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What Do Doctors Think About.

By John Dietz - Email Editor

Date: June 06, 2006

Everyday, the office is filled with client situations and stories. The good, the bad and the ugly. Every once in a while someone calls with concerns about liability that gets your attention and makes you stop and think. On this one particular day, a pleasant doctor called to discuss his fears. His thoughts are below.

Today I was called into the emergency room to evaluate one of my patients that is complaining of abdominal pain. The emergency room doc thinks the patient might have appendicitis. The diagnosis of appendicitis is not always obvious. This is a pretty common type of call, but it makes me worry... a lot. Let me explain why this call has me worried.

There are at least 8 different scenarios. My opinion can be “YES” or “NO.” The surgeon's opinion can be “YES” or “NO.” The patient's final outcome regarding appendicitis could be “YES” or “NO.” That makes 8 possible combinations. So let's examine what might happen with each of those 8 scenarios.

1) Me =YES, Surgeon =YES, Patient Outcome =YES. If the patient does have appendicitis and there are any complications, I will be sued because my name is on the chart. Lawyers need to sue everybody so they don't get sued for not suing somebody. But this manner of getting sued is expected. It does not matter that I had nothing to do with the complication.

2) Me =YES, Surgeon =YES, Patient Outcome =NO. In this scenario, the patient goes to the operating room and the appendix comes out normal, meaning the surgery was unnecessary, I can be sued for unnecessary surgery, an unnecessary hospital admission, picking a "bad surgeon," and of course, for any complications. During the trial, I will argue that in the USA, the standard of care requires that about 15 percent of appendixes that are removed should be normal to try to make sure we miss as few as possible. Somehow that never gets heard until AFTER I get sued.

3) Me =Yes, Surgeon =NO, Patient Outcome =YES. In this case I can be sued for picking a "dumb" surgeon. Never mind that I may have had no choice at all because this was the ONLY surgeon willing to be part of this patient’s HORRIBLE HMO. That won't make any difference. It does not matter that initially 90 percent of surgeons would have wanted to wait before operating. If there is a problem because of the delay, I am going to get sued.

4) Me =YES, Surgeon =NO, Patient Outcome =NO. In this case, I was wrong; the patient did not have appendicitis. I have NOT committed malpractice, but I was tying to be conservative. There was enough evidence for me to keep the patient overnight to make sure we did not miss appendicitis, but not enough to send every similar patient to the O.R. Although I probably won't get sued for the admission, I will get yelled at by the patient's HMO for causing them unnecessary expenses. They keep track of ALL the money I make them spend on health care, and will fire me if I cause them to spend more money than other doctors on the same plan.

5) Me =NO, Surgeon =YES, Patient Outcome =YES. In this case, I was smart enough to call for help, and the surgeon was smart enough to take the patient to the O.R. right away. I'll only get sued if there are complications. Funny thing about this scenario is that the reason I didn't know for sure about the diagnosis is because the HMO refused to approve the C.A.T. scan of the abdomen that I requested to confirm the diagnosis. The surgeon was so mad that he took the case to the O.R. without the C.A.T. scan. Thank God he did. He rescued me on this case because I send him a lot of cases. Now you know what the doctors are whispering about just outside your door…

6) Me =NO, Surgeon =YES, Patient Outcome =NO. In this scenario, just as in scenario number 5, we could not get a C.A.T. scan to confirm the diagnosis, so the Surgeon took out the appendix just to make sure we did not miss a bad appendix. But as luck would have it, the appendix was normal. Now I can get sued for complications, picking a "dumb" surgeon, and for unnecessary surgery. I guess that is better than getting sued for missing a bad appendix. Do you think that the HMO will at least forgive the "unnecessary" expenses on this case? Yeah right.

7) Me =NO, Surgeon =NO, Patient Outcome =YES. Oh man, we’re in trouble now. In this scenario, neither the surgeon nor I had enough evidence to send this patient home, so we kept the patient overnight for observation. Once again, we could not get a C.A.T. scan that would likely have helped us take the patient to the O.R. sooner. The HMO would not approve it. HMOs don't approve things after 5:00 p.m., on weekends or on holidays because they are not there. If the patient has any complications, the argument will be that the delay caused the problems. It does not matter that the patient weighs 450 pounds, was a terrible surgical candidate, and that we had to choose between taking a high-risk patient to the O.R. without a C.A.T. scan versus watching the patient overnight. It does not matter that almost any surgery would have killed this patient. Make sure that if you are a high-risk patient that you only get sick on Monday - Friday, 9-5:00 p.m.

8) Me = NO, Surgeon =NO, Patient Outcome =NO. In this case we were smart enough not to take the patient to the O.R. Granted, a C.A.T. scan would have made it easier to send the patient home, but we don't get that lucky. Instead, we raise the cost of medicine sky high by playing COVER YOUR ARSE. These kinds of patients are usually the ones that make me come to E.R. at 2:00 am, and are screaming bloody murder that I can't be there at 3:00 p.m. the next day to discharge them because I am seeing other patients in my office. Maybe they are really mad at me because even the law firm of DEWEY, SCRUEM and HOWE can't figure out how to turn this case into a lawsuit. Oh well. At least nobody died.

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