1. You still haven’t given me a prospective way of determining what “tests a patient does not need.” You are making a circuitous argument because the only way that an attorney judges that at test was “needed” is RETROSPECTIVELY – after an injury has occurred.

2. List of doctors? I don’t keep such a list, but here is “one example” that you clamor for (and it was a bullshit 20-20 hindsight case, also):
http://www.ama-assn.org/amednews/site/free/prca0116.htm

3. I have no idea whatsoever what point you are trying to make with this statement

4. You accuse doctors of “selfishness” for taking risk avoidance behaviors. Everyone takes risk avoidance behaviors by wearing seat belts and using nicotine patches. Are those “selfish” actions also?

5. This really burns me.
Attorney: “We need to set up a system to protect you from your selfishness. How about this: follow the standard of care.”
WhiteCoat: OK, I’d be happy to follow the standard of care. What is it?
Attorney: “I DON’T KNOW what the standard of care requires.” Besides, it is a “meaningless question.” Now pay my client $5 million so I can get my 40% cut, will you?
You use the same logic in your legal briefs?

6. Still waiting for that plethora of articles.

7. If you don’t like the suggestions that you’re “blowing smoke,” then back up your assertions with statements of fact and prove me wrong. So far you haven’t done so.

Sorry, but I don’t under stand your rational for saying it is “selfish.”

2. This was a strawman argument as that is not what “WhiteCoat” said. Assume for a moment that you had to put up your retirement and house as collateral in response to being sued while knowing you did nothing wrong. Are you going to sleep well at night? Are you going to have added stress? Is knowing that your financial status is on the chopping block going to make your performance in the workplace better or worse?

3. It is not that people should be excluded from the conversation, but rather that the people that are on the front lines of medicine have more direct knowledge of the situation.

5. You make WhiteCoat’s point for him. How can anyone be held to a standard that doesn’t exist, or one that constantly shifts depending on an “expert” or a lawyer? How would you feel if you were pulled over for a speeding ticket on a road where the speed limit changed daily and there were no signs saying so? One day the limit is 30, the next 40, then 25 and you don’t know. Is it right that you are held to “standard du jour?”

6. WhiteCoat’s assertion that there has been an influx of doctors into Texas is accurate. According to the New York Times, the licensing board has also received funding for more investigators and lawyers, so oversight of doctors may be increasing as well I don’t see how that you dismiss that with “not much else is happening.”

Docs resent the current med mal system because of the randomness of it. It’s a crapshoot. There are cases that are truly malpractice but will not be taken up because of their low potential payout. And there are cases of questionable merit that will be pursued with a vengeance because of the large potential payout. This is what “fighting for the little guy” is all about? And of course emotion is brought into play, sometimes ignoring the facts of the case. As you know, and as WhiteCoat has pointed out, you can ALWAYS find an expert that will say anything. For Docs, all it takes is ONE case, just one, that could ruin a career.

What drives the defensive/excessive medicine? Second guessing, especially when there is an adverse outcome, must have some effect. The lack of cost/benefit calculation. I certainly would have declined the x-rays in the case of the minor injury of my son. There was nothing to justify their cost. The humane tendency to show that one is an excellent doctor.

Since claims of malpractice are mostly wrong, the plaintiff bar does not help matters. “Perhaps that extra test saved a life” is the claim, but the lawyer who makes the claim can base it only on conjecture, as there is almost never a suit when treatment is effective.

1. Selfishness – you order tests a patient does not need that can be harmful them to protect yourself, this is selfish and wrong.

2. I’d like to see a list of doctors who lost their 401K and their house. Do you know one? Just one? They are going to be dwarfed by the numbr of doctors who died in car accidnts this month.

3. We need to go beyond the conversation of “you are doctor, you are there, so you know.” It leaves out meaningful contributions for the rest of us. Since doctors don’t make laws, we are going to included the rest of into your policy arguments.

4. I don’t get the seat belts and nictoine thing.

5. You demand that I tell you what the standard of care requires. I don’t know. It is meaningless question in the absence of fact – it is not abstract question.

6. I’ll put some atricle for you. Malpractice premiums are down but not much else is happening as they hoped in Texas. But yes, doctors are making money if that is the panacea for all.

7. I find troubling suggesions that I’m blowing smoke. Trust me, I’m making rational argument with which people smarter that you and me bother agree and disagee. I don’t think anything you are saying is silly. I think it is wrong. But nothing I’m saying is ridiculous. I’m glad for the debate but I’m not sure the whole “talking to me like I’m a child that does not understand” think is the best way for constructive dialogue.

