By DAVID E. WILLIAMS
I’m amazed at just how quickly physician employment has swung from small independent practices to hospital-based employment. I’ve heard about it anecdotally from medical societies and malpractice carriers who are seeing their constituents shift, and have certainly observed the shift from individual physicians, but I’m still surprised how fast it’s occurring. A new report from recruiter Merritt Hawkins tells the clearest story I’ve seen:
- In the last 12 months, 56% of physician search assignments have been for hospital jobs, whereas 5 years ago it was just 23%
- Just 2% of assignments were for independent, solo practice docs compared with 17% 5 years ago
Doctors are becoming more like regular wage earners, albeit high paid ones. There are some strong drivers of this trend including the need to support health information technology, comply with regulations and deal with health plans. There’s also a desire on the part of a younger, increasingly female physician workforce to have a better balance between work and home life. If anything the forces pulling physicians into hospital employment will strengthen in the near term with the arrival of Accountable Care Organizations and other forms of deep integration.
Yet when a pendulum swings it tends to swing too far. Especially considering how quickly things have moved, I do expect that there will be some backlash to the rush into employment. It’s really not all that much fun having a boss, especially when that boss is a big, bureaucratic hospital with other things on its priority list besides MD satisfaction and career development. Patients may not like it so much either. I know I’d rather see a physician who’s not too tightly tied to a hospital.
So what will the reversal look like? I don’t think it’s going to be doctors rushing to put up their own shingles or buy practices of retiring docs like in the old days. Instead I expect to see a new breed of physician employers who recognize what’s needed to make docs happy, treat patients well, manage compliance, and still make money. One example is so-called direct primary care practices such as Qliance. Time will tell what other forms develop.
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As a physician in practice for over 25 years, the trend is alarming. Physicians who join hospital systems will be very disappointed in their salaries as Medicare and Medicad payments to these institutions reduce in the coming years. Hospitals are businesses like any other, the difference being that the vast majority of their payments are based on Medicare rates. As the federal government continues to allow Medicare to become insolvent, Medicare rates will be cut dramatically over time. As the rate cuts occur, these newly salaried “employee physicians” will see lower paychecks. It will take five years, but we can have virtually 100% certainty that this will occur. Anything else is just not financially feasible. By jumping ship and joining the “safe haven” of a hospital job, they are guaranteeing lower paychecks in a dramatic fashion very soon.
I totally agree the shift is dramatic. Having after 20 years in private practice just finished my first two years as an employed physician I can tell you the only comforts have been the continued support of patients and a steady paycheck. The rest of it is a wash. Under layers of administrative voodo unsafe or nonproductive activities that one could see changed quickly in private practice now are no longer changeable. I have seen my principles regularly compromised. Buyer beware.
http://www.youtube.com/watch?v=-b5aW08ivHU
The ultimate physician employer is the patient. Physicians who collaborate with their communities and patients will be designing the clinics of the future.
Inspiring models: http://www.youtube.com/watch?v=4YJz5wvt2bk
and http://www.youtube.com/watch?v=dtEFIFqhw6I
Pamela Wible, MD
3575 Donald St. #220
Eugene, OR 97405
(541) 345-2437
http://www.idealmedicalcare.org
“(S)He is the best physician who is the most ingenious inspirer of hope.”
~ Samuel Coleridge
Hmm…
Sock puppet?
Yes, you would be pleased with the status quo that is to be Obamination care, automation health care without dissent or individual attention, just cookie cutter bs that focuses on money, and oh, who gets to pocket the alleged savings that will be made, as there always will be a profit margin in health care, even though politicians won’t admit to that.
MD as Hell is right on the money, “..no one has to care anymore.”
Enjoy your provider who quotes standards of care that do not care who or what your issues are.
PPACA. The new abbreviation for “hear the lie enough and it becomes truth.”
@MD as HELL
What a screen name!
I hope your bedside manner is not as harsh as your curmudgeonly public persona. If all I had to go on was your comments I would never want you for my PCP.
Tort reform is not the answer. We need tort elimination. Malpractice awards need to be removed from the court and handled like worker’s comp. The huge awards have never ever been justified.
DeterminedMD, I glaze over when I try to read Ms. Mayer. In general I agree with everything you say.
This post started about employee docs. Fact is medicine has become too complicated to do both. It did not used to be that way. Not every town had medical care. Private practice was the only model. Fee or no fee for service. Docs adopted a town or a population. Technology erupted and the government got into the direct to the voter benefits game. No hope now.
