6 Opinion OB.GY N. NE W S • March 15, 2005
L E T T E R S which we hand out Metamucil packets. An Agenda of Ignorance
We feel even more guilty because we en- I am an emergency physician who sees
Weighing the Risks of COX-2 Inhibitors they are becoming more effective. Safer dangered patient lives for the sake of re- nearly every day the effects of ignorance
The safety debate on cyclooxygenase-2 in- medications have empowered us, but they lieving their arthritis pain. After all, pain and lack of access to birth control (“Groups
hibitors stirs public hysteria for several rea- have also made us complacent. This com- and immobility are not such a big deal, Push to Obtain OTC Status for Plan B,”
sons (“New Data Fail to Resolve the Issue placency rubs off on our patients. right? Feb. 1, 2005, p. 6).
of COX-2 Class Effect,” Jan. 15, 2005, p. 5). Humans have an infinite ability to ac- The only way to preclude all risk is to Unfortunately, this is just one more is-
COX-2 inhibitors were initially market- cept infinite risk. Nicotine comes with stop prescribing all NSAIDs. Barring that, sue in the faux scientific approach taken by
ed because they were less likely to cause warnings that it can kill you, but it is be- we can take reasonable precautions. We the Bush administration to turn the clock
deadly peptic ulcers. People know how se- cause of those warnings that 7-Eleven will weed out those COX-2 inhibitors that back to a time of fear and false informa-
rious an MI or stroke is, but when they clerks do not have to worry about mal- are particularly dangerous. If it becomes tion. Whether it’s lying on the National In-
think of ulcers, they don’t think about old practice coverage when shopping for re- apparent that all COX-2 inhibitors as a stitutes of Health Web site about the re-
people exsanguinating to death in the ally, really good life insurance. Patients ac- class pose some risk, then before pre- lationship between early abortions and
emergency department. They picture cept the potential toxicity of statins scribing them, we may have to order breast cancer and depression, Sen. Bill
these Zantac commercials where the man because they want to avoid heart attacks screening tests such as baseline EKGs, Frist’s ignorance regarding AIDS trans-
wakes up with a tummy ache after eating without giving up chili dogs. They realize lipid panels, or even stress tests; prescribe missibility, or this attempt to stick our
too much pizza. the risks not because doctors inform them, COX-2 inhibitors only for limited periods collective heads in the sand about teenage
The hysteria is partly our fault. My gen- but because of a host of subtle cues: Doc- of time or for severe cases of pain; pre- sex, this administration’s agenda—largely
eration of physicians believes that if the tors ask them if their muscles ache or if scribe concomitant aspirin; or develop a unchallenged—is causing untold pain, un-
Food & Drug Administration approves their eyes have turned yellow, and patients risk reduction education program. (“If wanted pregnancies, and unnecessary
something, it must be safe enough to dis- undergo periodic blood draws to “watch you develop crushing chest pain, stop tak- health care expenditures.
pense in gumball machines. After all, the those liver enzymes.” All of this power- ing your Celebrex and notify your physi- When will someone with a voice that
real revolution in medicine is that med- fully communicates the risks posed by cian.”) These measures may not actually can be heard finally stand up and say,
ications—selective serotonin reuptake in- the pills we give them. save lives, but they will give our patients “Have you no sense of decency, sir, at long
hibitors, newer atypical antipsychotics, Patients feel betrayed by the COX-2 in- a sense of control over their health. last? Have you left no sense of decency?”
subcutaneous Lovenox, and so on—really hibitor debate because we dispensed Vioxx Arnold Kim, M.D. Kenneth R. Weinberg, M.D.
are becoming safer and easier to use while or Bextra with the same caution with Irvine, Calif. New York
G U E S T E D I T O R I A L
The Chasm Between Physicians, Lawyers
here is a tremendous lack of un- dark and the judges in chambers wonder- derstand about the legal process, the bet- But I don’t know what to do about this ter-
derstanding between physicians ing where the lawsuits went. ter you will be able to deal with this aspect rible situation.”
and lawyers, and the persistent hos- Are there obnoxious lawyers? Oh, yes. of the business life. My firm only agrees to look at 10% of
tility between these two professions is Are there lawyers who take trivial or friv- Let me explain where plaintiffs come the cases that we receive. Probably 50% of
counterproductive. However, profession- olous cases? Yes, but not many because from in obstetric cases. This is how a our time is spent evaluating cases we nev-
als in these fields have more in common they quickly will go out of business. Med- client typically finds me: er pursue. Much of that time is spent ex-
than one might think. With some effort on ical cases are expensive and risky, and the A woman who assumed she had a nor- plaining to people that the cause of the in-
both sides, they should be able to under- lawyer does not get paid unless the lawsuit mal baby gives birth to a baby with a se- jury had nothing to do with the medical
stand each other better. is successful. Most lawyers who do this rious defect. She feels that her baby has care, and restoring their confidence in the
Ob.gyns. go into medicine to heal. They work are interested only in very clear and been destroyed. Perhaps she and the father medical profession.
