OHSU to pay millions in malpractice liability

In December the Oregon Supreme Court told OHSU, where I am a third year medical student, that the cap for economic ($100K) and non-economic ($100K) damages in a well-publicized malpractice lawsuit involving a neonate named Jordaan was too low and that the family suing OHSU can ask for millions. OHSU is going to have to pay up. Story. OHSU has announced a number of changes to its budget and services to defray the estimated $30 million increase in malpractice liability.

I have mixed feelings about the decision. First, I think the tort cap is too low, and second I think there should not be a tort cap - or a very, very high limit - on economic damages. This poor family is burdened with the huge expense of providing for severely brain damaged child whose expenses will easily reach into the millions in the child's lifetime.

But here's how the decision will impact me and my fellow students:

• Tuition Increase of 17% for entering students ($32K to $37K). My tuition will increase 5%.
• Reduction in class size from 120 to 115 students that results from the elimination of the regional clinical curriculm allowing OHSU to utilize clinical sites in Eugene and Bend for students (the university hospital itself can only support 115 students)

These changes to the school of medicine are painful because the state already has a significant physician shortage, and already has the highest in-state public tuition of any medical school in the country. Year after year OHSU asks the state legislature for more medical education funding and year after year it is denied for budgetary reasons.

People in this state, despite liberal voting patterns in the metropolitan areas, are rabidly taxophobic. This is why we continue to have under resourced public schools - OHSU included. Sure I will be able to pay back the estimated $200K education debt some years after I graduate, but the lack of support from the state and the public hurts.

Some people complain that doctors make too much at the expense of patients, and this is driving up the cost of health care (it is not a significant contributor, by the way, but the attitude is persistent). Yet, when the public makes little to no effort to provide us with education, it is unfair for the public to then expect us to work on its behalf, divested of economic interest. Nearly all of my classmates would be more than happy to give back to their communities for the privilege of receiving a medical education - but at this point the burden is all ours.

The last month has been crushing on my surgery rotation. It is extremely fun, however, and somehow the 15 hour days just whiz by. Have had no time for anything else, which is a hard adjustment for someone who likes to play guitar and spend time outdoors.

It is said that a good attitude goes a long way in recovery. This is an understatement, and it is not just old wives tale; there is evidence that time to convalescence is associated with being positive, keeping a sense of humor, etc. There is one patient I have been following on our surgery for the past 4 weeks who typifies this. The gentleman developed necrotizing fasciitis of his shoulder and subsequent septic shock within a matter of hours of presentation to the hospital. A large placemat-size portion of his shoulder was debrided down to the bone and joint. His initial recovery was very slow in the ICU. He was on a ventilator for some days, suffered from massive blood clots in his legs, and is still recovering from kidney failure. For several days he was only hours away from death, but miraculously pulled through. Once he was off the ventilator I began to get acquainted with him and am struck every day by his positive, grateful, carefree attitude, and sense of humor. He has suffered an enormous amount of pain with his shoulder compared to most of the other patients I have seen over the last month. His wound is still open, but healing very well. Eventually he will need skin graft surgery. Indeed a lesser man would have died.

Another aspect of convalescence is support from family and friends. The past week we have had a diabetic elderly woman from India who developed a small bowel obstruction and ischemia that required resection. She was discharged today, a mere week after her surgery. Being old and diabetic in a foreign country are not points in your favor when recovering from major open abdominal surgery, but her hospital course was remarkably smooth. I attribute this to her attitude - she was stoic and always smiling every morning we came in to round on her, although I new she must have been terrified and in a considerable amount of pain. Moreover, her son, who works as a engineer at Intel, stayed with in the room at her side 24 hours a day. This is nearly unheard of in America, and perhaps he did this only because his mother only spoke Tamil. At any rate he commented today that he felt he had lived vicariously through his mom's operation and recovery. I told him indeed he has, and that is a big part of why she did so well.

The costs of over-hospitalization

This week on surgery I have a charming, but somewhat demented, 81 year-old retired lawyer who I saw two days ago during a pre-operative exam for an inguinal hernia. The hernia was reduced - meaning that there was not protrusion of the abdominal contents through the wall - and his surgery was elective (most hernias, by the way, do not require surgical correction unless the bowel is involved or there is intolerable pain). It turns out that he was anemic on routine blood test and he reported dark stools for several months. He also has a history of colon cancer (with surgery some years ago) and has had polyps removed during several different colonoscopies. We decided that the hernia repair should be delayed until the cause of anemia was investigated further, thinking obviously that he probably has some chronic GI bleeding, and possibly a recurrence of the colon cancer.

He was admitted to hospital and transferred to the medicine hospitalist team for work up of the anemia, and was given 4 units of blood. Indeed the cause of his anemia needs to be explored, but it is not critical that it be done in the hospital. Unfortunately he has now been in the hospital for 5 days, when the workup could have been done as an outpatient. This would have cost significantly less money and would have been much more pleasant for that patient, and avoided the risks of getting a nasty infection. He has been very cooperative and pleasant so far, but today he admitted to be impatient because he wanted more activity and the hospitalist team wrote orders that he must be accompanied for any ambulation (phooey, if you ask me).

I don't know why we lose sight of the big picture in medicine. Too often I have noticed (especially with residents) that we are too intent on keeping people hospitalized and over-managing their medical issues. "The guy is anemic! We must keep him in the hospital until his anemia is stabilized," the hospitalist replied when I asked when he was planning to discharge the patient (although to be fair, hospital admission stays are drastically shorter than they used to be, and there is much fear of lawsuits). I am sceptical of how much good we really do for patients by keeping them in the hospital with all these lines, tubes, tests, needles sticks, vitals checks and medicines that are usually ordered.

This guy is a good example of this typical story. His bleeding was not acute, he had been anemic for several months without having any symptoms, his condition was stable, he was functional and independent, he did not require nursing care. And yet, one day he was happily at home, then next - nothing had changed in between - he was in a hospital with all the economic and psychological costs that entails.