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Please note I re-edited this post slightly after its morning publication to improve clarity without changing any substantial facts or statements.

Alban Berg

Ahh. . . . the austrian economist doctor. Brilliant post--you put your finger on why medicine fails as a market in theis country.

But, why do you blame lawyers? (There must be a psychological disorder that affects doctors and that causes an aversion to the law resulting in irrationality and lapses in thought and judgment.)

Suits have nothing with the problem--that information regarding doctor performance and that a functioning market requires--is not accessible to consumers. The existence of malpractice does not encourage or discourage disclosure of generic health care data.

The problem is with the incentives of insurance companies (and their de facto employees) doctors. INsurance companies have an incentive to reduce cosst within the barest acceptable quality standards. Doctors have an incentive to stay on insurance companies good side to make sure they have patients--this involves HIDING empirical evidence about their performance.
There's nothing stopping you, or anyother medical service provider, from posting your performance metrics. But, you chose not.

If they made such info public, consumers would demand the best and increase costs--something insuarance companies would hate.

Insurance should be mandatory, preferably ONLY for catastrophic illness, and completely private.


I really appreciate your providing all this information!

A few years ago, full body scans (MRI) were advertised as buy one/give one as gift. My husband and I seriously considered gifting each other but were discouraged by our respective physicians from obtaining (the trendy)diagnostic full body scan . According to our personal physicians, the jury was out regarding the safety and accuracy of these expensive scans. Is the real issue accuracy of MRI imaging or the interpretation of these images?

You linked to MRI mammo - which, if I'm not mistaken indicates it is the technology of choice for mammo.
Can MRI also stored as digital media?

I have had the traditional mammo done several times. When directing me to my first mammo, my physician informed me that it would make a good baseline record for future tests. That first film (if still available from 1992) resides in another state. I would much prefer to have (even at my own expense) the most accurate and portable record as an option available to me.

MRI (to a lay person) seems like the ultimate imaging technology for diagnostics. However, in having been discouraged from the full body MRI scan, I'm a wee bit confused.

Is the MRI mammo acceptably accurate because it is specific to the breast area?

Is there excessive exposure when there is a full body scan?

With the limited time available to read each scan, regardless of the technology, is the reason for the question of accuracy regarding full body scans - the amount of time allotted to read?

In an earlier post (Part I) I asked if there was a term besides 'digital mammography' that I should ask my doctor about. A yahoo seach shows that it's available by that term in NYC . . .http://www.mimrad.com/digital.html
Does this link reflect what you are discussing re: digital mammograms?

Again, thank you. You provide an very valuable service with this blog. I started reading with the Schiavo case. I now check your site daily. :)



I didn't blame lawyers. I have no aversion to the law. I named tort attorneys as one of the powerful forces that have created the mammography crisis, and that help keep the market system from operating in medicine.

I am specifically referring to those lawyers ONLY who specialize in malpractice liability cases. They are a particular breed and I have met many of them -- enough to form a solid opinion about their motivations, intentions, and professional behavior.

Lawsuits have much to do with the problem. The lawsuits, the threat of lawsuits, and the settlement of lawsuits affects everything I do every day I work. I know of no radiologist who interprets mammograms who does not feel this way. I have no reason to make this up, or exaggerate; my purpose here is exposition.

This is a much more powerful force than statistics would reveal, especially because almost all cases are settled then SEALED as part of the settlement. If one reads 20-50 mammographic studies a day -- not uncommon in this era when no radiologist is willing to take on these examinations -- the year's total can be over 10,000. If one has a sensitivity rate of 95% (in baseball you can get to the Hall of Fame by batting .350!)then one can expect to miss 5 findings in every 100 that present themselves. This would translate to about 500 "misses" per year. If one of every five of these "missed" findings is important (cancer vs not cancer), then, with a 95% sensitivity, one could "miss" up to 100 cancers per year.

This translates, over the course of a few years, to thousands of mammograms floating out there that could be adduced as evidence of "malpractice." Proof of what I am illustrating was documented in a well-known study that showed almost 50% of mammographically identified cancers could be seen, in retrospect, on the previous year's mammogram.

