LET'S CALL A SPADE A SPADE...A SNAPPING TURTLE

Malpractice reform is all over the net, especially in the medical blogosphere. I've stated some of my views before. Recently, in a piece regarding John Edwards.

Kevin, M.D. quotes an article regarding the upcoming collision between trial lawyers and physicians, and RangelMD did his usual thorough job.

DB's Medical Rants says a lot about the issue, and is preternaturally patient with his lawyer letterwriters, carrying on discussions and debates that he clearly dominates in without being overweeing.

One new iteration I'd like to add to the ongoing and ever-intensifying melee is a neologism. I think we should call a spade a spade and give the tort lawyers/attorneys/litigators/esquires a name that better pigeonholes those who choose to channel fetuses. I propose torter. You know, like tort lawyer and snapping turtle all rolled into one.
I mean, we call Anesthesiologists gas passers and radiologists rads...I think TORTERS fits the bill. Ever see one in the street and try to pick it up? You're trying to escort it to safety, and it quickly clamps its crushing beak on your finger and in an instant your digit is fractured and macerated.

Comments

[db]

Thanks for the kind words. I do believe in polite discourse. One reason for blogging is to share ideas. While I may not agree with the torters, I believe that we should listen to what they say. They think differently.

I always believe in respectful dissent, even when I strongly disagree. Probably comes from my college days at UVa, a school for gentlemen.

[CBB MD]

db:

I guess I lost mysense collegially imbued fairness the first time I faced a torter who proceeded to twist the truth, attack with inuendo, and show complete disregard for facts, training, and reputation. And that was just the first time. Sure, they will discuss the issues politely with you, but when they dollars are up for grabs in the courtroom, their gloves are always off, and hidden in their fists are the brass weights. So, I say, back at 'em.

[Chris Rangel MD]

AHHHHhhhhhhhh! Torters! Yes! I love it. Much more polite than my second choice; "Bottom dwelling scum suckers". :)

[John C. Peick]

Let me get this fact out of the way. I am a trial lawyer. I am proud to be a lawyer even though I am not happy with everything that happens in the name of my profession anymore than I am sure doctors cringe when faced with sex abuse, drug abuse and preventable medical errors. I do not believe the debate over healthcare, its costs and its future direction is enhanced by mud slinging. Lawyers appreciate that doctors are being squeezed by lower reimbursement and higher overhead, including price gouging insurers raising their rates to maintain their income levels in a stagnant market. However, I read a statistic that 3.5% of the doctors licensed in this country cause 43% of the preventable medical errors. Yet, the state medical quality assurance commissions seem disinclined to yank their tickets. The recent Florida experiment with 3 strikes you are out will provide some insight into how the dynamics of malpractice litigation will change in that environment. So if the regulators were taking actions against repeat offenders, perhaps the "malpractice crisis" would be substantially eliminated, assuming it exists at all in reality. Thank you for your patience.

[CoeBlueBlogMD]

I never said there was no malpractice or that it wasn't a problem. I am all for rooting out malpractice.

My contention is that the current system is neither efficient nor effective in finding or remediating malpractice.

The current system involves a decision by a lawyer as to whether or not enough money can be extracted from a situation to pay his own bills. The intersection of that decision and true malpractice is coincidental. This is so inefficient as to be comical.

If society is really interested in addressing malpractice, then an intelligent and sensible methodology needs to be put in place to define, seek out and adress malpractice. At a point beyond this mechanism, I would have no problem with people seeking out attorneys to address their wrongs.

Most current malpractice lawsuits I see (and I've seen them steadily, weekly, for years) involve gray areas where the actual question of malpractice is not clear- cut and the issues are thorny; so if there is no clear-cut right or wrong, then the decision usually is in favor of the one concrete issue: the patient's claimed harm.

I'm sorry, but the tort lawyers I run in to -- consistently -- are people without a shred of concern for patients, the welfare of patients, or the integrity of our system. They look at these cases strictly from the vantage point of whether or not a settlement can be leveraged out of the insurance company. What disgusts me professionally and intellectually is the staggerring realization that many times these lawyers understand precisely that the patient's claim is contrived, and that the physician was doing the best he could -- yet they bull ahead knowing that it is easy (and profoundly cynical) to take advantage of the general public's poor grasp of statistics and probability by appealing to emotions rather than intellect.

It is a shameful state of affairs.

