Medico-legal issues

Kind vs. Kindly

Posted on November 14, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Medico-legal issues |

I’m altruistic, which isn’t the same thing as being kindly. I hold doors open for little old ladies. That’s not the same as liking the people I meet. Eliezer Yudkowsky

You know better than to think that a random doctor will have extraordinary clarity of mind and the power to find truth within confusion.  It is not any different in AGI.Eliezer Yudkowsky

There is a dominant part of me that believes one should never be punished for telling the truth. But that’s not realistic, is it? And so the conflict. Rational thought and behavior trumps etiquette, yet much of life (the way it is actually lived) requires going along to get along.

Suppose a doctor happened to possess a combination of the qualities Yudkowsky describes: an altruist with extraordinary clarity of mind and the power to find truth within confusion. That’s what you’d want in a doctor, right? Apparently not, if public record is of any significance. In fact, I would go so far as to predict that such a doctor would have a miserable litany of malpractice tort actions. Note that I did not say “a miserable record of acts of malpractice.” There is a wide berth between actual malpractice and a tort claim of malpractice.

While it may be quite an unpopular concept, I am persuaded that there exists an independent, sometimes antithetical, relationship between true altruism and kindliness. But try to conduct a medical practice based on true altruism and rational principles: you will be among the leaders in malpractice tort actions. The reason: the altruistic action may not seem like a kind action.

The actual practice of medicine is structured around historical outcomes, either clinically or experimentally. The inescapable problem is that no one knows exactly how humans work. There aren’t any treatments that always work. Consequently, the best-intentioned, most conscientious doctor, the one with extraordinary clarity of mind and the power to find truth within confusion, gets bad results. Since it is not truly science, there is always someone who will say the outcome would have been better if so-and-so. And the tort process begins. Unfortunately, not all doctors are like the one described. They are likely to create even worse outcomes. So, naturally, they will experience even more malpractice claims, right? Not necessarily.

Most instances of actual malpractice do not result in litigation; there are so many available references to this that I am not citing one. What converts a patient into a plaintiff? According to the loss-prevention program of my malpractice insurer, plaintiff polls show that the most important factor is the doctor’s attitude. Kindliness and empathy trump clarity of mind and the power to find truth. My medical generation had no courses in kindliness; in terms of skill and rationality, half of all medical students graduate in the lower half of the class. If kindliness and skill are independent variables, what are the chances that a doctor possesses both? I don’t know; I’m just asking.

Altruistic rationalism is Kind; it is not always kindly. Kill ’em with kindliness.

Addendum after comment: My first father-in-law was a pediatrician. He claimed that most of his patients would recover from their illnesses if he did nothing; a very few would not recover no matter what he did; and in the remainder, he hoped to make a difference in the outcome. In my own practice of penile prosthesis surgery, once the surgical wound was closed, there was essentially nothing I could do to improve the outcome. Because of this, in the early portion of my career, I scheduled my prosthesis patients to return two weeks post-op, the time when I intended to inflate the device to prevent healed wrinkles. During that two-week interval, the patients experienced impressive swelling and discoloration, as they had been advised to expect. My receptionist and my office manager, after a while, suggested that I begin seeing the patients three days post-op, to relieve their anxiety. Their people-skills were far superior to mine, and I followed their advice. Patient satisfaction skyrocketed, although outcomes were unchanged.

To combine these two stories (mine and the pediatrician’s), I firmly believe that people want to be told that everything will be OK. The problem is that some will not be OK, in spite of doing everything “correctly”. Occasionally, as the pediatrician told me, a child with a viral upper respiratory infection will go on to develop viral pneumonia. The parent then wants to know, “Why didn’t you give my child antibiotics?” The doctor knows that not only will antibiotics not help, but also they will actually increase the chance of secondary bacterial infection. After years of dealing with angry parents over unavoidable outcomes, the pediatrician treats the parent, rather than the child; antibiotics are started from the get-go. At this point, one ceases to be a doctor, and enters into the field of public relations.

With prostheses, assuming the surgery was done correctly, the big cause of failure is bacterial infection. Infection occurs at the time of surgery, or perhaps a few hours later, the source almost always being the patient’s own skin or fluids (this has been documented by tracer analyses). In my practice, the rate was just under 1%. Nothing can be done to prevent early signs of infection from progressing to conditions that demand removal of the device. Patients cannot be convinced of this. They intuitively feel that one-chance-in-a-hundred means, “it can’t happen to me.” Consequently, the post-op care in such patients turns to techniques of assuagement and demonstration of concern, which only postpone the ultimate outcome, and actually cause the patient an unnecessarily long convalescence. With the “public relations” approach, the failed patient is unhappy; with straight-forward fact-based actions, he is angry. Angry patients are the first step toward malpractice tort actions. Since we can’t completely eradicate infections, we begin to focus on eradicating lawsuits.

