02 September 2007

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.)

14 comments:

House Whisperer said...

The only solution is to scan more chests. (Got to irradiate as many people as possible until this kind of thing goes away.)

Anonymous said...

It is pretty hard to tell much from the $hit published by Seattle Times joke of a journalist. A few points:

"he computer-systems engineer died two days later from what was later discovered to be an aortic rupture, a tear in the heart's major artery."

A very healthy, 30 year old man. Unless, the guy had warning signs, (tachycardia, orthostasis, etc). Looking for this diagnosis would mean scanning everyone.

"When Hoang visited his regular doctor at the University of Washington-Belltown clinic two days later, he was diagnosed with a heart infection."

Whatever that means. Are we talking viral myocarditis or a bacterial endocarditis, or what? Don't think I would be sending someone on their way with an endocarditis, but again the article is journalistic $hit.

"The state Department of Health investigated Dy's actions and found that they fell "within the standard of care." The case was closed in April 2006."

Movin, I guess, the plantiff had better paid testimoney for the jury. Standard of care is whatever any hack with an MD, says it is to a jury. It's not about the truth or the evidence. It's about the show for the jurors. Best acting wins. I doubt Dr. Dy has a 5 million dollar policy. So her career is ruined on a very difficult diagnosis if their is lack of obvious objective evidence.

ER Tech Dude said...

Why didn't they sue his regular doc? Guess his pockets weren't deep enough.

Nurse K said...

I dunno---it says he collapsed at home and had chest pain. Not many people collapse from acid refulx-related chest pain....Who knows what he told the doctors at the time though.

Matt said...

"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."

We patients have to endure all those tests because of a case you have no knowledge of from a medical or legal standpoint? And which may be overturned on appeal? That's why you toss your professional judgment and skill aside?

And why would this doc's career be "destroyed"? There are many physicians out there practicing with multiple judgments.

shadowfax said...

Matt,

It's sad but true that much of defensive medical practice is driven by apocryphal and mythical "scare stories." The balance is driven by well-sourced and factual "scare stories," like the sort we get at educational conferences. Cases like this just reinforce the bunker mentality of doctors that they will get sued for a gazillion dollars every time they miss a rare disorder. Selection bias, sure, but when it's a page one headline in both local papers, it does catch the attention.

And it may be an exaggeration to say that her career was ruined per se, but it's a huge black mark on her record, and will place her at a significant disadvantage in any competitive job application in the future (and may already have cost her one job).

Matt said...

A "huge black mark"? In what way and why? If all physicians believe that most verdicts for the plaintiff are bogus, and the "quality assurance" board, whoever they are, said it met the standard of care, who is blackballing her? Where is she not getting a job? I think the "huge black mark" is yet another scare issue. Too many physicians with MULTIPLE payouts are still making a living around the country.

I understand you have a "bunker mentality". The question so few of you apparently stop to ask is, why? And does it actually do you any good?

shadowfax said...

I do the hiring for our group. If I have one applicant and they look great but they have a judgement, I'll review their story and try to decide whether it merits concern. If there are two candidates otherwise well matched, and one has a judgement and one does not, I am influenced by that -- it's human nature. I will probably try to keep it in perspective, but I can't exclude it from my mind.

The last time we advertised for hiring, we got over 70 applications. Having a big judgment against you has got to put you lower on the list against all the docs with clean records.

If you have two judgements -- well that's bad. Maybe you just got unlucky twice. Maybe you made one mistake and got unlucky once. But you are going to have a hard time getting hired anywhere desirable.

Is the risk overestimated by docs? Probably. But the consequences are so bad from the point of view of the docs that there is a very strong aversion to risk.

scalpel said...

She may have trouble obtaining malpractice insurance in the future because of this megajudgment. If she can obtain it at all, it will cost a lot more than it would cost someone with a clean record.

Thus if she tries to join a group that pays malpractice insurance for her (like every group I have ever worked for), they would likely choose a candidate with a clean record over her.

Not to mention the difficulty she may have obtaining hospital privileges.

It's not just a scare issue, and it's no more anecdotal than your "too many" rogue physicians still practicing despite multiple payouts.

Judy said...

1. They could prove the aortic rupture happened before he went to the ER the first time and not later?

2. Just because you're at risk of aortic rupture doesn't mean you don't also have GE reflux.

3. Nurse K should know that you can get some pretty impressive symptoms from GE reflux if you get a vagal response. Pale, diaphoretic, heart rate of 50. I called 911. The ER doc was sufficiently impressed to admit and observe over night. OK, his Hx of CAD did play into that, but he looked better with unstable angina than with GE reflux.

Anonymous said...

"She may have trouble obtaining malpractice insurance in the future because of this megajudgment. If she can obtain it at all, it will cost a lot more than it would cost someone with a clean record."

Again, lots of ifs, buts, and maybes there. They might all be true, but it seems like pretty sketchy evidence for one to take any action based on it.

"It's not just a scare issue, and it's no more anecdotal than your "too many" rogue physicians still practicing despite multiple payouts."

That's not anecdotal - many states have websites that will tell you that information.

scalpel said...

So do you really believe that someone with a multi-million dollar malpractice judgment against them will be able to easily obtain malpractice insurance at the same rate as someone with a clean record, and that hospital credentialing committees will just overlook the unfortunate black mark?

Or are you just being lawyerly?

Anonymous said...

"So do you really believe that someone with a multi-million dollar malpractice judgment against them will be able to easily obtain malpractice insurance at the same rate as someone with a clean record, and that hospital credentialing committees will just overlook the unfortunate black mark?"

I don't know what you mean by "easily". Without knowing how your insurer classifies its risks, it's impossible to know. The amount of the judgment doesn't mean that much once it's at policy limits.

If I have one car wreck, I doubt I have much trouble getting insurance, and probably at the same rates. If I have 5, that's another thing altogether.

Anonymous said...

My dad constantly got called for jury duty, and he warned us to stay out of courts, that there is seldom any sensible justice to be obtained. I think that is more true today than ever.

Those who think it's just fine to sue a doctor forget that lawyers are willing to help sue anyone at all, for any ridiculous thing at all. We're all in jeopardy in this lawsuit-happy culture.