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Tortious situation
The Dartmouth Medicine article "Study Debunks Medical Malpractice Myth" neglects to mention that the American Bar Association is delighted with the type of "research" Chandra is publishing.

First, there is no consideration of defense costs, which can reach $25,000, even in a case that does not go to trial. Administration, defense, and reserves for future cases are a large part of an insurer's cost. The fact that large, reputable insurers such as Prudential and St. Paul's Marine and Fire no longer provide medical liability insurance supports the idea that this area is not lucrative.

Second, basing results on the National Practitioners Data Bank often excludes self-insured institutions. This is important because these are the teaching and research hospitals that take care of the sickest patients. Their share of liability suits is probably higher.

Finally, a Rand Corporation survey has found that states with medical liability caps have lower medical liability premiums. In Florida, ob-gyns paid up to $203,000 per year for insurance in 2000. That same year, California ob-gyns paid up to $72,000. The difference was that tort reform in California led to the stabilization of medical liability costs.

In summary, Chandra's study and conclusions do not fit any of the above- noted facts. Rapidly rising malpractice rates in states without malpractice reform and the lack of profitability of malpractice insurance speak much more loudly than interpreting confusing claims data.

It is a disservice to the graduates of Dartmouth Medical School to publish these conjectures under the heading "Discoveries," while many graduates are undoubtedly suffering from the excesses of the tort system. We hope that any new research into this area will attempt to examine the reality of the situation and not manipulate statistics without further study.

David Goldmeier, M.D.,
DC '78, and Laura
Hulbert Goldmeier, M.D.
Saint Louis, Mo.

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Following suit
I read with interest the article about Amitabh Chandra in your Fall 2005 issue. His studies imply that insurance companies are garnering enormous profits from the medical tort system and that the amount of money spent on medical malpractice activities is a small portion of the healthcare dollar and only increasing in proportion to the overall cost of medical care.

However, in the real world, increasing insurance premiums are creating havoc for many physicians. To wit, a well- respected neurosurgical colleague of mine practicing in Philadelphia pays $660,000 per year in premiums for medical malpractice coverage! Who does Amitabh Chandra think pays to offset this astronomical cost of practice? Obviously the consumer—the patient.

While I'm no fan of med-mal insurers, I will say that the insurers in my area are

not reaping windfall profits and many are run by physicians as not-for-profits. In fact, many commercial insurers opted out of our area because they could not make a go of it.

Where then is the problem? In Amitabh Chandra's ivory-tower world, through his "research" we are led to believe that there is no problem. Well, from his vantage maybe not. I question if he has ever attended a malpractice court case or talked to lawyers and doctors who have experience in the field. I have, and I submit that the current system is escalating out of control. It is inefficient and horribly expensive, with lawyers, expert witnesses, and their fellow travelers (illustrators, jury consultants, and other facilitators of the theater) making $500 per hour and up.

Even without going to jury trial, considering time lost from practice, the current system is incredibly expensive. Into this mix add jurors who cannot comprehend the details of medical practice but are swayed by the showmanship of attorneys and expert witnesses (in spite of new rules requiring lawyers and doctors to serve as jurors, most escape). The whole system ends up as an abomination, and the patient ends up with relatively little.

In a recent case in which I was involved, the trial took four months and the
plaintiff's attorney spent over $400,000 and received a judgment in his favor of $2 million.

The answer is not to slough off the problem, as Chandra has done, but to develop a better system. While I would be the first to admit that a patient who has suffered from medical negligence should be compensated, there is a better way. Rather than more of the same, as Chandra suggests, the system should be revamped. Namely, professional review or arbitration panels should be set up, consisting of experts from the medical and legal systems who understand the nuances of medical practice in the context of the law. This would replace the expensive theatrics to sway the jury that we now experience, and the deceit of many expert witnesses, who present their views in depositions to opposing lawyers

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