Sooner or later, in any discussion of health care reform (to the extent that screaming and fear-mongering can be gotten past and actual thoughts exchanged), the issue of tort reform is raised. On that subject I'm of two or more minds. Neither a student of the various proposals nor particularly well-versed on the veracity of claims and counter claims about tortophobia adding to costs of medical care, I can only speak based on personal experience. Which is why I'm multi-minded. I've seen good and bad. I don't think I altered my practice style to avoid malpractice suits, but I can see why people would.

The central issue is this: there's a difference between malpractice and adverse outcomes. Most certainly, the one leads to the other; but the other does not imply the one. Were that distinction properly made and encoded in the law, the rest of the issue would become moot. If malpractice suits were about bad care -- actual errors, poorly thought-out diagnoses or treatments, willful neglect of patient needs; that sort of stuff -- I'd have no problem with them.

I was raised among lawyers. I've lived in their dens, eaten their food, learned their language. I agree with their claim that malpractice suits have, over the years, led to improvement in care, institution of protective procedures. And I absolutely agree there are bad doctors out there; lazy, lacking in judgment, in it for the money. Drinkers, drug users. Representing an overwhelmingly small minority, they nevertheless give us all a bad name; they are the cause of and the justification for the worst views the public has of us.

But, unlike the guy struggling to fix my freezer as I sit and type this (peering occasionally at what he's doing: my home improvement skills have largely osmosed from such viewings), I dealt with soft stuff. Every freezer of this type is exactly the same; the wires, the machinery, the outcome if you plug x into y. Not so of us humanoids. (I'm not saying what he does is less important; we're having to get along without freezing tonic cubes for our G and T's [a trick I highly recommend to anyone so inclined]. Or, judging by his grunts and mutterings, any easier. Just more predictable.) If he makes the correct diagnosis and replaces the parts properly, the outcome is the same for the same problem, over and again, on every like freezer. I've had some sub-optimal outcomes, despite (take my word for it, okay?) doing everything right. Not often. Not, thankfully, catastrophic. But the possibility is always there.

I've been sued, and I've written about it. It's humiliating, frustrating, depressing, and anger-inducing. I'd say that's entirely because of my certainty that in no case was malpractice, as I understand the term, committed. On the other hand, had I ever done something (or failed to do something) in a way that fell into that category, the last thing I'd want to do would try to defend it on a witness stand, nor try to prevent the patient from being compensated. Patients need a mechanism by which they can be protected from errors, and their injuries redressed. What form that takes is a complicated subject. The current system, because it fails to separate bad outcome from errors in management, isn't the proper mechanism. It wasn't my intent, in writing this, to suggest solutions.

My point, at last, is that I don't think tort reform, per se, will have much impact on the total cost of health care. Reducing errors will. Addressing inefficiencies and variations in treatments among doctors will. To the extent that docs order tests to cover their legal asses, such behavior would be reduced, asses covered, if there were guidelines that indicated when such tests were medically necessary and when not. It's true that there were times, when deciding a course of action based on clinical judgment alone (diagnosing appendicitis without a CT scan or ultrasound is a perfect example; taking a patient with a rigid abdomen to the operating room without the delay of additional testing is another), that I felt a slight breeze on my backside. Many docs are unwilling to do it; partly out of fear, but partly, also, out of being trained in the era of judgment coming in pixels. I guess you can't legislate judgment, but guidelines would help.

And yet it seems there's no discussing it without raising the specter of rationing and death panels. When President Obama suggests that investigating what works would save lots of money and improve care, he's exactly right. That's where the big bucks are spent, and wasted. Addressing it would solve much, including the need for tort reform.

The political party who has argued for reducing Medicare since it began, whose most recent candidate ran on cutting it, has now, for pale political reasons, resorted to demagoging attempts to do just that, as fascist terror. Without diminishing service at all, huge amounts of money could be saved by doing exactly what Obama proposes. Surely there are a couple of Republican senators and representatives who know this. But, clearly, the resistance is not about effective reform. It's about politics, and defeating the party in power.

The public be damned.

There is no doubt that health care is an enormously complicated issue, and the public has not been well served by the media nor its talking heads in trying to reduce it to sound bites. I believe any bill coming out of Congress will be a thousand pages long, and no one voting on it will have read it.

With Kennedy's death, stations are playing pieces of his pronouncements. One was from the Dem's convention where he declared "health care for all is a right, not a priviledge." I think that remains to be seen.

I have a great health plan, and a great clinic to go to. I went to my GP about a mole on my ear, and 15 minutes later a surgeon was removing it. He was from Canada, and told me Canada Health essentially drove him, and 15 of his colleagues to the US. He told me, if I lived in Canada, that mole would never have been removed, because it was elective surgery, and that no longer exists there. Reports from the CBC bear that out.

