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So many lawyers, so little time...

"The prospect of hanging focuses the mind wonderfully"--Samuel Johnson

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Location: Louisville, KY, United States

Gastroenterologist, cyclist, cellist, Christian, husband, father, grandfather.

Sunday, February 05, 2006

The principle of paradoxical risk

One of our "throw-away" journals recently ran an article with this startling conclusion: 'defensive medicine' is a huge problem in America, resulting in an enormous economic drain on our healthcare system.

Practicing physicians have known this for years. Out of narrow self-interest, the trial lawyers have been misrepresenting the magnitude of this problem. If they gave two hoots and a holler about the welfare of patients, they would at least acknowledge that this problem exists and perhaps come up with some constructive suggestions on how to fix it. But they don't, and they won't.

There are many thoughtful reviews about this problem, and I won't burden the Thinking Public with yet another one. I will suggest that among the forces behind the Defensive Medicine Crisis is the Principle of Paradoxical Risk. I have no idea whether anyone else has described this. I've never read it, so I'm happy to take full credit for the concept.

If I see an 80 year old who is complaining about passing blood in the stool, there is a reasonable chance that the patient has colon cancer based on their age alone. If I blow the diagnosis, then Ill be liable for economic damages which are going to be limited to the extend that the patient's "earning potential" is likely limited. If I live in a state with some sort of limitation on "pain and suffering" damages, then my liability will be further limited unless the court can prove that I was willful and malicious in my malpractice, and I get nailed with punitive damages.

Will the threat of malpractice influence my behavior in this case? Of course not. I get paid to make the diagnosis of colon cancer, and, knowing the odds, I'm not about to pat a patient on the back and tell him to take some Preparation H. I'll schedule the colonoscopy.

How about a 60 year old with the some complaint? The patient is less likely to have colon cancer, but the economic damages will be higher, assuming that the patient is still working. The "cost" of blowing the diagnosis of colon cancer will be higher, although the risk of the patient having colon cancer is lower. Again, this isn't going to influence my decision-making. The right thing to do is to proceed with colonoscopy, and I get paid for doing the right thing.

But what about the 20 year old who presents with the same complaint? If I blow the diagnosis of colon cancer I'll have the Devil to pay. The plaintiff will claim 45 years of high economic productivity that I'll be denying him. Unless I live in a tort-reform state, the plaintiff will also parade a steady stream of friends and family who point out how a beautiful young life was snuffed out because of my negligence. I'd be thrilled to settle within the limits of my malpractice insurance. No one would be happy about this.

What are the odds of a 20 year old having colon cancer (I'm assuming the patient has no risk factors such as chronic colitis or a family history syndrome)? What are the odds of complications from colonoscopy vis-a-vis the risk of colon cancer? What is the cost-effectiveness of putting 20 year olds with rectal bleeding through the mill over what is almost always hemorrhoidal bleeding?

The Principle of Paradoxical Risk states that "the less likely a serious medical condition is, the more likely you are to get your butt sued off if you don't diagnosis it".

The Principle of Paradoxical Risk states that these questions have no relevance to the discussion. If you miss the diagnosis of colon cancer in a 20 year old, you will be savaged in every conceivable way. You'll have to look at yourself in the mirror every day realizing that you could have saved the life of a person younger than your own children. You'll be financially ruined. The ordeal of a malpractice suit would drag on for at least 4 to 5 years (plaintiff attorneys do this because it is in their financial best interest).

Fifteen years ago, a gastroenterologist who performed colonoscopy routinely on 20 year olds with rectal bleeding would have been accused of churning. Do you think they would be accused of it now? What would you do? Saying you would just retire from medicine because operating in such an evil atmosphere would take too high an emotional toll is an acceptable answer.


Blogger Val said...

Just another reason I thank my lucky stars that I'm a veterinarian (although my dear dad desperately wanted me to become an MD)...

10:51 AM  
Blogger Elliott said...

How about this principle? You treat the disease that the patient has and not the one they fear they have. Not one study exists to show that practicing defensive medicine lowers your risk of being sued. Doctors won't take their own medicine though and just pretty much whine, whine, whine about what they most fear - financial loss and public shame - ignoring the fact that defensive medicine won't stop them from being sued. Damned if you do and damned if you don't can be the unfortunate lot in life for most doctors. On the other hand, being the highest paid workers in the USA does compensate them just a teeny, weeny bit for that aggravation.

It would be great if every doctor who threatens to quit because of the trials and tribulations inflicted upon them by the legal profession would actually retire. It's unlikely that health outcomes would get worse and we'd save a ton of money. It'd be better to have fewer doctors in the US. We overspend on healthcare and the primary driver is how many doctors there are.

4:58 AM  

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