LaneInStay

Wednesday, February 05, 2003:

We're in NJ, and NJ just experienced the largest doctor "work action" yet in the country. All indications seem to be that it worked to push through some legislation of some sort, though not exactly the blanked $250k limit on 'pain and suffering' damages the doctors wanted.

Amid all the emails favoring caps on our school email accounts, from attendings and from other students, we got a reasonable one expressing dis-ease with the embrace of this approach to stemming the medmal crisis. That was followed by condemning emails (for taking up bandwidth, for not swallowing the party line, for referring to renowned "liberal" groups like PIRG), the best of which thanked the writer for taking up the devil's advocate position...

Then we got this one:
There are certainly a lot of unanswered questions with the idea of caps on pain and suffering...here are a few from my devil's advocate position.

I would think that it's crucial to hear from malpractice insurers and their actuaries as to if they think that this will make them able to lower
their rates in NJ, West Virginia, Florida, wherever. Their input has been glaringly absent as far as I've seen, and I think we need to know that premiums (not just make higher profits when they are putatively not paying out as much).

What is the usual payout to successful plaintiffs? We hear about $70mil wins on occasion, but from what I've seen, most doctors' coverage limit is $1mil (per lawsuit). So how many of these very telegenic verdicts are actually paid out, with doctors necessarily bankrupting themselves to fulfill the obligation?

Also, what proportion of a typical medical malpractice claim is pain and suffering? I could imagine that the medical and economic damages -- to which no one is proposing a cap -- are quite high, and in a typical case capping the awarded pain and suffering may not much reduce the total figure.

I am more than a bit skittish the idea of legislating a blanket monetary cap on the pain and suffering that a patient might be caused. I think it's an excellent idea to have a more regulated system for expert witnesses, for pre-trial proof (from what I understand, we have this in NJ, where a plaintiff has to have an expert agreeing with them before real trial motions can begin -- and not an insignificant number of cases never make it to court because of this, reasonable, hurdle), and also probably for the amounts that can be awarded for various strata of pain and suffering causes.

Leaving anything up to a jury means that fantastical numbers will be conjured up (witness the tobacco verdicts -- $28 billion for an individual smoker in California in October 2002). It might be helpful to have guidelines to awarding reasonable pain and suffering amounts, caps individualized to the damage. I'm sure most of them would fall under $250,000, but maybe the hypothetical egregious deadly misdiagnosis of lung cancer as asthma would warrant a bit more...

Just one last bit: someone last week told me that at least the caps would limit the number of lawsuits pursued. Once again, I'd say that this is not a fair method to weed out frivolous lawsuits -- that should be done at the level of an expert witness opinion as part of the process of the suit. Limiting the power of the judicial system to correct flagrant wrongs (which is what the 'pain and suffering component' does much more than restitution of the real economic damages does) is taking away a good partof its charter.

I of course thought it was eminently reasonable ... but I was not unsurprised at the dopey silence that followed. Just think, four classes of eager-to-get-out-there medical students, some of whom have contrary opinions, but all of whom are mute. I suppose some don't like engagement -- they take up the spoonfed answer without the yen to dialogue. What has been most pitiful though (maybe this gets ad hominum...) is the flood of emails saying that these "annoying political issues" should be taken offline. Of course, these emails are mass-mailed, as are the "amens" that follow them. Hey, they're right. There should be a forum for this (it just remains unfortunate that most medical students are so wrapped up in remembering minutiae for exams that they wouldn't want to participate). It's been humorous to see the troglodytes who worry about their brainwidth being taken up by having to consciously filter their email -- they are universally people who frequently mass-post, perhaps unsurprisingly as they would be most familiar with email and comfortable opening themselves up to responses.

One creature tells us monthly about his club parties in NYC where he's been privileged to be allowed to open up a guest list, so you'd better call or email him now to sign up! You'll still have to 'dress to impress' and pay an entrance fee and hope that you have the right proportion of girls in your group, but because of his carefully-crafted relations with the bouncers you'll more likely be let in. So that's several emails a month because most people are lax about getting back to him in time to have their names calligraphied on His List. But hey, sorting through this other email is far too much. If it were about Superbowl betting, that's cool cause that's like about universal relaxation, not annoying politics.

So that makes me scared -- not just the congenital aversion to engaging with the realities of the outside world in our future doctors, but the need to foist personal preferences (I don't want political email!) and foibles ("I see 16 new messages and I think they're for me but they're for everyone -- pisses me off") in totally inconsequential matters upon us all is sad. When I was young I was afraid to learn to drive because it seemed like such a complex and dangerous thing. At some point I realized that I could learn to drive because everyone else could, and that I would just have to be wary of the inadequacies of other drivers. That's definitely also in some measure why I went in to medicine -- to take care of myself and my family without fully sacrificing myself to the whims of any yahoo who managed to sweat and wiggle his way through medical school.
shoshanabananah // 12:09 PM

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Wednesday, January 22, 2003:

So then there was Sex Week. As in, two weeks ago there was sex week. I think the purpose was to shock us with some rarefied specimens of humanity so that we would never flinch when told about beastiality or necrophilia when taking a patient history... Either that or the purpose was to prove Freud's "sometimes a cigar is just a cigar" wrong. In Sex Week, it gets drummed in that everyone is hiding cigars, or at least wishes they had a cigar or three, or wants to know what to do with their cigar, and it is our purpose to explore this, and in the process the real somatic disease that brought the patient in will be cured...or at least they will be so embarassed and disgusted by our line of questioning that they will flee the office.