There is no way a primary care doc is going into private practice. There are too many clinics funded by Uncle Sugar to compete with. Collections are stunted. Charges are capped. You have to do it the JACHO way and the CMS way and do it with “meaningful use” which is somehow evidence-based, satisfy the patient for the Press-Gainey surveys, all in 6 minutes. Add a side of “do you feel safe at home” and “are there guns in your house” and you have the future of primary care. Who would want that as a career? No one would design such a beast.
There is also no way to retire on the likely returns on a retirement plan, which you get to fund yourself. Give me matching funds and a defined benefit plan anyday. Give me a state government job.
The big problem is that no one has to care anymore. Patients beware.
@Dr. Mike
Fascinating approach, albeit a political stretch to enact. (I have a hard time imagining what interest groups might support or oppose such a construct.)
Pushing arbitration to the community (county) level would make it tough to abuse since all parties would presumably be obliged to live together with the results. School boards, grand juries and local draft boards are already precedents for such a system If adopted locally via referendum (I’m thinking smoking bans, liquor laws, land use codes, etx.) with state and/or federal waivers it might even be constitutional.
The more I think about it, the better I like it.
Would this board be elected or appointed? And if appointed, by whom?
A five member board with two elected, one appointed and the other two selected by the local medical and bar associations respectively would be a balanced mix.
Hmm…
Just brainstorming.
Given tort reform in many(most?) states why are we even discussing medical malpractice? It appears that this system is self regulating since you need a major injury for the lawyer to even consider your case.
“It would be difficult to simply make a list of the types of malpractice cases that are good or bad. Each case is unique and needs to be considered on its own particular merits and facts. But there are certain issues your lawyer will have to work through before deciding if he can accept your case. Since malpractice cases are so expensive and time consuming to pursue, one of the first questions your lawyer will need to address is whether the case is economically justifiable. A lawyer may spend as much as $50,000 to $100,000 in out-of-pocket expenses plus two to three years’ time on a single malpractice case. If a potential case only involves a temporary misdiagnosis of a medical condition, and the correct diagnosis was eventually made with no significant permanent injuries, then that probably is not a good case to pursue. No lawyer would want to risk two years of his time and $75,000 of his money on the possibility that he might recover $25,000 for his client. No client would reasonably want to pursue that type of case either. Legitimate small damage malpractice claims may be inappropriate law suits because the cost to the lawyer, and the potential benefit to the client, simply do not justify a lengthy, expensive legal battle.”
“Assuming the damages are serious enough to justify bringing suit, the lawyer must also determine if there is liability, i.e. did the action or inaction fall below the professional standard of care. He will most likely have to hire one or more doctors as expert witnesses to testify on this issue. Usually at least one expert will be hired before the suit is filed and additional experts are often hired before the case proceeds to trial. These experts will also help establish that the negligent conduct was the actual cause of the injuries complained of. Sometimes this is obvious, and sometimes not. For example, in cases involving negligent delay in the diagnosis of breast cancer, it may be easy to establish that the defendant misread a mammogram, but very hard to establish that the patient would have survived if only the cancer had been diagnosed six months earlier. Complicated medical questions arise such as what type of breast cancer was this? What size was it? What was the cancer cell doubling time? How far had it already spread when the misdiagnosis occurred? This issue of whether the alleged negligence actually caused any injury to the patient, or if so, then how much injury was caused by the negligence and how much was caused by the preexisting medical condition, is the main focus of many malpractice cases.”
“In Georgia lawyers are required to attach an affidavit from an expert witness at the time of filing the lawsuit in court, stating that the facts justify the claim.”
@ John Ballard
If it were up to me to design a system for medical malpractice claims, I would have each county set up a board (to include physicians and lawyers) that would evaluate each claim prior to it proceeding. They would determine if the patient suffered harm, and if that harm could have been reasonably prevented. Valid cases would then go to arbitration. Invalid cases, or those that failed arbitration could go to a loser-pays-all-costs trial.
I’ll check it tonight
Maggie have you ever held a real job at any time in your life? The stuff you say is so far detached from reality I’m honestly curious what sort of life experience you have had to develope these.
“But it would be much less costly for payors (insurers, hospitals) to settle quickly than to pay the very high administrative costs associated with suits that usually go on for years.”
Um, no it isn’t. The reason we figth these claims is becuase it is cheaper then paying them. I would think that is common sense. Do you really think these tens of thousands of executives and defense attorney’s have no idea what they are doing but Maggie Mahar with her hours of internet reserach knows better? Your liberal short commings are flaring up, that mental deficency that allows liberals to be liberals, you can’t see the consiquences of your ideas.
Why is Medicare and Medicaid so easy to rip off via claims, set guidelines that are easy to learn and manipulate.
