At Least Insurance Is Unhappy

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The day that medical insurance execs and medical malpractice lawyers are screaming that their sky is falling, is the day that the U.S. has gotten serious about health care reform.

It sounds like half that equation is at least whining, so maybe some modicum of real reform is coming.

Graduated – No Crying

The last days of residency passed – perhaps with a bang, and certainly no whimpers – and I am now full into my first week as a real, live doctor.

Everything feels the same, but with more sleep.

My graduation ceremony occurred 4 days ago, on Saturday.  For as emotional as I felt that night, I managed to survive the entire ordeal without much blubbering.  This had largely to do with my particular approach to the ceremony itself, which involved a skateboard, a wacky helmet and some iffy poetry.

Since there are only 6 graduating residents from our program, each of us enjoys (or endures) a sizeable amount of limelight as we graduate.  It starts with a picture slide show of us from our earliest days up to the present.  Some of my shots were strange, if not embarrassing, as you might imagine.

We are then introduced – for an agonizingly long time – by a faculty member.  Here our history, foibles and dreams are put on display for all in attendance to see.  This part can also be rather painful too.

It was then my turn to speak.  We aren’t given time-limits on our speeches.  As mentioned, there’s only 6 of us, so I guess we have the berth and he right to ramble a bit if we want to.

I survived the process with almost zero public display of emotion.

I’m not sure why this was some sort of goal for me.  I’ve always been a lousy crier.  I’m good at complaining, whining, moaning and bellyaching, mind you.  Rather too good.  But my crying skills must have atrophied somewhere in my childhood.

If I were to guess, I suppose it happened when I was about 5 years old and my biological father had just punched his girlfriend in the face.  He then leered at me and asked, “You gonna cry about that like a little girl?” in a drunken haze.

“Nope.”  I said.  And I never have.  These days, I can only cry when Ariel gets her statue of Eric blown up by King Triton, or the Broncos trade their franchise quarterback to the Bears.

So, I have some issues.  Fine.  I’ll bet you do too.  Intellectually, I admire the Roger Federers of rhe world who can stand on the international stage with unabashed tears streaming down their cheeks when they lose (or even win, sometimes) their latest tennis match.  Emotionally, I want to smack them with their own tear-stained pink hankies, tell them to find their purse and go back to the parlour where life doesn’t hurt so much.

Anyway, I wasn’t going to cry.  Smash my thumb with a hammer…we’ll talk.  But for this?  No way.

So, my approach was to first ride my Sector 9 longboard skateboard up to the podium wearing a tin foil-wrapped, overly-festooned bike helmet.  Why such a rather dumb graduation display?  Why, especially, at a solemn ceremony for a new practitioner of the healing arts?

sector9Aside from the fact that medicine is frequently too pompous and full of itself, I figured that if I could keep it fun and light, I could keep my eyes dry.  Plus, I ride my longboard to work most days, and I religiously never wear a helmet of any kind, much to the dismay and consternation of virtually every person I meet on the hospital campus.  For 3 years I’ve put up with near-constant haranguing to wear a helmet.

Why don’t I wear a helmet?  Well, I just figure that anyone traveling less than a mile, at about a mile an hour, while less than 3 inches off the ground…should garner me the right to feel the wind in their hair.  Granted, there isn’t much wind at that speed…and I don’t have much hair.  But that’s my metaphorical argument, people, and I’m sticking to it.

I also think that Americans are too stupidly safe these days.  We think we have allergies to things that 6000 years of humanity had no problem with.  We pad every corner in our houses and put seatbelts on our T.V.’s just in case the wall trembles and pushes that deadly thing over on a kid.  We have warnings on things like plastic 5-gallon buckets and nylon shower curtains.  Frankly, the fact that my children will never ride barefoot in the back of a bouncing pick up truck, screaming like golden-haired eagles as the wind whips wildly into their eyes, brings me no end of sorrow.

