An experience of the US health system - and suggestions for improving it

This is the future for a young person headed for a career as a physician in the US:

• 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 $160,000.00);
• 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 age 30-32;
• 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 work.

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 reasons.)

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 afford.

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 amounts.

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 problems.

What is the conclusion? For many US physicians it isn't worth it anymore to put up with all this. We are looking for ways out.

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?

1. I would arrange for a system that provides universal access to medical care.
   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 compromises.
2. I would find a way to limit reasonably the freedom to sue. Ridiculous, nuisance lawsuits should be blocked.
3. 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.
4. I would change the way attorneys get paid.
   I believe attorneys in a number of other countries do not have the contingency fee system and this needs either altering or eliminating.
5. 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.
6. I would find ways to require some patient responsibility.
   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 services.
7. I would maintain quality in the profession by reasonable systems of quality assurance and review.
8. I would maintain adequately attractive income and lifestyle in the profession in order to attract talented people to it.

(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.