Letters to the Editors

Med-mal report sparks a debate In "Behind the med-mal crisis" [Jan. 7] ( http://www.memag.com/memag/article/articleDetail.jsp?id=141338), the argument that malpractice rates should be based on experience rating destroys the rationale of insurance. I can assure you this is a disaster, having been the victim of frivolous claims that were dismissed.

Unfortunately, reform requires changing our legal system. The United States is the only country with a contingency fee, expert witnesses, and no "loser pays" structure. Until our system makes the loser pay, and until judges both appoint the experts and adjudicate cases rather than poorly informed juries, the system will remain broken.
Benjamin Van Raalte, MDDavenport, IA

In Arizona, which according to your article is only "approaching crisis," we are losing ob/gyns right and left. Furthermore, even neurosurgeons with no claims history are paying over $100,000 per year for coverage, and we have only two primary malpractice insurers. Even in my specialty of family medicine, rates have gone up more than 90 percent. Patients are losing good doctors, and the care available to them is being limited by the current situation. For example, in Tucson, an area of nearly 1 million people, you'd better not get a burn injury on the one day out of three we have no coverage for the burn unit!

Many thanks for Wayne Guglielmo's well-balanced and thoughtful perspective on the malpractice liability crisis. Although prior articles in Medical Economics have touched on the problem of unethical expert witnesses, this series did not focus a great deal of attention on the subject. However, several other mechanisms you mention, including certification of merit and a special medical court system, might help address this problem.
Louise B. Andrew, MD, JD New York City

There can be no meaningful malpractice insurance reform unless the problem of attorneys' fees-which consume over 50 percent of premium dollars-is addressed.

Possible solutions could include:

After reading your excellent article regarding medical liability, I would like to add my thoughts about malpractice and error. One point of discussion concerns the number of medical mistakes projected by the Harvard Medical Practice Study vs the actual number of malpractice claims made in the United States. It's a mistake to equate an error with negligence. One can practice competently, and in good faith, but err. Nevertheless, such conduct is wrongly labeled as negligence. I can't support a standard that holds that failure to be perfect constitutes neglect, without any middle ground. Our tort system should deal with the issue of error in the absence of outright patient neglect as a matter separate from negligence.
Ray Dempsey, DMDBoston

Doctors could pay their escalating malpractice premiums if the health insurers weren't discounting about 40 percent of our fees. We now need to see five to six patients an hour to get the same reimbursement we used to receive for two patients. If only we had time to listen more and counsel more, rather than having to order countless tests to make up for our time limitations. What a shame to dehumanize medicine and turn it into mass production, so the insurance industry can make its profits.

I guess it will take a total breakdown of the system before the insurance industry helps insure all patients, and spreads the wealth to help defray the expense for all.
Buddy Clayton, MDTriCities, TN

I must encourage you, and others, not to use the word "malpractice" to identify the issue of professional liability insurance. Malpractice, as well as negligence and misconduct-other labels used by trial lawyers in complaints-are accusing and confrontational. By adopting these words, we almost admit that they have value.

All of us have a potential exposure to a liability claim, so we insure for it. We purchase fire insurance for our homes, not arson insurance. Thus, physicians need professional liability insurance, not malpractice insurance. The crisis is not in malpractice but in affordability of insurance. The solution, as you have pointed out very well, lies in many directions.
Jan R. J. de Vries, MD Boswell, PA

Get legal assistance I suggest that if you're sued in a malpractice case of any kind ["How I foiled a frivolous claim," Dec. 3], hire your own attorney and don't use the one contracted or referred by the insurance company. It's a mistake to assume that the insurance company and the doctor have the same interests. The insurance company's attorney, who may be seeking further referrals, is more likely to settle to avoid court costs for the company, and he'll hold the physician's interests at a lower priority.

Your local medical association is a reliable source for malpractice attorneys who'll serve the interests of the doctor. I do agree with the advice in the article's box ("A note of caution") that the same type of results that ob/gyn Angelo Men-dez achieved may be better accomplished through a series of letters from an attorney-without the drama and risk.
Robert Webman, MDTorrance, CA

Courses to enrich the program I read with great interest the article, "What med schools should really teach," in the Nov. 19 issue ( http://www.memag.com/memag/article/articleDetail.jsp?id=133894). May I suggest the following basic courses be included in a medical school curriculum:

In addition, each student should go through a dexterity test and a three-dimensional aptitude test to help guide her in selecting a specialty based on aptitude rather than lifestyle, income, or the current trend. For example, an internist needs to be more analytical, while a surgeon needs dexterity, and a radiologist needs to have superior visual correlations. Inborn aptitude tends to make an average doctor into a superb doctor.
K. J. Lee, MDNew Haven, CT

An alternative hospice evaluation In "My new view of hospice" [Jan. 7] ( http://www.memag.com/memag/article/articleDetail.jsp?id=141348), family physician Todd Crump asks why his nursing home patients need hospice care. Patients have a right to hospice assistance. In fact, Medicare provides hospice as a benefit to all its beneficiaries, including nursing home patients. Hospice provides additional staff attention, free medications for the terminal illness, bereavement care, and other services. I believe a physician who is not using hospice is depriving a patient of free services. Yes, sometimes hospice patients live longer than six months. However, Medicare states that as long as a physician certifies that, in his best medical judgment, the patient still meets hospice criteria, that patient continues to qualify for benefits.

Why do some patients who receive hospice improve? Perhaps a patient was not taking her medication because she couldn't afford it. Given that hospice pays for the medications, the patient improves. Wouldn't it be terrible to discharge that patient after six months and have her revert to her prior situation? Hospice adds quality back to the life of a suffering patient and family. Please don't think badly about all hospices because of a couple of bad apples.
Nancy C. Grabb, RNColleyville, TX

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