I grew up burning leaves, shooting bottle-rockets out of my hand and hunting fish with a whittled stick.  I think life is risky, and living life is an exercise in managing that risk.  Knee-jerk safety measures without true analysis of risk leads to heard-mentality that rarely leads to anything but really really bad groupthink: racism, genocide, militant nationalism, day-glo, Milli Vanilli, toilet-seat-shaped pillows for airplane flights that everyone carries around airports but never actually use for more than 10 minutes, to name a few.

So, in truth, I don’t wear my helmet when longboarding because I’m determined to not become a Nazi.  Gotta admire a guy like that, right?

Anyway, I understand that most of you dear readers will find fault in my little tirade, and will probably want to admonish my opinion about helmets just like all of the faculty, nurses, staff and freaking maintenance workers I see.

But take heart!  You don’t need to worry!  I rode to the podium in a helmet for the first time.  Just to make everyone happy.  Just to acknowledge that I’ve finally heard the message.  I give up.  It’s time to be responsible and extra-duty safe.  I’m a doctor now.

‘Course, my helmet was covered in tin foil and had sticks extending from it in every direction with tinfoil balls on the end of the sticks…but it was a helmet.

Then I delivered a poem.  It was supposed to be a rap – with a thumping beat and maybe a couple of dancers and lights flashing/spinning with everyone on their feet, their hands in the air all hip-hoppin’ on the floor.

But I’m white.  I’m a doc.  I’m in a tie.

Forget it.  It’s a poem.  A really bad 1-2-3-2 rhyme sequence that rhythmically scans like ice cream might feel if you were dumb enough pick a pile of it out of a sandbox and eat it.  But, in honour of my creation and the initial inspiration for it, I allowed that I would not in fact be delivering a rap, OR a poem that night.  It would be an amalgam, a mixture…a PAP.

This is fitting, of course, since we were all gathered to celebrate my new status as a fully-trained family medicine doctor.

My Pap made my mom cry.  I think my Dad too.  Kinda my wife.  And most of the people I talked to afterward said it made them a bit misty.  My goofy, two-bit hyper-syllabic tossed salad?

Cool.  People cried.  I didn’t.  I was too busy looking goofy, or saying goofy things.

Dear old Dad would be proud.

Jesus Christ EMR

Obama seems to have totally hit the Kool-Aid bong about EMR’s saving the American Health Care system.

Go! Go! Go! Go! EMR! EMR! EMR!

He’s not the only one, either. I recently heard some analyst yakker on PBS proclaiming in breathless tones that instituting and EMR would lead to such better health in America that it singleRAMedly would lead to all the cost savings we’re looking for in our health system. She was so spun up about it at one point I thought one of the other interviewees might suggest she get herself a room so she could give herself a little tension-release (or at least re-powder her face).

EMR’s only barely improve medical care. The overhead costs – in maintenance and updates of both software and hardware – is tremendous. They worsen charting time because they have so many boxes and forms to click and fill out on every patient. They do nothing to prevent or protect against litigation.

Their biggest utility is, so far, a theoretical one. Connectivity. If everyone in our country had their medical record in the same system, you could see a doc in Tulsa one day and Tacoma the next, and both docs could essentially function as the same care provider because they could both see the same record and continue each other’s plan.

But the idea is a myth.

Oooooooo. It glows....Bzzzz, bzzz...

This is a capitalistic country, so there’s dozens of EMR companies fighting for market share. There’s lots of venture capital involved because this is a big game with HUGE payoffs if you win it. Each EMR has some merits; NONE of them talk to each other. By none, I mean NONE. The EMR’s hate each other. They’re Mortal Kombat enemies. I’m being as genteel as possible when I describe the standoff with words like hatred, vituperation, caustic acid on mucous membranes. Get it?

Even if the EMR’s all went to counseling and became friends, the governmental obsession with medical privacy – so onerous it is now unreasonable – requires Pentagon-level encryption that nobody can afford in both time and money.