Since most cases are settled, and there is no trial, "community standards" do not come into play. So, an unscrupulous, or ignorant person can use almost any cancer along with the year's previous mammogram to trump up malpractice and force a settlement.

The effect of this is psychological, and monetary. Why would a radiologist read mammograms for a $15-20 fee when one can read CT's and MRI's for 5-10x more? Believe me, the malpractice insurance for mammographers is steep, and it adds to the overhead of the women's center, furthering the economic disincentive to own and operate mammogram facilities.

Insofar as revealing information to the public, I am all for it. I think it is essential, and important. But, it cannot be unilateral. Without a backround, or grounding, consumers cannot hope to gain a rational foothold to be able to understand, interpret, and use the information correctly. The effort needs to be widespread, in all fields, and the effort needs to be universal, with government, media and professionals opening up and helping in the task. The ignorance is so deep, at this point, it is going to take a massive effort to reverse.

All that being said, I would STILL welcome the opportunity to open everything up to the public. I have no problems defending what I do, how I do it, and what my results are. I would also like to be free to point out medical and therapeutic inconsistencies, and errors, I see, when I see them. But, get serious. What would be the first thing that would happen? There would be a conference for liability lawyers in Miami Beach so they could plan strategies and plot ways to use this information in liability suits against me (doctors). Web sites would pop up advising liability lawyers in the proper way to manipulate this data to prove malpractice. Tis is not fantasy. As you know, such conferences go on all the time and these websites are common.

Let's not be like academics who pretend reality is not an issue. The reality is that with the malpractice laws the way they are, and the incentives as they are -- and people being people -- revealing data and quality control issues in a naked format would result in a legal disaster.

That's why it isn't done.

And those are the reasons why liability lawsuits and lawyers are a large part of the crisis in mammography.

Dear CodeBlueBlog,

Thank you for your thoughtful response. Fair enough. Certainly under the current regulatory climate making info. public is an invitation for law suits. Or, at the very least, doctors have nothing to gain from disclosure.

But, the cause for this is our third-party player regime which makes the insurance company the purchaser of medical services--not torters to use your locution.

Undoubtedly, the threat of suits affects doctor's behavior. But, why is that bad? if, as you point out, consumers are out of the loop as far as quality and, therefore, the consumer cannot discipline doctors through the market, what else but lawsuits will discipline doctors. If I go to a doctor and have no idea about his quality, how do I know he'll do a good job--the best I have is that if he screws up, I'll sue him and take away is Lexus.

The answer you usually get is doctor's own professionalism will ensure quality. Hmmmm. Undoubtedly, there is some of that, but serious economic research has indicated that self-policing rarely works. The moral hazards are too great.

Finally, you estimates about 5% error are fascinating--thank you for your openness, which is extraordinary and brave. but, to be frank, the number is appalling. You certainly seem highly intelligent and are certainly the most intelligent medblogger out there (at least you don't use purple prose to describe your exquisite sensibility about dying people)--but that's a terrible rate of error for any industry. Would WALMART tolerate 5% error in its inventory count? Would an accountant tolerate a 5% error is an earnings statement?--Would we tolerate 5% of all airplane crashing--would we tolerate 5% failure rate (meaning contraction of the underlying disease) even for vaccines? NO.

Of course, the mechanism that force industries to expend that extra effort to go to 99.9% accuracy (always the hardest hurdle) is the market. Of course, medicine is a monopoly--the medical professional decides who can practice it. Monopolies tend to lower quality and output and raise prices. A natural corollary of your argument is elimination of all licensure. Are you game, doctor?

Curious JD

Settlements are sealed at the request of the defendant 90% of the time. They will continue to be sealed because insurers make them a part of almost all settlement offers. To suggest that community standards don't come into play is silly. The insurer knows that the standard of care in med mal is based on a reasonable physician in that locality.

Care to tell us how many cases are based on previous mammograms missing cancer? Or is that just a claim without a fact behind it?

"I named tort attorneys as one of the powerful forces that have created the mammography crisis, and that help keep the market system from operating in medicine." If you eliminated every lawsuit against any health care provider out there, you still would not have a "market system" in medicine. Lawsuits, legitimate or not, are a fraction of the cost of medicine and have almost nothing to do with the lack of a free market. Limiting access to the courts, however, is the first step towards a national health care system. The next step is when a whole bunch of pensioners get dumped on the federal government. Probably about 3-5 years from now, unless GM can start producing cars that sell.