So there was the salacious aspect. Fine. The bad part was the self-delusion about how to deal with teen sexual behaviour... The next time someone gets up and tells me that the answer is to encourage the use and availabilty of dental dams and condoms for oral sex and beyond, I'm going to ... whatever. Calmly point out that that is totally unrealistic, and since that advice will go unused by teens, everything else they say carries no credibility either? Realism, people. The idea of teaching abstinence is an anathema too, which I find sad. Lots of really crappy things can happen once sex starts, sexually transmitted infections (or even non-sexually transmitted infections because of the new activity down there) and pregnancy being the obvious ones. We, in these parts anyway, treat teenagers as sexual steamrollers with our role being to try to get them to agree to do their incessant ramming through a condom, at best, or to go on the pill at least, or at the very least, to have that abortion so that high school can still be finished.

And on that note, I'm waiting for an honest discussion of what abortion's like for a woman -- we know that she will be ok. Her fertility will be intact with our modern, sanitary methods. Emotionally she will get over it (unless she goes over to the other side and becomes a spokesvictim and becomes unable to talk about anything else), probably quickly, I'm sure most abortions happen because people don't want to be pregnant and then they're not. But something should get out about the factory process that it is, how it is that this is one procedure that is so intimate and invasive and yet performed so fast and impersonally. Comparatively few doctors regularly will perform abortions; many of the others have disdain for those who do, I think partially because they are often getting involved in this machinery-like care. It's something that we don't want to talk about, that the woman understandably wants over quickly, and so we keep it legal but quiet.
shoshanabananah // 6:18 PM

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If it's Wednesday it must be Psychiatry class! Fortunately today I was saved from the usual inanity of psychiatrists getting very excited about either very sexy and rare topics like multiple personality disorders, or very lucrative topics like post traumatic stress disorder. We tend to gloss over the more common debilitating and long-term serious illnesses like schizophrenia -- social workers take care of that; electroconvulsive therapy doesn't work (this decade's thinking) on it; psychotherapy seems not to go anywhere with them and so it's depressing for the practitioner.

However, today we had a lecture on psychotherapy, replete with the usual cartoons showing the neuronal synapse along with the admonishment that things are probably more complicated than we (as a profession) can understand, much less draw. It was a good time though -- but it's too bad that the psychiatrists running our course left this topic till now, the end of the course, preferring to concentrate on electroshock therapy and psychotherapies as preferred modalities, which is probably a little unrealistic for most mentally ill people out there.

Because it was psychopharmacology we got the usual anti-pharmaceuticals rant. Of course no one ever says that the pharm companies suck because their drugs are no good...no, they suck because they are pricing their drugs to *gasp* make a profit. For someone as disenchanted with the current climate of private medical practice as I am, an industry where they fight to maintain profits coming in looks like a particularly attractive place to work. Naturally, none of our anti-pharm professors has expressed concern over the increasing price of generics. And why should they remain low? If there's a market, barring government regulation the prices will begin rise to meet what the market will bear, or so I would imagine. That's what's happening with medical malpractice insurance companies now, even as doctors delude themselves into thinking that the recent sudden increases in price directly reflect operating expenses, and will fall commensurate with operating expenses...

shoshanabananah // 5:51 PM

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Tuesday, January 21, 2003:

I have to say, one of the most difficult things about medical school is unflagging idealism that we all do feel, somewhere, that gets ruined by stupid things like professors who don't email out copies of their powerpoint presentations before they give their lectures. We have wrath for that, we allow ourselves to become a bit more jaded when confronted with that sort of opposition, but we overlook, say, the major crises facing our careers. We (well, they) ridicule and distrust the doctors who come in to lecture to us or proctor our clinical activities but make it very clear that medicine is no longer their passion, that they have seen incomes and autonomy drop with no corresponding decrease in hours worked or personal responsibility required. We try not to listen and we joke and we sometimes experience moments of clarity and our stomachs churn a bit and we say that we hope it's all worked out by the time we are out there on our own, several years from now. And you know, I think, from growing up around doctors and from learning from and watching them now, that what they hate most is the turmoil and being forced to take stands on these issues. If we settled in to some new local minimum, but a nice quiet one, we would, yes, settle.

Some more foward-thinking students do try to get involved -- they forward us plaintive emails about how we are the future of medicine and therefore we should read the important announcements coming out from doctors' organizations such as the AMA. Before I would even start trying to fisk the confused statements coming from such industry (industry only in the most humane and altruistic way of course) leaders, I would just point out that their url is pretty stupid as the second 'a' of ama stands for association, which I assume is also what 'assn' means.