Why is SS Disability so wrought with fraud, same thing, a regulated and defined set of rules that are more important then the facts.
PigFord discrimination settlement, again nothing but a fraud.
If you passed regualtions like you suggest everyone with any medical error would be getting a payout, even those that are no harmed. Most medical errors don’t result in any adverse consiquences, that is why most medical errors aren’t compensated. If you start reimbursing people for the error not the consiquence your cost will sky rocket. If you start defining all this in an administrative program people will learn it and game it like they do immigration, disability, welfare, and everything else.
“If doctors get behind “full disclosure” I think they would be doing themselves, and U.S. medicine, a world of good.”
full disclousre would never work in the US with trial lawyers. How do you go into court and defend when the doctor has admitted he made a mistake. Even though the argument is about the damage the mistake did and not rather it happened, if you prescribe the wrong pill but the patient never takes it should they be compensated? A trial lawyer will argue mental distress, fear of taking a pill again, and all sorts of BS to get paid.
Peter
Peter– Yes, and so well-put!
ROFLMAO! *bows*
Dr. Mike & Tim–
I understand what you are saying. Physician fear of a lawsuit is quite separate from the odds that any individual doctor will be sued.
The emotional cost of a lawsuit is incalculable. As Justice Brandeis said: there are two things to fear in life: death and litigation.
This why I belive that we need to move away from an adversarial approach to malpractice to a “full disclosure” approach. Yes, we need better laws in many states to protect the “disclose, apologize and offer an early settlment” strategy, but in places where this has been done well (Michigan, for instance) it works.
This does mean that hospitals and doctors s would have to admit that inevitably, they make mistakes. In many cases, more than one person drops the ball, and the hospital needs better systems to reduce the opportunity for errors.
Patients who fall victim to a mistake should be fully compensated.
But it would be much less costly for payors (insurers, hospitals) to settle quickly than to pay the very high administrative costs associated with suits that usually go on for years. Without those exorbitant administrative costs, payors could be more generous when it comes to compensating patients who suffer terrible injuries and still save a fortune. It’s a win-win.
As for doctors, we need to get away from the “shame and blame” that would make you feeling like leaving town if your name were associated with a malpractice suit.
I’d urge you to read Dr. Atul Gawande’s “Complications: A Surgeon’s Notes On an Imperfect Science.” He talks candidly, and with humility, about mistakes he has made as well as near-misses.
If doctors get behind “full disclosure” I think they would be doing themselves, and U.S. medicine, a world of good.
The only way to reduce mistake mistakes is full disclosure: that way doctors and hospitals can figure out how to reduce errors.
Anybody here has knowledge of, or cares to comment on, the Kaiser mandatory arbitration model?
“I, and hundreds of thousands of others like me, will continue to practice defensive (and unnecessarily expensive) medicine until the day you fundamentally change the system. (Economic caps are pointless, they change nothing)”
Okay. I’ll buy it.
All you say is obviously from a solidly honest place deep within your being.
So what or how, in your opinion, is the remedy?
How should the “system” be changed in a manner that will lead to better outcomes at lower per-patient costs?
What about the system is changeable that would make you feel different?
Is technology and progress advancing so rapidly that ongoing price increases are inevitable?
I’m intrigued that you say economic caps change nothing. Have you any opinion about safe harbor courts?
“They play the settlement lottery.”
___
Two words: Loser Pays.
Nate–
You’re mistaken.
First, this is what a “closed claim” is: (As you can see, it can be a case that was settled, or a case that went to court.)
“Professional Liability Insurance Report of Closed Claim
——————————————————————————–
Instructions
A claim is any demand for damages (whether or not for a specified amount, and whether or not a lawsuit has been filed) for personal injuries alleged to have been caused by error, omission or negligence in the performance of professional services, communicated orally or in writing to the reporting insurer or risk management organization.
Pursuant to G.L. chapter 112 section 5C, Form PLICC must be filed with the Board within thirty (30) days after any of the following events:
a final judgment
a settlement, or
a final disposition not resulting in payment on behalf of the insured
For the purposes of determining the date that triggers this filing requirement, please use the following guidelines:
Final judgment – the date of the judgment entered by a trial court. If the judgment is appealed and any information in the original report is no longer correct, a second form must be filed within thirty (30) days of the decision of the appeals court.
Settlement – The earlier of:
the date of the settlement agreement
the date of the release and waiver signed with respect to the licensee reported on the form, or
the date that the settlement agreement or other final document was filed with the trial court.”