[John C. Peick]

I cannot speak for the entire country's jury results, but I know that in the Pacific Northwest, 80% of all jury trials end in a defense verdict, the doctor wins. It would not appear from these statistics that juries composed of laypersons are succumbing to emotion rather than intellect. I must respectfully disagree with your initial premise that juries will favor the plaintiff's harm. My 29 years of experience in the non-med mal tort arena is completely contrary to that perception. I think juries realize medicine is just as much an art as a science, and for all the high tech surrounding it, sometimes doctors are simply making informed guesses. You also should ask yourself why insurance defense attorneys uniformly ask for juries to hear cases, if they believed juries would fall for plaintiff counsel's blandishments.

For a variety of reasons, my firm does not handle professional malpractice cases. The primary reason is the firm's focus on providing legal services to healthcare providers and cross-selling our plaintiff personal injury practice, sans med mal. Most med mal cases are exorbitantly expensive due to insurers piling on forensic experts who must be deposed at all points of the compass. It is not unusual to spend $50,000 to $100,000 on costs in a vigorously contested lawsuit. Only the young and the professionally short-lived would take cases without merit. Besides, I do not know any med mal attorneys that would dream of taking on a case unless they had one or more physicians telling them the defendant committed malpractice. So why is the opinion of the potentially guilty physician so notable as to evade accountability?

I suppose we are faced with a chicken or egg argument in determining what came first, the desire to avoid admitting mistakes and covering up; or the appearance of the tort lawyer on the scene calling the physician to task. As I referenced in my earlier post, part of the problem is the failure of state regulators to police the profession. Which brings to mind your suggestion that some screening process occur or forced process prior to seeking legal assistance. We will ignore for the moment the constitutional problems such a system might encounter. However, who will make the preliminary decision. Doctors who live in the same medical community with the alleged offender? Doctors practicing in the same field of medicine suffering from the "There but for the grace of God go I"? How objective will the process be? If it is not going to be fair and objective, then it ceases to be a mechanism to make the system more efficient, and simply serves as a shield to save physicians from being held accountable. So I would be interested in seeing some flesh placed on your skeletal concept. We have been using lay juries and trained advocates for centuries. A U.S. citizen does not have a constitutional right to receive medical treatment, but they sure as hell have a constitutional right to be judged by a jury of their peers.

However, I think there is a deeper social issue which permeates tort law, particularly class action product or drug liability cases. We have become a deeply risk averse society. It appears that a drug which saves thousands of lives is defective if less than 1% suffer side effects of any measurable amount. Society seems to believe that nothing should be marketed unless it is absolutely 100% safe. 100% is a myth until all human beings are cloned from one genetic map. You and I might find some common ground when it comes to abuses in the class action arena, but I would have to review med mal cases on a case by case basis before passing judgment across the board.

Thank you for your patience and courtesy in this exchange.

JCP

[Eliyahu Rooff]

First, a disclaimer: As a paralegal in an office that does no medical malpractice work at all, I have no personal financial interest in the outcome. Now, on to the argument...

First, complaints about jury awards are generally misdirected right from the start. Here in Washington State, over 95% of the jury demands in medmal cases are made by the defendant's attorney. In other words, it's the doctor and not the injured patient who is insisting on having a jury hear the case. The patients are usually quite satisfied to have it heard by a judge. If you're worried about jury awards, why insist on a jury?

Juries, by the way, don't come from some special sheltered environment. They're people from the community who have been exposed to all the "tort reform" arguments over the past few years and who have generally come to think that recipients of large jury awards have won some sort of lucky lottery. Has anyone asked the mother of a child who will spend his life in a wheelchair because of gross negligence or incompetence on the part of a physician how she feels about being a "lucky winner"?

Secondly, comments about the incomes of trial attorneys are no more valid than responses about the equally-large incomes of physicians. That's not what the suits are about, although both groups derive their livelihood from what they do -- practicing medicine and practicing law. Median incomes for both groups are not that far apart.

Press releases in all 50 states claim that doctors are leaving each of them because of rising malpractice costs, including those states with award caps in place. Where is this mysterious 51st state in which physicians find miniscule insurance rates and parsimonious jurors?

It's uncontested by either side that the vast bulk of malpractice claims come from about 5% of the practicing physicians. When will the various medical associations begin actively policing their own ranks and removing those who are incompetent to provide quality medical care? It's easy to mis-identify with doctors who make mistakes and think, "I could have done the same thing," but the fact is, you didn't do it, and there are others who keep making the same mistakes.

