29 September 2007

It's getting chilly in Hell

Not frozen over, but nippy with a light frost.
The Chicago Cubs are NL Central Champs!

Now if only we can get over that damn goat!And Steve Bartman!It's only been 99 years since our last World Series Championship...

26 September 2007

Straw Men

Filed under "things that make me crazy":

From the usually admirable MedPundit (h/t Kevin):

"Universal Pander
What are people really wishing for when they say they wish for a single nationalized health insurance program? Security. Our current employer-provided system means that most of us are just a pink slip away from losing our insurance coverage. It also means that, deprived of the bargaining power of large corporations and unions, the self-employed are left with fewer choices and higher premiums. Handing over the whole kit and kaboodle to the government is a seductively simple solution. But it would also be a very expensive solution.

The British are often held up as the standard to which we should aspire."

Arrgh! (sound of head exploding)

NOBODY is advocating for an NHS! Not even nut-job lefty elf Kucinich! NOBODY! Primarily that's because the NHS is a disaster. There are other reasons, too, but I'll leave it at that.

Also, you miss one major fact in your coda -- the UK spends less per capita, but not because UK citizens are dying and not utilizing their health care. The average life expectancy there is in fact longer. They spend less because they pay doctors less, have invested much much less in medical infrastructure, and cut corners on utilization of health care (from doctor visits, to simple labs, to heart caths to MRIs). The effect this has on outcomes has not been well established.

You are right, though, in your central point, I think: Universal health (or a government-run national health insurance) will do little to contain the exploding costs of health care. Universal Coverage and Cost Containment are two very different things, and I have not seen a proposal which adequately addresses both. I'm not sure it's really possible to address both in a single unified proposal. Even the most dramatic proposal, Medicare for all, would achieve only temporary reduction in cost due to a reduction in administrative costs, but would not inherently reduce the amount Americans spend on health care, or the growth in health care spending. HillaryCare and EdwardsCare and ObamaCare have only vague pretensions to cost control and focus primarily on expanding the number of people with access to health care.

Which is fine with me.

The crisis right HERE and NOW is the 48 million-plus Americans who have no access to medical care. The future crisis is the economic sustainability of the system. Both need to be addressed, but my preference is to fix the pressing humanitarian crisis first and then address the sustainability factor down the road. Honestly, not only is universal coverage more urgent, it's easier. There doesn't seem to be any easy solution to the cost growth -- there are too many variables, cultural factors, scientific questions, and interested stakeholders to allow for a quick & simple fix. There is, however, a number of quick & easy fixes to universal coverage.

So let's just get busy with that and figure out how we'll pay for it down the road.

The Bishop!



Devious: Now then, vic. What's the trouble?
Vicar: It's about this letter you sent me regarding my insurance claim.
Devious: Oh, yeah, yeah - well, you see, it's just that we're not...as yet...totally satisfied with the grounds of your claim.
Vicar: But it says something about filling my mouth in with cement.
Devious: Oh well, that's just insurance jargon, you know.
Vicar: But my car was hit by a lorry while standing in the garage and you refuse to pay my claim.
Devious: (rising and crossing to a filing cabinet) Oh well, reverend Morrison...in your policy...in your policy...(he open the drawer of the filing cabinet and takes out a shabby old sports jacket; he feels in the pocket and pulls out a crumbled dog-eared piece of paper then puts the coat back and shuts the filing cabinet)...here we are. It states quite clearly that no claim you make will be paid.
Vicar: Oh dear.
Devious: You see, you unfortunately plumped for our 'Neverpay' policy, which, you know, if you never claim is very worthwhile...but you had to claim, and, well, there it is.
Vicar: Oh dear, oh dear.
Devious: Still, never mind - could be worse. How's the nude lady?
Vicar: Oh, she's fine. (he begins to sob)
Devious: Look...Rev...I hate to see a man cry, so shove off out the office, there's a good chap.

Charming.

From The Consumerist (via the Great Orange Satan):

"Blue Cross Blue Shield Calls Miscarriage 'Elective Abortion,' Denies Claim"

Click through the link for the story, but the headline pretty much sums it up. The patient, explains in her own words:

"I just got off the phone with the hospital and was told that the claim was not miscoded. The billing clerk told me that the wording clearly stated that I had had a spontaneous miscarriage and not an elective abortion. I was also informed that this is common practice with BCBS of Kansas City to deny miscarriage clams as an "elective abortion." [...] Mind you we have had Blue Cross and Blue Shield of Kansas City for less than three months, they have denied every claim we have submitted to them. EVERYONE!"

