Flashback in Medical Economics
As the malpractice crisis worsened, doctors in high-risk specialties saw their liability insurance costs double or triple within a single year. In several states, they faced high-five-figure premiumsif they could still get coverage at all. Commercial carriers were fleeing the market before a relentless surge of claims and giant awards to plaintiffs.
Coast to coast, organized medicine led the clamor for legislative relief from the litigation plague. State lawmakers began to respond, and our publication spread the hopeful news.
Senior Editor Stanly (that's right, no "e") Ferber reported on the measure hailed by many doctors and other observers as the most promising of state-level actions: Indiana's malpractice relief law. Although that law stopped short of providing every reform doctors wanted, it did give them several important gains:
No physician could be held responsible for an award or settlement of more than $100,000 for a single malpractice action. Maximum compensation for a plaintiff was fixed at $500,000with everything above $100,000 to be paid from a special state fund financed by surcharges on all health care providers' malpractice premiums.
Contingency fees for plaintiffs' attorneys were curbed. No cap was applied to the lawyer's fee for winning an award up to $100,000, but for larger awards, the ceiling was set at 15 percent.
Indiana's statute of limitations was tightened, restricting malpractice filings to two years after the alleged negligence occurredexcept in cases involving small children. Then the two-year clock would start running at age 8.
A medical review panel would look at each claim before it went to trial. The three-doctor panel was to include one physician chosen by each side, with the third physician picked by the other two. The panel's finding would be admissible in court if either party insisted on taking it there.
The new law was laudedand not just by Hoosier physicians. Organized medicine, insurance industry leaders, and defense attorneys throughout the nation hailed it. Not surprisingly, the plaintiffs' bar complained that it gave doctors favored status and should be wiped off the books.
Meanwhile, in New York state, a program aimed at resolving patients' claims before they reached a judge and jury was showing progress. Senior Editor Arthur Owens described it, conservatively, as "one small light at the end of the tunnel."
New York's compulsory malpractice mediation program, launched in Manhattan in 1971, was extended by the mid-'70s to the whole Empire State. Each malpractice claim had to go before a mediation panel that typically included a presiding justice, a doctor from the specialty involved in the case, and an active trial lawyer. Attorneys for the two sides made presentations to the panel and responded to questions. Usually, the litigants didn't attend.
When the panelists reached their decision on the claim, they attempted to get the opposing sides to accept it. If they couldn't, the presiding justice could order another hearing or put the case on a court calendar.
The most promising development reported by Owens: In the latter half of 1974, 37 percent of Manhattan cases ended at the mediation stage. And New York physicians, through their state medical society, were pushing for legislation that would require all claims of $25,000 or less to be decided by arbitration.
We profiled a 67-year-old pediatrician, still in full-time practice in suburban New Jersey, who took a break each day to write poetry. He wasn't the first physician to versify in his spare time, but one achievement set his writing apart: William Carlos Williams had won the National Book Award (and, a few years after our article appeared, a Pulitzer prize).
Bill Williams was honored for his volumes Paterson III and Selected Poems. The long poem "Paterson," perhaps his most recognized work, dealt with the New Jersey town that was home to the nation's silk industry for many years. His poetry drew mostly rave reviews ("the Dreiser of US poets," Time magazine called him) and only a few raps (his books "read as if they might have been written by a Greenwich Village vagabond," sniffed the Kansas City Journal). Williams' response to critics: "I'll write whatever I damn please, whenever I damn please, and as I damn please."
His first volume of poems had been published in 1909, three years after Williams finished med school at the University of Pennsylvania. Over the next 40 years, the doctor turned out 22 volumes of poetry, short stories, novels, plays, and other works. Colleagues "used to think I was little cracked," he admits, "but they've learned to tolerate me."
As his reputation blossomed, Williams found himself being encouraged by such literary icons as James Joyce and Gertrude Stein. He also found his mailbox loaded with letters and manuscripts from novice authors hoping he could help them break through to fame. Each letter was answered. "Many people feel they're admitting to weakness when they say they like poetry," Williams said. "They need to be reassured."
Not for a moment, though, did Williams forget that first and foremost, he was a doctor. "I take care of babies and make them grow," he said. "Nothing is more appropriate to a man than an interest in babies."
"A certain physician had developed the habit of attempting to see situations from his patients' point of view." So began "The Fable of the Over-Kind Physician." In his short essay, Edward N. Reed, a practitioner from Ocean Park, CA, described an unnamed doctor (want to bet it wasn't Reed himself?) who had realized that for "those of modest income, any prolonged or serious illness was prone to become a tragedy, quickly devouring the savings account and often creating a burden of debt."
To ease that burden, this doctor was "careful to make no unnecessary calls . . . dispensed the more common drugs . . . and often conducted cases in the home, rather than the hospital." At times, when a patient in dire financial straits asked what he owed for a visit, the physician would reply: "Let it go this time. We'll even it up some other time, after your ship comes in."
Then came a patient who opened the good doctor's eyes to a sad fact. The young mother of five, a victim of incipient pulmonary tuberculosis, needed every cent of her paycheck to help feed and clothe her brood. Mindful of that, her physician sent no bill for diagnosing her problem, making house calls, and treating her conservatively. All the while, according to Reed, he "endeavored to educate [the patient and her relatives] as to nature's methods of overcoming a tubercular infection."
In return, he received not gratitude, but growing criticism from the patient and her family. "They seemed to feel that he overrated the seriousness of the situation," Reed wrote, "and apparently thought that there must be some more vigorous treatment, if their doctor but knew it, by which the cure could be forced to a speedier termination and the patient back to work without so much lost time."
The woman's family took her to another doctor. Shortly afterward, Reed continued, the kindly physician heard his frustrated office assistant repeat neighborhood gossip: "They called Dr. Windjam, and he charged them $20 for his examination and diagnosis and $25 for the first month's treatment [remember, this was 1925]and he got that $45 in advance. We have never had a cent for all the time we've given them. What's worse, her father is telling all over town what a wonderful doctor Windjam is, and how he'll get the money to pay him even if he has to mortgage his home. And he tells people that he had to discharge you from the casetoo slow or too behind the times or something of the sort."
Bitter at first, the malignedand unpaiddoctor finally admitted to himself: "I did not do my duty by my patient. If I had made [the family] pay for my services, I should still have the case and should have had much better cooperation."
And so, author Reed concluded, the good physician had learned his lesson: "Most people appreciate only that which costs them something."
James Hendricks. Flashback in Medical Economics. Medical Economics 2000;11:181.