBO's figures may still be too high because they count millions of Americans who are Medicaid-eligible, and therefore have coverage whenever they need it
Equating being elegible with having the service ! Last time I checked being elegible doesn't necessarily imply one actually obtains the service, so adding them to those who are NOT covered isn't a bad idea...I'd like to see statistic on how many potentially elegible you-win-your-health actually win.
The only possible way to explain this is that they take refuge in the CBO's finding that the original, faulty government statistic does happen to be roughly equivalent to the number of Americans who lack insurance at any specific point in time, rather than for the entire year.
And that's not important no no no...let's spin it like its the CBO taking all the advantage..there's nooo problem in having 40
million people at risk of not receiving medical care at any moment in time in the world richest country...oh sorry, in the country
in the world that harbors the few richest.
Whether it is administered by government or the private sector, compulsory health coverage means government-run health care.
Oh welfare for private sectors ? How surprising..for some reasons they are not able to compete ? Oh poor ones, it must be anything except incompetence, greed and risk offloading.
It's clear that Cover the Uninsured Week will drag on until all health care costs are socialized and individual responsibility is nil
Well if true they have learned from private companies quick to socialize all the costs and privatize all the profits. But hey let's spin it another way...if I get good healthcare, splitting the costs among many is a nice idea and probably a good thing..of course if you ask me to pay a part of your car and your dvd player I'm going to say FUCK NO but I'm a tradionalist with strict priorities like health, house, food and education. Go figure why.
A better goal would be to restore to America's largely socialized health care system the market processes where producers compete to provide consumers with value, and consumers keep costs down by patronizing efficient producers and avoiding inefficient producers.
Hot air, hot air , hot air. If the producers were already so much more competitive why don't they just offer ? People will flock..or maybe not enough people could afford that because the price would be too high for many so the market isn't really that interesting ?
Probably it's only an attempt at grabbing an already existing market, inserting a lot better marketing and spin so that the sensation of a better service is offered. Obscure everything behind private sectors secrets et voilà, profit.
posted by elpapacito at 1:53 AM on December 19, 2005
Originally, "40-something-million-uninsured" meant the persistently uninsured, i.e., those who lacked health insurance for the entire year. The Congressional Budget Office shot holes in that statistic last May when it reported the correct figure is between 21 million and 31 million.
Ahh the goddamn CBO ! Let's concentrate on the fact that the CBO..ihihihi ..made a 10 million error. They must be nuts, these republican librulz ! Ok ok it's ONLY 30 million..relax ! That's just 1 out of 10 in U.S. population, it's not like there's still
an huge problem. Nothing to see, move on.
he CBO's figures may still be too high because they count millions of Americans who are Medicaid-eligible, and therefore have coverage whenever they need it
Equating being elegible with having the service ! Last time I checked being elegible doesn't necessarily imply one actually obtains the service, so adding them to those who are NOT covered isn't a bad idea...I'd like to see statistic on how many potentially elegible you-win-your-health actually win.
The only possible way to explain this is that they take refuge in the CBO's finding that the original, faulty government statistic does happen to be roughly equivalent to the number of Americans who lack insurance at any specific point in time, rather than for the entire year.
And that's not important no no no...let's spin it like its the CBO taking all the advantage..there's nooo problem in having 40
million people at risk of not receiving medical care at any moment in time in the world richest country...oh sorry, in the country
in the world that harbors the few richest.
Whether it is administered by government or the private sector, compulsory health coverage means government-run health care.
Oh welfare for private sectors ? How surprising..for some reasons they are not able to compete ? Oh poor ones, it must be anything except incompetence, greed and risk offloading.
It's clear that Cover the Uninsured Week will drag on until all health care costs are socialized and individual responsibility is nil
Well if true they have learned from private companies quick to socialize all the costs and privatize all the profits. But hey let's spin it another way...if I get good healthcare, splitting the costs among many is a nice idea and probably a good thing..of course if you ask me to pay a part of your car and your dvd player I'm going to say FUCK NO but I'm a tradionalist with strict priorities like health, house, food and education. Go figure why.
A better goal would be to restore to America's largely socialized health care system the market processes where producers compete to provide consumers with value, and consumers keep costs down by patronizing efficient producers and avoiding inefficient producers.
Hot air, hot air , hot air. If the producers were already so much more competitive why don't they just offer ? People will flock..or maybe not enough people could afford that because the price would be too high for many so the market isn't really that interesting ?
Probably it's only an attempt at grabbing an already existing market, inserting a lot better marketing and spin so that the sensation of a better service is offered. Obscure everything behind private sectors secrets et voilà, profit.
posted by elpapacito at 1:53 AM on December 19, 2005
So the fact that doctors kill more people than cars, jobs, and terrorism combined is swept under the rug as a footnote to a summary study that is not widely circulated.
"I often say a great doctor kills more people than a great general."
--G.W. Leibniz
Do you care to back up your numbers with some statistics? Or provide a link to this study?
As far as Leibniz goes, they haven't even invented an internal combustion engine back then.
Dumbass...
posted by c13 at 3:13 AM on December 19, 2005
"I often say a great doctor kills more people than a great general."
--G.W. Leibniz
Do you care to back up your numbers with some statistics? Or provide a link to this study?
As far as Leibniz goes, they haven't even invented an internal combustion engine back then.
Dumbass...
posted by c13 at 3:13 AM on December 19, 2005
Nice, elpapacito. I was going to make similar comments.
One thing I'll add is the problem I see with Cato's general approach to welfare, which is the same problem with most strong conservatives' views on the subject. (Disclaimer: I'm a moderate conservative with some libertarian and some liberal leanings).
Namely, they often invoke the free-market philosophy, suggesting that if the "invisible hand" were allowed to act unfettered, it would take care of everything. Competition would lead to efficiency and voila! A kinder, gentler society.
The problem with this view is that the invisible hand is also a discompassionate one. It doesn't care, really, if someone is stuck without access to health care. The invisible hand of free market economy only really cares if there is some profit-generating utility to insuring them. If there is not, then that person (or millions of persons) will fall through the cracks.
The idea that Cato would propose personal health savings accounts, as a solution to poor people not being able to afford insurance, is pretty laughable. If folks could afford to be saving sufficient money to create a meaningful nest egg for such an account, to weather significant illness, they could probably afford insurance to begin with.
If someone has significant health problems, they simply WILL NOT BE PROFITABLE to insure unless their insurance premiums are enormous. And if you're poor, that's impossible to support. So, you can get royally bitch-slapped by the invisible hand that Cato likes to kiss so often.
