Recently in Bad Medicine II Category

41-year-old South Texas personal injury solo practitioner Hermes Villareal was admitted to a McAllen hospital on April 16, 2005, reporting that his heart was racing. The hospital put him on a 24-hour EKG. Villareal reported being under stress, but refused a psychiatric consultation or the recommended medication. At 5 a.m. on April 19, 2005, the day of his scheduled discharge, "Villarreal summoned the nurse on duty and requested a razor, saying that he wanted to take a shower and shave his chest, because the EKG monitor leads attached to his chest were bothering him." The nurse complied with his wishes, and Villareal locked himself in the bathroom and committed suicide with the razor.

This was, said Villareal's family, the hospital's fault; since it's South Texas, a Hildago County jury, after a three-week trial, awarded $9 million in March (which looks to be reduced at least to $1.64 million under Texas law capping damages). Ironically, the opening line of the Texas Lawyer story says "It was a suicide no one saw coming," but doesn't question the resulting jury verdict.

Somehow, the trial lawyer, Raymond L. Thomas, a close friend of Villareal's, interjected himself into the closing argument, telling an emotional story of a Rolex Villareal had given him as a gift that left the jury in tears; the press coverage doesn't acknowledge the blatant violation of ethical rules (see also Texas Rule 3.04(c)(3)), much less indicate whether he got away with it because of the failure of the defense to object or a judge's failure to oversee her courtroom. (Jenny B. Davis, "Attorney, Interrupted: Seeking Meaning, Recovery for a Legal Life Lost," May 5 via ABA Journal).

In June 2004, we wrote:

In the complicated surgery to correct scoliosis, screws and rods are inserted and bone added into the spine. The risk of nerve damage or paralysis is such that there is something called the Stagnara wake up test, whereby the patient is woken during surgery to ensure she can move her feet. In 1999, however, Joshua Terry was one of the unfortunate 0.1% who was paralyzed during surgery. And, according to the newspaper account, his lawyer, Jay Kelley, found four surgeons to testify against defendant Dr. Ernest Lindell that "paralysis was not a potential complication" from surgery on the spine to correct scoliosis. A Lucas County, Ohio jury awarded $8.4 million to Mr. Terry and another million to his parents. And Dr. Lindell will no longer perform spinal surgery. ("Paralyzed area man wins $10M judgment", Toledo Blade, Jun. 16; P. Stagnara, et al., "Functional monitoring of spinal cord activity during spinal surgery", Clin. Orthop., 1973; 93: 173-78).

Perhaps there was malpractice in this case; paralysis is relatively rare, and one can't tell the merits one way or the other from cursory press coverage. (Terry claims that Lindell "lost control" of an instrument during surgery, and it's unclear whether that claim is the result of concrete evidence or a wishful inference.)

If the press account is correct, the plaintiffs' attorney put a finger on the scale through expert testimony claiming that paralysis doesn't happen except through negligence. Even a relatively well-educated lay jury isn't well situated to resolve which expert is telling the truth. It's another example of why the current litigation system is poorly situated to resolve disputes of this sort.

Jay Kelley writes us:

Trial lawyers like to repeat statistics similar to this (Bizarro-Overlawyered just did so this week) as an argument for medical malpractice being a problem of the doctors, rather than the lawyers. The problem is, as I noted three years ago, that the statistic is fallacious.

Some small X% of doctors responsible for large Y% of payouts is always going to be true simply by random chance. It's going to be true over any time period: the problem is that if you take that time period and divide by two, the X% in the first half of the time period are going to be almost entirely different than the X% in the second half of the time period. Even if you were to fire every single one of those doctors in the tail in the first time period, all you have is X% fewer doctors; the very next year, it's going to be a different small A% of doctors responsible for large B% of payouts, and you've solved nothing. With very rare exceptions medical malpractice payouts have absolutely nothing to do with the quality of the doctor, and everything to do with the risk profile of their practice.

It's worth noting Eugene Volokh's excellent explication of the issue:

Lacking specialized knowledge in this area I'm not well situated to evaluate the contents of this letter from reader J.W., but perspectives and advice from medically knowledgeable readers would be more than welcome:

One of our friends apparently has focal segmental glomerulosclerosis, which has a substantial risk for progression to end-stage renal disease.

Apparently, getting a nurse to come and administer albumin, which is a blood product, is a real problem. About three years ago, liability laws stopped the companies that produce albumin from allowing it to be used at home. There is a real possibility she will have to go to "Day Hospital" every day for five hours and perhaps have to be readmitted every weekend.