As for tort reform, I can't help but say that doctors have been their own worst enemy. They have put themselves on such a high pedestal, the great gods of healing, that the public believes they are infallible.

As a student of language, and language strategies, I was intrigued by a study I once read about how doctors express themselves to patients when it comes to close calls; when the patient almost dies. Many invariably say something to the effect that "You almost left us." "You almost died on us." Notice that the culprit is the patient, not the doctor. The patient in unconscious, and yet appears to be responsible for flat-lining. How many times will a doctor admit publicly that he screwed up? When will an anaestesiologist say, "Damn, I over-gassed that guy."? Or a nurse say "How did I leave that sponge in there."?

I am no fan of lawyers, nor their desire for big paydays. They are sharks. But in my experience with doctors, a giant dose of humility would also be salutary.

JR: many points to address, but for now, just this: the Canadian system is not on the table. And -- splitting hairs -- "elective surgery" is not what you imply. It's surgery that's not an emergency. Which means that elective surgery is most certainly done in Canada. Colon resection for cancer, hernia repair, etc. "Of questionable need" is more like what you're suggesting.

Whether a mole which is clearly benign (making no assumptions about your personal dermatopathology) needs removing, for cosmetic purposes only, under a government paid plan, is arguable; assuming people agree in general with the idea that there's only so much money in the pot. As it were.

A study done in the around the turn of century showed that the rising cost of doctors' insurance was in no way related to the cost of defending lawsuits, but rather to the net worth of the insurance companies' financial holdings. This study was done in the Greater St. Louis area, which includes the Illinois counties of Madison and St. Clair, two national Meccas for lawsuit-happy lawyers. (My source was a news broadcast on St. Louis TV; I have been unable to find a net reference, possibly due to poor search terms.)

I've long found it interesting that those who want less interference in their lives from government clamor for tort reform, an act in which the government basically tells the people that they aren't smart enough to form a jury and make a reasonable decision based on facts in evidence.

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for cosmetic purposes only

Well, I should have been more specific. It was on the back of my earlobe, unseen to anyone. I was hardly aware of it. It was my GP who said I should have it looked at. And that was my point: I went from her to a surgeon in no time, he looked at it, and said "Let's remove it and get a biopsy." It was done in the space of a few minutes. How does that compare with the time lag for hip replacements and MRIs in other countries?

Let us know the pathology report, if you feel like it, JR. This could (acknowledging... yada... yada...) be a good example: removing things that could be left alone. We have a term, "Wallet biopsy." Not that it applies...

Once again, the health care reform being talked about would not affect the speed with which a procedure is done (except, perhaps, because of more people being able to see a doctor, which isn't a problem of reform, per se. In part that's because no one is seriously suggesting ending "fee for service." Also because no one is talking about nationalizing the caregivers. A surgeon with time on his hands will still be motivated to snip here and there.

On the other hand, many is the time I looked at a skin thingy and told the person that as far as danger was concerned, there was no need to remove it. Interestingly, if the person wanted it removed anyway, and I did, I don't recall ever being refused payment. Which says something important; if only I could figure out what.

How much do the claims for 'malpractice' come to in total cost and in total number of claims in the USA ?

In the UK, National Health Service Litigation Authority, which handles claims against NHS bodies,in its report for year 2008/2009, states there were 6,080 "clinical negligence" claims made against the NHS. The total cost of all those claims, including damages paid and legal costs , where those costs were paid by the NHS, was £769 million viz. $1,260 million [in Britain the losing side pays the legal costs of the winner. In cases that settle, an agreement on costs is part of the settlement]. At a guess, claims against hospitals and surgeons in the US are a bit more than that.Of course, a private hospital or doctor who was doing privately paid work for a claimant ("plaintiff") patient would not usually fall within those figures.They could, presumably, if they were being privately treated in an NHS hospital. The NHS figure is not too bad, considering it covers the whole population of some 60 million people, though bad enough.

Damages in Britain are generally lower than in the US. For one thing, the liability is judged and damages are assessed by judge alone.There is no verdict or input from a jury.The judge might award punitive damages but that would be wholly exceptional, because the cases for those are, in strict law, extremely rare. His or her finding and assessment can always be taken to the Court of Appeal. For another, the damages will cover loss of life expectancy, pain and suffering , loss of amenity (inability to pursue hobbies, loss of quality of life), loss of present and future earnings, and cost of care etc but the cost of future medical treatment will ordinarily be a cost to the taxpayer under the NHS, so that figure is not great.One way or another, the losing defendant NHS is going to pay for that.

Typically only 4 per cent of claims reach court.

There were also 3,743 "non-clinical negligence" claims ( claims by staff, claims by visitors etc).

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Let us know the pathology report, if you feel like it, JR.

It turned out negative for melanoma. But, what do you do when the doc says check it out? Laymen naturally capitulate. I try to keep up on a lot of things. Witness the example when my GP wanted to do the prostate test on me (not the digital), and I told her a recent JAMA article said that there was a 50% false positive on it. So I didn't take the test. She hadn't read the article, but concurred anyway.

JR: you're right that the patient is sort of stuck. It's part of what I was saying: some docs less willing/able to stick their necks out. Not implying anything in your case, since I have no way of knowing. Just a general observation; is a situation like yours an example of tortology, "wallet biopsy," or being careful? I have no idea the distribution, but in a hundred cases, there could be double digits of each.

Just out of curiosity, what do you think of the one size fits all numbers for such things as cholesterol, bp, blood sugar? I have read that MDs in other countries consider US standards are way too low. e.g., <200 cholesterol. I tend to think too many MDs are in cahoots with big pharma and their multi-billion dollar Lipitor, Xanax, Evista, etc. My GP's office is full of pharma stuff: clocks, pads, pens, charts.

Yeah, I never allowed drug reps in my office.

I'm not the one to comment on cholesterol levels. Not my area of expertise, and I must admit to not keeping up on the latest. If I can't remove it or fix it, I don't read about it. Sort of.

'It’s estimated that 2.5 million unnecessary surgeries are performed each year, with hysterectomies, heart bypass grafts, lower back surgery, and angioplasty leading the list. Just two procedures alone, coronary artery bypass grafting (CABG) — known in the trade as cabbage — and balloon angioplasty cost $100 billion annually. With long waiting lists for CABG, you’d think it was vital for prolonging the lifespan of heart patients, but that’s a mistake. Current statistics suggest that about 3% of bypass surgeries extend life expectancy, with angioplasty scoring even lower at zero percent...

...If you have a cold or flu, there’s a 73 percent chance that you will be prescribed an antibiotic, which is useless against viruses...' The Medical Myth of “More Is Better”

I think that last point is common to many health care systems - you have to give people a pill to get them out of the office, apparently. However, just as the US seems to hold many myths about foreign health care, us miserable, communist, care-rationing foreigners have our stereotypes of care in the US. One is that those with insurance get 'gold-plated' service - to the point that too many tests or procedures are done - while those without insurance get nothing. In centrally-planned (or whatever term you'd like to use) systems, resources are (or should be) shared around more thoughtfully and fairly.

I'm always a bit skeptical of statistics about "unnecessary surgery." For example, if a person is thought to have appendicitis but found to have a normal appendix, some call the surgery unnecessary; whereas it's fairly well accepted that you can't make the diagnosis with certainty no matter what methods you use, and there's a high morbidity associated with failing to diagnose early. Likewise, there are differing data on the place of CABG vs angioplasty vs drugs in certain situations. I don't dispute that there are some operations done without proper indications; but there's a broad gray zone. Another reason for establishing a way to look more deeply into it, a proposal met with demagoguery and dishonesty from the right wing.

What incentive does an American doctor have to a) perform only those tests and procedures which are strictly necessary
b) prescribe the cheapest of the drugs which will produce the desired effect
c) exercise preventive medicine?

Don't know about your mole, JR. It might or might not be removed under the NHS depending on the circumstances and the individual case.It's such a simple op,I imagine, that it might be,however it didn't sound a noticeable or disfiguring one.There are guidelines about such matters .It's possible to have cosmetic surgery on the NHS and also a sex change ('gender reassignment ' is a 'necessary treatment' within the NHS, following a Court of Appeal ruling) In the last 5 years, some 100 people in Scotland alone (population 5 million) cost the Scottish NHS £1.5 million for sex change ops. So whatever may have happened to the mole, JR, come over here, get registered, and change sex and, after that, have breast enlargement (or reduction).You may as well get our money's worth!

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There are guidelines about such matters .

Which is exactly my point.

My scenario:

"Hmmmm. That mole is suspicious. Go down the hall and have Dr. So-and So look at it."

NHS scenario:

"Hmmmmm. That mole is suspicious. I'll submit my finding to the NHS and we'll let you know."

Canada Health scenario:

"Hmmmmmm. That mole is suspicious. But we're too understaffed to deal with it. If you can get to Detroit maybe they can help you."

Probable Obama scenario:

"Hmmmmm. That mole is suspicious. If you were a member of Congress we'd remove it."