Don't get me wrong - I'm generally in favor of free market dynamics. But I think it's just common sense to realize that they have to be tempered to make sure that those regions of the economy (or society) that you want to preserve and protect are not neglected (or worse, exploited) by a dispassionate market dynamic. Hence, to "promote the general welfare" as stipulated in the preamble of our Constitution requires mandated some social programs which effect desired outcomes, so the are not simply left up to experiments in "the dismal science".
posted by darkstar at 3:55 AM on December 19, 2005
One thing I'll add is the problem I see with Cato's general approach to welfare, which is the same problem with most strong conservatives' views on the subject. (Disclaimer: I'm a moderate conservative with some libertarian and some liberal leanings).
Namely, they often invoke the free-market philosophy, suggesting that if the "invisible hand" were allowed to act unfettered, it would take care of everything. Competition would lead to efficiency and voila! A kinder, gentler society.
The problem with this view is that the invisible hand is also a discompassionate one. It doesn't care, really, if someone is stuck without access to health care. The invisible hand of free market economy only really cares if there is some profit-generating utility to insuring them. If there is not, then that person (or millions of persons) will fall through the cracks.
The idea that Cato would propose personal health savings accounts, as a solution to poor people not being able to afford insurance, is pretty laughable. If folks could afford to be saving sufficient money to create a meaningful nest egg for such an account, to weather significant illness, they could probably afford insurance to begin with.
If someone has significant health problems, they simply WILL NOT BE PROFITABLE to insure unless their insurance premiums are enormous. And if you're poor, that's impossible to support. So, you can get royally bitch-slapped by the invisible hand that Cato likes to kiss so often.
Don't get me wrong - I'm generally in favor of free market dynamics. But I think it's just common sense to realize that they have to be tempered to make sure that those regions of the economy (or society) that you want to preserve and protect are not neglected (or worse, exploited) by a dispassionate market dynamic. Hence, to "promote the general welfare" as stipulated in the preamble of our Constitution requires mandated some social programs which effect desired outcomes, so the are not simply left up to experiments in "the dismal science".
posted by darkstar at 3:55 AM on December 19, 2005
Purple – I’m not sure if anyone has performed such a rate of pay to errors – but again, let’s get away from that terminology. We’re all lost if we really talk about “malpractice” in the terms of negligence or “s/he really shoulda did that and since not, patient dead.” It’s rarely so clear. And, in the cases where it clear we either have criminal laws that are much better at righting that sort of wrong OR the no fault system would even be well equipped to get such doctors out of business – why? – because it would be a mixed panel of scientific/medical/laypeople who’d be deciding if the offense was worthy of losing one’s license.
That being said, I’d probably state the rate of errors is not all that pay dependent. I say that purely because the level of training is so long and comprehensive versus most other professions. Remember, you are not really allowed to make a complete decision by yourself until a minimum of seven years training. What other profession demands that? It’s not because doctors are better people or more altruistic. They might or might not be. It’s just that the system is actually set up so that you learn a lot over a long time and then you are actually responsible for knowing a lot about a certain field – especially if you specialize. Moreover, once out in practice, collaboration and consultation are encouraged to get the right diagnosis and result.
About the market arguments: Listen, it's all well and good to have the cheapest, fastest toaster -- something the market is great at encouraging. But, for health care, the market encourages both cheap and fast when such are the very things that are destructive to good health care.
The vaccine shortage from last year is a great example. Why was their a shortage? Well, according to Bush, litigation forced American vaccine makers out of business, so we had to rely on British supplies. There were errors in their producing it, so we had a shortage. YES, THE MARKET WAS WORKING! -- no inexpensive vaccines the market couldn't bear was produced. BUT, in health care, true market forces can't comprehend that perhaps it's ok to lose money on vaccines if that save you tons of $$$$ later by reduced hospital visits for pneumonia, meningitis, or even ER visits that didn't have to happen. Cato morons are never going to think like that because of their invisible hand worship. That sentence is really funny btw.
Archae – if you believe your posts about the futility of medicine in 2005, you are in idiot. I’m surprised you could find your keyboard to type that garbage.
posted by narebuc at 7:13 AM on December 19, 2005
That being said, I’d probably state the rate of errors is not all that pay dependent. I say that purely because the level of training is so long and comprehensive versus most other professions. Remember, you are not really allowed to make a complete decision by yourself until a minimum of seven years training. What other profession demands that? It’s not because doctors are better people or more altruistic. They might or might not be. It’s just that the system is actually set up so that you learn a lot over a long time and then you are actually responsible for knowing a lot about a certain field – especially if you specialize. Moreover, once out in practice, collaboration and consultation are encouraged to get the right diagnosis and result.
About the market arguments: Listen, it's all well and good to have the cheapest, fastest toaster -- something the market is great at encouraging. But, for health care, the market encourages both cheap and fast when such are the very things that are destructive to good health care.
The vaccine shortage from last year is a great example. Why was their a shortage? Well, according to Bush, litigation forced American vaccine makers out of business, so we had to rely on British supplies. There were errors in their producing it, so we had a shortage. YES, THE MARKET WAS WORKING! -- no inexpensive vaccines the market couldn't bear was produced. BUT, in health care, true market forces can't comprehend that perhaps it's ok to lose money on vaccines if that save you tons of $$$$ later by reduced hospital visits for pneumonia, meningitis, or even ER visits that didn't have to happen. Cato morons are never going to think like that because of their invisible hand worship. That sentence is really funny btw.
Archae – if you believe your posts about the futility of medicine in 2005, you are in idiot. I’m surprised you could find your keyboard to type that garbage.
posted by narebuc at 7:13 AM on December 19, 2005
I'm really surprised that no one has yet to touch on the real root of the higher premiums.
In the early 1990's insurance companies had vast reserves of capital (much like corporate pension programs) so they did what every big business does with such capital, they invested it. The stock markets soared, many got rich. Then, as we all know, the bubble burst. All that capital was gone.
As the companies that the capital was tied up in went bust, the lawsuits began. Expensive paper chase after wild goose chase to recover investment capital, all of which cost an arm and a leg to insurers (and pensions) but few saw and worthwhile returns.
The corporate boards meet and demand to know what happened to those fantastic figures of 1998? Why are we suddenly in the red? What are you, Mr. CFO, going to do about it?
The answer was simple for any MBA brainiac, raise premiums. Voila, so the rest of us have to pay for some moron's overzealous investment.
posted by Pollomacho at 7:33 AM on December 19, 2005
In the early 1990's insurance companies had vast reserves of capital (much like corporate pension programs) so they did what every big business does with such capital, they invested it. The stock markets soared, many got rich. Then, as we all know, the bubble burst. All that capital was gone.