Daniel Newby

"Finally, you estimates about 5% error are fascinating--thank you for your openness, which is extraordinary and brave. but, to be frank, the number is appalling."

That's the nature of the problem. Tiny tumors do not show up much on x-rays, and normal breast tissue has a lot of variability that does show up. Is that a tumor? Or did bits of fatty tissue just happen to line up in a way that looks like a tumor?

Setting the threshold lower would mean fewer false negatives (missed cancerous tumors), but it would also mean more false positives (unnecessary fear, biopsies, and mastectomies). You have to set the sensitivity threshold somewhere in between and try to minimize overall cost. There is no magic way to get perfect results.


Hey...I'm really young, probably too young to comment on this site, but I'm a huge fan of 24 and CSI. I think that the people blogging on the site would love the Forensic Files on Court TV. Of course TV is my life right now...haha.

Alban Berg

Dear DN,

1. Typical doctor's response, but really quite flawed. The choice to biopsy a suspicious looking mass is really a question of personal risk aversion. Why can't doctors say (more often), there's a mass that looks like a bunch of fatty tissue, but maybe it's a small tumor. What do you want to do, acknowledging that a biopsy has risks both physical and (I guess) of false positives? Doctors rarely have answers. The problem is that they often act as if they do.

2. Yes, the number is appalling. Yes, the technical challenge is great. My only point (repeating the one made by CodeBlog) is that if there were a free market in medicine so that anyone could practice it and treatment would not be subject to our program of socialized medicine, medicare, we'd have better technology.

"Setting the threshold lower would mean fewer false negatives (missed cancerous tumors), but it would also mean more false positives (unnecessary fear, biopsies, and mastectomies). You have to set the sensitivity threshold somewhere in between and try to minimize overall cost."

No offense, DN, but that's a horrible, patronizing argument. Who is the "you" and whose cost are you trying to minimize?

The balance between false negatives and false positives should be set by the individual-- at least in a free market system. There is no "magic answer" to how much risk one wants to assume and at what cost because only an individual can answer that question--not doctors!

Part of the trouble with medicine today is that this question of risk is too often taken out of the hands of individuals and given to insurance companies and doctors--neither of whom are competent to find the ideal level of acceptable risk for any particular individuals,

Daniel Newby

1. The trouble is that the probabilities themselves become rather uncertain for low-risk results. The typical patient is already baffled by statistical recommendations. Telling them that one study says their risk of cancer is 1 in 500 and another says it is 1 in 2000 doesn't help them make an informed decision. Meanwhile one biopsy study might show a 1 in 17000 risk of death and another might show a 1 in 300 risk of complication. Add to that the fact that studies LIE. The uncertainty compounds; there is no right decision. For the patient to contribute to the decision for a marginal result is basically just taking the dice out of the doctor's hand. (There's nothing wrong with that. It is just the way it is.)

2. A good place to start would be rolling back the courts' interpretations of the Commerce Clause. According to our judicial masters, if a radiologist takes a mammogram and gives the woman a report right there on the spot, he has just engaged in interstate commerce. Therefore the lobbyists in D.C. get to regulate it to their hearts' content, using Congress's commerce clause power. (Silly me, thinking that interstate commerce should actually involve, you know, crossing a state line.) I suspect that fixing this will take either a civil war or divine intervention.


Hey Doc??

I have been waiting with great anticipation for your next post!

Where are you??

Zami :)

Retorting Doc

a very intriguing post, providing lots to think about. of course the lawyer-types can only consider one aspect of your thorough commentary - malpractice. and once again they rally to the cause of doctor-bashing with a telling threat to 'take away your lexus'. i'm learning not to blame them for their ignorance though. they have no concept of the decade we give up to become doctors, nor the daily responsibilities we struggle with in making medical decisions that 'do no harm'. their wish for a world full of black-and-white, right-and-wrong, justice-and-injustice leads them to bend and distort the very truths they once went to law school to uphold. babies aren't gauranteed a birth free of complications and breasts aren't gauranteed to be free of cancer. life is not lived in absolutes, and medicine is not practiced with complete certainty. they don't get this. they'll come back at you with indefatigable rationalizations and half-truths. specialized medical courts are going to be a reality, because i believe they will compensate injured patients fairly, more often, and with greater efficiency. they will help to establish real standards of medical care via evidence-based medicine applied by expert judges. doctors will be fairly sanctioned with the horrible ones weeded out. the real losers will be the as$holes who bring frivolous lawsuits and the multimillionaire trial lawyers who prey upon juries' emotional quotients and salivating desires to redistribute wealth from the doctors they are so convinced make more money than them.