To log onto my EMR, for example, I have to enter a number from a digital keychain that refreshes itself every 3 minutes, plus my user name. I then have to enter my username and password at 2 other stages, all of which are preceeded by boot-ups, loading pages and security cross checks.

As mentioned, it turns out that charting in EMR’s takes longer than charting on paper. This means doctors will see fewer patients and spend more time charting.

Keep in mind that I’ve semi-rigorously calculated that I already spend at least 30 – 50% of my time totally avoiding patients and patient care so I can document. So, when you hear that we have a doctor shortage in this country, assume what is meant is that we actually have the right number of doctors… but because only half of their time is spent actually doctoring, we’re really about 50% short on docs.

Still I love techololgee...TURN IT OFF! TURN IT OFF!!

If you look at good socialized health systems around the world, you don’t really see many EMR’s. In fact, obsession with glowing technology is what gets American medicine in trouble all the time. We already order too many high-tech tests that do nothing to increase life expectancy or quality.

The cost of our health care system isn’t a result of not having an EMR. Our costs are driven by all the extraneous junk that makes us uniquely inefficient.

Follow the Liiiight, and You Shall Be Saved

Look at good health care systems, and the main thing you don’t see is entire industries piggybacking on the cash cow of medicine. Insurance companies are heavily regulated, and thus make reasonable profits. Some are government-administered and make no profit at all. Litigation is highly limited, preventing not only absurd payouts, but also preventing the much larger hidden costs to the system, which is excessive testing and charting meant to protect doctors and hospitals from dreaded litigation (the irony is, it doesn’t).

More technology is just more expense. What we need is less. Less specialization. Less litigation. Less technology. Less capitalizing on the sick among us. EMR’s are not the Jesus Christ of the American Medical system. They probably won’t help at all.

Technology won’t solve this problem, only common sense will.

Another Study

A group called The Physicians’ Foundation came out with yet more evidence (check it out here) supporting what you probably hear from most of the MedBlog community in different forms all the time.  If you read my blog regularly, you’re probably also aware of some of my cyber-colleagues like Kevin M.D., Dr. Wes, The Happy Hospitalist, Fat Doctor, Shadowfax and others espousing similar concerns.

We’ve all talked about how primary care is becoming untenable.  Now there’s a questionnaire survey that was mailed to every primary care doctor in the country, and it backs up our claims too, essentially asserting:

Primary care medicine sucks if you can’t spend time with your patients.

We didn’t go into medicine (and enormous debt) to do paperwork and argue with insurance companies.  People who do paperwork and filing for a living don’t understand our intolerance for their way of life, but it’s a fact that not everyone likes the sterile confines of alphabetization, algorithms and cubicles.

Some argue that the answer is more allied-health providers for primary care, like N.P.’s, Dr. Nurses (weird one, I know), P.A.’s, etc.  I disagree.  Excellent health systems provide excellent health care, and that starts with well-trained providers with doctorate-level education.

Residency-trained family medicine doctors average 12 THOUSAND hours of training before practice.  Nurse Practitioners average around 3500 hours.  Same for P.A.’s.  These people are easily as intellectually-equipped as doctors, but I think the idea that they are as well trained or can replace physicians is ludicrous.

I also hope lawmakers intent on saving our system don’t rush to the EMR (electronic medical record) as the messiah of American medicine.  It isn’t.  I use one every day, and it does very little to improve care and absolutely nothing to improve efficiency.  If EVERY doctor used an EMR that talked to all other EMR’s, efficiency might improve somewhat.  But our capitalist system has provided us with dozens of competing companies and, given our obsession with medical privacy, none of these programs communicate with each other.  Digital charting takes hours and is only slightly improved by hacking away on the keyboard during the entire patient encounter, detailing everything as it happens.