I have to dispute several of issues that Ron raised.
In your first comment, how is it that being unwilling to risk your life savings and your home to miss some bad outcome in a patient you’ve never seen before translates into “selfishness” on a physician’s part? I’m not sure how “selfishness” even comes into the discussion … taking risk avoidance behaviors? Gee, next thing you know seat belts and nicotine patches will be on the hit list.
Since I am just a dumb doctor, enlighten me, Ron. Take the example that Walter quoted in the first paragraph of my post above. What does your coveted “standard of care” require be done in that patient? What actions should a physician take to make sure that the patient is adequately evaluated to the point that you and your brethren are satisfied that “enough was done” even in the event of a bad outcome? Then put your house and your 401k up as a collateral just in case I can find some “expert” to testify otherwise and convince a jury that you were really wrong. Come play in my world for a little while, not your retrospective Monday morning quarterbacking settle-for-the-policy-limits-or-else world. Go on. Show me what to do prospectively. Tell me what the standard of care requires. Until you do that, you are blowing smoke from your rectum and every person that reads this blog will know it.
You know damn well that there are a cadre of plaintiff experts – even I can name the usual suspects in emergency medicine – that will testify that the standard of care requires anything that the plaintiff attorney pays them to say. Forget that seventeen other physicians say the standard was followed. One expert to the contrary and it’s “game on.” The whole concept of a “standard of care” is a joke. You’re perpetuating that joke.
Regarding comment #4, you’re right, most doctors are good people – just like the members of any other profession, including law. There are a few scumbags that milk the system – just like any other profession, including law. That has nothing to do with defensive medicine. You’re wrong about the reason for defensive medicine. I live the life and talk to doctors about it. You don’t.
You give the example of Texas and tort reform. Doctors not fleeing there? Read the newspapers a little. Since passage of Proposition 12, there have been so many extra applications for licenses in Texas that the board is having trouble keeping up with them. There was a 30% increase in applications for licenses in 2007 alone. The numbers of neurosurgeons, orthopedic surgeons, and obstetricians have all increased significantly. Malpractice premiums have dropped for 5 consecutive years and are now 68% of what they were in 2003. You have some statistics to the contrary?
Don’t even try to compare civil med mal cases with a “tipping of the scales” standard to criminal cases with a “beyond a reasonable doubt” standard. Completely different birds. When you use the comparison with people that know better, they can realize that this argument is disingenuous. When you use it with people that don’t know better and don’t disclose the differences, you’re being misleading.
“Some” defensive medicine is good? Where do you draw the line? Oh, I forgot, you’re using a retrospectoscope. The “good” defensive medicine is something that retrospectively shows an abnormality. The “bad” defensive medicine is a test that is ordered and shows “nothing.” So tell the readers of this blog, Ron: Where should everyone draw the line between “good” and “bad” defensive medicine? What tests should we stop ordering? Prospective opinion, please.
Your response in comment 4 paragraph 3 shows that don’t understand the concept between being held responsible for negligence and being held responsible for a bad outcome in the absence of negligence. Big difference. Doctors are trying to avoid the latter rather than the former. I know this — not on a hunch — but because I have discussed the issue with a lot of doctors.
Am I biased the “other way”? Maybe a little. I’m trying to look out for my patients, though.
The perfect storm is almost here. Medical care in this country is going to become largely unavailable. Defensive medicine plays a big part in that equation and fear of frivolous lawsuits drives a large portion of that defensive medicine.

Jim, welcome to the world that the attorneys have created. Without knowing all the facts of your case, my guesses are the following:
If you’re heavy, your legs were probably swollen. Did you need the Doppler? Probably not. But you got it because then the doctors could prove to the lawyers and the jury that they didn’t miss a DVT if you later developed a pulmonary embolism and died. Did you need the EKG? Depends. If you had a fast heart rate, that way the doctors could prove to the lawyers and jury that you were not in an arrhythmia if you later suffered a bad outcome.
Defensive medicine sucks, doesn’t it?

Allow me to offer some counterpoints to your response. I’ll keep the same numbering system you initiated.

2. As I said originally, the CBO never issued its methodology for gathering data. This includes what they define as “defensive medicine.” The common definition used in other studies seems to be “practices that give a defense in the case of litigation, or practices that help pay for increased costs from litigation.” (increased maplractice insurance, etc.) While your point that “almost every doctor would prefer a lawsuit in a case where they were not responsible than NOT getting sued in a case where they seriously harmed someone” is valid, the fact remains that many doctors are practicing “defensive medicine” to either try to avoid being sued, or to help pay for insurance costs driven by others who HAVE been sued. Either way, there is no doubt that the practice of “defensive medicine” is out there and prevelant.

3. I believe the exact opposite. The doctors who practice defensive medicine are the ones more likely to try and stay in the profession and not get litigated out of it. While I appreciate your qualifer of “some,” the fact remains that “some” implies the “majority” of the doctors are practicing defensive medicine for the reasons stated which have nothing to do with patient care. “Defensive medicine” is practiced because of the “bottom line.”

4. I think you missed the point. The CBO study doesn’t give methodology, so it is impossible to figure out where they were getting their data and therefore their conclusions. Other studies that offered methodolgy questioned doctors and nurses – the “boots on the ground” – and came to radically different conclusions than the CBO study. Which study is more believeable? You mileage may vary, but I am going to take the one where the methodology is given and the people questioned are directly involved rather than a unknown methodology based on unknown inputs.

Unfortunately, we are training our medical students to order tests like crazy and not to have them be fiscally responsible with healthcare resources. If we allow evidence based medicine to be the “Standard” we can be fically responsible and use the healthcare dollars for more care rather then “litigation care” and actually reform medicine. The problem of course is the patient with the headache who come to the er and has classic migraine and then sues years later for the undiagnosed meningioma that is and always has been asymptomatic.