Running Late – Sometimes it’s Helpful

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Staying on time in my clinic is always a challenge. Typical follow-up appointments for my internal medicine group are 15 minutes, which is not a lot of time when dealing with patients with multiple complex problems. I also have to deal with test results, some of which can’t wait, take calls from other doctors, do refills and other tasks. If patients show up late or have problems that take more than 15 minutes, it’s easy to run late.

I had an elderly woman come in with her son. My nurse warned me that she was getting anxious because I was running late. When I walked in, 45 minutes after her scheduled appointment time, she told me they had worked out their issue. Her son had brought her in because he was concerned about some behavioral problems. While sitting in my exam room, they discussed her social isolation since moving to a new place. She was lonely being away from old friends, had no way to get around, and did not want to impose on her son. They were dealing with common issues that affect millions of people. While waiting for me to come in, they had mostly figured out on their own what was causing the problem, and agreed on how to make things better. If I had showed up shortly after they were checked in, perhaps they wouldn’t have had their insights, and I might have prescribed an antidepressant instead.

That was an atypical response, but sometimes being late can be a good thing.

Cataracts and Hip Fractures

A recent study showed that cataract surgery helps prevent hip fractures. It looked at a sample of Medicare patients with cataracts who did or did not have cataract surgery.  Those who had cataract surgery had a 16% less change of subsequent hip fractures than those who did not have the surgery, though the absolute difference between the groups was small, because hip fractures were not that common in either group.

The design of this study was not optimal. It would have been better to randomly assign patients to get cataract surgery or not, to eliminate possible biases, but such a study is not practical.

We treat osteoporosis with medications such as Fosamax (alendronate) and vitamin D, but that just decreases the risk of a fracture. It’s still important to prevent the fall. There are various things that can help, including physical therapy to improve gait (walking), good lighting, good shoes, lack of loose rugs, canes, and more. Add to the list cataract surgery for those affected. Not only will such patients improve their vision, but they may save themselves from a hip fracture that at best will lay them up for a while, and at worst kill them from complications of pneumonia or a deep venous thrombosis (DVT or blood clot) and pulmonary embolism (blood clot to the lungs).

Tort Reform and the Sanctity of the Jury

I serve on WAMPAC, a political action committee for the Washington State Medical Association (WSMA). To help guide our members, last month we met with candidates for Washington State governor Rob McKenna and Jay Inslee.  They were both generous with their time and answered our questions.

As physicians, one of our issues is tort reform. We are concerned that large and unreasonable malpractice awards increase the cost of medical care and cause physicians to order unnecessary tests as ‘defensive medicine’. Attorney General Rob McKenna said he was supportive of tort reform, though didn’t give much specifics. Congressman Jay Inslee said he did not believe in malpractice caps because, he said, unlike others, juries are untainted and therefore we need to respect their decisions. That prompted me to send him the following letter. One month later, he has yet to respond. I wonder how I’ll vote in the primary?

Dear Mr. Inslee,

I enjoyed meeting you, and appreciate your spending time to talk with the Washington State Medical Association WAMPAC Committee 7/3/12 regarding your candidacy for governor.

On the issue of tort reform, you mentioned that you didn’t support malpractice caps because you believed in juries making the decision, as they are untainted by lobbyists or others.

Speaking for myself, I have some concerns about this. Short of Plato’s philosopher kings, juries may be the best choice to decide cases, but they are hardly perfect. There are numerous well documented cases of people sentenced to death, yet later found innocent by DNA evidence. In malpractice cases, I would argue that juries are far from perfect. How else could you explain the differences in the chances of being sued and the size of the award based on specialty (http://www.nejm.org/doi/full/10.1056/NEJMsa1012370)? The average neurosurgeon is sued once every 5 ½ years. You would be hard pressed to find a retired neurosurgeon who has never been sued.

Even if juries make perfectly logical decisions, it’s only as good as the cases presented to them, which may be flawed.

In cases where juries decide the outcome, there are restraints. There are judicial guidelines, and juries cannot impose the death penalty for shoplifting, for example, even if they wanted to. Putting financial caps on malpractice cases would be no different. The jury could still decide if the defendant is guilty, but guidelines would cap the size of the reward.

I hope you will reconsider your view on tort reform.

Sincerely,

Daniel Ginsberg, MD, FACP