peak oil

Zami, perhaps he will have more to say about the 'fractures' of both ankles, both knees, both sacroiliac joints and ribs when the Terri Schiavo autopsy xrays are published.

Mad House Madman

hey, what happened? did you get tired of writing?
c'mon CBB this is one great blog. don't stop


Hey peak oil, where did you hear about the 'fractures' of Terri Schiavo? Have a link?

Yes, I have been waiting much anticipation for Terri's autopsy, although given the secrecy surrounding the autopsy, I have little hope that the evidence or report will provide any conclusive results. Somewhere I had heard that they weren't going to allow the x-rays to be published. I hope that I heard wrong. Or at least somehow they find their way onto the internet.

And, I keep hoping the Doc will provide us with his analysis.


peak oil

Zani, there have been many claims of multiple fractues. These were common on the Court TV discussions though some of the nastier posters have been banned. They can be found on and were promulgated by the codeblueblog discussions. Or on TV programs as when Hannity interviews the Shindlers. It is likely that these claims are bogus. One physician posting on CBB gave a convincing physiologic explanation for the bilateral hot spots.

peak oil

Link http://www.sptimes.com/2002/11/13/TampaBay/Attorney_claims_a_bea.shtml


Thank you, peak oil.


This is the link to an article I read yesterday about the medical examiner, why he wouldn't allow the family to have an additional examiner present, who he is, why he is so "ethical", why he won't let the "politics" of Terri's case "influence" him, and why it will take at least 3 more weeks for the autopsy report.


(via MichelleMalkin.com May 18)

Article is now missing.



peak oil

I am getting worried. Where is CBB. Combat fatigue. If my math is correct there were about 1800 posts related to Terri Schiavo. It was not easy to find the gems buried in the noise. Kate Killibrew M.D. had some interesting comments regarding the findings on the nuclear bone scan. It might be worthwhile to see a critique of her analysis. Scroll down from

peak oil

Correction http://codeblueblog.blogs.com/codeblueblog/2005/03/csi_medblogs_co_1.html#comments


Thank you for the link, peak.

I am worried, too. I hope it is just needing or taking a vacation and nothing else.

Been more than a month.

Is there a doctor in the house??



MRI is not the ultimate imaging technology it depends on what structures you are interested in. It is generally accepted that MRI images are superior to assessing soft tissue structures, while CT scans are superior for assessing bone structures.
MRI has no radiation exposure, CT scans are what you are referring to. MRI's are just really powerful magnets. Unless you have any metal (pacemakers) in your body you are pretty much safe.
As for your doctors recommendations. One problem is that even if abnormalities are found, most are not significant. However, doctors will feel obligated to practice defensive medicine and send you for a work up, which carries with it a whole new set of risks and discomforts. For example, suppose the image shows something in the colon, then you might be sent for an unnecessary colonoscopy.
In practice MRIs are suppose to be done when the are 'medically indicated."
You can still get it done, if nothing else you will have a nice set of images to compliment you wedding photos. Its still pretty cool to see the body from that perspective



I am not sure why anyone would think that a colonoscopy is unnecessary. If someone has a change in bowel habits, or other symptoms that might be worrying, then the colonoscopy can at least help in relieving the worry that one might have bowel cancer. Also, this is used to detect more than cancer. It is also useful in detecting other diseases of the bowel. It is the same with the endoscopy. That is how it was detected that I had an inflammation of the stomach lining caused by an ulcer. I was not aware that I had an ulcer until I had that test. It is through the detection of this problem that further problems are avoided.

These tests are uncomfortable but in the long run they do give peace of mind if there is no cancer detected.

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