As the companies that the capital was tied up in went bust, the lawsuits began. Expensive paper chase after wild goose chase to recover investment capital, all of which cost an arm and a leg to insurers (and pensions) but few saw and worthwhile returns.
The corporate boards meet and demand to know what happened to those fantastic figures of 1998? Why are we suddenly in the red? What are you, Mr. CFO, going to do about it?
The answer was simple for any MBA brainiac, raise premiums. Voila, so the rest of us have to pay for some moron's overzealous investment.
posted by Pollomacho at 7:33 AM on December 19, 2005
Those who would compare doctors to engineers can go read The Human Factor: Revolutionizing the Way People Live With Technology by Kim Vincente.
It has nothing to do with the complexity of systems and everything to do with the way errors and mistakes are handled. In many parts of the medical world, secrecy is still the order of the day. When a plane screws up (be it a mechanical failure or a human mistake) the whole thing is ripped apart and changes are made to help prevent the problem from happening again.
posted by GuyZero at 8:06 AM on December 19, 2005
It has nothing to do with the complexity of systems and everything to do with the way errors and mistakes are handled. In many parts of the medical world, secrecy is still the order of the day. When a plane screws up (be it a mechanical failure or a human mistake) the whole thing is ripped apart and changes are made to help prevent the problem from happening again.
posted by GuyZero at 8:06 AM on December 19, 2005
The most widescale problems in medicine are failures in diagnosis and failures in medication.
I foresee a technological leap in medical diagnosis in the future, in which, before the patient see the doctor, they routinely, at least annually, receive a "complex screening". Individually, it would be prohibitively expensive, so a system would have to be designed to process a huge number of people a day.
To start off with, their entire medical history is put into an electronic database, and vetted with both the patient and the doctor. This incorporates as much as possible, to include dental records, dietary supplements, alternative therapies, etc. Any current acute or chronic problems, no matter how minor, would be included. This is done at leisure prior to the screening.
Then the actual screening would begin. When they arrived at the screening facility, they would bring with them a stool sample. They would get a full-body CT and Xray, which would be computer analyzed looking for eccentricities, highlighted for a CT and Xray expert to examine. (Annual full-body CTs have already proven their value where used, saving enormous amounts of health care money by catching conditions early.)
At some point they would provide a DNA, PAP or semen, urine and saliva specimen, and enough blood for a complete work-up. By then, hopefully, their blood could be drawn by a machine instead of a person.
Other test would be done on site, including weight, hearing, ophthalmological, respiratory, and even a brief degree of motion, reflexes, and neurological profile.
Once this base line had been established for them, subsequent follow-up examinations would be considerably simplified. A full complex set would probably be only needed once a decade.
For the majority of people, this complex screening would clearly create an entire program of preventative health maintenance specific to them. Almost everybody would receive a report advising them about pre-existing conditions, from genetics, health risk "windows" they were in, diet they should maintain, behaviors they should avoid, and medical treatments they should consider.
Ironically, much of this is already done, but done in a haphazard, often redundant, often neglected manner, and the data from these tests are not consolidated or put in a form most useful to the physician. So yes, initially, the cost is quite large, but the long-term costs drop drastically.
*********
The next step is a far more advanced version of a system currently in use. Doctors can plug in symptoms into a computer, and a diagnosis is reached as to probable condition and treatment. This confirms a doctor's suspicions, or it suggests a condition overlooked by the doctor.
If used in tandem with the complex screening, this system would be far more accurate. Beyond a certain point, it would be *objectively* certain of a course of treatment; which might effectively immunize a doctor against malpractice.
***********
Lastly, doctors are *not* pharmacists. This should be known and remembered by all patients. Doctors are reliant solely on trial and error of drugs, based on patient feedback, and what the doctor might learn in a haphazard way.
Even critical, life saving drugs are not standardized in their use in emergency rooms in the US. Drugs that have been long dismissed as safe and effective for conditions are still regularly used. This is most notorious for heart conditions.
Since the only rating system that really matters *is* from doctors and patients themselves, drug prescriptions should be rated for certain conditions and listed from most effective on the previously mentioned diagnosis system. It would be hard to justify malpractice if for a given condition, over 30,000 doctors had given their patients a drug which worked, but for one person they didn't.
A complex screening could also strongly help determine which was the right drug, and how much, for a person. It would take into account their age, weight, other conditions, other medications, etc., far better than could their doctor or their pharmacist.
************
The bottom line to this health care philosophy is high front-end costs and consolidated data. Its benefits really show with fewer health care dollars needed in the future, better treatments for patients, and avoidance of much error.
A truism is that "70% of our health care dollars are spent on people in the last four years of their lives". But much of this expense is just because conditions were ignored or undiagnosed for years, patients ignorantly engaged in high risk behaviors, and diagnosis and prescription were flawed.
posted by kablam at 8:07 AM on December 19, 2005
I foresee a technological leap in medical diagnosis in the future, in which, before the patient see the doctor, they routinely, at least annually, receive a "complex screening". Individually, it would be prohibitively expensive, so a system would have to be designed to process a huge number of people a day.
To start off with, their entire medical history is put into an electronic database, and vetted with both the patient and the doctor. This incorporates as much as possible, to include dental records, dietary supplements, alternative therapies, etc. Any current acute or chronic problems, no matter how minor, would be included. This is done at leisure prior to the screening.
Then the actual screening would begin. When they arrived at the screening facility, they would bring with them a stool sample. They would get a full-body CT and Xray, which would be computer analyzed looking for eccentricities, highlighted for a CT and Xray expert to examine. (Annual full-body CTs have already proven their value where used, saving enormous amounts of health care money by catching conditions early.)
At some point they would provide a DNA, PAP or semen, urine and saliva specimen, and enough blood for a complete work-up. By then, hopefully, their blood could be drawn by a machine instead of a person.
Other test would be done on site, including weight, hearing, ophthalmological, respiratory, and even a brief degree of motion, reflexes, and neurological profile.
Once this base line had been established for them, subsequent follow-up examinations would be considerably simplified. A full complex set would probably be only needed once a decade.
For the majority of people, this complex screening would clearly create an entire program of preventative health maintenance specific to them. Almost everybody would receive a report advising them about pre-existing conditions, from genetics, health risk "windows" they were in, diet they should maintain, behaviors they should avoid, and medical treatments they should consider.
Ironically, much of this is already done, but done in a haphazard, often redundant, often neglected manner, and the data from these tests are not consolidated or put in a form most useful to the physician. So yes, initially, the cost is quite large, but the long-term costs drop drastically.