Secondly, a description of how the reserachers got the claims:
“We investigated the merits and outcomes of malpractice litigation using structured retrospective reviews of 1452 closed claims. The reviews included independent assessments of whether the claim involved injury due to medical error. Our aim was to measure the prevalence, costs, outcomes, and distinguishing characteristics of claims that did not involve identifiable error.
Methods
Study Sites
Five malpractice insurance companies in four regions of the United States (the Northeast, Mid-Atlantic, Southwest, and West) participated in the study. Collectively they covered approximately 33,000 physicians, 61 acute care hospitals (35 of them academic and 26 nonacademic), and 428 outpatient facilities. The study was approved by ethics review boards at the investigators’ institutions and at each review site (i.e., the insurer or insured entity).
Claims Sample
Data were extracted from random samples of closed-claim files at each insurance company. The claim file is the repository of information accumulated by the insurer during the life of a claim (see the Supplementary Appendix, available with the full text of this article at http://www.nejm.org). We also obtained the relevant medical records from insured institutions for all claims included in the sample.
Following the methods used in previous studies, we defined a claim as a written demand for compensation for medical injury.15,16 Anticipated claims or queries that fell short of actual demands did not qualify. We focused on four clinical categories — obstetrics, surgery, missed or delayed diagnosis, and medication — and applied a uniform definition of each at all sites. These are key clinical areas of concern in research on patient safety; they are also areas of paramount importance to risk managers and liability insurers, accounting for approximately 80 percent of all claims in the United States and an even larger proportion of total indemnity costs.17-19
Insurers contributed claims to the study sample in proportion to their annual volume of claims. The number of claims by site varied from 84 to 662 (median, 294). One site contributed obstetrics claims only; another site had claims in all categories except obstetrics; and the remaining three contributed claims from all four categories
When an attorney refers to “brining a case” he is not talking about “filing the initial paper work.” Here is a statement from alawyers website:
“Bringing a malpractice case can cost up to $100K. The lawyer has to front that money.”
That $100 K assumes that the case does not go to court. Much of the cost is “discovery” . The average case in the study that I talk about above lasted 5 years. In t he study they talk about how mucch the average plaintiff received if they “settled” vs. if the won a verdict in court.
Becasuse malpractice suits are so expensive, the number of suits has plunged over the past two decades. Award amounts have also fallen sharply.
The investigators in the study (all physiicans) were etremely distrubed by the fact that 16% of plaintiffs who were seriously injured (or died) that was caused by medical negligence suffered through a 5-year case and received no compensation.
If you want to know more, take a look at part 1 of the post –it should be up on http://www.healthbeatblog.org within the hour.
Talking about the results of jury awards and the reasons for defensive medicine are two different topics. Doctors don’t study Harvard research about what juries did and did not get right; they practice so as to avoid the next lawsuit.
I have intimate knowledge of many malpractice suits over many years. I can tell you that:
Juries do indeed like doctors and are not easily duped. But this is irrelevant.
Lawyers do not bring suits expecting to go to a jury. They play the settlement lottery. They do not spend millions of dollars on malpractice cases; they can spend very little to get to a settlement with a doctor who spends much more than they do for every hour spent on the case.
In my experience, about 8 of 10 lawsuits filed against orthopedic surgeons have no merit. That means that out of 10 board certified orthopedists who look at that chart, 9 would say the suit had no merit. The plaintiff attorney finds the other 1.
If doctors are reviewing charts of cases FILED in county courts, and finding most have merit, then they are… idiots. The cost of defensive medicine is America is huge. The studies are simply not measuring it.
“The problem with your comment is that you cannot become rich in America working for a salary”
“For an orthopedic surgeon, it might be working with a device manufacturer to develop a more effective or longer lasting device on which he can then earn royalties. For an oncologist, it might mean working with a biotech company on the development of new cancer treatments in exchange for stock options or stock awards.”
Yea Barry, orthopedic surgeons and oncologists must suffer with low salaries longing for the day they strike it “rich” with a device or biotech company. What this country needs to solve health care is more rich participants.
” in which doctor reviewed the files of closed malpratice cases,”
Closed cases from where? Cases filed in court which renders everything you said after this pointless, or cases consulted with an attorney? I would be curious how they reviewed or obtained cases not filed with the courts as insurance companies and defence attorneys try to keep these settlements from being public knowledge.
You probably have no idea why this makes a difference but it makes all the difference in the world. 10 to 1 they only reviewed court cases.
“Bringing a malpractice case is very expensive,”
BS it is. It cost a couple hours and few hundred dollars to start a case, only if it goes to trial does it get expensive, again if you don’t know the difference you shouldn’t be running on about it.