This is the problem with for-profit health insurance. They have a motive to engage in practices which minimize the amount of claims actually paid. It's well-known in ER billing circles that insurers use computer filters to automatically deny a certain fraction of claims, knowing that some consumers won't bother to appeal (or lack the sophistication to navigate the byzantine appeals process), and those denied claims are pure profit for the insurer. Any claim that isn't a "clean claim" -- meaning submitted in accordance with each insurer's idiosyncratic rules and procedures -- is automatically returned to our billing office denied, usually with minimal explanation, forcing us to research why it was denied and resubmit. Maybe 5% of our claims are denied in this manner -- but we see over 120,000 patients a year. And if some of those denied claims get lost in the shuffle and never are resubmitted? Pure profit for the insurer.

Contrast that with Medicare: claims filed electronically, paid quickly and without hassle, funds electronically deposited in our account. Sure, it's not perfect -- the Medicare compensation rate is about half that of the typical commercial insurer, and Medicare can audit us and send me to jail on a technicality. But forgive me for sometimes wishing Medicare was the only payer I had to deal with.

25 September 2007

Back Door to Single Payer?

Maggie Mahar over at The Health Care Blog looks at Edwards and Clinton's health care plans, and she hits it out of the park. Money graf:

Quite simply, Clinton has opened the door to the single-payer model—if people want it. The beauty of her plan is that no one is forced into a government plan. Americans will wind up in a Medicare-like plan only if they choose it over a private insurer.

Clinton is not alone. Last spring John Edwards unfurled a proposal that would force private insurers to compete with a public plan that he calls “Medicare-Plus.” Today, in a web-cast sponsored by the Kaiser Family Foundation, he reiterated his goal “to give consumers a choice; they could gravitate in either direction.”

One journalist on the panel was blunt: “Is this a back-door to single payer?"

Edwards liked the question. “That’s partly right and partly wrong,” he said, with a big smile. “It’s not intended to take us to single-payer. It’s designed to let Americans decide whether or not they want single payer.”
Interesting take on it. I like the idea of giving people the option. If done right -- i.e. no structural gimmicks to favor private over public plans, or vice versa -- it will be interesting to see which way the market drifts. As a private provider of health care, I like the idea that there will be no monopsony driving down the cost of my services. -- i.e. the health plans will have to compete to maintain adequate networks. As the administrator of a small business, I like the idea that I will have more options (and hopefully more affordable options) to provide my employees with health insurance.

I've gone on record saying Hillary is not my candidate of choice -- I'm pulling for Obama. But more smart policies like this from her and I could definitely warm up to her in the general, if it should turn out that way.

20 September 2007

Secret Shopper

One of the nice things about medicine is that it is still a respected profession in the average community, and as I have become more involved in the medical staff of our local hospital, an inevitable corollary is that I have begun to get involved in local community activities: charitable foundations, local politics and the like. It's a time burden, but personally rewarding, so I don't mind, and if nothing else I get to meet lots of interesting people.

One day, not long ago, I walked into a board of directors meeting for one such activity. As I entered the crowded room, about ten minutes early for the meeting, a loud voice cut across the murmur of small talk and chitchat that precedes any such convocation:

"Hey, I know that guy! He took care of my heart!"

I really don't generally look forward to these interactions: meeting former patients in a social setting. There's usually (always) a complaint about how long they had to wait, or the smelly drunk in the gurney next to them, or the "real" diagnosis given to them by their follow-up doc. I looked over my shoulder, hoping somehow that I had been followed into the room by a cardiologist, but there was nobody. I turned back, resigned, to face my fate. A cheerful, ruddy-faced fellow was forcing his way through the crowd, followed by a small phalanx of hangers-on and goons. The entire assemblage had stopped chatting and was turning to see what the excitement was about.

Moments later, he was pumping my hand up and down and breathlessly gushing, "I don't know if you remember, but you saved my life about six weeks ago." He mimed a defibrillator going "zap." I had no recollection, of course, but I said "Yes, yes, I recall, but I am sorry because I can't remember your name...." If nothing else, that usually buys me some time to think. He introduced himself as [name of prominent regional politician redacted]. Still nothing, but I've a terrible memory for names and am good at faking it. "Oh yeah, I remember now. So how're you doing?"

