Paper Chase 05 – The Effect of Malpractice Reform

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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William F., DO -

I would like to see data on patients not covered by medicare. That would add a lot of credibility to what they were trying to conclude. I see it as somewhat of a weakness to publish data on a group of patients that already have a higher incidence of disease. Does tort reform have a different effect on CT's ordered on younger healthier people? I really would like to know that. I do not work in a tort reform state but it certainly sounds attractive. Any thoughts on this?

William F., DO -

I see you addressed this issue (in above comment) in the summary.

Joseph M. -

Defensive medicine is not only about avoiding a lawsuit. We also practice defensively in order to avoid hassles, complaints, bounce-backs and criticism from patients and follow-up or admitting colleagues. Patient and medical staff expectations and satisfaction may be the main driving force. Also, current emergency physicians have been trained and have practiced this way for a generation. It is not realistic to expect an abrupt change in practice.

Jesse A. -

I have not read the original article and am not an emergency physician (just a hospitalist who often works closely with the ED), but I agree that it is hard to reach the conclusion that this study as described shows we have all just been practicing good, patient-centered, caring medicine all along. That is certainly a possible conclusion, but the cited survey data, where over 2/3 of participants see themselves practicing defensively, makes it unlikely. Other possible conclusions are that it takes time for the culture to change or, as above, that we are not just defending ourselves against lawsuits but a host of other outcomes as well. I would, however, float still another possibility, and that is that, even in the face of the declining number of malpractice cases in the study states, no one really believed they were less likely to get sued or to get sued big. Malpractice lawsuits are like the bogeymen of medical practice in the US, and like bogeymen, how we worry about them is probably only loosely connected to reality. I suppose this is another way to say that it takes time for the culture to change. But I guess I would argue that when practice patterns are only vaguely connected to reality in the first place, simply changing the reality may not be enough to change the pattern. To truly change practice patterns, in addition to tort reform, there will have to be a concerted effort to teach medical students, residents, and attendings alike what they need to know about malpractice. If this is done, maybe we will be able to sleep at night, with the lights off...and both eyes closed.

Mario P., MD -

I live and work in Texas myself and often am amazed in talking with docs from other States when at conferences. This study would have done better to look at other costly and litigiousness things, most notably chest pain admissions. Here in Texas I only try to admit less than half of chest pain patients and maybe a fourth of them even do get admitted. In other States those numbers are inverted.

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