And, for a future blog, those records do nothing to protect doctors from litigation.  Trust me.  Nothing.  If anything, they help the plaintiff.

Also on the EMR topic, it is colossally more expensive to sustain than just some basic paper and dictated notes.  Companies LOVE the idea of EMR’s because the required tech support, and database maintenance, and program upgrade requirements are virtual gold mines.  In the end though, it’s another of thousands of examples of business and enterprise making money on medicine – the real reason American medicine is falling apart.

Like the canary in the coal mine, as Family Medicine goes, so goes American health care.  If well-trained doctors are getting out of the business, the natural corollary is that you, over time, will be getting sicker (and poorer).

Time to Zip It

I’ve certainly gotten the point: SHUT UP about the fired resident already!

Numerous comments have come in, some from fellow medical bloggers whom I respect as “attendings” in the cyber-world due to their longer time in the games of both blogging and medicine (thanks shadowfax and Kevin).  Graciously, they weighed in on this topic with advice, support and commentary.

But the overwhelming message, both publicly and by email, is to shut my trap especially now that I’m genuinely involved in the proceedings of this situation.

I should point out that I agree with everyone who points out that nothing is anonymous, truly anonymous, in the blogosphere.  In fact, I started this blog assuming that anyone who wanted to figure out my identity, could do it with about 5 mouse clicks and give or take a modicum of human reasoning.  By comparison to, say, public school janitors (who I bet could write some pretty interesting blogs), there just aren’t that many doctors around.  Give even a few details about yourself (as I do) and you can figure out who a doc is with little effort.

So, I write this blog with the assumption that you know who I am.  The name of the blog is more of an expression of personality than any sort of attempt at identity obfuscation.  Thus, my comments thus far on the resident recently fired from my program have been made with every belief that they are available and visible to anyone involved with this situation, including the resident himself.  I’ve tried to just give my honest opinion; one that I would give any patient or the local barber – just hit it with a #1, please, and yeah that resident was a pretty good guy…most of us were surprised he got the boot.

That said, now I’m getting a bit antsy.  Maybe I’ve already said too much.  Maybe I shouldn’t have even mentioned this.  Maybe I shouldn’t blog at all.  Maybe I should sew up my lips like that ’80’s horror movie and never say another word as long as I live.  ‘Course, the problem here is more of a typing thing, so along with my lips maybe I should sew my fingers together so I have one wide “probe” extending from each arm.  That’ll teach me.

Anyway, publicly or privately, I await any opinions about whether or not I should pull down the blogs I’ve already written about this topic.  I understand that in cyberspace, once written, a blog is effectively permanent.  Judging by the traffic I’ve received these past few days, I’m sure those posts have settled into the web page loam of the internet and can be recalled from somewhere even if they’re gone from here.  But it would be harder to do.  It would be one more layer of insulation between me and what is almost sure to go from our country bumpkin appeals process into full-blown legal action.

Irrespective of the previous posts, I can say that this is the last you’ll hear about this topic (until possibly some careful recap when everything is over).  I can say it would be quite fun to report on the proceedings ‘from the front-line’, but I understand quite clearly how un-fun that little experiement could likely turn out.

Swear Words in the ER

I recently arrived at the ER to see a patient who repeatedly swore at anyone within eyesight, “Listen, you #@%s!!  I want some %##$ing serivce before I rip someone’s head off and ##$@@% this place up.  I’m dying in here!”  From my nook at the doctor’s station I watched my soon-to-be patient as his demands repeatedly met with the exquisite uninterest only an experienced ER nurse can master as they replied with some version of, “You want some Tylenol?”

I felt a twinge of – well, I won’t call it pity, but some sort of desire to get this guy caught up on the New World Order of the ER.  He had the right idea, using swear words to get what he wanted.  But what he clearly didn’t understand was that ER vulgarisms differ substantially from your average, garden-variety verbal swill.  He certainly needed to cuss, but with a decided ER twang.  He wouldn’t even need to yell.

