How Malpractice Suits Are Damaging Health

Question: Does the fear of being sued ever affect a doctor's judgment?

Atul Gawande: I'm sure. I'm sure it does. Less so in the operating room. I think the place where it affects your decision-making is often in the office, where someone comes to you with a problem, it doesn't seem like a big deal, but then you get the what if? We had a meeting, for example, with -- a surgical meeting where I met a surgeon who was from Cedar Rapids, Iowa, and he was talking about some data they'd collected on how many CT scans they'd gotten in his hometown. This is a town of 300,000 people, and when they pulled out the numbers they found they'd done over 50,000 CT scans for the population in the previous year. The vast majority were normal scans that were probably unnecessary. On the other hand, what do we mean by unnecessary? So, 10,000 were largely for head scans, head CT scans, for people with headaches. Only a dozen found any abnormality. And most of those were unusual headaches. They probably could have followed guidelines that said that you don't need the head CT for nearly anything like the percentage of people who got them. But the fear of a lawsuit if you should miss something led to lots of scans. The irony here is, there is probably even more risk from the scans themselves. They have high doses of radiation. And the number of scans Americans are getting nowadays, we know they're generating hundreds if not potentially thousands of cancers down the road.

Question: How does it feel to make a mistake while operating on another person?

Atul Gawande: I still make them. You know, I operate on about 250 to 300 people in a year. I have a 3 percent major complication rate. At least half I can look back on and see that there were things we should have and could have done differently. And when you recognize that situation -- I wrote in my most recent book of a patient who nearly died on the operating table because I ended up making a wrong move that led to a tear in his vena cava, the major blood vessel going back to the heart, and he lost his entire blood volume into his belly in 60 seconds and arrested on the table. And it was just fabulous teamwork that saved him; that I got lucky. And what it feels like is shame. You know, there's guilt, which means you feel badly for what you've done; and then there's shame, where you feel that you are what was wrong. And because we are in a system where we want to convey to people that we are infallible, we have a hard time grappling with our own fallibility. And in a sense, I don't want that shame to go away. But we've got to use that sense of shame more productively. When that sense of shame leads us to clam up and not want to talk to even the patient about the situation, have a hard time being willing to let the public see our results because of fear of what the data might say about us, that's when it has paralyzed us and kept us from solving problems. Where it's good is **** feel responsible. And the culture of surgery has fundamental components that are driven in ways that make every surgeon recognize that they're fundamentally responsible, they're responsible for the results of their patients, even when it isn't necessarily their own hand that's slipping here. Things can go wrong in lots of ways.

Question: How can a person be a better patient?

Atul Gawande: It's a good question, because I think it is -- there are two things about it. Number one is there's no straightforward recipe. But there are things that we recognize we can do. I think number one is to understand that making the system work well is something that we're only starting to grapple with. Medicine has been about parts; it's been about having a great drug, a great doctor. It has only in the last few years started to become about making all of that fit together as well as possible. And the most important role, I think, that patients play is, they're the only ones that see when things are falling through the cracks. You see one specialist and then another specialist, but they don't talk to each other, and what they're telling you doesn't make sense or fit together. A third of patients by the end of their life have 10 or more specialists in their care. And we're not very good at knitting all of that together.

And so I think the most important part the patient plays is not being passive about their part on the team. They are -- we're not great at drawing out the patient; we've wanted the patient to be passive and not so involved, just do what we say. But the more we have different people involved, what we tell people is contradictory. It doesn't always help them the way it should. And as we get our act together, I think what we're learning is, the patients play a key role.

The fear of massive settlement fees has forced doctors to take a number of generally excessive precautions—including unnecessary CT scans that may cause cancer down the road.

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