*********
The next step is a far more advanced version of a system currently in use. Doctors can plug in symptoms into a computer, and a diagnosis is reached as to probable condition and treatment. This confirms a doctor's suspicions, or it suggests a condition overlooked by the doctor.
If used in tandem with the complex screening, this system would be far more accurate. Beyond a certain point, it would be *objectively* certain of a course of treatment; which might effectively immunize a doctor against malpractice.
***********
Lastly, doctors are *not* pharmacists. This should be known and remembered by all patients. Doctors are reliant solely on trial and error of drugs, based on patient feedback, and what the doctor might learn in a haphazard way.
Even critical, life saving drugs are not standardized in their use in emergency rooms in the US. Drugs that have been long dismissed as safe and effective for conditions are still regularly used. This is most notorious for heart conditions.
Since the only rating system that really matters *is* from doctors and patients themselves, drug prescriptions should be rated for certain conditions and listed from most effective on the previously mentioned diagnosis system. It would be hard to justify malpractice if for a given condition, over 30,000 doctors had given their patients a drug which worked, but for one person they didn't.
A complex screening could also strongly help determine which was the right drug, and how much, for a person. It would take into account their age, weight, other conditions, other medications, etc., far better than could their doctor or their pharmacist.
************
The bottom line to this health care philosophy is high front-end costs and consolidated data. Its benefits really show with fewer health care dollars needed in the future, better treatments for patients, and avoidance of much error.
A truism is that "70% of our health care dollars are spent on people in the last four years of their lives". But much of this expense is just because conditions were ignored or undiagnosed for years, patients ignorantly engaged in high risk behaviors, and diagnosis and prescription were flawed.
posted by kablam at 8:07 AM on December 19, 2005
A truism is that "70% of our health care dollars are spent on people in the last four years of their lives". But much of this expense is just because conditions were ignored or undiagnosed for years, patients ignorantly engaged in high risk behaviors, and diagnosis and prescription were flawed.
Um, couldn't this be also because people get sick or injured and die, thus their healthcare would be taking place during the last moments of their lives so that when you average out the rest of us it comes to your 70% w/in 4 years figure? I've luckily never had much serious medical care in my life, but if I get hit by a bus, I'm probably going to, especially if it is a critical or fatal accident, right?
posted by Pollomacho at 8:16 AM on December 19, 2005
Um, couldn't this be also because people get sick or injured and die, thus their healthcare would be taking place during the last moments of their lives so that when you average out the rest of us it comes to your 70% w/in 4 years figure? I've luckily never had much serious medical care in my life, but if I get hit by a bus, I'm probably going to, especially if it is a critical or fatal accident, right?
posted by Pollomacho at 8:16 AM on December 19, 2005
This is not an argument for maintaining the US healthcare status quo, but are you really sure that catching diseases earlier on would cost less then treating them at the catastrophic end-stage? In the sense that "catching them earlier on" would require more universal primary medical coverage? Just a thought....
posted by ParisParamus at 10:00 AM on December 19, 2005
posted by ParisParamus at 10:00 AM on December 19, 2005
I'm really surprised that no one has yet to touch on the real root of the higher premiums.
"So to a first approximation, the reason that insurance rates are up hugely since 2001 is that the stock market is bad"
posted by Heywood Mogroot at 10:03 AM on December 19, 2005
"So to a first approximation, the reason that insurance rates are up hugely since 2001 is that the stock market is bad"
posted by Heywood Mogroot at 10:03 AM on December 19, 2005
I stand corrected, I missed that in the noise, sorry jellicle.
posted by Pollomacho at 10:08 AM on December 19, 2005
posted by Pollomacho at 10:08 AM on December 19, 2005
but are you really sure that catching diseases earlier on would cost less then treating them at the catastrophic end-stage?
umm, for nearly everything I can think of, yeah, when looking at the overall societal costs, including productivity.
because they count millions of Americans who are Medicaid-eligible
like being on Medicaid (or Medicare for that matter) gives you access to a system of the quality of Canada's. My mom's on medicare, and has had a bitch of a time getting a red spot on her hand looked at by a dermatologist.
posted by Heywood Mogroot at 10:09 AM on December 19, 2005
umm, for nearly everything I can think of, yeah, when looking at the overall societal costs, including productivity.
because they count millions of Americans who are Medicaid-eligible
like being on Medicaid (or Medicare for that matter) gives you access to a system of the quality of Canada's. My mom's on medicare, and has had a bitch of a time getting a red spot on her hand looked at by a dermatologist.
posted by Heywood Mogroot at 10:09 AM on December 19, 2005
The most widescale problems in medicine are failures in diagnosis and failures in medication.
Hmm. Diagnosis and Treatment. That narrows it down.
Annual full-body CTs have already proven their value where used, saving enormous amounts of health care money by catching conditions early.
Wrong. Annual full-body CTs expose patients to the same amount of radiation they would get from hundreds of chest Xrays. They cause cancer in a predictable proportion of patients. Although early diagnosis will save some lives, much more often 'incidentalomas' are found which have to be 'worked up', costing money, illness and sometimes lives (iatrogenic causes).
...a brief degree of motion, reflexes, and neurological profile.
Actually, very few things we doctors do for 'screening' has ever been shown to be effective in saving lives. While the concept of the more tests the better is attractive, it is fatally flawed.
...this complex screening would clearly create an entire program of preventative health maintenance specific to them. ... diet they should maintain, behaviors they should avoid, and medical treatments they should consider.
Avoid junk food, don't smoke, wear your seatbelt, get smoke detectors, get a flu shot, vaccinate yourself and your children, don't drink and drive, child-proof the home, wear a condom, etc. etc. There, I've just saved you thousands of dollars in medical tests.
Doctors can plug in symptoms into a computer, and a diagnosis is reached as to probable condition and treatment. This confirms a doctor's suspicions, or it suggests a condition overlooked by the doctor.
If used in tandem with the complex screening, this system would be far more accurate. Beyond a certain point, it would be *objectively* certain of a course of treatment; which might effectively immunize a doctor against malpractice.
Hmm. Robodoctor. Sorry, I'm not a believer. Maybe once AI has advanced to the point where computers have a consciousness I'll buy it. Again, as a practicing physician I know there's an art to medicine... things you pick up intuitively and from experience from the patient... simple things like 'does this patient look sick'. I refer to a computer for things I can't be bothered memorizing, but a patient with a computer for a doctor is a fool. 'Objectively' applying algorythms in an attempt to escape responsibility for bad outcomes is not my definition of a 'good doctor'.