I felt like sidling up to him, kindly putting my arm around him and saying, “Dude.  Tomorrow night, when you show up here again, try this line… I have chest pain.

Try it.  See how long you wait then.  If you’re still watching “America’s Got Talent” after 10 minutes, use the words shortness of breath and mix in that you’re feeling dizzy and seem to be sweating.

Front of the line.  You’ll be seen in 2 minutes.  Or less.  Putting those words together in an ER is worse than a creative spew of explectives strung out like Christmas lights glowing through the weed-haze of a freshman dorm room.

The truth is that ER staff get sued so often they don’t really have the luxury of thinking much.  They have to react to what they’re told so that if someone dies, they can say they did everything.  Never mind whether or not the claim has any merit to it.  And never mind the fact that a thoughtless workup leads to stratospheric medical costs and just might get a guy some rather intense medical interventions based on a FALSE positive test.  Every test has a statistical rate of false-positivity.  Every time you get a medical test, there is a possibility it will tell you you’re sick when you aren’t.

It’s lawyer thinking that got us to this point, by the way.  Lawyers don’t necessarily understand medicine, but they sure comprehend theatrics.  No doctor wants to try to explain to a jury why they didn’t order cardiac enzymes on some guy who had the drug-munchies reeely reeely bad and also vaguely hinted that he had chest pain when he was told to go find a sammich at the local mission.  So, he gets the work-up (and some dinner).

Watching that guy sitting in the EMERGENCY room with his back pain or a cold or any of a thousand not-actual-emergencies, I could see he had reached his limit.  All he needed was to use some ER swear words.  He may not get his back looked at…but he could just end up with a cardiac catheterization, which I guess is almost as good.  And he wouldn’t have had to wait so damn long for it, either.

Instead, I walked into his room and doggedly launched into my familiar mantra, “Hi Mr.–.  Sorry for the wait.  I heard from the nurse that you have back pain…”

Certain Lawsuit

Here’s a sure way to get sued:

Use TPA on 100 patients. That’s all it takes. 100 times, statistically, and it’s off to the courts.

TPA is a pretty cool drug because it is the only one that actually breaks up blood clots. Effectively Drain-O for the body, TPA drills through plugs holding blood from crucial areas of the brain. Ostensibly, it could be used for clots in other areas like the heart and the legs, but it usually isn’t. In fact, there are EXTREMELY strict guidelines for exactly when to prescribe the drug. Roughly, those rules claim that you can only use it within about 3 hours after a person exhibits classic symptoms of a stroke. An ischemic stroke, by the way, not a hemorrhagic one.

Why so many rules? Wouldn’t a drug like that be the answer to the world’s medical problems? Think of how many people die every day because of clots forming in our vasculature that shouldn’t be there. This is why docs are so obsessed with cholesterol, for example. It contributes to clogging up coronary arteries. Arteries get blocked, heart muscle doesn’t get oxygen…heart attack. Pretty simple, really. So this drug should save the world. Maybe we should all take it on a regular basis, just to keep things thinned out.

The problem is that the drug works incompletely. It does, in fact, break up clots, but sorta like a photon torpedo from the Star Trek Enterprise would break it up (it must be quite cool to watch). You end up with bujillions of little clots in your blood stream. If they’re small enough, they will pass through even the smallest capillaries and not clog anything up. But usually, all those clots will lodge somewhere else and cause more problems…like mini-strokes, mini-heart attacks etc.

But the legal problem with the drug is that approximately 1 in 100 patients will end up with a brain bleed as a result of the drug. The reason is because after a clot forms, holes open up in the artery downstream from the clot as things dry up. The holes are basically caused by shrinkage like anything shrinks after it dries out. Then the TPA comes along and busts up the clot. Blood starts flowing again, and viola! it rushes across the newly-formed holes and pours into the brain.

“My doc gave me a hemorrhagic stroke.” Defend THAT mister docta man.