"Oh great!" He began speaking to the crowd of people around us, "This guy fixed me up real good. I haven't had a problem since. You wouldn't believe the stuff they do there in the ER!" He began recounting the details of his visit to the assemblage, with a somewhat over-dramatized version of my own heroic role in the events. And I did begin to recall his case, with that prompting.

It was, from my point of view a totally satisfying case, though hardly heroic. A simple cardiac arrhythmia, symptomatic enough to require urgent treatment, and most effectively treated by DC Cardioversion (zap). His complaint and vital signs had gotten him a bed and me at the bedside promptly, despite presenting on a busy holiday. I remembered him as a pleasant professional middle-aged guy, frightened, with a very anxious wife at the bedside. We established a good trust, terminated the arrhythmia with some electricity, and he went home happy. I never made the association between his name and the powerful local politician with the same name. He had been in bed 3-2, which is in a double room, and was in the ED about three hours. Bizarrely enough, during that time frame, we had no fewer than three acute ST-Elevation MIs come in, and all three were briefly in room 3-1 before being whisked off to the cath lab.

So this fellow gets his own heart shocked and happens to get to overhear my "You're having a heart attack" speech to three temporary roommates. No wonder he thought we were so great.

I shook my head -- what dumb luck, that a guy in this position of influence should have had that one-in-a-million ER experience. And I had no clue who he was at the time! It makes me think of long ago, when I used to work in a large retail chain as a sales associate, we would get these "Secret Shoppers," or "spies" as we bitterly called them, who would come in posing as regular customers but actually rating the performance of the employees. He had been sort of a medical version of a secret shopper.

I guess I passed.

18 September 2007

Be Thee Warned . . .


Avast, ye filthy lubbers!

Tomorrow be International Talk Like A Pirate Day!

Arrr!

17 September 2007

HillaryCare, part deux

Long-awaited, here it is.

I should say in advance that I'm not too interested in the details of the various health care reform plans that the candidates put out. If Hillary (or Barack or Edwards) gets elected, their plan still has to get through the meat grinder of Congress, and will come out looking rather different, presuming anything at all comes out the other side, which is hardly a certainty.

But the health wonk in me just can't resist the urge to peruse the details, which I will justify as perhaps giving some insight into the values and priorities of the candidates. The details are sketchy as yet, but FWIW:

The Good

  • Continues the system of commercial insurance carriers competing for subscribers (and providers)
  • Opens the Federal Employee Health Benefit Plan to individuals
  • Establishes a "ground floor" for benefits (i.e. FEHBP)
  • Requires plans to be community rated (i.e. no "pre-existing condition" exclusion)
  • Personal responsibility: individuals are required to purchase insurance
  • Tax credits for low-income working families to purchase insurance
  • Tax credits for small employers to offer insurance
  • Inter-state standardization of insurance regulations
  • Appears to be universal
The Bad (or unanswered questions)
  • How will the mandate be implemented (and enforced)?
  • Is it really universal?
  • What incentive/requirement is there for employers to continue to purchase insurance for employees?
  • Does not eliminate Medicaid; universality seems to be based on a patchwork of programs
  • Phantom cost-savings ("Over half the savings come from the public savings generated from Hillary Clinton's broader agenda to modernize the heath systems and reduce wasteful health spending" Huh?)
Overall it looks good; certainly as good as Obama's or Edward's plans. (And not too different from them, except in the details.) I'm not bothered by the lack of a real cost-control mechanism. There are two crises in American Health Care right now -- the uninsured crisis, and the escalating cost crisis. While they are to a degree inter-related, I suspect that they will have very different solutions and I actually prefer that they be addressed separately. It is irritating that despite creating a mechanism for universal coverage, the plan does not take the next logical step of eliminating Medicaid. Medicaid is an abomination of bureaucracy and a huge drain on federal and state budgets. Why not ditch it and roll in the indigent into the health plans, either through tax credits or some government subsidy? There may be some cracks in the universality of the plan, also -- what about those who for whatever reasons do not qualify for Medicaid but don't make enough for the tax-credit based private plans? A small gap, to be sure, but still a gap.

One of these days I'll try to put together a more comprehensive post comparing the details of the candidates' plans.

Home Alone

Ahhh. Monday morning. I'm off today (worked all weekend). First-Born Son is off at school, and The Lovely Wife took Second-Born Son and went out for coffee with a friend. So I am home alone in a quiet house, I have a hot cup of coffee myself, and I can do anything I want to.