Given the likelihood that she will die from her disease, I'm sure she is comforted by the fact that she'll spend so much time in the hospital for legal reasons.

But I feel safer, so that's nice.

...or the universal adoption of round-the-clock patient guards or restraint devices, it's hard to go along with the notion that hospital falls should be so-called "never events". (Happy Hospitalist, Jan. 15, Feb. 20). Nor is the concept much more useful when it comes to patient suicide attempts or hypoglycemia, among other misadventures (White Coat Rants, Feb. 5)(via KevinMD). Related: letters section, 2004 (pressure wounds/bedsores).

Mandatory lunch breaks for unhungry nurses, hurdles to get over in prescribing pain medication, and more. (Toni Brayer, EverythingHealth, Jan. 27).

A Utah federal court will consider the Pace family's lawsuit against California anesthesiologist Barry Swerdlow, whom they had earlier hired as an expert witness as part of their medical liability suit against another anesthesiologist, Stephen Shuput, whom they blamed for their late daughter's death. After agreeing to come on board as an expert for the Paces, Swerdlow examined Shuput's deposition and concluded that Shuput had met the standard of care; he proceeded to inform Shuput's lawyers of this, and they quickly got the case dismissed. The Paces then sued Swerdlow for "malpractice, fraud, negligent misrepresentation, breach of fiduciary duty, breach of contract, breach of the implied covenant of good faith and fair dealing, and negligent infliction of emotional distress," to quote AMNews's catalogue. Swerdlow conceded that he was new at the expert witness game and that it would probably have been a good idea for him to have read Shuput's deposition earlier. The EleventhTenth Circuit ruled that a lower court should consider the Paces's contention that they had suffered legally actionable damages from Swerdlow's actions. (Bonnie Booth, "Expert who changed mind claims immunity, but plaintiffs still sue", American Medical News, Apr. 14).

Judge Gorsuch, dissenting from the EleventhTenth Circuit's ruling, wrote:

Parties already exert substantial influence over expert witnesses, often paying them handsomely for their time, and expert witnesses are, unfortunately and all too frequently, already regarded in some quarters as little more than hired guns. When expert witnesses can be forced to defend themselves in federal court beyond the pleading stage simply for changing their opinions - with no factual allegation to suggest anything other than an honest change in view based on a review of new information - we add fuel to this fire. We make candor an expensive option and risk incenting experts to dissemble rather than change their views in the face of compelling new information. The loser in all this is, of course, the truth-finding function and cause of justice our legal system is designed to serve.

(Decision of the Day, Mar. 5; Karen Franklin, Forensic Psychologist, Mar. 7; The Briefcase, Mar. 7).

One of the 16 other physicians hit in the "shotgun" pleading reports that the process was neither easy nor painless nor without its lingering costs to the present day. (Mitchell S. Cappell, "A baseless malpractice suit still cost me", Medical Economics, Feb. 1)(via KevinMD).

When money is paid out on a medical liability claim, the doctor's name is automatically entered on this federal database -- and that may have more serious consequences for the doctor's career than the payout itself. (Vicki T. Brenthall, Medical Economics, Feb. 15).

...and then wins a settlement against the hospital for letting him do so [ER Stories, Feb. 2]. (For sharp-eyed readers: this post replaces one linking to a story on the same blog that -- my lapse -- Ted had already covered).

Colloquy of Coyote and commenters, based on the John Ritter malpractice jury verdict.

"A Glendale jury on Friday cleared an emergency room doctor of negligence and liability in John Ritter's death, holding he did everything he could to save the comic actor. ... Jurors, who voted 9 to 3 against liability for Lee and Lotysch, said they were torn between sympathy for Ritter's wife and children and their conviction that the doctors were blameless." (John Spano, Los Angeles Times, Mar. 15). Earlier here and here (noting that Ritter family had already obtained $14 million in settlements from other defendants).

Which means, says Kevin Pho, that you're not always going to succeed in catching the extremely rare aortic dissection: "No test is 100% accurate, and there will always be missed cases no matter how good the care was." (Feb. 18; John Maxfield, "Besieged by scourge of medical ‘malpractice’", Naples (Fla.) Daily News, Feb. 16 (Mahoning County, Ohio case)).

There is no shortage of examples of medical malpractice litigation where plaintiffs blame doctors for failing to perform a CT scan. E.g., Oct. 2006 and Feb. 2004. This plainly raises costs far more than the direct costs of medical malpractice insurance that you see when the trial bar claims that malpractice reflects only 1-2% of health-care expenses. Tom Baker, among others, argues that defensive medicine has to be viewed as good with bad, because of improved health-care outcomes from the additional care. But not all defensive medicine is positive; it can be irrelevant, or, worse, adversely affects health results.