Since the only rating system that really matters *is* from doctors and patients themselves,
Oh good, we can stop all those expensive randomized double-blind clinical trials and just do a Gallop Poll to see which drugs work.
This writer actually illustrates the problem with malpractice trials... they hinge too much on people's biases rather than science.
I used to work part-time for an 'exectuive health' company giving lavish physicals. There's an argument to be made that *this* is actually a form of malpractice.
The 'full body scan' fad is dying out, partly because they are a waste of money in terms of, on average, making any average patient live longer.
-Kevin
posted by kevinsp8 at 11:39 AM on December 19, 2005
Hmm. Diagnosis and Treatment. That narrows it down.
Annual full-body CTs have already proven their value where used, saving enormous amounts of health care money by catching conditions early.
Wrong. Annual full-body CTs expose patients to the same amount of radiation they would get from hundreds of chest Xrays. They cause cancer in a predictable proportion of patients. Although early diagnosis will save some lives, much more often 'incidentalomas' are found which have to be 'worked up', costing money, illness and sometimes lives (iatrogenic causes).
...a brief degree of motion, reflexes, and neurological profile.
Actually, very few things we doctors do for 'screening' has ever been shown to be effective in saving lives. While the concept of the more tests the better is attractive, it is fatally flawed.
...this complex screening would clearly create an entire program of preventative health maintenance specific to them. ... diet they should maintain, behaviors they should avoid, and medical treatments they should consider.
Avoid junk food, don't smoke, wear your seatbelt, get smoke detectors, get a flu shot, vaccinate yourself and your children, don't drink and drive, child-proof the home, wear a condom, etc. etc. There, I've just saved you thousands of dollars in medical tests.
Doctors can plug in symptoms into a computer, and a diagnosis is reached as to probable condition and treatment. This confirms a doctor's suspicions, or it suggests a condition overlooked by the doctor.
If used in tandem with the complex screening, this system would be far more accurate. Beyond a certain point, it would be *objectively* certain of a course of treatment; which might effectively immunize a doctor against malpractice.
Hmm. Robodoctor. Sorry, I'm not a believer. Maybe once AI has advanced to the point where computers have a consciousness I'll buy it. Again, as a practicing physician I know there's an art to medicine... things you pick up intuitively and from experience from the patient... simple things like 'does this patient look sick'. I refer to a computer for things I can't be bothered memorizing, but a patient with a computer for a doctor is a fool. 'Objectively' applying algorythms in an attempt to escape responsibility for bad outcomes is not my definition of a 'good doctor'.
Since the only rating system that really matters *is* from doctors and patients themselves,
Oh good, we can stop all those expensive randomized double-blind clinical trials and just do a Gallop Poll to see which drugs work.
This writer actually illustrates the problem with malpractice trials... they hinge too much on people's biases rather than science.
I used to work part-time for an 'exectuive health' company giving lavish physicals. There's an argument to be made that *this* is actually a form of malpractice.
The 'full body scan' fad is dying out, partly because they are a waste of money in terms of, on average, making any average patient live longer.
-Kevin
posted by kevinsp8 at 11:39 AM on December 19, 2005
Annual full-body CTs have already proven their value where used, saving enormous amounts of health care money by catching conditions early.
This is so fucking stupid, so blitheringly wrong, so laughably, idiotically ignorant, that I'd have to be high on acid to not to shit myself blind trying to explain this cretinous assertion.
posted by docpops at 11:57 AM on December 19, 2005
This is so fucking stupid, so blitheringly wrong, so laughably, idiotically ignorant, that I'd have to be high on acid to not to shit myself blind trying to explain this cretinous assertion.
posted by docpops at 11:57 AM on December 19, 2005
AAAAAAAAAAAAAH. Please let's not make statements like "most of end of life care is due to undiagnosed or missed ailments".
I hate to break it to you kablam, but you're going to die. Yup, it's true. And, it probably won't be peaceful. Dying in the age of modern medicine probably rarely is. Whereas 50 years ago, an 89 year old's heart would hit its planned obsolescence and a heart attack would kill him or her, today it's caught at the hospital and the "heart failure" is managed for an already sick person. $$$$ of drugs are thrown at that heart. Tons of tests are used to learn where the infarct was. Then, the appropriate regimen to at least ensure a teeny bit longer life than would have happened 50 years ago is a gigantic process of trial and error and careful refinement as there are thousands of ways you can control abnormal hearts (B-blockers, calcium channel blockers, nitrates, etc., etc.). I'm not saying we need to stop giving such care. In medicine, that's never the goal. BUT, please try not to stand there and say it's "missed diagnoses" that are managed in a costly way at the end of life. I'm sorry, but it's true that, with each heart beat, your heart is taking a beating. But, you know, the pounding it takes during an appropriate cardio workout (not too hard, not too light) actually might help that damage not be so bad. That, among lots of other reasons, is why exercise is good for you. Sort of complicated, huh? Well, that's the human body for you.
No matter what, a great percentage of people are going to want every treatment in the book in order to live longer when old age's underlying ailments: failing kidneys, poor colons, a not so powerful immune system, etc. are inevitably going to ask for the $$$$$$ that is thrown at end life care.
It's funny but "old age" is not an official cause of death. It's heart failure, or pneumonia, or cancer, etc. But, underlying that stuff is really old age. They said Reagan died of pneumonia, but might you not think Alzheimer's and the accompanying mental anguish and disappearance of much of life's realized pleasures (and, it's proven link to immune system strength) had a bit to do with him not being able to battle a lung infection like he did when younger? Did treatment of that really go misdiagnosed?
Great post btw kevinsp8.
posted by narebuc at 11:57 AM on December 19, 2005
I hate to break it to you kablam, but you're going to die. Yup, it's true. And, it probably won't be peaceful. Dying in the age of modern medicine probably rarely is. Whereas 50 years ago, an 89 year old's heart would hit its planned obsolescence and a heart attack would kill him or her, today it's caught at the hospital and the "heart failure" is managed for an already sick person. $$$$ of drugs are thrown at that heart. Tons of tests are used to learn where the infarct was. Then, the appropriate regimen to at least ensure a teeny bit longer life than would have happened 50 years ago is a gigantic process of trial and error and careful refinement as there are thousands of ways you can control abnormal hearts (B-blockers, calcium channel blockers, nitrates, etc., etc.). I'm not saying we need to stop giving such care. In medicine, that's never the goal. BUT, please try not to stand there and say it's "missed diagnoses" that are managed in a costly way at the end of life. I'm sorry, but it's true that, with each heart beat, your heart is taking a beating. But, you know, the pounding it takes during an appropriate cardio workout (not too hard, not too light) actually might help that damage not be so bad. That, among lots of other reasons, is why exercise is good for you. Sort of complicated, huh? Well, that's the human body for you.