Pure bliss.

14 September 2007

Headline not from the Onion

"Lone Icelandic Soldier to leave Iraq"

Seriously, not from The Onion.

From The Onion:

U.S. Troops Draw Up Own Exit Strategy

In a striking rebuke of the assertions of the Pentagon and the White House that a swift exit is neither practical nor possible, soldiers of varying rank have outlined a straightforward plan of immediate disengagement, dubbed "Operation Screw This."

13 September 2007

More sad tidings

Three weeks ago I linked to an unusual and powerful op-ed in the New York Times, written by seven members of the 82nd Airborne who are -- were -- currently deployed in Iraq. At the time of publication, one of the authors had been seriously injured, and was recovering from a gunshot wound in a hospital in Germany.

Two more of the seven, Sgt. Omar Mora and Sgt. Yance T. Gray died Monday in a vehicle accident in western Baghdad, two of seven U.S. troops killed in the incident which was reported just as Gen. David Petraeus was about to report to Congress on progress in the "surge."

Their voices were eloquent and thoughtful, and I admire their courage in speaking out, as I admire their courage and dedication in the prosecution of the war. When I first read their piece, I was impressed with the sophisiticated analysis they presented and the broad scope of their argument. I assumed that the authors must be high-ranking officers with considerable education and experience, and was surprised to learn at the end of the article, that they were "only" enlisted soldiers and NCOs: sergeants and specialists. I think it really says something about the quality of people, the training, and the professionalism in our armed forces that such insightful and relevant commentary could come from the "common" solders, the rank and file.

America has lost two more of its best, brightest, and bravest. How many more?

11 September 2007

The Big Chill

This strikes me as potentially big news:

Everett diagnosis takes positive turn
Injured Bill moves limbs in 'unexpected' development

BUFFALO, N.Y. (AP) -- Kevin Everett voluntarily moved his arms and legs on Tuesday when partially awakened, prompting a neurosurgeon to say the Buffalo Bills' tight end would walk again -- contrary to the grim prognosis given a day before. [...]

Everett's agent, Brian Overstreet, also said Everett's mother told him the player moved his arms and legs when awakened from a deeply sedated sleep.

"I don't know if I would call it a miracle. I would call it a spectacular example of what people can do," Green said. "To me, it's like putting the first man on the moon or splitting the atom. We've shown that if the right treatment is given to people who have a catastrophic injury that they could walk away from it."

Green said the key was the quick action taken by Cappuccino to run an ice-cold saline solution through Everett's system that put the player in a hypothermic state. Doctors at the Miami Project have demonstrated in their laboratories that such action significantly decreases the damage to the spinal cord due to swelling and movement.

"We've been doing a protocol on humans and having similar experiences for many months now," Green said. "But this is the first time I'm aware of that the doctor was with the patient when he was injured and the hypothermia was started within minutes of the injury. We know the earlier it's started, the better."
I am truly happy for Kevin Everett, in that what appeared to be a catastrophic injury may yet yield the possibility for significant functional recovery -- though it is yet much too early to say.
This is, however, the first I have heard of this particular therapy. It is really no surprise. At out facility we have been performing therapeutic hypothermia for post cardiac arrest patients for a while now, and this is functionally the same thing.

The concept is simple: Neurons have a voracious appetite for oxygen, and when deprived of it, very quickly begin to undergo cell death. So, the theory goes, by dropping the body temperature very rapidly as quickly as possible after an anoxic insult to neural tissue, as the brain is deprived of oxygen during cardiac arrest, you can slow the metabolic rate and greatly reduce the magnitude of cellular damage. And since it is pretty clear that spinal cord injuries (SCI) have a fundamental mechanism of cord contusion/edema/anoxia as the actual mechanism of injury, it makes sense that this application might be beneficial for SCI.

We'll see if it's the real deal. And there's obviously a huge time-sensitive factor here, like for strokes, since neuron death occurs quickly. But it seems to this jaded eye that this is the first treatment for SCI that has actual promise. I look forward to seeing some real studies on this.

So can we stop wasting ten grams of Solu-medrol on all our SCI patients now?

