From: km@speedy.cs.pitt.edu (Ken Mitchum)
Newsgroups: sci.med
Subject: Re: Mercury in dental fillings?
Date: 2 Sep 92 20:31:42 GMT
Reply-To: km@cs.pitt.edu (Ken Mitchum)
Organization: Computer Science Dept., University of Pittsburgh

In article <Btx0Hr.3Dw@wpg.com> russ@wpg.com (Russell Lawrence) writes:
>
>BTW, did you get a chance to read the special article on the 
>crisis in US health care in the July issue of _Consumer Reports_?  
>A special insert on pg 443 explained that the AMA's chestbeating 
>about malpractice concerns is a "straw man", albeit widely 
>believed by the US public.  The conclusions of Consumer Reports 
>were supported by studies conducted by HHS as well as a Harvard 
>University study funded by the state of NY.  

I read all three articles in the CR series, and while they stated
they thought the malpractice problem was a "straw man", they also
stated that there was insufficient data to evalute this. They also
had a letter to the editor from a physician who agreed with the
idea that the malpractice problem was not the issue, and who said that
all the extra "care" people are getting is a good idea, including
such things as skull xrays for everyone who falls, because 
otherwise doctors would miss things.

The point this doctor made is ludicrous. Your are taught in
medical school and internship/residency how to examine a patient
who has hit his/her head, and based on the examination you can
figure out whether or not a skull film is needed. Getting skull
films on everyone is unnecessary and a waste of your training,
not to mention money. The same thing is true for getting CT scans
on everyone before doing a lumbar puncture (spinal tap). You
can figure out, based on clinical setting and physical examination,
whether the CT scan is necessary, i.e., if the possibility of
herniation exists. But everyone gets the CT scan first, because
of fear of being sued: if something bad happened later, even
if not directly related to the lumbar puncture, someone would
pick up on the fact that you didn't do the scan. 

The fact is, there are a lot of unnecesary things being done
in medicine today - that is precisely the fact behind the drive
to "managed care" and physician accountability: if unnecessary
things were not being done, then the people behind these
ideas would not have any basis on which to limit costs.
There are many reasons for unnecessary things being done, and
I can tell you that ONE of these is the malpractice problem.
I can only speak for myself, but I know that many of the tests
I order every day are for the chart only: I know what the
results are going to be before I order the test, and the chances
of the test influencing what happens to the patient are very
low.

You may have studies supporting the view that the possibility
of getting sued does not increase costs, but I would have a
difficult time accepting them until I see a good control group
that has everything American medicine has EXCEPT the malpractice
problem. If doctors in such a system order all the same tests
that we do, then I would obviously be wrong, and assume that
doctors are just inheritly inept at using their training.

To be very cynical, I could also point out that doctors are not
paid for their time, but by the patient, and it takes several
minutes to evaluate the patient and do an exam. It only takes
a few seconds to order a CT scan. This problem is, of course,
not caused by malpractice problems, but by payment schemes
set up by bureauocrats, many of which have law degrees. I
don't usually engage in lawyer-bashing, but I do sometimes
wonder how lawyers would act if they were not paid for their
time, but by the head. I also wonder how they would feel about
systems that would impose fixed incomes on lawyers in the same
manner as is being proposed for doctors.

Overall, CR did a useful job in it's report, but I think they
glossed over some things, and painted too rosy a picture of
the Canadian system. This is surprising, since they did point out
major problems with managed care systems. One of the things
I have noticed in the debate over how the health care system
should be changed is that only a few people involved think
that doctors themselves might have some positive ideas about
changing the system, and when some of these ideas, such as
malpractice reform, are raised, they are given little credence
in terms of ability to improve health care and reduce costs,
but are instead viewed only as a means of protecting doctors'
incomes. I find that a bit cyncial as well.

 -km




Newsgroups: sci.med