Today I was reading a great blog post over at KevinMD.com. Much of it had me nodding in agreement with the physician-blogger who wrote it.
The blog post’s title was “Lawsuits Are More Of An Emotional Issue Than A Financial Issue” and the author made many sound points. As the author pointed out, it makes little sense to cap damages on doctors as part of an effort to lower medical malpractice insurance premiums when Medicare and Medicaid already price the cost of malpractice insurance into what they reimburse a doctor in a given state. Tort reform therefore constitutes a windfall for most doctors.
But then the blog post began to lose me. The author posed a hypothetical wherein an otherwise healthy thirty-six year old woman goes to the doctor’s office complaining of chest pains that have lasted two days. The doctor does not run every expensive diagnostic test in the book but concludes that the patient’s chest pains are unrelated to a blockage and is subsequently sued for malpractice when the patient is discharged and dies of a heart attack.
The hypothetical reminded me of one of the main problems with doctor-led discussion of medical malpractice law: they don’t understand medical malpractice law anymore than I do the ins-and-outs of their subspecialty.
In order to prove medical malpractice, a patient has to prove a whole heckuva lot more than, “There was some expensive test that could’ve been run that would’ve prevented my injury.”
The plaintiff has to show that the standard of care in the medical profession would have dictated that the doctor run the tests. In effect, the doctor is judged by what the average doctor would do, rather than by some superhuman standard.
There’s a world of difference between the two.
If more doctors understood the standard that applies to medical malpractice, there would probably be a lot fewer cries for tort reform.

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Dr, Atul Gawande, one of the heroes of this blog, has a great new article in The New Yorker on the importance of coaches in improving performance.
As Dr. Gawande notes in his article, for the first several years after becoming a surgeon, the rate of complication in operations he performed declined — until he was beating national averages. But then his performance plateaued. His rate of complications continued to be exemplary but it was not falling anymore.
Then Dr. Gawande took a single lesson with a tennis coach that really improved his game. Soon afterward, Dr. Gawande was watching a tennis tournament and the camera panned to Rafael Nadel’s coach. A thought occurred to Dr. Gawande that has occurred to few others in medicine: If Rafael Nadel, who’s the best in the world at what he does, can benefit from coaching why can’t doctors and surgeons?
We tend to think doctors and surgeons don’t need coaching because they’ve already acquired all the knowledge and mastered all the techniques that are necessary to do their job. Very often, wrapped up in our whole notion of professionalism is the idea that a professional is someone who is done with education, someone who does not need to be taught anything further. But in certain fields, the most elite practitioners continue to receiving coaching and tutelage.
The dichotomy exists in music. Most instrumentalists don’t have coaches; they graduate from music school and are thought to have received all the coaching that they need. (Yitzhak Perlman is a rare and notable exception; he attributes much of his success to the coaching of his wife, a concert-level violinist herself). But vocalists differ: all of the world’s best vocalists have voice coaches. Rather than reflecting some underlying difference in the complexity of playing an instrument and singing, the differing attitudes toward coaching appears to be a historical contingency, a quirk.
Gawande convinced one of his former professors, Dr. Robert Osteen, to come out of retirement and coach him in the operating room. The first operation that Dr. Osteen coached – a thyroidectomy – was not one that Osteen had performed a lot in his career. But after the operation was over, Dr. Osteen had some great coaching tips for Dr. Gawande. Dr. Osteen noticed that the way Dr. Gawande had draped the patient, while perfect from the standpoint of maintaining a sterile environment, interfered with the movement of the surgical assistant and the resident. Dr. Osteen gave Gawande a list of other equally astute coaching tips.
Since taking on a coach, Dr. Gawande’s complication rate has gone down. The sample size is, at present, too small to declare the coaching to have been a statistically significant contributor to the decreased rate of complications, but Dr. Gawande believes that the coaching will prove to be important.
Dr. Gawande closes the article with an anecdote of one patient in the operating room who, prior to being put under anesthesia, asks who Dr. Osteen is. When Dr. Gawande explains to the patient that Osteen is in effect a coach, the patient gives him an uneasy look.
If your doctor ever tells you that she has a coach, perhaps you should count yourself lucky instead of sharing that patient’s unease.

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