” unless he thinks it is a very good case.”
You obviously have no idea what your talking about. Or unless he thinks he can get a quick settlement. Doctors can’t afford to have their name in the paper as subject to a suit, not to mention the stress. Insurance companies only care about the quickest solution, on multiple occasions our E&O, professional malpratice, has paid bogus claims becuase it was less then our deductible, in fact it cost them nothing to settle but stuck us with the bill. If they can pay $20,000 and be done with it that wont even get their attorney’s out of bed. The problem isn’t the handful of cases that go to court, its the tens of thousands that don’t.
“The physicians examining the cases thought that the doctor or hospital was negligent in more than 16 percent of the cases where the jury found in the doctor’s favor and the plaintiff received no compensation.”
This is going to blow your mind but that actually sounds low to me. The fact you think this supports your argument shows how little you know. If a doctor is treating a dieing person and cuts open something by accident yes they made a mistake but unless it changed the outcome or caused greater damage there is no actionable tort. With our aggresive medicine I’m surprised only 16% got off, that tells me doctors are being held to a god standard.
Barry–
A year after Gawande wrote that New Yorker piece, he was involved in a study done by Harvard’s School of PUblic health in which doctor reviewed the files of closed malpratice cases, and decided whether the patient had indeed been injured, and whether the injury was casused by medical erroir.
They concluded that there were very, very few frivolous cases. In the vast majority of cases, the patient had died or been seriously injured. Bringing a malpractice case is very expensive, so an attorney isn’t going to sink six year of his life into it (the average length of time from inijury to conclusion of hte case) and the money needed to discovery, experet witnesses, etc., unless he thinks it is a very good case.
The physician-reviewers found few frivolous cases, and they found that rather than sympathizing with plaintiffs, juries tend to assume the doctor knew what he was doing. The physicians examining the cases thought that the doctor or hospital was negligent in more than 16 percent of the cases where the jury found in the doctor’s favor and the plaintiff received no compensation.
Other studies point out that when a judge (rather than a jury) decides the case, he is likely to be much tougher on the doctor and/or hospital.
Finally, they point out that onlyl about 2 percent of the patient who are sesriously injured by malpractice sue. The chances of a doctor being sued are much lower than manhy physicians think.
Craig –
Thanks for your comment. Perhaps you could estimate for us what percentage of the total cost of the medical services, tests, procedures and drugs you recommend or prescribe would you classify as defensive medicine. I’m always interested in the real world perspective of practicing doctors. When I asked my NYC cardiologist that question recently, he estimated that for his practice and all the other practices in the area that he’s familiar with, about 15% of the cost of medical decisions and recommendations constitute defensive medicine. Satisfying patient expectations may be part of it as well, but his best estimate is that 15% of the cost of the healthcare utilization that results from his medical decisions, referrals and prescriptions are defensive at their core.
My “lieing eyes” tell me that the “facts” presented in this discussion are essentially correct, but the meaning of those facts are and forever will be lost on me. I think about malpractice every day, with almost every single patient. Every decision about whether or not to order a test is made in light of the malpractice risk of that decision. Standard of care be dammned, if ordering or not ordering places me at risk (what I perceive to be risk) then I will make the decision in the way that reduces that risk. Arguing about whether or not the current malpractice system gives out its “rewards” appropriately is completely irrelevant. I don’t want to be sued, ever. I don’t don’t care about the money – I have insurance for that. $Million? Who cares, won’t come out of my pocket. I just never, ever want to go through that process, or to even have my name in the paper as having been named in a suit, even if I am eventually dropped. I would consider leaving town if that happened. If anyone reading this doesn’t understand how visceral is a physician’s fear of this process then that reader is an idiot. Citing facts and statistics will never make this current system acceptable (not that the claim was ever made in the comments above, but the implication was “oh, it’s not that bad”) It is that bad. In my gut it is that bad. You can’t change that with facts. I, and hundreds of thousands of others like me, will continue to practice defensive (and unnecessarily espensive) medicine until the day you fundamentally change the system. (Economic caps are pointless, they change nothing)
You just don’t get it Craig,
What you and other praticing doctors actully experience is anecdotal, a small step above not being real at all. Now a study posted on the internet by academics who have never worked an honest day in the field or a poll funded by an organization pushing a political agenda, now thats real, thats science.
You need to stop believing your lieing eyes and get on booard with the “Facts” she has the internet reserach to prove it and the hours, yes hours, invested to find them.
Who are we to question a Journalist? On the royality scale they are right there with politicians at the top, now fall in line.
