March 7th, 2013

The Bogus “Risk of the Procedure” Defense

With great regularity I hear people write off bad medical outcomes as simply a “risk of the procedure.” It happened again today in an email from a company that helps lawyers find medical-legal experts. One of their experts wrote:

A 52 year old woman presented to Hospital and underwent a total hysterectomy. The surgeon perforated her bladder during the procedure….

…The question is whether perforation of the bladder is a known risk of the surgery and, if so, are there ever instances where it is nonetheless a breach in the standard of care?

That is wrong, wrong, wrong, 1,000x wrong. That is not how to frame the question.

And you can appreciate that it is framed wrong if you simply substitute a car accident for the medical procedure. Isn’t getting into an accident a known risk of driving in a car?

The fact that something is a known risk is a game that defense lawyers play. It does not simply absolve a defendant.

But the real question that a jury gets is whether the injury could have been avoided with the exercise of reasonable care. So an auto wreck may be a known risk of driving in a car, or it may not.

An example: You drive on the highway and a deer leaps out of the woods into the path of your car. This may be unavoidable even with reasonable care. Or the deer may have been standing in that spot for 20 seconds but you were busy texting while driving and didn’t see it.

It isn’t any different in medicine, and those magic words “known risk of the procedure” should set off alarm bells. Is having a sponge left behind after surgery a known risk? Yes it is. But it is also negligent because someone wasn’t keeping track of all that went into the body to make sure that all came out.

A doctor might, or might not, have been negligent in the way treatment was rendered, but the fact that something is a “known risk” doesn’t answer the question.

If you ask the wrong question, you might be lead to wrong conclusions.

December 20th, 2012

Oprah Winfrey, Diane Sawyer and My X-Rays

This is a story of two famous women, and a bunch of x-rays that hang in my office. Both wanted to use them on their shows as examples of surgical equipment that had been left behind. One of the films is to the right, and the others on my web site.

A few years ago I received an email from the Oprah Winfrey show. It seemed that some guy named Dr. Oz wanted to use those x-rays for a show on medical mistakes.

Sure, I said, you can use them, so long as you give me credit so that these don’t disappear into the public domain. Interested parties should know their original source. Thus started the most ludicrous negotiation I’ve ever had in my life on any subject. After a few dozen emails over several weeks, they successfully overlawyered the issue to death and they never saw the light of day on the almighty Oprah show.

I confess that, when I finally wrote As Seen On Oprah! (Kinda, Sorta, Almost) I had a lot of fun. More fun than should be legal, perhaps. It never got much in the way of pageviews, but it’s always been one of my favorites.

So this afternoon I get a call from a producer from Diane Sawyer for ABC News. They also want to use the x-rays for show on medical mistakes.

We consummated a deal in about a minute. You can see the clip here as my films have their 15 nanoseconds of fame and glory.

Two different media divas; two different ways of handling a routine matter.

August 2nd, 2012

New York’s Medical Malpractice Crisis (Huh? Where did it go?)

Senator John DeFrancisco (Republican, Syracuse)

Since I’ve twice hit the subject of “defensive medicine” in the last couple weeks — doctors claiming to do extra procedures out of fear of being sued — I thought it would be a good time to update the state of the medical malpractice crisis in New York. OK, I didn’t really think of this on my own as a time to update. I got a press release on the subject. And while I don’t generally act as a distributor of press releases, this one seems to be particularly important.

The author is New York State Senator John DeFrancisco (Republican, Syracuse). He is currently the powerful chairman of the Senate Finance Committee and was formerly the chair of the Judiciary Committee.

And guess what? The “crisis” doesn’t exist. Without further ado, a brief press release from today:

STATEMENT FROM SENATOR DeFRANCISCO

This year’s modest malpractice insurance increases confirm that there is no malpractice crisis in New York State.

Malpractice costs have been rising more slowly than overall medical inflation in recent years, and the number of malpractice cases filed has gone down in every successive year since 2007. Today, New York has the fourth most doctors per resident of any state, and continues to graduate many of the nation’s new physicians every year.

Given the improving financial outlook of Physicians’ Reciprocal Insurers and the record $1.2 billion surplus that Medical Liability Mutual Insurance Company recorded last year, significant increases in malpractice insurance costs are unlikely in the years to come. In fact, even today’s modest increases may have been unnecessary.

Moreover, numerous studies have shown that malpractice costs can be dramatically reduced by implementing safety programs that protect patients and reduce preventable medical mistakes before they happen.

August 1st, 2012

Sanjay Gupta Gets It Wrong

In an op-ed in today’s New York Times (More Treatment, More Mistakes), Dr. Sanjay Gupta argues that we currently face a crisis of about 200,000 people dying each year from medical mistakes. In doing so, Dr. Gupta — a neurosurgeon and chief medical correspondent for CNN — says that many of the injuries and deaths come from too many tests and procedures.

He cites a few war stories to support his theory about too many tests — and injuries/deaths that come from the treatments or misdiagnosis. But that is not the part that I take issue with.

This is the problematic part: Dr. Gupta claims that the reason too many tests are ordered are, you guessed it, “defensive medicine” because doctors fear lawyers and lawsuits. The problem is not with the medical community, he says, but the legal one. He writes:

Certainly many procedures, tests and prescriptions are based on legitimate need. But many are not. In a recent anonymous survey, orthopedic surgeons said 24% of the tests they ordered were medically unnecessary. This kind of treatment is a form of defensive medicine, meant less to protect the patient than to protect the doctor or hospital against potential lawsuits.