There is no incentive in our system to NOT bring litigation against doctors or anyone else. Sure, most lawyers don’t want to waste their time, but when there is a basic complaint as glaring as “my doctor caused my brain to bleed”, most will give it a whirl. Think about it: Plaintiff attorneys have a 50-50 chance of winning on the basic charge alone. Some poor patient gets on the witness stand, drooling and drooping and describing what their life was like before Dr. Flamethrower over there pasted him with that terrible medicine. But even if the case loses, most lawyers make money. Bringing charges…brings charges. Trial lawyers bring cases with big pay off potential (most stroke cases fit this bill), settlement potential, or when the patient can pay up-front.

I think there should be a litigation approval process where complaints can’t be filed unless approved by a board of medical professionals. The proper use of TPA should never lead to litigation – bleeding or otherwise, if the risks of using it are described to the patient, or the patient’s family if the patient is incapacitated.  In many situations, TPA is the patient’s only hope of salvaging some brain tissue.

But this isn’t how things work in this country. A person can sue for any reason – rational or not, understandable or not. Fortunately for me, family docs don’t often use TPA. Use of the drug is left to ER docs and neurologists. With this kind of involvement of the un-trained legal profession in the medical world however, more and more docs of all specialties are taking a hard look at that 100th patient who could use TPA. Statistically, the lawsuit is virtually assured.

Chaperone – That’ll fix it

Chaperones in the exam room have become a way of life in residency.  Ostensibly, a M.A. will protect me from a patient who either: 1.) is trying to come up with reasons to sue and hit the lottery, or 2.) might misinterpret a normal physical exam as sexual assault. 

The idea seems to be a good one.  Between emphasizing better communicating through the exam itself – “I’m not listening to your heart…I’m going to lift your shirt so I can listen to your lungs” and having a second pair of eyes in the room, it seems that misunderstandings and craven accusations will both be kept to a minimum.

Still, the addition of another, salaried, person in the room is yet another way that costs in medicine are rising due to litigation.  Litigation itself, obviously, is expensive.  But the secondary costs – like chaperones and a host of other additions in the medical field meant to protect us from law suits – are where the real money is being spent. 

The doctor in my area who was recently tried for sexual assault apparently did not have chaperones with him during most of the physical exams in question.  On the surface, one might gape in disbelief at this lapse in standard of care…especially considering that he came from my program where this practice is drilled into us.  But I’m tempted to forgo the chaperone almost every day I’m in clinic.  It’s a pain.  It slows things down.  Half the time I’m ready to do the exam and nobody is available.  A 3rd person in our small rooms makes things cramped.  My biggest problem with it, however, is the implicit message to my patient that “I don’t trust you, and you may not be able to trust me.”

And will chaperones really save us all in white coats?  I doubt it.  This latest doc in question is being charged by patients who he saw at a chemical dependency unit.  Places like that necessitate long histories prior to or following a physical exam.  It isn’t practical – or really even possible – to have someone sit through the entire meeting from start to finish.  So, a patient could easily just charge that the assault happened before or after the chaperone arrived.

Maybe more technology is the answer.  Maybe we could rig security cameras in every exam room.  The entire time the pt. is on the premises, s/he would be taped, with the patient’s knowledge before they even enter the room.  The entire meeting would be archived, with an index to the exact start time and date of the encounter for reference later if needed.  In every chart would then be a reference to where you could watch the entire visit.  All the data could be stored somewhere “safe” and cut from the hardlines that connect the clinic to the internet. 

I don’t mind chaperones in the room, especially when they hand me stuff and remind me to do everything involved with an initial pregnancy speculum exam.  Some procedures just need assistance.  But most don’t, especially in family medicine.  And in the end, a determined litigant will find a way around chaperones.  So will a determined predator.