@Ms. Mahar,
This thread is very strange. Trying to deny the costs of defensive medicine is, to me, like trying to deny the sky is blue. You can come up with all the “facts” and studies you want, but the sky is still blue.
Defensive medicine pervaded my medical education entirely, literally from the first day of medical school. A dean warned us that every patient we see is a potential plaintiff, and to treat them accordingly. Fortunately, I was taught to compartmentalize in my mind what was really necessary, and what was just defensive. The cost is quite impressive, actually. It is unfortunate that the defensive medicine modus operandi is pervasive in medical decision making. Trying to separate out real medicine from the defensive is difficult for many physicians, let alone lay people.
However, denying the huge expense of defensive medicine does not help anybody, particularly if one is trying to control costs.
“Our health care system is much more dangerous than systems in other developed countries.;”
Whats next Maggie are you going to start citing High School Year book polls? A subjective poll across borders in disparet systems….wow that has about as much scientific value as throwing darts. I’m curious given the wring medicine is that based on future medical findings or what they were told on TV? I also seem to remember people saying adnasuem how we receive more care, test, and drugs then other countries, I don’t see where this study accounts for that, if they did an error rate per 1000 test for example I might start being interested. This is just another propoganda piece from the hacks at commonwealth.
Maggie –
Actually, I googled and read Dr. Gawande’s article titled “The Malpractice Mess” he published in The New Yorker Magazine in November, 2005. He highlights everything wrong with the medical tort system from its adversarial nature to the lengthy process it takes to bring a case to a resolution. There is no doubt that some patients are harmed by medical errors from a missed diagnosis to a mistake during surgery. There are also a huge number of cases that lawyers don’t take because either no harm was done or the potential payoff for the lawyer isn’t sufficient to cover the expenses necessary to pursue the case. I think that phenomenon is an illustration of our “sue happy” culture in the U.S. exemplified by the person who was annoyed that he had to wait four hours in the ER before receiving (proper) treatment.
I found it interesting that the system we have to compensate people injured by adverse side effects from vaccines adds about 15% to the cost of vaccines. Gawande suggested that such a system probably wouldn’t work for healthcare generally.
While it’s impossible to prove definitively, I suspect that if we superimposed the U.S. medical tort system, U.S. patient expectations, and our inclination to sue or at least consult a lawyer when there is a bad outcome on other countries, their healthcare systems would be considerably more expensive than they are. They would probably still be less expensive due, in part, to lower prices per service, test, procedure or drug.
Barry–
I’m a little disappointed. Saying that we could “go back and forth” on this subject— rather than responding to the evidence I have offered–seems a bit of a cop-out.
Out of respect for your intelligence, and your willingness to grapple with ideas, I spent quite a bit of time responding to your comment on malpractice–doing research and thinking about the problem. I assumed that you would think about the evidence I offered, rather than just blowing it off (or ignoring it.) Also,I find that when I respond to readers who are interested in the facts, I, too, always learn something.
Meanwhile, as I responded to your comment , at a certain point I realized that I was writing a post. So I have spent the last few hours turning it into a post for HealthBeat (www.healthbeatblog.org). It should be up tomorrow.
Here, let me just say that Europe’s experience with Health Courts will surprise you.
And while the doctors you talk to see malpractice suits as an unfarir threat, many practicing doctors who have written articles in peer-reviewed journals are more concerned about the amount of malpractice (medical errors) in this country. Our health care system is much more dangerous than systems in other developed countries.;
From Health Affairs:”One-third of patients with health problems in the U.S. report experiencing medical, medication, or test errors, the highest rate of any nation in a new Commonwealth Fund international survey. Assessing health care access, safety, and care coordination in Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States, the survey found that . . . , the U.S. stood out for high error rates, inefficient and lack of coordination of care.” http://www.commonwealthfund.org/Content/News/News-Releases/2005/Nov/International-Survey–U-S–Leads-in-Medical-Errors.aspx.
We have more malpractice suits, in part, because we have more malpractice.
Finally, no doubt you and I talk to different doctors. And certainly, doctors disagree on this issue. But I’m more impressed by those who actually look at the research on medical mistakes and malpractice.
Maggie –
We could probably argue back and forth on defensive medicine for a long time. It would probably be helpful if some of the doctors weighed in on this. In particular, I would like to hear from rbaer since he has also worked in Germany and France, I think.
Doctors tell me that defensive medicine pervades the medical culture in the U.S. It gets factored into the evolution of practice patterns that become the local community standard to which most doctors adhere. They suffer no financial consequences for doing too much rather than too little and they often benefit financially from doing more rather than less. This is especially true for diagnostic testing in order to protect against failure to diagnose suits, and most of the tests are not painful or invasive which makes them even easier to justify.
