This is the future for a young person
headed for a career as a physician in
- four years of challenging college
work and pressure to get excellent grades;
- four years of interesting but exhausting
and expensive medical school (average
debt of graduating med student is about
- 4-5 years (depending on the residency)
of exhausting residency training at
modest pay for 80-100 hours work per
week, start career with large debt at
- begin making probably around an average
of about $140,000.00 gross per year
working 60 hour work weeks (about $50.00
per hour - obviously some surgical specialties
make much more but these estimates are
nearer the average);
- extraordinary surveillance of most
that you do - from hospital quality
assurance committees, insurance companies,
PPOs, HMOs, and the government;
- near certainty of about three lawsuits
in the course of your career (with the
increasingly huge judgments fear that
you might be destroyed financially);
- increasing liability insurance costs
combined with decreasing availability;
- increasing demands by patients to
work magic or else;
- intimidation by government that if
you somehow break some regulation they
will prosecute you into oblivion; and
- if you can get past all this … rewards
of helping many people while doing interesting
With brevity in mind I will give only
one statistical example of where we are
in terms of liability risks. Emergency-department
physicians here have a rate of lawsuits
100 TIMES the rate in Japan! We are vulnerable
to suit if there is a bad result or if
a patient simply is annoyed that he didn't
get what he wanted. (For example, I work
part-time at a state penitentiary. One
inmate sued me because I couldn't get
a CT scan ordered for his headaches. I
didn't feel it was indicated. But I actually
requested one through the utilization
review committee anyway. They appropriately
declined to authorize it. This way I was
not alone in refusing the test. Nevertheless,
he sued. It is true that the suit didn't
go anywhere. But it is still a great nuisance
to deal with this sort of thing and still
a worry since sometimes in this country
people do win judgments for ridiculous
And, of course, when a physician falls
prey to human frailty and occasionally
makes a mistake, he is highly vulnerable.
The experience of getting sued is, at
best, a great deal of stress. But now
there is a real risk of career destruction.
I have a friend who is an OB/GYN. He had
excellent training here in the US and
practiced in Oregon until a few years
ago. He was sued for an OB case. He didn't
think he had erred but advised settling.
It is interesting that the insurance company
wanted to fight, indicating that they
thought the case was very defensible.
The case went to court and the result
was an $8 million verdict against my friend.
This exceeded the limits of his policy
and he expected to go bankrupt. But the
company decided to cover it all since
he had advised settling. However, the
next year his insurance premium went to
$200,000.00 per year. That put him and
his entire group out of business. He is
still trying to get restarted in an altered
career without OB somewhere in this country
where he can get insurance that he can
The hypocrisy of our legal system adds
to the galling situation. Attorneys usually
say sanctimoniously: "Well, if doctors
just practiced good medicine, there wouldn't
be a problem." I don't have room
to respond to this in detail. But I believe
the quality of medical care in this country
is probably better than ever before. So
why were there far fewer lawsuits 100
years ago? Why also are there not many
suits and huge settlements against attorneys
when they make mistakes or simply have
a case with a "bad outcome?"
Why are the attorneys not paying enormous
premiums for their insurance?
Still, the problem goes deeper than the
attorneys. It is lies in a pervasive attitude
in our society that promotes greed and
irresponsibility. Juries award judgments
in situations that are highly questionable.
Even worse, they are awarding astronomical
Until these attitudes change there is
little, if any, hope for significant change.
I suspect that when, and if, the US
government has to take over the system,
the rules of the game will change. For
example, physician friends in the military
tell me they do not face these kinds of
What is the conclusion? For many US
physicians it isn't worth it anymore to
put up with all this. We are looking for
There are many complex issues to face
and we need to deal with these by weaving
certain laws of life back into the system.
Responsibility by courts, attorneys, and
patients must be practiced - rather than
excess privilege to take whatever they
can out of the system. The respect for
the high value of human life must be preserved
but balanced against high technology costs
and limited resources. Individual freedom
must be balanced against limitations for
the common good.
So what would I do if I had the power?
- I would arrange for a system that
provides universal access to medical
You can argue whether health care is
a right or a privilege. But in the end,
I think if you live in an affluent,
modern country, you don't want access
limited. You don't want people dying
simply because they cannot get medical
care. Many consequences follow from
this commitment, though. It would be
so expensive, that there must be certain
- I would find a way to limit reasonably
the freedom to sue. Ridiculous, nuisance
lawsuits should be blocked.
- I would find a way to limit reasonably
the size of judgments.
They need to be brought in line with
what more sensible countries are doing.
- I would change the way attorneys get
I believe attorneys in a number of other
countries do not have the contingency
fee system and this needs either altering
- I would start society working to make
some tough decisions regarding treatment.
For example, we now do not transplant
a liver in an alcoholic without a period
of time of sobriety. Perhaps the day
will come when we will say that you
cannot have coronary bypass surgery
if you continue to smoke. And so on.
The hard truth is that we simply don't
have enough resources to go on endlessly
avoiding issues like these.
- I would find ways to require some
For example, they would have to pay
some sort of co-payment in order to
discourage over-utilization of medical
services. Also, if a person engages
in very unhealthful behavior, this might
alter the availability or cost of certain
- I would maintain quality in the profession
by reasonable systems of quality assurance
- I would maintain adequately attractive
income and lifestyle in the profession
in order to attract talented people
(I'm sure we could think of many more
things to do, but these are what quickly
come to mind.)
Even if I am right about the merit of
these ideas, there is one big problem.
I don't believe there is the slightest
political chance that any of these things
will happen without a near-apocalyptic
crisis in the access to care in this country.
Therefore, I think physicians here have
three options: work in a hostile environment,
change careers, or move to another country.
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