Moral Monsters

There’s lots of reasons why the lawsuit over John Ritter’s death (the “Three’s Company” actor, if you remember that show) is categorically asinine.  You can read about the latest here.  But here’s one of the biggest problems with the case:

The suit is for 67 million dollars.

The jury are being told that the doctors did everything wrong, largely because they treated Ritter for a heart attack when in fact he was having an aortic dissection.  Only mildly important in this case is the fact that the dissection actually did lead to a heart attack and that, in general, they are extremely easy to miss.  There’s lots of ways to interepret the actions of the medical staff and lots of mistakes that can be identified now that we have all the information about the case.  But note who is making the claim – lawyers.  Not doctors who have been in these situations.  Not doctors who have made similar mistakes.  Sure, they’ll get some doc to say exactly what they want on the stand, but the argument is being made by lawyers.  These are people with no training in medicine and who probably had to look up ‘aortic dissection’ before they took the case.  They aren’t in this game for truth, or to improve the medical system.  They want one thing:

Show them the money.

As I’ve mentioned before, the major problem with medical litigation in the U.S. is the financial incentive.  Ritter’s lawyers have already successfully sued the hospital and 8 medical personnel for close to 14 million dollars.  Now they’re suing two doctors for an additional 67 million.  These lawyers stand to make a fortune on this case.  They’ve hit the jackpot.  A typical John Edwards haul.  Soon, after the minor detail of catastrophically destroying the emotional and possibly professional lives of two doctors, these lawyers will be able to enjoy their 26,000 square foot homes, $400 haircuts and send their kids to the best schools in the land, just like our earstwhile presidential candidate who also sued doctors to ascend to his upper-class life.

You can say that people are basically good; that common decency would dictate that you don’t excoriate someone for an honest mistake, especially if the truth is murky and unclear anyway.  You might assert that we all need grace in the harsh light of hindsight and you might be honestly grateful for the times when this kind of grace has been extended to you.  Most people believe these things.

But I bet you still wonder at times – while living out your grim job day after day with no hope of real financial freedom – just what it would be like to live in a mansion and never have to worry about money again.  What would it be like to get the best service, own nice cars, have the ability to take care of your financially ailing family?  We’d all like to live that way…the allure of a life like that is intoxicating even for good people who generally want to do good things in the world.  This is why the system is broken.  When it comes to medical litigation, the very rules  we follow entice even the moral among us to become monsters.

Make It Right – More Thoughts on Medical Litigation

Thanks to all who dropped by over the past few days. My latest post about apologizing in medicine caused a more than 300% increase in hits to the blog. That particular post was listed at #24 on the WordPress Blog of the Day list as well. The coolest part about that was seeing my wave avatar – the greatest avatar of all time – in line between some guy’s face and a picture of handcuffs! Anyway, I seem to have hit a nerve.

Although not the only thing I think about in my job, I will continue this line of thought with a little (true) story:

2keets.jpgI had a friend in high school who had two pet parakeets. They seemed like they were pretty close pals in their cage – snuggling together at night, chirping at each other…you know, parakeet stuff. When my friend (let’s call her “Beth”) woke up to find one of the parakeets droopy and sick-looking, she quickly put him/her into a little shoe box and whisked it to the nearest veternarian to get checked out.

The vet, who no doubt had many years of education behind him, probably didn’t see many vaguely ill parakeets. Be that as it may, his “physical exam” didn’t go so well. In the course of pushing on one part of the bird, my friend hear a distant *snump*, and suddenly the bird’s head pointed in an acute angle from the body. In short order, the bird went completely limp. The sweet little parakeet – singer of songs, snuggler of partner parakeets – now dead at the hands of the medical professional entrusted to it. The vet looked up to what I’m sure qualified as highly uncomfortable stares of reproach and surprise. Beth was too shocked to much more than mutter, “Oh my god, you just killed my bird.”