want to deliver babies and do very serious cases. Anything hear from pediatric neurologists that they The cases we do pursue have been ex-
the other wonderful things else represents potential eco- are facing a lifetime of 24-hour-a-day care. haustively screened by multiple, highly
that drew them into obstet- nomic disaster. The parents may feel that their lives are be- qualified, and conservative experts in ob-
rics and medical care in gen- Are there lousy physicians? ing ruined, that the lives of their other chil- stetrics, perinatology, neonatology, pedi-
eral. But they also want to Yes. You’ve probably dealt dren and extended family members are be- atric neuroradiology, pediatric neurology
make a living, raise their chil- with some and heard of oth- ing ruined. They may wonder, “What do and placentology. In this regard, we are
dren, and have a good life. ers. But these are the excep- I do about this? How do I provide for my not the exception, but the rule. To take a
Lawyers want to represent tions. I’ve been a plaintiff ’s at- child?” These are the kinds of thoughts case that is not properly screened and
their clients well. They want torney for 36 years and that drive some people to seek help. proven to be worthy of a serious invest-
to give their clients security practiced in many different Most people do not turn to lawyers. ment of time and money is nothing short
and help to ensure a future states. Very, very few times One study found that only 10% of “ac- of economic suicide.
for people who suffer devas- have I run into a lousy physi- tionable” medical cases (situations where A physician once asked me, “What can
B Y J A M E S S.
tating injuries. They care B O S T W I C K , J. D.
cian whom I felt shouldn’t be patients had a legitimate reason to sue) I tell a young doctor starting a career that
about their clients just as allowed to practice medicine. ever resulted in a legal filing because in the you as a plaintiff lawyer might advise
physicians care about their Most of the physicians who other 90% of cases, the patients weren’t an- about avoiding the process of litigation?”
patients. And, like physicians, lawyers end up on the other side of the table from gry. They went on with their lives. There I would say that being an obstetrician is
want to make a living, provide for their me are very competent, caring physicians are people out there who have brain-dam- a little like being an anesthesiologist—
families, and have a good future. who just made a human mistake that aged babies but they love their doctors and 98% of the time the case is boring, and it
Everyone has heard the message from caused a serious injury. When they face a they never sought the advice of a lawyer. goes along as you expect. Two percent of
insurance companies, and read every- potential lawsuit, it’s just another aspect of Why? Probably because their doctors con- the time, it is sheer terror, and then you
where, that ours is a litigious society. the medicine business—an aspect that they tinued to communicate with them. have to make the right decision.
However, most people are not as litigious don’t understand and certainly don’t like, Often new clients complain that the Most women could give birth to their ba-
as you may think. The overwhelming ma- but it’s just part of doing business. doctor stopped talking to them. The doc- bies at home. The field of obstetrics is de-
jority of people who seek the help of a I’m a professional liability specialist. I tor shut down when there was a bad re- signed to treat that small percentage that
lawyer hate the idea of a lawsuit. They are don’t just sue doctors, I also sue lawyers sult. The doctor wouldn’t answer their goes wrong. As a clinician, you have to re-
just in desperate circumstances. and other professionals such as architects questions or be honest with them. Other main vigilant for the cases that don’t go as
Although physicians practice in fear of and accountants. That’s right—lawyers doctors involved in the case stopped talk- you expect. If you could maintain that vig-
a lawsuit, there are fewer cases filed per get sued, too. Indeed, many lawyers, in- ing to them. A wall went up. These peo- ilance for an entire career, staying alert for
capita today than there were in the 1700s! cluding myself, have been sued at one ple are not stupid, and they get angry. the case that is not going to go as expect-
The majority of noncriminal trial days in time or another. No professional likes to Then they go see their general-practice ed, that would make a huge difference.
U.S. courtrooms today involve corpora- be accused of malpractice or even to be lawyer, or a lawyer whom a friend knows, When that case comes, handle it appro-
tions suing each other and family law dis- challenged. The difference is that lawyers and that lawyer calls me. It is a rare occa- priately, document it well, and never stop
putes. In the area of obstetric litigation, understand the process better than most sion for a person to come to me and say, communicating with your patient. s
the number of lawsuits filed is declining. physicians because they are dealing in “I want to sue.” Clients usually say, “I’ve
Walk the hallways of most civil court- their own arena. Lawsuits are part of the never sued anyone, and I hate the idea of MR. BOSTWICK is a plaintiff ’s attorney in
houses, and you will find the courtrooms business. As a physician, the more you un- suing. Nobody in my family has ever sued. San Francisco.