No matter what, a great percentage of people are going to want every treatment in the book in order to live longer when old age's underlying ailments: failing kidneys, poor colons, a not so powerful immune system, etc. are inevitably going to ask for the $$$$$$ that is thrown at end life care.
It's funny but "old age" is not an official cause of death. It's heart failure, or pneumonia, or cancer, etc. But, underlying that stuff is really old age. They said Reagan died of pneumonia, but might you not think Alzheimer's and the accompanying mental anguish and disappearance of much of life's realized pleasures (and, it's proven link to immune system strength) had a bit to do with him not being able to battle a lung infection like he did when younger? Did treatment of that really go misdiagnosed?
Great post btw kevinsp8.
posted by narebuc at 11:57 AM on December 19, 2005
The 'full body scan' fad is dying out, partly because they are a waste of money in terms of, on average, making any average patient live longer.
anecdotal I know, but I wonder if Steve Jobs' pancreatic cancer was caught (last year) by one of these scans...
posted by Heywood Mogroot at 11:58 AM on December 19, 2005
anecdotal I know, but I wonder if Steve Jobs' pancreatic cancer was caught (last year) by one of these scans...
posted by Heywood Mogroot at 11:58 AM on December 19, 2005
Thanks, Kevin, for saving me the time of going through kablam's post in similar fashion. It's logical, of course, to assume that technological advances will have long term positive impacts on medicine, but to try and nail them down specifically without any idea of the science that is at work is pretty silly, and not even helpful to the point of the argument. Kind of reminds me of War of the Worlds... the martians arrived in large canisters fired ballistically out of cannons. Why? Because rockets hadn't been invented at the time it was written. If we could predict techology before it was invented, we wouldn't have to wait for it to be invented. And if we don't need fundamentally new technology for a goal, then we should be showing signs of progress in that area already. At least some proof of concept. Kablam's strange attempt at prophecy seems to miss the mark on both of these scenarios.
posted by Farengast at 12:01 PM on December 19, 2005
posted by Farengast at 12:01 PM on December 19, 2005
HM, I googled the pancreatic cancer that Jobs had and, it can actually show up via symptoms due to which pancreatic hormone (insulin, glucagon, etc.) is the cancerous cell. Such levels (or their effects in things like blood sugar) are usually wildly elevated on regular blood testing that most people his age should be getting or can be called for by complaints of things like hyper or hypo glycemic states or low/high acid levels.
But, who knows, he might have got a scan.
You can read more about his cancer at:
http://www.emedicine.com/radio/topic363.htm
posted by narebuc at 12:07 PM on December 19, 2005
But, who knows, he might have got a scan.
You can read more about his cancer at:
http://www.emedicine.com/radio/topic363.htm
posted by narebuc at 12:07 PM on December 19, 2005
hmm, as kevinsp8 says, mebbe all that scanning, if Jobs indeed was undergoing it annually, actually /caused/ the cancer. That would indeed suck.
posted by Heywood Mogroot at 12:20 PM on December 19, 2005
posted by Heywood Mogroot at 12:20 PM on December 19, 2005
Jedicus sez: The main findings were that malpractice is relatively rare, most injured patients do not bring claims, and (this is the biggie, I think) there is no correlation between the existence of malpractice and whether the patient won the suit. In fact, there is some suggestion that it is precisely those cases without merit that win and those with merit that do not.
Is the result of the cases that actually reach court all that important? I would imagine that by the time it's in court and won or lost, the majority of strong cases have been settled. So what you have then is a bunch of outliers, at least from the standpoint of examining how worthy a case is. The fact that the bad cases won isn't even all that noteworthy; presumably the good cases would have been settled if the beancounters had looked at them and thought there was a good chance of the litigant prevailing.
posted by phearlez at 3:55 PM on December 19, 2005
Is the result of the cases that actually reach court all that important? I would imagine that by the time it's in court and won or lost, the majority of strong cases have been settled. So what you have then is a bunch of outliers, at least from the standpoint of examining how worthy a case is. The fact that the bad cases won isn't even all that noteworthy; presumably the good cases would have been settled if the beancounters had looked at them and thought there was a good chance of the litigant prevailing.
posted by phearlez at 3:55 PM on December 19, 2005
A: Someone who's still more intelligent and hardworking than 99% of the general population that could never even dream of making it that far.
posted by drpynchon at 9:48 PM PST on December 18
So let me get this straight: someone graduating at the very bottom of their class in med school is more intelligent and hard working than 99% of the lawyers, chemists, physicists, writers, and ditch diggers? Do you have any evidence of that?
posted by Optimus Chyme at 4:37 PM on December 19, 2005
posted by drpynchon at 9:48 PM PST on December 18
So let me get this straight: someone graduating at the very bottom of their class in med school is more intelligent and hard working than 99% of the lawyers, chemists, physicists, writers, and ditch diggers? Do you have any evidence of that?
posted by Optimus Chyme at 4:37 PM on December 19, 2005
Annual full-body CTs have already proven their value where used, saving enormous amounts of health care money by catching conditions early.
Oh, look, kablam is one hundred percent wrong about something again. Are you pretending to be a medical historian today?
posted by Optimus Chyme at 4:39 PM on December 19, 2005
Oh, look, kablam is one hundred percent wrong about something again. Are you pretending to be a medical historian today?
posted by Optimus Chyme at 4:39 PM on December 19, 2005
Well, Optimus, 99% is probably too high of a number. I'd say its about 90%. Why? Because about 1 out of 10 applicants gets accepted into a med school. Given that the drop out rates are pretty low, its fairly valid to say that whoever gets accepted, graduates. And those 10 initial people that did apply, come from different background (undergrad majors), including chemists, physicists and writers. I don't count the ditch diggers at all, and you have to go to grad school to be a lawyer.
posted by c13 at 4:50 PM on December 19, 2005
posted by c13 at 4:50 PM on December 19, 2005
Optimus, when the docs pull out their God complex, you just pat them on the head and say "that's cute dear."
/sarcasm
But really, the doc was speaking hyperbolically at a slight to his profession, I bet.
posted by teece at 5:10 PM on December 19, 2005
/sarcasm
But really, the doc was speaking hyperbolically at a slight to his profession, I bet.
posted by teece at 5:10 PM on December 19, 2005
kevinsp8: My error was in one sentence, about the "annual" use of CT scans. My intention, however, was to establish a comprehensive diagnostic baseline for the use of the physician later. The impression that the entire process would be annual is false. I suggested perhaps at decade intervals, but I was unaware of the radiation hazards now associated with CT.