So I'm not sure really what I'm allowed to reveal in terms of email privacy and whatnot, but anyway we got a missive from "Speaker of the House John A. Knote, MD, Vice-Speaker Nancy H. Nielsen, MD, and I [Michael Maves]" entitled "News You Can Use" -- and I shall try to use it to point out the incompetence of this major organization as they stand up tall for physicians everywhere in this "med-mal" crisis... The "talking points" of the text is available here; we med students were also treated to a handy FAQ, presumably to print out and keep handy in the pockets of our white coats for whenever we might be called upon to defend ourselves.

The AMA has found that our nation has a full-blown crisis in at least a dozen states: Florida, Georgia, Mississippi, Nevada, New Jersey, New York, Ohio, Oregon, Pennsylvania, Texas, Washington and West Virginia. A crisis is looming in more than 30 other states.
I thought that was cute -- all I can say is please tell me what those at most eight states are! I'm off!

According to Jury Verdict Research, the median jury award increased 43 percent in just one year (1999-2000). More than half of all jury awards today top $1 million, and the average jury award has increased to $3.5 million.
So if I draw upon those guesstimating skilz from my high school publik edukashion, that means that there are lots of awards hovering around 3.5mil or a bunch of stratospherically high awards yanking up the average.
Just based on my experience as a proto-doctor (not procto, proto) with ears, I know that most doctors carry coverage that only will pay out like 1mil (per case), with the rest hypothetically seized from the doctor's assets, and I've never seen that happen, and they're saying here that at least a million is awarded in half of all cases.
But actually if I can use google to check out who those numbers are attributed to, I find these guys. And yeah, since all you see there is the home page of a possibly sleazy (this is the internet after all) but maybe legit company, the report to which I think AMA is referring is here. There they've got that 43% number and the report is from last March. And they say not a word about the 3.5mil average -- so AMA is promulgating this provocative number unattributed.
And if you look at the chart of increases, you see the 50% increase in 1997-8 -- and then that decrease for 1999-2000. What did medical malpractice rates do then? And the roundness of certain years yet the exactitude of others smacks of some sort of special attention to numbers...

I think the situation could be described by a minimum of statistics from a reputable source -- AMA and their choir have pointed a latex-gloved finger at malpractice litigation, and in doing so are promising us, or at least themselves, that doctors' malpractice insurance premiums directly reflect the contemporaneous trends in lawsuit and settlement awards -- values and numbers, I would hope. I would pipe up here that perhaps we should not be so quick to assume that insurance companies will mirror the trends as we are experiencing, and as AMA is trying to engineer, them to be. So we also need to hear from the insurance companies.

AMA brings up California, where a limit to the pain and suffering component of a lawsuit award was imposed in 1975. AMA, like the Red Hot Chilli Peppers, want to bring Cali to the whole country. This is the packaged solution -- look west. Nevermind that strikingly absent from their evangelizing materials presented on the internet and to us is a full look at the nearly 30 years California has been experiencing this cap...

They should, however, have to answer the question of the effect that California Proposition 103 (passed in 1988) has had on med mal rates -- as per 103, insurers must hold public hearings whenever they wish to significantly (>15%) raise their rates. One company tried this once, furor ensued, and they retreated -- seeming evidence of the power of 103. According to this advocacy group (hey, also from Cali!), 103 has been a success. AMA entreats us budding physicians to answer questions on 103 thusly: Anyone who tells you Prop. 103 is the reason for
California's successful medical liability reforms is not dealing with the facts. Oh okay. 

Clearly there's a lot that's missing from this debate, and a big problem is that doctors are always loath to really stick their necks out and in to business (and are not really allowed to by law -- the 'privilege' of providing healthcare requires keeping your hands clear of possible commercial conflicts of interest), and then all those non-doctors, aka patients, are wary of what will happen to their medical fees and no one but doctors will ever complain that doctors don't make enough money...
And meanwhile insurance companies and lawyers have these captive populations (doctors need insurance to practice; lawyers will always get paid out of pocket) to squeeze. I'm no fan of government intervention and the wording of Cali's 103 makes my toes curl -- it's the state coming down and limiting (ostensibly) insurance company profits, analogous to the state dictating ridiculously low compensation for doctors for services provided to Medicare and Medicaid patients.

shoshanabananah // 10:29 PM

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Starting a blog has been an inevitability of mine for awhile. I talk a lot and get very excited and sometimes it tires those around me out, and sometimes it depresses me that they seem to not care enough to be multiply-informed and gregarious.

I'm a Jewish-American Princess/Medical Student, and I find myself and my future all over the news these days. Over the past several months my laptop and spotty DSL connection and I have started to find more blogs, and more blogs have started to be written, that give me fodder for thought and talk. I'll try to use this blog as a outlet for my thoughts and analyses and those that I find elsewhere.

The name LaneInStay comes, of course, from the admonishment "STAY IN LANE" written on highways in no-passing zones and meant to be read, I've always felt very artificially, as it is encountered by the vehicle and driver.
shoshanabananah // 12:02 AM

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