I take issue with that last part I put in bold. Actually, it isn’t just that I take issue with it, but that it flies directly in the face of empirical data. It seems to be accepted wisdom in the medical community that lawyers are to blame for increased costs (and now, increased injuries and death). I noted this exact same issue a couple weeks ago when Florida doctor Lee S. Gross made similar comments to his local paper.

Given that the medical community has a long and rich history of doing research to improve medicine, you would think that, when research challenges accepted wisdom, that the community would sit up and take notice.

As I noted to Dr. Gross, when Texas implemented medical malpractice “reform” back in 2003 that capped pain and suffering awards at $250,000, the expectation was that there would be fewer lawsuits (that part worked), more doctors coming to Texas (that part failed) and lower medical costs (also a failure). The reason for fewer lawsuits, of course, is that medical malpractice cases are so difficult, expensive and risky to bring, that lawyers can’t afford to take smaller suits.

If you chop out the significant issue of pain and suffering, you are left with economic loss. And if the patient makes just a modest living, that economic loss component would also be low. Lawyers won’t take the cases because lawyers also have mortgages to pay and offices to run. It’s basic economics. The victim is left in the cold looking at the closed courthouse door.

Now back to the studies I just referenced. The actual data in one study showed that:

There is no evidence that the number of physicians per capita practicing in Texas is larger than it would have been without tort reform.

And the data from a second study showed that so called “defensive medicine” continued even after patient rights had been eviscerated. In fact, medical expenses went up 13% faster than the national average.

There are really only three potential reasons for Dr. Gupta’s theory of too much testing.

Doctors get reimbursed for each test they do, so there is a financial interest in over-ordering tests;
Doctors simply want to look under every rock in the search for what ails the patient;
Doctors have heard so much about lawsuits, that they order extra tests to protect themselves (i.e. defensive medicine).

The problem here is that 2 and 3 above seem to be conflated by many, that being fear for the patient and fear of the patient. If the Texas Malpractice Experiment is a failure in controlling costs and encouraging doctors to move to Texas, then the problem has to be either the financial interest or the desire to do good. But let’s not confuse the desire to do good with “defensive medicine” to protect against lawsuits. Because the empirical data has shot that theory down.

Don’t blame lawsuits for more testing and more deaths from unnecessary treatments. Gutting the Texas malpractice system did not reduce medical costs and tests. The problem lies within the medical community.

[Updated — More on this from Max Kennerly: Atul Gawande Versus Sanjay Gupta On Defensive Medicine]

July 19th, 2012

Sorry, Dr. Gross, But You’re Wrong (Florida Malpractice Proposal)

In an opinion piece today in the Tampa Tribune, Dr. Lee S. Gross, treasurer of a local county Medical Society and president of the Florida chapter of Docs4PatientCare, advocates replacing the current medical liability system with a type of worker compensation system.

Dr. Gross’s argument, in a nutshell, goes like this:

By eliminating the fear of being sued, the wedge between patients and physicians will be removed, allowing doctors to choose the best health care for their patients. Fewer unnecessary tests and procedures will result in decreased health care costs for individuals, employers and state and federal governments.

The problem with this argument? It’s already been debunked by studies. The biggest study I know of is Texas, which turned itself into a lab study by eviscerating patient rights in 2003 by capping pain and suffering awards at $250,000. Since medical malpractice cases are so difficult to bring and expensive to prosecute, this effectively gave a big helping of immunity to the medical community.

The Texas logic in doing this? That by closing the courthouse door more doctors would come to Texas, whose population was swelling.

And the Texas experiment has now been shown to be a failure. It gave protections and immunities but didn’t do what it was intended to do. I wrote about this two months ago (Study Says Texas Medical Malpractice Tort “Reform” Is A Bust (Is Congress Listening?)), and you can read that post if you want more, but this is the summary:

There is no evidence that the number of physicians per capita practicing in Texas is larger than it would have been without tort reform.

But that wasn’t the only failure of the Texas Malpractice Experiment. It also failed to control costs. Since Florida’s Dr. Gross thinks reform will cut costs in Florida by eliminating “defensive medicine” tests, it’s worth noting that a different study showed Texas medical costs rose 13% more than the national average after its “reforms” were put in place. The problem, it seems, is that doctors get paid to do those so-called defensive tests.

While it is certainly possible that some docs at some points may practice defensive medicine, the real problem is that costs go up when you have a fee for service system.

And so, if you think that destroying the medical liability system in Florida is likely to lead to lower costs, there is an uphill fight because the data says otherwise. Will doctors make more money? Yes, they will. That happens when income stays the same and expenses (malpractice insurance) goes down. But it won’t help those injured by malpractice who will bear the burden of the injuries and it won’t help lower medical costs. What it really means, is that those injured will have to fight in an administrative forum for compensation, instead of a judicial forum, and do so for compensation that does not make them whole.

And last, a final note of irony: Dr. Gross, as I noted at the top, is part of an advocacy group called Docs4PatientCare. They oppose big government intervention in the healthcare system. Except, I guess, when the big government intervention is to help give them immunities and protections and increase their profits. Then, it seems, it is A-OK.