Finally, before heaping abuse on attorneys in general, it might be worth remembering that attorneys were writing the Constitution and Bill of Rights for this United States while the physicians of their day were bleeding, blistering and purging George Washington to death.

[CodeBlueBlogMD]

I never mentioned jury trials. I am well aware of those statistics. Of all the suits that come through my department (as I said several weekly for fifteen years) I have only seen a handful (2 or 3?) go to trial. None of this is about a jury trial or the expenses incurred there.

It is precisely because the tort lawyers understand those statistics and those costs that they target the settlement as their objective -- making the whole process even more degrading intellectually and professionally. It's a barter. I'm willing to pay you to leave me alone -- even though I have to say that I committed malpractice and I get reported to the Department of Professional Regulation and get put into the databank -- becuase that is a sm,aller negative than the possibility I might lose ten times more in court.

The reason those court cases are frequently won by the physician is because that's the only time we GO to court. When there is absolutely NO case against us -- and even then we can and do lose.

When I said that the lawyers look for gray-area cases I was referring to the desire of the attorney to extract the largest settlement possible without a trial -- in cases where nothing can be scientifically proven or demonstrated.

In the meantime, as a defendent, I'm spending (via my insurance company) 20-50K on defense in each one of these cases.

I in no way defend venal physicians who support this process. They disgust me more than anyone involved and deserve as much or more scorn. The experts, in my experience, are usually no experts at all and the motivation for their testimony is money. Period.

I have no problem with REAL experts offering opinions, but I do believe that choosing retired bankrupt urologists to testify that a pneumonia was mishandled is an egregious wrong and I don't know how we accept it.

[Eliyahu Rooff]

You wrote: "The experts, in my experience, are usually no experts at all and the motivation for their testimony is money. Period.
I have no problem with REAL experts offering opinions, but I do believe that choosing retired bankrupt urologists to testify that a pneumonia was mishandled is an egregious wrong and I don't know how we accept it."

There are many problems with expert testimony, not the least of which is that competent professionals are often under so much pressure that they don't dare to testify for fear of losing hospital privileges or being disciplined by their professional associations for doing so. That often limits the available pool of experts to those who are retired or outside mainstream. That said, if you were in trial and your attorney didn't get proffered testimony by a physician who was testifying entirely outside of his field or expertise (your "retired urologist" testifying re pneumonia) excluded, that attorney is probably guilty of malpractice himself. Court Rules and Rules of Evidence sharply limit the scope of "expert" testimony, and jurors also aren't impressed by those "experts" who can be shown on cross-examination to have limited knowledge in an area.

A bigger problem for plaintiffs in all areas of personal injury is the high cost of obtaining medical experts for trial. One of the attorneys with whom I've worked recently had an automobile accident case in which one of the treating physicians demanded payment of $1000 per hour for depositions and trial testimony. That's four times the hourly rate on which the attorney bases his own fees, and comes out of the pockets of the client, not the attorney. It's higher than the $500-$600 that we more commonly encounter, but it still pushes the costs of trying a case through the ceiling. Bottom line is that there don't seem to be too many folks involved in the resolution of personal injuries of any kind, whether it be medmal, auto accidents or otherwise, who aren't making a good living from it.

I would mention one difference, though... if the plaintiff's attorney loses the case, he doesn't get a nickel. The expert witness gets his fees no matter who wins.

[CodeBlueBlogMD]

To E. Roof:

I never mentioned jury awards. I never mentioned jury trials. I never said one word about the amount of the settlements. I also never said that doctors or their societies were able or capable to police, root out, or remediate malpractiuce. Don't assume my argument is the standard or pat argument against this system.

What I said -- I repeat -- is that this current system only finds malpractice by accident or coincidence. The final determinant as to whether a tort lawyer accepts a case depends on whether or not he can make his nut when all is said and done. This has nothing to do with whether or not malpractice actually occurred.

If what we are all so concerned about is MALPRACTICE then we should have some semblance of a system that is designed to FIND malpractice and FIX malpractice.

How anyone can believe that malpractice is being addressed or identified or corrected by the current tort system is a FANTASY to me. Yet we continue to have this endless argument.

It reminds me of the WWF -- you know the outsized professional wrestlers -- who pretend that what they are doing is wrestling when all that's going on is a show to mesmerize children and the mentally infirm. But it lives on and gets high ratings.

