I’d like to highlight two blog posts that essentially summarize the problems with malpractice and the current culture of medicine.
The first: $11,000 hospital bill from the emergency department from KevinMD. A quick summary: Mike, unemployed 29 year-old guy struggling to get by goes to the ED with indigestion after wife has read that this can be a sign of a heart attack. Patient gets an EKG, chest x-ray, CT scan of the chest, labs, and admitted for possible acute coronary syndrome (after declining to leave AMA), get stressed, goes home. Later, the $11,000 bill arrives. No one is happy.
First thing’s first: who knows what this patient said to the EP to get this workup. Maybe it involved pleuritic chest pain, or maybe he had an abnormal EKG. I don’t think anyone should question the EP’s workup unless they were there. Admittedly, it sounds like a pretty exhaustive chest pain workup (and admission), but we’ve all see dead 29 year-olds, and we’ve all seen patients who look very ill or give a very concerning story that you can’t ignore, despite their age. Who knows.
The comments are really where it gets juicy, and where it easily gets spun in either direction: Mike should have left AMA, Mike should have taken Maalox at home, Mike called 911 for indigestion, and yes, this costs money. The doctor scared Mike into staying, the doctor was scared of litigation. I like this quote particularly:
Bottom line, I went to medical school to treat the probably. Now I spend much of my clinical day ruling out the improbable. Not by choice. But lawyers ad [sic] patients want that. So as a result unfortunate souls like the patient end up paying the bill.
I guarantee you no one is happy with this situation: certainly not Mike, who isn’t a medical professional and has to listen to the doctor standing in front of him, who probably himself/herself estimates Mike’s risk of acute coronary syndrome as low, just given his age. And certainly not the doctor, who thinks the risk is probably low, and doesn’t want to really admit Mike or work him up, but now he’s here in the emergency department after calling an ambulance for “indigestion.” And so now both parties end up with an unwanted outcome (big expensive workup for indigestion in Mike’s case, working someone up and admitting them because you’re not allowed to miss a single cardiac event as an EP).
And next up is Inevitable Malpractice by my colleague-in-blogging, WhiteCoat. The post is worth a read yourself, so I won’t spoil it for you, but it’s the not-too-uncommon situation we run into in the ED all the time: damned if you do, damned if you don’t; rock and a hard place; insert your own cliche here.
As I’m heading soon into attendingship, I’m starting to think more about these issues (especially having just applied for my state license that will soon be practiced under while I’m supervising residents). I can only come to a few generic conclusions:
- The system is broken.
- The system has changed the fundamentals of the doctor-patient relationship. It’s not teamwork; it’s not “shared decision making;” it’s not us helping them. Or us guiding them. It’s us versus them. And in a system where that’s increasingly becoming the norm — where doctors are scared of their patients and their lawyers — we’re all in trouble. The perverse incentives of medicine today are probably destroying us all in the process.
- I wonder if the data can help us at all here. You run Mike’s info through the GRACE ACS Risk Calculator, or the Duke Risk Calculator, or the TIMI Risk Score for UA/NSTEMI, and you can give Mike a pretty realistic estimate of his risk of MI. You talk with Mike, explaining we can’t rule out cardiac badness in the Emergency Department, but that his risk is approximately 2%, say, and see if that’s a risk Mike is comfortable with or not. It’s shared decision making, it’s educational, and who knows, it might make both parties happier with a well-documented discussion in the chart and discharge with close primary-care followup.