Malpractice litigation does change doctors' incentives, but only with respect to short-term results. Because doctors won't be sued for long-term consequences of defensive medicine, there is a substantial risk of overexposure to radiation in the course of defensive CT scans—a problem identified in a study in the latest issue of Annals of Emergency Medicine (Winslow, et al., Quantitative Assessment of Diagnostic Radiation Doses in Adult Blunt Trauma Patients; Reuters summary), finding that standard trauma treatment—1005 chest X-ray equivalents—results in an additional 322 cases of cancer per 100,000 treated because of use of CT scans. Earlier: Feb. 2004.

(Update: Walter writes in to note that "the problem of needless or avoidable CT and MRI scans has been getting a fair bit of discussion at the medical blogs lately, e.g. White Coat Rants, GruntDoc, and KevinMD.")

On Feb. 7 a jury found the Charleston Area Medical Center in West Virginia had wrongly revoked the privileges of vascular surgeon R. E. Hamrick, Jr. over a financial dispute. It awarded Hamrick $25 million, including $20 million in punitive damages; the dispute arose over Hamrick's desire to set up a self-insurance fund against professional liability as opposed to purchasing outside insurance. CAMC has retreated from initial talk of pay freezes for staff, but it is unclear where it will come up with the money -- about 4 percent of its annual budget -- in ways that have no impact on patients: "'Any time you have to spend $15 million, how can it not affect the way we care for people?' asked Dr. Tom Bowden, who also serves on CAMC's Board of Trustees." However, expert witness Jonathan Cunitz of Westport, Ct., who testified for the plaintiffs on punitive damages, told the Daily Mail that patients and employees "shouldn't be concerned for a second" about cutbacks because the nonprofit community hospital could just pull the money from the magic rainbow wishing well could cover the punitive damage award "just out of the money generated by Hamrick's surgeries," in the newspaper's phrasing. It sounds almost as if hospital revenues from surgery constitute pure gravy and do not involve any correlative expenditures. The hospital's CEO notes that the damage award "was higher than the $15 million CAMC spent to purchase the former Putnam General Hospital in 2006." (Justin D. Anderson, "Doctor responds to colleague's lawsuit win against CAMC", Charleston Daily Mail, Feb. 12; Eric Eyre, Charleston Gazette, Feb. 13, Feb. 20, Feb. 21; Chris Dickerson, West Virginia Record, Feb. 7).

The lowest medical malpractice insurance rates are found in Minnesota, Wisconsin, Iowa and the Dakotas. Why is that? Probably not because doctors there have managed to achieve anything resembling error-free practice; and probably not because the five states, taken as a whole, are distinguished by any unusually pro-defendant set of tort laws. MedInnovationBlog takes up the question here and here, and speaks with a mutual insurer executive in search of explanations, which may include (among others) a "culture of collegiality among doctors and society as a whole", a hard line against doubtful claims, and a paucity of giant verdicts of the John Edwards variety. (cross-posted from Point of Law).

Following up on our discussion of HIPAA and the New York therapist murder, police have reported a break in the case, arresting a mentally disturbed man who has told investigators of having been committed to a mental institution 17 years ago by Dr. Kent Shimbach, the doctor who was injured in the rampage (and who shared offices with the therapist who was killed, Kathryn Faughey). Dr. Shinbach apparently has told investigators that he did not recognize the assailant and has no memory of any contact with him in the past.

Helen Smith ("Dr. Helen") at Pajamas Media recalls the case of Vallejo, California psychologist Ira Polonsky, Ph.D., "who was shot and killed by what family members believe was a former patient. Unfortunately his death is still a mystery. Why? Blame the confidentiality laws in California:"

…police have been stymied in pursuing that line of investigation because of confidentiality laws protecting Polonsky’s patient records and appointment books.

Vallejo police detectives are in touch with a court-appointed attorney – a “special master” – who is working with the county court to see if there can be at least a limited review of protected records, but neither police nor court officials will comment on progress in that area.

And Hans Bader takes note of a recent Volokh thread discussing cases in which it seems Massachusetts privacy law was construed to prohibit the taping of ransom discussions with kidnappers (Commonwealth v. Jackson, 1976, mentioned in passing here) and a Florida court considered (but rejected!) the argument that a murderer's privacy was infringed by his victim's having tape recorded the murder.