Would it, or would it not be advantageous to you, as a physician, to have a health base line, an ordered set of data, from which you can compare to a patients current condition?
Second, while you may be loathe to use a computer to *verify* your diagnosis, not *make* your diagnosis, do you assume that other physicians are similarly inclined to trust in their own, innate superiority in diagnosis? Perhaps you might reconsider, if by verifying your diagnosis, it provided you a modicum of legal protection from malpractice.
Third, while you seem to have great confidence in double blind testing, you are still not a pharmacist. Pharma advertisements are hardly a good source of what is best for a patient, even if their drugs have been judged "safe and effective" in some circumstances.
And a special note to Optimus Chyme: I got a sentence, or perhaps an entire posted message wrong. You are a lawyer. You got your entire soul wrong.
posted by kablam at 6:26 PM on December 19, 2005
Would it, or would it not be advantageous to you, as a physician, to have a health base line, an ordered set of data, from which you can compare to a patients current condition?
Second, while you may be loathe to use a computer to *verify* your diagnosis, not *make* your diagnosis, do you assume that other physicians are similarly inclined to trust in their own, innate superiority in diagnosis? Perhaps you might reconsider, if by verifying your diagnosis, it provided you a modicum of legal protection from malpractice.
Third, while you seem to have great confidence in double blind testing, you are still not a pharmacist. Pharma advertisements are hardly a good source of what is best for a patient, even if their drugs have been judged "safe and effective" in some circumstances.
And a special note to Optimus Chyme: I got a sentence, or perhaps an entire posted message wrong. You are a lawyer. You got your entire soul wrong.
posted by kablam at 6:26 PM on December 19, 2005
kevinsp8:
While the concept of the more tests the better is attractive, it is fatally flawed.
Indeed "more" is not "better" neither does it constantly imply "better" ...yet the same could be said for "less" or "none"
For instance let's take a very simple do-at-home test as concentration of glucose in blood ; eventually repeating it
several times a day is not going to -cure- the -cause- of diabetes and is not adding much significant information to
what is already known ; yet a glycosylated emoglobin test seems to give some measure of average daily blood glucose which is interesting information alone or combine with spikes. That should be a recommended test, I think, as early diagnosis could reduce the number of chances of patient incurring into too high or too low sugar level.
So ,I guess, a doctor that suspect diabetes is likely to order the latter test ...but what about other pathologies that
don't show telltale signs like being overweight ? Of course there must be some cost benefit analysis, cost meaning NOT monetary cost which must remain a problem but, imho, must become the least problem...but if the cost benefit analisis is going to be made by private companies they, quite obviously, will try to discourage the most expensive ones or the ones who give the least returns or are more likely to be dangerous to the company.
So maybe a standardized, forced-into-low-cost test could become a good idea, if anything to force reduction of cost by standardization and mass production.
posted by elpapacito at 7:08 PM on December 19, 2005
While the concept of the more tests the better is attractive, it is fatally flawed.
Indeed "more" is not "better" neither does it constantly imply "better" ...yet the same could be said for "less" or "none"
For instance let's take a very simple do-at-home test as concentration of glucose in blood ; eventually repeating it
several times a day is not going to -cure- the -cause- of diabetes and is not adding much significant information to
what is already known ; yet a glycosylated emoglobin test seems to give some measure of average daily blood glucose which is interesting information alone or combine with spikes. That should be a recommended test, I think, as early diagnosis could reduce the number of chances of patient incurring into too high or too low sugar level.
So ,I guess, a doctor that suspect diabetes is likely to order the latter test ...but what about other pathologies that
don't show telltale signs like being overweight ? Of course there must be some cost benefit analysis, cost meaning NOT monetary cost which must remain a problem but, imho, must become the least problem...but if the cost benefit analisis is going to be made by private companies they, quite obviously, will try to discourage the most expensive ones or the ones who give the least returns or are more likely to be dangerous to the company.
So maybe a standardized, forced-into-low-cost test could become a good idea, if anything to force reduction of cost by standardization and mass production.
posted by elpapacito at 7:08 PM on December 19, 2005
You are a lawyer. You got your entire soul wrong.
posted by kablam at 6:26 PM PST on December 19
My profession as referenced in my user page is a knock at former poster esquire, who claimed to be a lawyer but who was in reality a third grader with special needs. My enemies list is a knock at dios, and my "home page" isn't even mine. I am a scheming and duplicitous fellow. :)
posted by Optimus Chyme at 7:45 PM on December 19, 2005
posted by kablam at 6:26 PM PST on December 19
My profession as referenced in my user page is a knock at former poster esquire, who claimed to be a lawyer but who was in reality a third grader with special needs. My enemies list is a knock at dios, and my "home page" isn't even mine. I am a scheming and duplicitous fellow. :)
posted by Optimus Chyme at 7:45 PM on December 19, 2005
Because about 1 out of 10 applicants gets accepted into a med school. Given that the drop out rates are pretty low, its fairly valid to say that whoever gets accepted, graduates. And those 10 initial people that did apply, come from different background (undergrad majors), including chemists, physicists and writers.
There are plenty of brilliant chemists, physicists, lawyers and writers who have no wish to become doctors. I don't think a Drake equation-style back-of-the-napkin estimate counts as evidence, either.
posted by Optimus Chyme at 7:49 PM on December 19, 2005
There are plenty of brilliant chemists, physicists, lawyers and writers who have no wish to become doctors. I don't think a Drake equation-style back-of-the-napkin estimate counts as evidence, either.
posted by Optimus Chyme at 7:49 PM on December 19, 2005
Optimus Chyme....if you are scheming and duplicitous -- you'd be a great lawyer. :)
And, I'd say about 25%-30% of physicians are foreign trained. Smart people, but they test much lower than American trained physicians on average and might have gotten into medical school because, simply, they could pay in their own country. Also, you have osteopathic physicians here -- who, while also not stupid, do score lower on average than American medical students.
I just point it out to state that not all doctors went through a completely tough weed out process.
Next, most of medical discovery is PhD related -- where would be without, say, antibiotics or knowledge of physiology?! Doctors are humanists, at some level, and people who apply scientific discoveries usually created by people a lot more naturally smart than they, or at least more innovative.
Medical malpractice and corporate lawyers do suck though.
posted by narebuc at 8:35 PM on December 19, 2005
And, I'd say about 25%-30% of physicians are foreign trained. Smart people, but they test much lower than American trained physicians on average and might have gotten into medical school because, simply, they could pay in their own country. Also, you have osteopathic physicians here -- who, while also not stupid, do score lower on average than American medical students.
