The Malpractice Lottery
by Kevin Pezzi, MD
Ambulance personnel often cover patients they're transporting with a blanket to keep them warm. As the next patient rolled into the ER, I couldn't help but notice that this blanket was conspicuously bowed upward. No, the 18-year-old patient wasn't pregnant—she was simply obese, although “simply” seems a tad understated when we're talking about 275 pounds on a 5'1" frame. I often get a gut feeling about certain things, and my gut feelings about her were on target. In a split second, I'd guessed that she was a smoker, unemployed, and—of course—on welfare. I also guessed that this was no emergency. Such uncanny insights.
Dr. Pezzi: What brought you into the emergency room today?
Patient: The ambulance.
Dr. Pezzi: (I thought, “Oh, we're a smart aleck, too, eh?”) Why did you come in?
Patient: I've been having chest pain for two weeks.
Dr. Pezzi: Two weeks?
Patient: Well, maybe three . . .
Dr. Pezzi: Have you seen your doctor about these pains?
Patient: No, not yet.
Dr. Pezzi: (Thinking, “Well, what are you waiting for?”) Why did you decide to come in today?
Patient: 'Cause me and my boyfriend are going on a trip tomorrow. He got his disability check today, and we're going to the Mall of America to go shopping.
Dr. Pezzi: (Musing, “No wonder my taxes are so high!”) Did you come to the ER because your pain is getting worse?
Patient: No, it's getting better, actually.
(Add another $2000 to the national debt. A bevy of tests later, I had CYAed her to the max, even though I knew I would find nothing1. To an attorney, my professional opinion means little; he wants proof, so I give it.)
Dr. Pezzi: (While the history, physical, and tests supported a benign diagnosis, I began to counsel the patient on things she could do that would reduce her risk of serious health problems, such as losing weight, giving up cigarette smoking, and exercising.)
Patient: I don't like to exercise.
Dr. Pezzi: Why?
Patient: It makes me tired.
Dr. Pezzi: Have you tried dieting?
Patient: I tried it once, but I got hungry. My Mom always said I was a big eater. She says I've got big bones.
Dr. Pezzi: (Thinking, “No one's bones are that big!”) It's very important that you stop smoking and lose weight. Otherwise, you will eventually develop serious problems.
Patient: So what?
Dr. Pezzi: Aren't you concerned about these risks to your health?
Patient: No. When I die, I die. I don't care when I die, as long as I can do whatever I want while I'm alive.
Hmmm . . . Fair enough. Everyone is entitled to their own opinion, especially on that matter. However, I wondered, if that is your opinion, why did you come to the ER by ambulance—wasting thousands of dollars—when you have no intention of following medical advice? For a moment, I began to mull over the “why,” but my thoughts were interrupted.
Patient: Will you get out of here?
Dr. Pezzi: (Startled, I thought, “Excuse me for intruding in your emergency room!”) Pardon me?
Patient: Come on, hurry up! My boyfriend wants to talk to me about our trip tomorrow!
Dr. Pezzi: (Miffed, I felt like saying, “OK, you insolent blimp, I'll leave.” However, I doubted that she'd know the meaning of “insolent,” so the implication would be lost. I turned around, paused for a moment, and left. On to my next patient.)
1 At this juncture, it would be reasonable to ask, “Well, if you knew the tests would be negative, why did you order them?” A good question deserves a good answer, and I have one. In this case, the patient had done nothing more serious than pull one of her chest muscles. It took me about 10 seconds to unravel that mystery, and I could have been on to see my next patient, or to hold the hand of the grandmother who was dying of lung cancer in the next room—but no, I had to play the CYA game. In this country, there are far too many malpractice attorneys out for blood. These prostitutes don't care if you're right; if you haven't provided concrete substantiation of your diagnosis, they will make you pay for their next Rolls-Royce. “But,” you interject, “if you're right, she doesn't have a serious problem, so nothing will happen to her, so she can't sue you.”