Thoughts on 9/11


I have a strange and complex emotional response to 9/11. Casting my mind back six years, I remember the shock and horror and fear, the anger and awe. It is one of those things that you don't forget. I recently saw the 9/11 movie with Nicholas Cage, and it was a wrenching emotional experience -- it brought back all those emotions as fresh and as vivid as they were in 2001. But it's curious -- I don't really connect those feelings to "9/11" any more. Some might say that I have forgotten, but that is inaccurate. Rather, my emotional response to 9/11 has been replaced by another. The intense, unique feelings that day induced have been displaced by more chronic, less intense but more pervasive feelings of anger and betrayal.

In 2001, the President had a rare opportunity to lead a truly unified country. All Americans were, for a little while at least, united behind him in our desire to see justice meted out to the perpetrators of that vicious attack, and to see America made stronger and safer. Bush could have led in a manner consistent with that national spirit; he had the opportunity to become one of our great presidents. But we all know that's not what happened.

Now, when I think of 9/11, the first thing that comes to my mind is the way that contemptible little man in the White House has waved the bloody banner of 3,000 dead Americans to demagogue the American citizenry into a state of fearful acquiescence, to impugn the patriotism of the opponents of his policies, to mislead the country into a war of choice, and to justify a continuation of that war long after the strategic objectives have been lost. 9/11 was used as a pretext to strengthen the power of the police at the expense of civil liberties, to arrogate unprecedented and dangerous powers to the executive office, to dishonor our servicemen and women by authorizing torture, and to detain American citizens indefinitely without access to any judicial body.

I feel angry. Osama bin Laden and his followers attacked America. But all the damage they did was knock down a couple of buildings and kill a limited number of citizens. I don't mean to minimize the tragedy and trauma that represents for those who directly experienced the attacks, or the families of the slain. Certainly, their experiences are life-changing and not to be dismissed; my sister-in-law was in NYC on 9/11, and can attest to the suffering that day. But the damage caused that day was relatively contained; America is resilient and will recover from this, as we have recovered from other national traumas. Bush has misappropriated 9/11, and the symbols and emotions linked to it, to inflict deeper and more long-lasting damage to our nation and the constitutional framework of our government. And so 9/11 makes me angry.

And also kind of sad.

And lest you think me callous, I do mourn the lost of 9/11, as I mourn the lost servicemen and women of the Iraq War, Operation Enduring Freedom, and the civilian casualties of the Iraqi people.

06 September 2007

"Poachers and dabblers"

Annals of Emergency Medicine reports this month on a speech given this year by American Society of Anesthesiologists (ASA) president Mark J. Lema: “What are the Current Issues Challenging the Status Quo?”

Among the answers he supplied was:

“Poachers and Dabblers.” By this, he explained, he meant "ER MDs (Emergency Surgery"

Nice. I haven't been in a good turf war since the Latin Kings battled the Vice Lords in Cicero when I was growing up. (I was a Vice Lord, of course.) Actually, I tell a lie. I have been in several turf battles, all of which were with anesthesiologists.

When I started at our practice, not so very long ago, the battle had only recently been won regarding the ability and privilege of ER docs to perform rapid-sequence intubation. This was a fresh issue in our institution, which boggled my mind because the large east-coast academic institutions I had trained at had been utilizing this technique for over a decade, and airway management was definitely viewed as a core competency for graduating ER docs. It was in this context that we launched into the next battle to allow us to perform moderate/deep sedation. The anesthesiologists used the same arguments they had previously used - that ER docs were not appropriately trained to perform these procedures, that it is unsafe for patients, that only a ABA-certified anesthesiologist can safely do so... etc.

I wondered why they put up such a fight. It was exceedingly clear that this was only a marginal economic issue for the anesthesiologists -- such procedures are reasonably uncommon, and in any case, they had never been very interested in coming down to the ER at 0300 to provide the service when asked, and it's manifestly clear that ER docs are in fact trained and capable of providing the service. In the end, I think it was just 'turf.' Sedation -- and control of propofol, the best drug for deep sedation -- was their turf and they took a very proprietary interest in it, even if they were not exercising that prerogative on ER patients.

Ultimately, we won, and have now done thousands of cases without a single adverse event. And every once in a while, I get someone who is ASA class III or IV (i.e. relatively high risk for complications) and I call the anesthetist to come and do the sedation for me. Their response has been quite positive, seeing that we do recognize the limits of our abilities and respect the technical skills they bring to the table. So it is disheartening to see the president of the ASA deride ER docs as "poachers and dabblers."