I just point it out to state that not all doctors went through a completely tough weed out process.
Next, most of medical discovery is PhD related -- where would be without, say, antibiotics or knowledge of physiology?! Doctors are humanists, at some level, and people who apply scientific discoveries usually created by people a lot more naturally smart than they, or at least more innovative.
Medical malpractice and corporate lawyers do suck though.
posted by narebuc at 8:35 PM on December 19, 2005
So let me get this straight: someone graduating at the very bottom of their class in med school is more intelligent and hard working than 99% of the lawyers, chemists, physicists, writers, and ditch diggers? Do you have any evidence of that?
Umm, no. Close (well, not really) reading would reveal that I said they are smarter than 99% of the general population. And for the most part, physicists, chemists and lawyers tend to be in the other 1% too. Though there was some hyperbole in the numbers.
posted by drpynchon at 9:52 PM on December 19, 2005
Umm, no. Close (well, not really) reading would reveal that I said they are smarter than 99% of the general population. And for the most part, physicists, chemists and lawyers tend to be in the other 1% too. Though there was some hyperbole in the numbers.
posted by drpynchon at 9:52 PM on December 19, 2005
The most widescale problems in medicine are failures in diagnosis and failures in medication.
Completely inaccurate.
They would get a full-body CT and Xray
No point in both.
Annual full-body CTs have already proven their value where used, saving enormous amounts of health care money by catching conditions early.
Completely, malignantly, idiotically inaccurate. Regardless of whether it's annual or not, and even ignoring all the radiation therein.
Doctors can plug in symptoms into a computer, and a diagnosis is reached as to probable condition and treatment.
Entirely impractical and unreliable.
Doctors are reliant solely on trial and error of drugs, based on patient feedback, and what the doctor might learn in a haphazard way.
Are you on crack?
Even critical, life saving drugs are not standardized in their use in emergency rooms
Actually, yes they are. It's called ACLS.
But much of this expense is just because conditions were ignored or undiagnosed for years,
As with virtually every other point in your comment, you clearly have no idea what you're spouting off about.
posted by drpynchon at 10:06 PM on December 19, 2005
Completely inaccurate.
They would get a full-body CT and Xray
No point in both.
Annual full-body CTs have already proven their value where used, saving enormous amounts of health care money by catching conditions early.
Completely, malignantly, idiotically inaccurate. Regardless of whether it's annual or not, and even ignoring all the radiation therein.
Doctors can plug in symptoms into a computer, and a diagnosis is reached as to probable condition and treatment.
Entirely impractical and unreliable.
Doctors are reliant solely on trial and error of drugs, based on patient feedback, and what the doctor might learn in a haphazard way.
Are you on crack?
Even critical, life saving drugs are not standardized in their use in emergency rooms
Actually, yes they are. It's called ACLS.
But much of this expense is just because conditions were ignored or undiagnosed for years,
As with virtually every other point in your comment, you clearly have no idea what you're spouting off about.
posted by drpynchon at 10:06 PM on December 19, 2005
Umm, no. Close (well, not really) reading would reveal that I said they are smarter than 99% of the general population.
posted by drpynchon at 9:52 PM PST on December 19
Ninety-nine percent of doctors shouldn't argue definitions with those who majored in English. Just let me know what professions you want to take out of the general (i.e., concerned with, applicable to, or affecting the whole or every member of a class or category; not limited in size or scope) population so that your numbers work.
posted by Optimus Chyme at 10:38 PM on December 19, 2005
posted by drpynchon at 9:52 PM PST on December 19
Ninety-nine percent of doctors shouldn't argue definitions with those who majored in English. Just let me know what professions you want to take out of the general (i.e., concerned with, applicable to, or affecting the whole or every member of a class or category; not limited in size or scope) population so that your numbers work.
posted by Optimus Chyme at 10:38 PM on December 19, 2005
Ninety-nine percent of doctors shouldn't argue definitions with those who majored in English. Just let me know what professions you want to take out of the general (i.e., concerned with, applicable to, or affecting the whole or every member of a class or category; not limited in size or scope) population so that your numbers work.
What about the 1% of doctors who also happen to have degrees in English such as myself? You presumptuous dolt. Perhaps they didn't teach you how percentages work while you were learning all those fancy words. I don't need to take any professions out of the general, that being 100%. Most people in some few professions wind up in a certain 1st percentile, whereas most people in certain other professions end up in the lower 99th percentile. But I tire of explaining the obvious to someone so obtuse. Feel free to e-mail me. Perhaps I can teach you a few things I learned about fancy numbers while I was getting my other degree in biophysical chemistry.
posted by drpynchon at 11:06 PM on December 19, 2005
What about the 1% of doctors who also happen to have degrees in English such as myself? You presumptuous dolt. Perhaps they didn't teach you how percentages work while you were learning all those fancy words. I don't need to take any professions out of the general, that being 100%. Most people in some few professions wind up in a certain 1st percentile, whereas most people in certain other professions end up in the lower 99th percentile. But I tire of explaining the obvious to someone so obtuse. Feel free to e-mail me. Perhaps I can teach you a few things I learned about fancy numbers while I was getting my other degree in biophysical chemistry.
posted by drpynchon at 11:06 PM on December 19, 2005
I'd have to be high on acid to not to shit myself blind...
I admit it: I chuckled at that.
posted by darkstar at 2:59 AM on December 20, 2005
I admit it: I chuckled at that.
posted by darkstar at 2:59 AM on December 20, 2005
What about the 1% of doctors who also happen to have degrees in English such as myself?
You have to admit it would have been a pretty sweet burn if you didn't have that degree, though.
My larger point was that if you continue to remove certain professions from the "general" population, it ceases to be general.
Most people in some few professions wind up in a certain 1st percentile, whereas most people in certain other professions end up in the lower 99th percentile.
Then perhaps I know an unusual number of non-doctor one percenters.
posted by Optimus Chyme at 7:26 AM on December 20, 2005
You have to admit it would have been a pretty sweet burn if you didn't have that degree, though.
My larger point was that if you continue to remove certain professions from the "general" population, it ceases to be general.
Most people in some few professions wind up in a certain 1st percentile, whereas most people in certain other professions end up in the lower 99th percentile.
Then perhaps I know an unusual number of non-doctor one percenters.
posted by Optimus Chyme at 7:26 AM on December 20, 2005
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posted by jperkins at 7:25 PM on December 18, 2005