Oh, if life were only that simple! The patient was a smoker; smokers are prone to blood clots; blood clots can travel to the lung, causing a pulmonary embolism (PE)—and kill! This patient had other traits which heightened the risk of a PE, such as morbid obesity and a sedentary lifestyle. She was planning on taking a long automobile trip to another state the next day, which substantially increased the chance of clot formation. (It doesn't matter that the risk of a PE, even in this person, is relatively unlikely in the near future. I see so many thousands of patients in one year it is inevitable that some are going to develop serious problems, or die.) If she indeed had nothing but a pulled muscle on the day I saw her in the ER, but she developed a clot the next day, then died, what do you think would happen? Her family would point their fingers at me, and unleash a rapacious lawyer. He would scream, “She had the clot on the day she saw you, and you said she just had a pulled muscle! You let her die! Now, sign the check.” And you know what? In this screwed-up country, I would have to sign his million-dollar check, out of fear that the original O.J. jury, now free to pursue other interests, would award the family a few million more.
Now do you get my drift? Even if she did not have the clot when I saw her, I couldn't prove it—so I would pay dearly, even though I was 100% correct. When a person comes (or, in this case, rolls) into the ER, there's one more entrant into the Malpractice Lottery. The fact that I see a patient in the ER is enough to make me potentially liable for any adverse event which might befall this person in the future. That's why I grit my teeth when an obese, chain-smoking fast-food addict waddles into the ER: I can diagnose them correctly, but if they die in the near future—and there's often a good chance of that—it's not a natural death, brought on by slovenly habits and outright stupidity, it's malpractice, or so it will be alleged. Spin the wheel, write the check. Do you know what it is like to be charged with something that you know you're innocent of? It's enough to put you in a bad mood for a few years, I'd say. And how will this make you eye your next patient, who might be your next lawsuit? With distrust, extreme wariness, and—of course—a heaping dose of CYA. I'm tired of playing this game; how about you?
Ironically, in the years to come, there will be increasing justification for malpractice lawsuits, because future doctors will be less intelligent than the doctors of today, and hence more likely to botch things up. What, did Pezzi say that? Bear with me for a moment; it makes sense. Society has made it incredibly difficult to become a doctor. The average physician has an IQ of 130, which might not sound very impressive when compared to everyone's average of 100—but just take a gander at the intelligence bell-curve histogram, and see how far up the ladder this is. Way up, as in borderline genius. Not bad for raw material, eh? But this is but one prerequisite, society deems. Now, take your youth, and devote it not to having fun, but to cramming an ungodly amount of information between your ears. And, as compensation for this torture, you get to pay for it! A would-be doctor must either have rich parents, or an incredible tolerance for debt, 'cause med school ain't cheap.
Then, finally, you're a doctor. Is it over yet? Not quite—it's just beginning. You become a resident, and work 110 hours a week for an hourly wage that's two steps below that of a trainee at McDonald's®! You're a good decade away from your last real pleasure, and you haven't seen your Mom in ages. Your best friends think you've died, and your girlfriend . . . uh, where is she, anyway? She's left you to be with someone with a semblance of a normal life. That's what you have given up to become a doctor—a normal life, a fun life.
Then, you're out. You're the fabled “real” doctor; that is, a doctor with a license to practice medicine. Gee whiz, after all that, you might think someone would trust your professional opinion, but no. Vultures, schooled as Monday-morning quarterbacks, are there to tell the jury that you're wrong, even when you were right. Such an enjoyable game! Now, who wants to play? Increasingly, bright people, being bright, are saying “No, thanks!” to medicine, and are putting their intellectual gifts to other uses. It doesn't take a genius to realize that such an eventuality will cause a decline in the IQ of future doctors. As I mentioned above, the average med student IQ is 130, but there are a good number of medical students with IQs of 140, 150, 160, and even higher. The question is not what can they do, but what can't they do? The answer is, not much. They certainly don't need medicine to make a decent, tolerable living—they can go to work for Bill Gates at Microsoft and become a millionaire in a few years, and not have some shyster cant to the jury, “He's wrong, he's wrong, he's wrong.”
Diverting bright people away from medicine will either result in many empty seats in the medical school lecture halls, or it will result in future doctors being less intelligent—and hence, less capable—than current doctors. Do you really want a neurosurgeon with an IQ of 110 poking around inside your head? I didn't think so. If the current trends continue, you won't have much of a choice. Someone has to pick up the scalpel and play brain surgeon, right Jethro? If the bright people are all working at Microsoft, you're out of luck.
Take a half-serious, half-tongue-in-cheek glimpse into the future of medical schools by clicking the thumbnail image below: