When I have to make a judgement on whether to give tpa or not I wish a had the luxury or years, and experts, and a twelve person jury to decide….because after all know a jury is a collection of our “peers”

Now it is my turn not to understand your first paragraph.

I was simply stating one of the fundamental tenants of clinical epidemiology that tests must be interpretted in the clinical setting. All tests have sensitivity, specificity, positive predictive value, etc. The skilled clinician therefore looks at test results not as yes/no but as a variable that adjusts the pre-test liklihood. The thing that many in the public do not realize is that there are many many clinical situations where the pretest probability is so low or high that the test becomes absolutely 100% useless. A good example is that if the patient has classic symptoms of appendicitis, then a CT of the abdomen is fairly useless (as demonstrated by several studies). If that patient has classic symptoms of appendicitis and you do get a CT scan and it is negative, you still think they have appendicitis and the test has told you nothing. Conversly, if the disease is very rare and the symptoms are not classic (ie atypical chest pain in a 25 year-old female), then any test you order is much more likely to be a false positive than a true positive and the patient is more likely to be damaged due to treatment because of the false positive result than they are to be damaged by the small chance that they have the disease. The problem is that the public and I dare say many lawyers tend to think that you should always order the test and just see if it is positive or not. Good physicians know that there are times when it is better not to order the test even though there is a chance they may have the disease, but most of the public and lawyers do not accept that. The frustration I sense that many physicians have is that the rules for interpretting tests are different in court than they are in clinical practice. So you say trial is just getting the facts out in the open to settle a difference in opinion, but that is precisely the problem – that there are different ways of looking at tests in court than in the clinic. The way that many of the public and lawyers look at tests is different but is fundamentally not the correct way to look at it.

I didn’t say I don’t understand why you dislied being sued in fact quite the opposite. I have been sued myself, for something not covered by insurance in fact, and it’s zero fun. However the point of the suit is to get the facts out there with regard to a dispute and get it resolved. You say you’ve seen physicians sued having done nothing wrong but that’s an opinion based on full knowledge of the facts, something the plaintiff may not have had at the time of filing.

I’ve been involved in a medical practice splitting up and the litigation as the partners all sued each other. To a man, every party thought the other side’s case was patently frivolous. Without a doubt. Defendants always say and many believe the other side has no case. Even when physicians sue health insurers, which they do often and for large sums, the health insurers claim they’ve done nothing wrong. Believing ones side is in the right is why we have lawsuits. If both sides agreed one was wrong why would you need to file unless you were just arguing over damages?

In school we are taught that tests do not tell us yes or no, they just change the shade of grey a bit. There is no such thing as a fool-proof test. Trials attempt to make the outcome an absolute term – ie you were right or you were wrong. There are times when the doctor is clearly negligent, but I think the frustration that many doctors have with the legal system is that it tries to change the rules and make something that was never concrete and never absolute into something that is a yes/no. No doctor in his/her right mind ever orders a treatment and says “this is 100%. The human body has 100,000 proteins (we only know the function of a few thousand), and an MI looks like one thing in one patient and a different beast in another. Often times we must play the odds – vascular surgery may save their leg but increases their risk of heart attack enormously. You are wrong if you do and wrong if you don’t.

It doesn’t help that we have all seen the physician do right by the patient but have a bad outcome and get sued. You may think that is the price of doing business, but for doctors it is personal – it damages the self-esteem and makes it hard to make tough decisions, it takes away family time for years, it damages reputations, and it can threaten our ability to get malpractice insurance and continue to make a living. You may disagree with it, but if you can’t understand why doctors don’t like malpractice then you apparently are missing something upstairs

Again, you want an assurance that you will never be sued. But NO dispute resolution system has that ability to stop claims BEFORE they are filed. That would require knowing the future. How do you propose to accomplish this.

As to what lawyers want, I think you assume a unanimity of opinion among those with a law degree that doesn’t exist.

“I think it’s a stereotype that we’re arrogant. ”

My stereotype wasn’t to do with arrogance so much as for some reason physicians are more afraid of a negligence lawsuit than anything else it seems. And it’s those that they are asking for legislative protection from. It’s from that I derived the conclusion that you despise being questioned about your medical decisions. After all, you’re not trying to get legislation to keep you from being able to be sued in contract disputes.

I agree that caps are fairly poor solution. Personally I favor a separate system of health care courts. I understand that this has problems too, but in my mind is a better overall solution.

As for the IOM reports I think the big issue in my mind is somewhat akin to the idea of “never events” Certain events such as wrong site surgery obviously should never happen. But others such as delirium in the elderly would be nice to avoid but I don’t know how. In fact I’m unaware of anyone that knows how to prevent it 100% of the time. Similarly some of the “errors” are really just bad outcomes with no clear evidence that they could have been prevented.

The real goal of these reports should be to identify systemic errors that can be addressed and corrected, similar to what the FAA does for aviation issues. Unfortunately the discoverability peer review processes that can be used to identify these errors is not protected – which silences those who would seek to fix many of these underlying problems.

What I think physicians mainly don’t like is being brought into the system at all and having their actions questioned. After all, it’s not like they’re even remotely likely to PAY a judgment. But given that the fact the lawsuit is filed is their primary gripe, there’s no way to alleviate that complaint.

There must be a dispute resolution system. There must be questioned answered under oath. There actions will be inevitably questioned by others in ANY system. No matter what we devise, they’re not going to like that part of it, and will complain it’s “broken”, “unfair”, etc.