It may just represent some sour-grapes griping, because the standard has moved strongly towards ER docs providing this service -- all of my friends at academic centers do, and the majority at community hospitals do as well. A small ASA survey indicated that 59% of hospitals do credential non anesthesiologists (largely ER docs and ICU docs) to perform deep sedation. Yet the president of the ASA, as well as the clinical policies of the ASA continue to insist that only an anesthesiologist should administer propofol. It is also true that the primary "target" of the anesthesiologists are GI docs who want to use propofol in office-based endoscopy suites. (A practice which does seem questionable to me. We always have a second ER doc to do the sedation, while the first does the procedure. And I don't know whether a GI doc can manage an airway, but I know I can.) Which makes it doubly insulting to have ER docs lumped in, if that is the primary concern.

Fortunately, we now have a good, collegial relationship with our gas-men; it's pretty clear that we are good at what we do, and that we don't represent either an economic threat or a danger to patients, so there is no likelihood that there will be any attempt to roll back our privileges. And I think the national trend is pretty clear on this as well. Let's hope the ASA can get over itself and allow the feud to pass quietly into the mists of time.

Gone Fishin' Fishin'

Hmmm.
Apparently I actually am going fishing.

I haven't held a fishing pole in my hands since I was about half the age I am now (maybe longer). But First-Born Son wishes to go fishing, and it would take a harder man than I to ignore the pleas of a five-year-old boy who wants to go fishing with his Dad.

So I got some tackle, and tried to remember how it all goes together, and we're off to beautiful Lake Crescent, WA, for a few days of canoing, fishing, and general relaxation. I hear they have great trout, but alas, it's all catch and release there. Which saddens me not at all, because gutting a fish is really not something I anticipate with pleasure.

See you all Monday!

05 September 2007

Larry Craig's Constitutional Defense

From WorldNetDaily:


WASHINGTON – Sen. Larry Craig, R-Idaho, didn't have to plead guilty to sex charges stemming from a men's room encounter with an undercover cop in Minnesota.

All he had to do was hand the police officer a copy of the U.S. Constitution – the document the senator swore to uphold upon first taking office in Congress 27 years earlier.

There is little ambiguity in Article 1: Section 6, which clearly states no member of Congress can be arrested while traveling to or from official session.

Article 1 of the U.S. Constitution says no member of Congress can be arrested while traveling to or from official session except for treason, felony and breach of the peace

Craig was arrested just after 12 noon June 11. He cast a vote on a high-profile cloture motion on the Senate floor at 5:55 p.m. that same day.

That's so cool. I mean, all partisan snark aside, what an obscure and archaic bit of law -- not just any law, but the highest law of the land -- to defend such a petty and low offense. How often does that happen?

And from the partisan snark perspective, one can't but help enjoy the spectacle drag on a bit longer.

02 September 2007

Medical Liability Follies, Part 2

Some more thoughts on the $5.39 million malpractice verdict:

I've said for a long time that one major deficiency of the medical liability system is that it delays and denies justice to those who truly have been injured by medical negligence. In this case, presuming that the verdict and award are upheld -- a big presumption -- the likelihood is that the plaintiffs will see only a small fraction of that award. According to the coverage as I understood it, the verdict was solely against the doctor -- not the hospital or her employer, though the media is notoriously imprecise in reporting that sort of detail. The medical liability insurance market in Washington is such that ER docs can't buy insurance for more than $1 Million per incident. It's just not available, not at any price, and certainly not in 2004. So the insurance company, having already expended a lot of money preparing and defending the case for trial, will pay the balance of their obligation under the policy. What does it cost to defend a case with a month-long trial? $100,000? $200,000? I don't know, but it's not cheap. Anyway, the absence of any other defendants with liability in this case -- the absence of any deep-pocket defendants, that is -- means that the plaintiffs will probably wind up with maybe 15% of the actual award (less attorney's fees). So there's justice for you.

This is assuming that Dr Dy is not independently wealthy and exercised a modicum of common sense in the disposition of her assets. It is rare for doctors to have to pay malpractice damages out of their own pockets. It's pretty easy to shield yourself from judgments: just pour all your liquid assets into your house, your retirement, and your life insurance. Most of these are not attachable. if you are lucky enough to own a vacation house or an airplane, well, that's going to be at risk unless you do some fancy legal footwork. It kind of sucks, because you may have a lot of money but can't easily access it, but it beats getting bankrupted by a huge lawsuit. (Some docs used to put their assets in their spouse's names, but it has been pointed out that the likelihood of getting divorced is a lot higher than the likelihood of getting a $5 million lawsuit!)

