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medpundit |
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Wednesday, April 09, 2003I think that your discussion of whether large malpractice awards make patients feel better misses something important: one of the primary purposes of malpractice lawsuits is to incentivize doctors to take the appropriate amount of care with their patients. It's an extremely tricky economic problem to figure out what the appropriate level of award to provide an optimal incentive is, but it's not at all clear that the number would be lower than the current malpractice awards as opposed to higher. In particular, if only a small number of malpractice cases are ever detected, the level of the award needs to actually be higher than the patient's loss in order to have the average cost of malpractice to the doctor to be correct. He has a more detailed analysis of this here. Although I’m not adept enough at statistics to critique the detailed analysis, I have reservations about the general premise that fear of lawsuits keeps doctors honest. I suppose that’s true to some extent. But, I think that far more often, fear of a lawsuit causes us to overtreat and to order unneeded tests to protect ourselves. All doctors experience this, and not just occasionlly. Here’s another example from my own practice. A patient came to me after her sister was diagnosed with ovarian cancer. She wanted to make sure she didn’t have it. I discussed how we don’t really have a good screening test for ovarian cancer. She should have yearly pelvic exams to check for ovarian masses, but by the time those are felt, cancer is usually advanced. We could do yearly ultrasounds, but a cancer could still crop up in the intervening months, and be quite aggressive. We could do yearly blood tests for a protein that’s produced by ovarian cancer cells, but the test isn’t specific for ovarian cancer. It can be elevated for other reasons, resulting in a lot of worry and perhaps a needless surgical procedure. Again, a cancer could develop in the intervening months. Early diagnosis of ovarian cancer doesn’t necessarily improve outcomes, because ovarian cancer tends to be aggressive. We discussed genetic screening, which also can’t tell her with any certainty whether or not she’ll develop cancer, but only whether or not her risk is increased. In the end, she looked at me blankly, shrugged her shoulders, and said, “I don’t know. You decide. I trust you to do what’s best for me.” But, in the case of screening tests like that, I don’t know what’s best for her. I don’t know if the false sense of security she gets from a normal screening test is worth the lower level of daily anxiety. I don’t know if she’ll think that a surgical procedure initiated by a false positive screening test would have been worth the risks it entails. But, I do know this. If I don’t do those tests, and she gets ovarian cancer, I’ll be the one who gets the blame. Maybe not by her, but certainly by her family. So, completely out of self-interest, I ordered the tests. They probably won’t make a difference in her life expectancy. They will certainly cost her insurance company a lot of money. But, they’ll keep me out of court. I know that I'm not alone in this. Everytime I get a radiology report that hedges on the result and suggests more studies, I know the radiologist is doing the same thing. I suspect most of my mammogram call backs are due to this. There are times when exercise stress tests are equivocal for evidence of heart disease, the history not very convincing, yet patients get cardiac catheterizations "just so we don't miss anything." And there are plenty of times when we all order x-rays looking for fractures when we know full well the yield is likely to be small. All of this adds up quickly. And we all pay the price. As one of my older, more experienced, colleagues once said, "It used to be that ordering a lot of tests was a sign of a doctor's inexperience. Now, it's the standard of care." posted by Sydney on 4/09/2003 09:15:00 AM 0 comments 0 Comments: |
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