Before they officially became presidential candidates, the Illinois and New York senators co-authored an article in the May 25, 2006 issue of the New England Journal of Medicine, entitled "Making Patient Safety the Centerpiece of Medical Liability Reform." (See: http://content.nejm.org/cgi/content/full/354/21/2205)

They sympathized with physicians over escalating insurance costs and condemned the current tort system for creating an "intimidating liability environment." Still, Clinton and Obama said, it's more important to focus on how to improve patient safety than "areas of intense disagreement," such as caps on financial awards to patients.

They introduced legislation, which died in committee in 2006, to provide money and assistance to physicians, hospitals, insurers, and health care systems to start programs for disclosure of medical errors and compensation to patients. The bill would have created an office of patient safety and health care quality to establish a database to track incidents of malpractice and fund research into guidelines to prevent future injuries.

"Physicians would be given certain protections from liability … in order to promote a safe environment for disclosure. … This legislation would provide doctors and patients with an opportunity to find solutions outside the courtroom. In return, [hospitals, insurers, and others] would be required to use savings achieved by reducing legal defense costs to reduce liability insurance premiums and to foster patient-safety initiatives."

(Mark Crane, MedPageToday, Jan. 7). More: see Ted's December post at PoL.

More HIPAA madness? On Wednesday, in a crime that cast a chill through the mental health community, a Manhattan therapist was brutally slaughtered in her office by a man whose actions seemed consistent with those of a current or former patient with a grudge. The assailant escaped on foot, and although his image had been captured on surveillance tape, police were nowhere near beginning to know where to start looking for him: "Because of privacy laws, police hadn't been able to access patient records as of late yesterday, sources said." (New York Post, Feb. 14)(via Bader). On medical privacy laws and the Virginia Tech rampage of Seung Hui Cho, see Jun. 16, 2007.

More: Commenter Supremacy Claus says not to blame HIPAA, which has an exemption for police reports.

Friday morning sequel: This morning's New York Post sticks with the original story and fleshes out the HIPAA role somewhat:

The hunt for the savage beast who butchered an Upper East Side therapist has hit a roadblock - because detectives can't access her patients' medical records under federal privacy laws, The Post has learned.

Police believe the meat-cleaver-wielding psycho who killed Kathryn Faughey on Tuesday night inside her office on East 79th Street could be the doctor's patient - and need access to her records to identify him.

But police sources said because of the Health Insurance Portability and Accountability Act, signed by President Bill Clinton in 1996, investigators are having a hard time gaining access to those records.

"A case like this gets complicated because of medical privacy protections," a source close to the investigation told The Post yesterday.

The federal law states that doctors, hospitals and health-insurance companies must protect the privacy of patients - even in a murder investigation - and that only through the use of subpoenas can authorities hope to obtain such information.

Police sources said investigators have applied for a subpoena, but have yet to receive it. Even if the subpoena is issued, patients can sue to keep their records private. ...

[D]etectives have tried to get around the law by tracking down patients through sign-in sheets at the building's front desk and through surveillance cameras in the lobby, sources said.

(Murray Weiss, Jamie Schram and Clemente Lisi, "Vexed by 'Slay File' Madness", New York Post, Feb. 15). My Times (U.K.) article on the problems posed by health privacy laws is here.

An instruction sheet for doctors providing defense-side "independent" medical exams in injury cases reads in part as follows:

# Point out whatever findings or claims are not related [to the sued-over incident]. Otherwise be silent on causal relationship.

# If prognosis appears good, then state that - otherwise be silent

# If you can state that plaintiff can participate in all normal activities, do so. If not, be silent

Eric Turkewitz, who brings this story to public attention (Feb. 12), wonders what ethical questions might be posed for both lawyers and doctors when expert witnesses are coached in this way to give partial and incomplete (to say no more) testimony. I don't know what New York legal and medical authorities would do, but in the mother of all witness-coaching scandals in recent years -- the inadvertent release of Baron & Budd's "Preparing for Your Deposition" memo in asbestos litigation in Texas -- nothing at all wound up being done by established authorities to discipline or punish the plaintiff's lawyers involved. In fact, even more incredible, Baron & Budd succeeded in hiring more than one well-known academic ethics specialist to sign affidavits attesting that the coaching practices were in no way objectionable -- details here and here (see pp. 161 et seq. of Brickman's Pepperdine article). So if Integrated Risk Services, Inc., of Long Island, New York, which bills itself suggestively as a firm providing "Attorney Managed Independent Medical Consultation Services", finds itself in hot water, perhaps it should give Prof. Silver in Austin a ring.

P.S. Jane Genova at Law and More doubts it works well before juries -- though of course persuasiveness to a jury might not be the only objective for those who engage in coaching.