Another thought, which to me supports the notion that the verdict in this case may be at odds with what a reasonable medical observer might find: They went to trial. Now I have, as administrator of a large ER group, worked with a number of defense attorneys on cases being litigated. They are smart people. They make it really clear -- if there is significant risk, you do NOT proceed to trial unless you have a bullet-proof defense. I can't imagine a much more sympathetic plaintiff in this case -- young active professional, sent away from the ER, drops dead, multiple dependents. Geez, I wouldn't litigate this unless I really felt we had met the standard of care -- and felt we could show that at trial. Now maybe Dr Dy just made a bad decision and refused advice to settle, maybe her defense got shredded on cross-exam, or maybe the plaintiff's counsel set an unreasonable requirement for a settlement. Or maybe (my cynical side suggests) they presented a great defense but a jury voted with their hearts and not their minds.

Which ties into my next thought: we'll never know. A jury just made a strong statement as to the standard of care for diagnosing Aortic Dissections. Unless the case gets published, as a practicing ER doc, I have no clue how I am to incorporate this standard into my practice. What was the error that Dr Dy made that I must now avoid? How does this verdict improve American healthcare? As far as I can tell, it does not.

One sort of clinical thought: it is hard to read between the lines of the fuzzy media report, but they say that the plaintiff "collapsed at home and complained of chest pain in the ER." To me, this implies that maybe his chief complaint was syncope. Syncope is a tricky problem to work up in the ER. It's true that syncope with superimposed chest pain does send up a red flag that more investigation might be required -- though I would be more suspicious of PE than Aortic Dissection. It's for this reason that I have started sending D-Dimers on pretty much all my syncope cases that aren't obviously vagal. I have heard that a D-Dimer can be a useful screening test for Aortic Dissection as well, which makes sense based on the pathophysiology. But I think evidence to support that practice is not yet firmly established.

And one last thought, which really should have been my first thought: my heart goes out to Dr Dy. It sucks to lose a patient, or to have a case go bad unexpectedly. It sucks to get sued. It sucks to have a lawsuit hanging over your head for three years. And it sucks to lose at trial. Yes, I also feel bad for the family of the decedent, but I feel a special kinship and sympathy for the doctor, who has also suffered enormously through this process. For doctors, being sued destroys careers, destroys relationships, causes depression, substance abuse, all sorts of horrible consequences. If she's reading this, I hope you're taking care of yourself and I hope you have some family and friends to rely on in this tough time.

Medical Liability Follies

Jury Awards $5.39 Million to family in suit over medical negligence

I read about this case in the Seattle Times. I do not, of course have any direct knowledge of the case from a medical standpoint or any knowledge of the legal aspects and how it played at trial. And it may yet be overturned or reduced on appeal. So any commentary I deliver on it must be taken with several of the proverbial grains of salt.

But.

This is the sort of case that drives ER docs crazy, and drives the defensive medicine epidemic. First of all, the verdict rings false to me. I suspect it's bullshit. I don't know: maybe the ER doc really was negligent -- maybe the patient gave some clear sign that he needed further work-up. But maybe not, and it's more than likely unfair for this doc's career to be destroyed by a case viewed retrospectively. This unfortunate man had a very rare and highly lethal disease; he also had a very common complaint. I see 30-year-olds with chest pain every single day. Like the ER doc in this case, most go home with a reassuring diagnosis and some supportive medication. And I have been lucky -- none of them unexpectly dropped dead. And I know, as all ER docs working in the pits know, that if and when one does drop dead, the ER doc (or whomever last touched the hot potato) is going to be blamed. So I test like crazy and just hope that I happen to be ordering the right test on the right patient. Some of what I do is cookbook medicine, but a lot of time the patients don't read the textbook before coming in, so I have to cast a wide net -- what we call using the "shotgun approach."

So when you come in to the ER and you have to wait hours to be seen, maybe you have to endure multiple semi-necessary tests, maybe you get admitted or get an invasive procedure "just to be safe," this is why. Because I do not wish to suffer the same fate as the poor Dr Dy. Whose name, I note, is no longer listed on the medical staff of the hospital where the event took place -- a hospital which is very prestigious and well-compensated. Maybe she just moved on. More likely she was shown the door.

And the state Physician Quality Assurance Commission did review the case and found Dr Dy's care to be within the standard of care. (pity that's not admissable at trial.)