[John Peick]

Dr. Doc CB:

I feel your point. There should be a system to find and fix malpractice. So let us see if we can agree on a framework. Would you agree to the formation of an independent national, regional or state commission to which suspected cases of malpractice are referred? I am not speaking about the state regulatory boards because all too often they are political appointees beholden to their respective medical societies.

Who would have the right to present such a case? The patient or survivors, the hospital or institution or just some co-physician?

How would the evidence be gathered, investigated or presented to the commission? Would advocates be involved, whether lawyers, staff, or physicians?

How would we insure the independence of the Commission? If a truly independent board of medical and public members found evidence of malpractice, would such finding could be released to the patient or their survivors?

DO you agree that if a physician committed actual malpractice, and a patient or survivors were harmed, that some compensation should be determined for their loss?

Would the Commission's findings be admissible evidence for any litigation later filed in the absence of settlement.

Most institutions have QA committees but their investigation and findings are confidential and not discoverable. How would we balance the need for an open discussion of the potential mistake and remedy, but still allow the patient or survivor access to the information if the Commission finds malpractice?

Would any dispute over compensation be arbitrated, tried before a judge, or tried before a judge and jury?

Would there be any limit on compensation. The problem with most caps is that one size fits all discriminates against children and older people. Would you agree that a child condemned to a wheel chair for the rest of their life should be compensated more than most non-economic caps being tossed around.

Perhaps we should collaborate on creating a model act which would address these issues and all the other issues I am undoubtedly overlooking. Sort of like a malpractice Linux open source code. Put some model act together and place it on the site for comment and input? Would be more constructive than the tort reform efforts going on now, because those tort reform efforts have nothing to do with rooting out real malpractice either.

Thanks for your time.

John Peick

[John Peick]

The continuing problem I have with the commentary on these websites is that there is much rending of clothes and gnashing of teeth over venal trial attorneys, but I am not seeing much in the way of acknowledging there are incompetent doctors, arrogant doctors, and medical errors that maim or kill patients. I asked you to collaborate on a system to address these issues, and you have been notably quite. Put up or shut up. Medical errors occur. People are hurt. How do we deal with that reality. You are ranting against symptoms and not the underlying condition.

[SoonToBeSonographer]

JCD says: "I cannot speak for the entire country's jury results, but I know that in the Pacific Northwest, 80% of all jury trials end in a defense verdict, the doctor wins."

What this says to me is that tort lawyers are clearly bringing way too many cases to trial that are not genuine malpractice cases. They are clearly injurious to the medical professionals and the patients that they treat through rising malpractice costs which can only be passed on to the patients.

How about a "3 strikes, you're out" for attorneys? You bring 3 malpractice cases to trial that fail and you lose your license. Compensatory and fair? You're asking the same for doctors. Swallowing you're own pill might be a little harder.

[kerok]

I am pleased to see more reasoned discussion at this site. As with many controversial topics, I believe the answer lives somewhere in the middle.

Current med-mal worries affect day-to-day practice in my specialty (Emergency Medicine), and contribute directly to costs of doing medicine. Very few test-averse physicians remain. Almost all are risk-averse to the point of "buffing the chart" to the nth degree even when all their experience and training tells them no significant condition exists. When defensive medicine becomes standard practice (which it has) it makes it difficult to accurately determine true additional costs or impact.

On the other hand, in each geographic location I have practiced it has become quickly apparent that there are physicians in the community (invariably loved by their patients because of superior interpersonal skills) whom you would NEVER trust to take care of anyone. Why are these providers still practicing in an unrestricted fashion? There may be no concrete evidence available, or specific instances may never be investigated because they are never discussed.

In my opinion, the current med-mal system does nothing to identify the infamous 3.5%. Nor does it provide help to the majority of patients with poor outcomes, whether due to negligence or not. This should be reworked.

Physicians do not police themselves well, if at all except in the most egregious cases. Unless we can demonstrate a new ability to perform this task, some other means must be found.

Both of these goals will require open discussion of procedures, bad outcomes, inadequate or poorly designed systems and incompetent providers with some surety that you will not be hit over the head with a $10 million club. Nothing will get better without open discussion of problems. However, injured patients as well as those with simply bad outcomes should have some way to seek compensation or help. This needs to be outside the current tort system which currently weeds out only those cases with the potential for high payouts, leaving many deserving of help by the legal wayside. Physician discipline will probably require oversight of non-involved parties in the same specialty.

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