“Uh..,” He searched around the exam room. Reaching into a drawer, he pulled out a brown paper lunch sack, dropped the corpse into it, rolled up the top and handed it to Beth’s mom. “That’ll be no charge,” He said, subdued. “Sorry about that.”

So my friend went home with her bird that may very well have died anyway, but now was dead for certain. And from a broken neck, not some mysterious infection. She showed the carcass to her other bird, who let out a warble of what any human raised on a steady diet of Disney anthropomorphisms for a decade could only interpret as the parakeet version of rending garments and gnashing teeth (or beak) in abject sorrow. Furthermore, she thenceforth enjoyed her surviving bird very little at all. It quit singing and became rather “pecky”. It also began masturbating an average of 5 times a day, which altogether made for a rather dispiriting pet, especially when there was company (they had to hide the hapless, undersexed avian in the closet).

So, the vet messed up. But imagine if after dropping the bird unceremoniously into the paper bag, he had unabashedly walked out to his front desk and filled out a bill for a typical visit. “Sorry about killing your bird. That’ll be 80 bucks. Cash or credit?”

In my mind, if you make a mistake in good faith, you should apologize and then try to make things right between you and the person who has been harmed. This entirely justified premise, I think, led to the birth of medical litigation. But this perceived need for litigation came about because of hospitals themselves. Just a few days ago, it was announced with some fanfare, that hospitals here in the Pacific Northwest, would “tear up” bills to patients who endured medical mistakes. They just decided to employ this policy? After 30 years of catastrophic, irrational and flagrantly craven medical litigation, they’re just starting to do this? Can you imagine going to the hospital and leaving with the wrong leg amputated…and then getting a $26,000 bill for the procedure? Until recently, this was actually pretty common. No wonder people got the courts involved!

Hospitals provide free care to homeless and destitute – largely through their ER where they can’t turn people away – on a regular basis. My hospital gives away over a million dollars in care every year. They write it off as charity care and the government gives them a break on their taxes for it. They have a budget for this already. There is absolutely no reason why they can’t designate some patients as qualified for free care for certain problems caused by the hospital staff. No, some guy can’t have monthly chest CT’s because a hangnail got infected while walking across the parking lot to pick up 80 cartons of Virginia Slims. But any continuing care associated with a medical mistake should be free.

Imagine a patient and family being seated in a nice conference room. In attendance are the top administrators of the hospital, the lead doctors and nurses and anyone else heavily involved in his/her case. The doctor then verbally apologizes for a serious mistake that was made even though the entire team had the best intentions. S/he can describe what led up to the mistake and explain how it actually occurred. Then there is an explanation of what is being done to try to protect others from a similar situation. After the doctor is done, the hospital C.E.O. can then tell the patient that all care related to that mistake will be covered by the hospital. Forever. It’s taken care of. Then, the patient and family gets to say talk. They can say anything they want – to the doctor, the nurses and staff on their case, or the administration. This is their chance to rant, to bitch, to tell off the medical team if they want to. They can get everything off their chest and ask any questions they have. They can make recommendations and requests.

I believe that a hospital (and individual clinic) process like this would nearly eliminate high-payout medical litigation. With one other major additional change: Cases should NEVER result in financial independence for the plaintiff. Courts should be used help find blame when the patient and the hospital/doctor disagree. If it is found that the doctor is to blame, then the doc and the institution should be required to provide any related care for as long as necessary. Multi-million dollar payouts, by contrast, provide too much incentive to win the case for Machiavellian reasons. Suddenly, instead of just trying to figure out who is to blame, people are trying to prove incompetence, denigrating character and reputations and flat-out excoriating one another. This system is why I’ll never trust John Edwards, who lives in 26 THOUSAND square feet of house, but professes to care so much for poor people.

It’s easy to say this whole tort system is about the patients harmed, about justice. But as the system is set up, it’s mostly about the money. Lawyers and too many patients get involved with medical litigation to make themselves rich. They should be getting involved to make things right. There’s a big difference.