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rather than to a non-biased panel of experts.

Unfortunately, this does not seem to be on the horizon and will be even less so if armchair experts in economics keep saying that there is not a problem. Additionally, I know for a fact that many neurosurgeons are avoiding lengthy high-risk operative procedures that lead to cures in favor of noninvasive palliative procedures that fail to cure but only temporize, pushing the problem down the road. Good luck to Amitabh Chandra in his move to Harvard to evaluate "defensive medicine"; in that he has found a true myth.

Bennett M. Stein, M.D.,
DC '52, DMS '53
Bernardsville, N.J.

We offered Professor Chandra an opportunity to respond to these letters. He replied as follows:

"These two letters highlight the acrimonious nature of the medical malpractice debate and illustrate the degree to which questionable evidence, casual anecdotes, and 'kill the messenger' attacks are favored over careful, empirical analysis. This is a common response among individuals whose self-interested convictions have been challenged. Fortunately, there is no room for such tactics in science.

"1. Contrary to the Goldmeiers' assertion, our research does not contradict the role of damage caps in lowering medical malpractice pressures. In fact, our paper did not study the role of damage caps at all—it only documents trends in malpractice payments made on behalf of physicians. By refuting the presence of explosive growth in these payments, our paper challenges the role of payment increases in raising malpractice premiums.

"2. The Goldmeiers' letter correctly notes that rising administrative costs may raise malpractice premiums. We also noted this point explicitly in our paper. However, the growth of defense costs represents a different mechanism for the increase in malpractice premiums than the payment-premium nexus that is commonly asserted.

This article about a study by a health economist sparked two critiques.

"3. Contrary to the Goldmeiers' assertion, it is not known whether self-insured hospitals (by virtue of disproportionately being teaching and research hospitals) face a disproportionate share of malpractice suits—there is no academic paper that establishes this fact. Even if this statement were true, the exclusion of self-insured institutions from both payment and premium data means that this is not a source of bias.

"4. Our research was carried out under Rand Corporation auspices, so we are extremely familiar with Rand research on this topic. In fact, Seth A. Seabury, Ph.D., a distinguished Rand researcher, is a coauthor on the paper. Contrary to the Goldmeiers' assertion, Rand does not conduct a survey of malpractice premiums. Nor has any Rand study ever noted the numbers they state above. Furthermore, contrary to another statement made by them, the Rand study of California's MICRA legislation limited its analysis to the study of awards and attorney fees. It did not study, or even speculate upon, the effect of MICRA on premiums.

"5. Dr. Stein's letter attributes
conclusions to our paper that we never stated. At no point did we claim that insurers are making windfall profits. Indeed, we explicitly state that insurers' investment losses have contributed to the

pressure to raise malpractice premiums. Nor do we believe that the right policy approach is 'more of the same.' It is naive to infer that because we do not share his doomsday view of the malpractice crisis, we are endorsing the present system. Unfortunately, Dr. Stein's anecdotes, and statements that begin with 'I know for a fact . . .,' do not constitute evidence in a scientific debate.

"While no peer-reviewed study should be viewed as establishing 'truth,' ad hominem attacks on the authors of opposing viewpoints, anecdotes about the experiences of colleagues, and mischaracterization of other work do not further the cause of more informed public policy. The language of science, comprising dispassionate evidence-based research, is taught to everyone at Dartmouth, but until physicians and trade associations replace speculation with statistics, they will continue to be

marginalized in the debate over medical malpractice reform."

We might add to Chandra's comments that the stories in our "Discoveries" section cover research that nearly always has been explained in depth in a peer-reviewed journal. We are much more limited in the space we can devote to each study. We strive to represent the work accurately but are unable to include all the caveats and procedures described in the original paper. That said, the use of the phrase "frivolous lawsuits" in our story about Chandra's study may have been misleading, since the study looked at the relationship between malpractice premiums and trial judgments, but not at the costs of defending against "frivolous" suits that may or may not go to trial. Chandra's paper can be read in full at www.healthaffairs.org; put his last name in the "Author" field of the search panel. Readers who don't have access to the web can obtain a copy of the paper by e-mailing us at DartMed@Dartmouth.edu or by calling 603-653-0772.

Plain white caps . . .
I enjoyed the article "Beyond Nightingale" in the Fall 2005 Dartmouth Medicine. One of the photographs on here is labeled "undated." This is actually the MHMH School of Nursing Class of '73. This

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