And then we’re not doctors.

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Bigger is better

Posted on October 13, 2008. Filed under: Medico-legal issues, Sexual issues |

In the mid-1970’s, few doctors and almost none of the general public were aware of the existence of one of the 20th century’s most wonderful and most overlooked inventions: the inflatable penile prosthesis. Not so for the late Lafayette, Louisiana barrister J. Minos Simon (it’s a Cajun name, pronounced “minus see-maw”). His private medical library rivaled that of the local hospitals, and he often appeared in court seemingly better informed about the medical aspects of his clients’ cases than the health-care professionals he routinely grilled. A bulldog when convinced of the legitimacy of his position, Simon successfully sued Pope John Paul II in the early ’80’s as part of his ground-breaking attack on serial pedophile Father Gilbert Gauthe, a moral, ethical, and social vilification from which the Catholic church has never recovered.

Simon championed “lesser” causes as well, albeit for 40% of the action, but hey, that’s the American way. One such led to his involvement with the IPP. Lafayette is the “headquarters” for offshore oil and gas exploration and production in the Gulf of Mexico, as indicated by the presence, among other oil service companies, of the largest private helicopter company in the world. The offshore oil and gas industry is a magnet for personal injury attorneys because of the Jones Act, a federal statute that comes into effect beginning thirty miles offshore. Closer in, workers’ injuries are no-fault, covered under state Worker’s Compensation, and limited mainly to actual expenses and loss of income. Under the Jones Act, the sky is the limit, allowing huge punitive awards shared by the plaintiffs and those champions of the underdog who stand up to “the man” for millions of dollars in attorney fees. Simon had such a case in the person of Leroy Meaux (name changed to prevent a flood of calls from interested women). Leroy had been seriously injured while working about 100 miles offshore on a major-company oil rig. Among the consequences of his injuries was the inability to achieve penile erections. (more…)

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No good deed goes unpunished

Posted on October 10, 2008. Filed under: Everything you wanted to know about doctors, Medico-legal issues, Sexual issues |

“Doc, I just cain’t get a hard-on by no-ways, and it’s torturin’ my wife and a-killin’ me.” The man was from the “redneck” area of Louisiana, a society very different from the Cajun-influenced culture of “Acadiana”, the site of my practice. He was an evangelical born-again-Christian 54-year-old hypertensive diabetic who had not been able to have sex with his wife for over two years. He had been referred by his family-practice doctor, who managed his diabetes and hypertension, after failing to respond to the pills. Short of traumatic nerve damage, such as is seen in spinal cord injuries, impotent men usually retain the ability to have orgasms. Many are incredulous when they first find that they can ejaculate without ever achieving an erection, but in reality, the two functions are completely separate. Consequently, if erections can be restored, they’re back in business.

There are very few physical causes of erectile dysfunction for which treating the underlying cause improves the erections. For example, normalizing the blood pressure or gaining better control of the blood glucose will not help the problem at all (in fact, getting the BP back to a normal level actually makes atherosclerotic ED worse, since there is less pressure to drive the blood through the narrowed penile arteries). To see where we stood, I tested the man by injecting alprostadil into the muscle of his penis (described here). He developed about 50% rigidity, a level which buckles easily when pressed (such as in the attempt at intromission). As often happened, he was thrilled at what seemed to me to be a terrible result, since he had not been seeing any response at all. He felt certain that self-administered injections were the answer. As another similarly encouraged patient told me, when I opined that the injection-produced rigidity was inadequate: “Doc, I’ve been screwin’ with a limp dick for so long that I’m sure I could shoot pool with a wet rope.” (more…)

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Here’s your summons, doctor. Wanna play tennis?

Posted on August 22, 2008. Filed under: Everything you wanted to know about doctors, Medico-legal issues |

In this recent post, I mentioned in concluding that I would give an opinion about a cause for the lack of aggregate marginal value of American medicine, as documented by economist Robin Hanson. I began reading Overcoming Bias a little while back, and, being a doctor, my curiosity was tweaked by a series of articles like this one about the lack of efficacy of American medicine. As I mentioned in a previous post, I found the arguments of math-ninja/economist Robin Hanson persuasive. He goes overboard, as you can judge for yourself, by suggesting that modern medicine is a conspiracy to defraud. (more…)

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    The director of the Sexual Medicine Center leaves penile implants behind, and launches a quest for knowledge about Artificial Intelligence, extended life, and the issues inside the health-care industry.

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