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• W2090593516 abstract "A healthy 18-year-old high school senior with no family history of sudden unexpected death or syncope and a normal physical examination is told that his budding football career is over when an unsolicited screening electrocardiogram shows a QTcB of 480 ms. A 65-year-old man with syncope, a normal heart, no family history and a negative electrophysiology study is told he needs a cardioverter-defibrillator when an implantable loop recorder discloses 10 seconds of an irregular, wide-complex tachycardia at 180 beats per minute while sleeping. An 89-year-old healthy woman with mild hypertensive heart disease and aortic sclerosis is told she will need a pacemaker when a Holter monitor records a 4-second pause while she is watching television. A 70-year-old woman with sinus node dysfunction and a permanent dual chamber pacemaker is told she will need to start warfarin when 3 high atrial rate events of 2–5 minute duration are discovered during routine pacemaker interrogation. What do all of these cases have in common? In each, a well-intentioned electrophysiologist weighed the available evidence and made a decision that had an enormous impact on a patient's life. In each, the doctor used an abundance of caution, and chose what might be interpreted to be a “conservative approach.” Therapeutic decisions such as these are difficult. They need to take into account unique patient characteristics while being mindful of what medical evidence might bring to bear. Unfortunately, clinical trial data do not always pertain to a particular patient or provide sufficient granularity to help us make our final recommendation. Likewise, as sophisticated as our patients are these days, they simply do not have an adequate knowledge base to participate truly in the process, and they appropriately ask for our learned guidance. I would submit that in our struggle to understand the components of complex decision making, we may have omitted an important element: doctors order tests and recommend procedures because they are afraid of being sued. I do not believe the point is arguable; what remains to be determined is how many times it happens, how important it is, how much wasted and inappropriate care it causes, and how much our patients suffer as a result? It strikes me as nearly comical that politicians, government economists and lawyers think they know the answers. The latest reports from governmental accountants estimate that a mere 3% of health care costs are attributable to the medicolegal circus in this country.1 It is hard to know how they came up with that number, but practicing doctors—the people who actually do the work—scoff at those estimates. Most of us are fairly certain that we are dealing with a minimum of double digit wastefulness.2 A recurring number I hear from good doctors is 30%, an order of magnitude different from the bean counter estimate. The reason this debate is so important is that acceptance of a smaller number provides justification to leave the current tort system as it is. This is a huge mistake for several reasons beyond the economics. Medical malpractice suits are ruining medicine. Once a doctor has been through the meat grinder, he or she is fundamentally changed.3 We adopt a much different attitude about our patients. We are less honest, and more concerned with documenting than explaining. We order tests that patients do not need, and we do procedures because commission is better than omission. Exactly how much money this costs the system is not the whole point. What matters is that our patients are exposed to the risks of tests and procedures that are not truly necessary. The doctor–patient relationship is contaminated and the harm can never be undone. Unfortunately, tort reform has fallen off the political stage. Our professional organizations have stopped making it an advocacy priority.4 They think there are bigger fish to fry, like trying to maintain decent payments for medical care. However, I would submit that ignoring tort reform is missing an extraordinary opportunity to improve medical care while positively impacting the cost. This is not to say that doctors oppose compensating patients for harm. In fact, we know that within the current system there is a poor correlation between medical mistakes and malpractice lawsuits, and the disconnect goes in both directions; that is, there are just as many important errors that are missed as there are suits brought for no good reason.5 Most of us advocate prompt, learned, participatory, even nonbinding arbitration of cases in which patients have been harmed, with payment to compensate fairly patients and their families.6 Eliminating excessive attorney fees and contingency arrangements will make millions available for those who have a just case.5 Such a system would also help to solve the problem of inadequate physician oversight that has also led us to the pitiful place we are. It would also allow doctors to employ the most appropriate strategy, saying we are sorry, without fear of enticing a lawsuit.7 The system is clearly broken and we are stuck. How can we re-energize? I decided to depart from the usual venue to write a novel. I hoped that a story about a doctor's struggles with an unjust malpractice case would make our patients aware of what their physicians are facing. In the new novel Lethal Rhythm, a good electrophysiologist is sued for malpractice when a patient with a mild case of the long-QT syndrome dies suddenly.8 The doctor is devastated, sinks into an alcoholic depression, and loses his career, his family, and nearly his life. How much the malpractice litigation issue influenced the doctors in our 4 clinical vignettes is unknowable. Likewise, no one can be certain that changing the system will transform every doctor into a wiser or more caring person. There are many reasons why physicians and other health care providers make treatment recommendations in complex cases. Some of them are not necessarily righteous, and a few are downright selfish. But removing the fear of being summoned to court to spend several days being called negligent, careless, incompetent, and ignorant has to help doctors make good and informed clinical decisions in complex cases. Our patients deserve nothing less. Editor's Note: Dr. Kowey examines the effect of medical malpractice litigation on the practice of medicine, which I believe is grossly underestimated by politicians and others. It is common practice for physicians in the United States to practice defensive medicine that often translates to ordering unnecessary tests. I have discussed this situation on many occasions with my colleagues from the less litigious cultures of Europe and Asia, and their reaction is always the same utter bewilderment at the concept of defensive medicine. And a note of caution to those physicians who think there is safe haven in practicing good, evidence-based medicine as outlined in official guidelines. At several trials, when I was an expert witness for the defense and attempted to explain how the physician treated the patient according to Class I recommendations, the judge ruled that guidelines could not be entered as evidence. By the way, I read and enjoyed Dr. Kowey's book, Lethal Rhythm, and recommend it to anyone interested in a good yarn. Eric N. Prystowsky, M.D.Editor-in-Chief" @default.
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• W2090593516 date "2011-02-18" @default.
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• W2090593516 title "How Much Has Malpractice Litigation Altered the Care of Cardiac Rhythm Patients?" @default.
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