Some blame the fee for service payment model for part of this. However, doctors in most other developed countries are also paid on a fee for service basis. Defensive medicine is not nearly as significant an issue in Western Europe and Canada as it is in the U.S. and it’s even less so in Japan. Maybe some of it has to do with differences in culture and patient expectations.
In our culture, I can easily understand why doctors can come to see every patient as a potential plaintiff. It doesn’t matter how many patients don’t sue when they are harmed or how often doctors prevail in court. Enough of them sue when there is a bad outcome but no malpractice to influence practice patterns in the direction of doing more rather than less in order to stay out of court at all costs. If we had health courts instead of juries deciding these cases and a loser pays rule like they have in the UK, I think we would have far fewer lawsuits and, eventually, less defensive medicine.
Barry-
“You write: “What drives physicians to practice defensive medicine is the total lack of objectivity, fairness and consistency both across jurisdictions and even within a jurisdiction as how medical disputes are decided. Juries of lay people who cannot understand the often conflicting scientific claims in these cases can be easily swayed by emotion and sympathy for injured plaintiffs”
These are assertions, without evidence.– what I would call fictions.
Here are the facts (from a JAMA article)
“Over the years, our understanding of medical malpractice has been plagued by a number of myths, many of which have been exposed by a remarkable series of reports from two groups.1-3 As a result of these reports, and contrary to popular belief, we know that adverse events due to negligent practice rarely result in a lawsuit (only 2% of such events lead to malpractice claims),1 juries are not systematically biased against physicians (malpractice defendants win more than two thirds of cases, a better record than defendants in other kinds of personal injury cases),2,4 and juries decide cases on the basis of the physician’s quality of care rather than the patient’s severity of injury.2”
“In this issue, Burstin et al 3 expose another persistent myth about medical malpractice. It is commonly believed that poor patients are more likely than wealthier patients to bring suits.”
You’ll note all of the footnotes– citing reserach which backs up what the authors are saying.
Regarding the poor, another JAMA article desccribes a study looking at 51 hospitals in New York State which concluded: ” Poor and uninsured patients are significantly less likely to sue for malpractice, even after controlling for the presence of medical injury. Fear of malpractice risk should not be a significant factor in the decision to serve the poor. Tort reforms that would protect physicians who serve the medically indigent from malpractice suits may not be warranted.”
Conservatives who argue for tort reform have spread the myth that the poor are more likely to sue, and have suggested that, for that reason, doctors who are kind enough to treat poor patients shoudl be exempt from malpractice suits. (Which would mean that the poor are stripped of their legal rights for compensation, simply because they are poor.”
The phrase “the poor aren’t shy about suing” troubled me because it suggests that they should be shy— or shyer about suing than other people.–presumably because they should be grateful that a doctor is willing to try to treat them (which suggests that thte poor don’t have the same “right” to healthcare as everyone else. )
I believe that this may not have been what you were thinking–you may simply have been echoing a phrase that you have heard others use.. But if you think about it, it’s quite different from simply saying: “The poor are as likely to sue as anyone else.
And, in fact, the truth is that “The poor are much less likely to sue.”
As you know, I too would like to see “a dispute resolution system presided over by judges with specialized knowledge and the power to hire neutral experts to help them sort through conflicting scientific claims..’
But I would point out that there is no such thing as a completely “netural” expert and in many cases Ithere is no clear “right” answer as to whether the doctor or hospital committed an error.
For example, in some of the most painful cases, an infant of mother has died during childbirth. There may well be legitimate differences of opinion as to whether under those particular circumsgtancese, the doctor should or shouldn’t have performed a C-section. (Sometimes the C-section is more dangerous; sometimes it is less dangerous. Hindsight is always easier than making the decision at the time.
Then there are the cases where back surgery makes the back pain worse. Should the doctor have recommended surgery? In many cases, back surgeons would disagree with each other. (See what I say at the end of this comment about how doctors who reviewed malpractice cases were confident in their judgment less than half of the time.)
Medicine is not cut and dried. As Dr. Atul Gawande writes in his book Complications (which I urge you to read), lay people do not appreciate the “ambiguities” of medicine.
Cerebal Palsy is a good example. Nate asserts that “the link between doctor error and cerebral palsy is questionable, at best.”
Iin fact, medical reserarch reveals that there are many possible causes of cerebral palsy–including what happened just prior to and during birth.
A very recent story in the LA Times points out that “r, a study published Thursday suggests that general improvements in the care of infants just before, during and after delivery are making a difference. Researchers in the Netherlands studied almost 3,000 infants born prematurely between 1990 and 2005. Cerebral palsy rates declined 6.5% from the start of that period compared with the years from 2002-05. The study also found a decrease in the severity of cases, . . Various strategies have been tested to lower cerebral palsy rates, such as Cesarean section delivery, fetal monitoring and various medications, such as antibiotics and corticosteroids. Still, it’s not clear why the prevalence of white matter lesions that cause cerebral palsy is falling, said an author of the study, Linda de Vries, of the University Medical Center Utrecht. It seems that overall care of infants is just better.
“There is not really a single factor we can point out,” De Vries said. “It is more general improved perinatal care”
So it seems that what doctors do can reduce cases of cerebal palsy. We know, for instance, that late birth (days after the due-date) can be a cuase of cerebral palsy. The question then is: should the doctor have performed a C-section or induced labor sooner? In a recent case where the mothers” amniotic fluid had dropped by half and her physician waited days to perform a Caesarian section,” the jury found in favor of the parents.” Were they wrong?
It’s just not clear.
WE do know that many cases of CP are NOT caused by physician error.f
The cause may be genetic, or it may be connected to an infection the mother contracted long before deliver.
Last year, JAMA published an article which said that , following a long study of kids with CP, ” the investigators said, only 19.9% of a population with cerebral palsy, might be considered on the basis of MRI scans as having some type of obstetric mishap as the cause of their brain damage.”
“Reviewing the possibilities for prevention, the investigators suggested that more attention be paid to the importance of infections during pregnancy and that despite legitimate concern about overprescription of antibiotics, there should be no question about treating infections during pregnancy. ”
Given what we now know, is an OB-GYN guilty of malpractice if he tells a pregant women not to take antibiotics to treat an infection, and the baby is born with CP? It’s unclear. If standards for best practice said that the pregnant woman shoud take antibiotics, then perhaps the doctor woudl be vulnerable to a lawsuit. But again, it’s not clear.
This brings us back to the Harvard study where physicians reviewed malpractice cases and decided, in retropsect if the physician had committed an error.
tBarry-
“You write: “What drives physicians to practice defensive medicine is the total lack of objectivity, fairness and consistency both across jurisdictions and even within a jurisdiction as how medical disputes are decided. Juries of lay people who cannot understand the often conflicting scientific claims in these cases can be easily swayed by emotion and sympathy for injured plaintiffs”
These are assertions, without evidence.– what I would call fictions.
Here are the facts (from a JAMA article)
“Over the years, our understanding of medical malpractice has been plagued by a number of myths, many of which have been exposed by a remarkable series of reports from two groups.1-3 As a result of these reports, and contrary to popular belief, we know that adverse events due to negligent practice rarely result in a lawsuit (only 2% of such events lead to malpractice claims),1 juries are not systematically biased against physicians (malpractice defendants win more than two thirds of cases, a better record than defendants in other kinds of personal injury cases),2,4 and juries decide cases on the basis of the physician’s quality of care rather than the patient’s severity of injury.2”
“In this issue, Burstin et al 3 expose another persistent myth about medical malpractice. It is commonly believed that poor patients are more likely than wealthier patients to bring suits.”
You’ll note all of the footnotes– citing reserach which backs up what the authors are saying.
Regarding the poor, another JAMA article desccribes a study looking at 51 hospitals in New York State which concluded: ” Poor and uninsured patients are significantly less likely to sue for malpractice, even after controlling for the presence of medical injury. Fear of malpractice risk should not be a significant factor in the decision to serve the poor. Tort reforms that would protect physicians who serve the medically indigent from malpractice suits may not be warranted.”
Conservatives who argue for tort reform have spread the myth that the poor are more likely to sue, and have suggested that, for that reason, doctors who are kind enough to treat poor patients shoudl be exempt from malpractice suits. (Which would mean that the poor are stripped of their legal rights for compensation, simply because they are poor.”
The phrase “the poor aren’t shy about suing” troubled me because it suggests that they should be shy— or shyer about suing than other people.–presumably because they should be grateful that a doctor is willing to try to treat them (which suggests that thte poor don’t have the same “right” to healthcare as everyone else. )
I believe that this may not have been what you were thinking–you may simply have been echoing a phrase that you have heard others use.. But if you think about it, it’s quite different from simply saying: “The poor are as likely to sue as anyone else.
And, in fact, the truth is thath “The poor are much less likely to sue.”
As you know, I too would like to see “a dispute resolution system presided over by judges with specialized knowledge and the power to hire neutral experts to help them sort through conflicting scientific claims..’
But I would point out that there i