Friday, April 15, 2011
Bin Laden is Laughing at Us
This is the Police State that has wrapped its tentacles around us, so subtly, without a whimper of protest....
Thursday, April 14, 2011
Weekend Palin/Trig fun!
Here's an entertaining read by some history professor in Kentucky who went through the evidence and concludes that Trig is not Sarah P's son. Just remember---before all you Palinites start brandishing your pitchforks---- all Palin ever had to do was produce Trig's birth certificate and the relevant hospital records and this all goes away.....
More Bariatric Follies
There's a paper out in Archives from March that pretty much slams the door on the idea of laparoscopic adjustable gastric banding (LAGB) becoming a universally accepted treatment option for morbid obesity. 151 patients were contacted over ten years after having had LAGB for follow up. Only 60% were overall satisfied with the long term results. Alarmingly, nearly 50% required surgical removal of the bands due to erosion. Long term reoperation rates were over 60%. That's bad medicine, baby.
And then I read an article like this one in the Journal of Pediatric Surgery, that tries to defend/justify the practice of slapping a choker on a teenager's stomach. Here's from the abstract:
And then I read an article like this one in the Journal of Pediatric Surgery, that tries to defend/justify the practice of slapping a choker on a teenager's stomach. Here's from the abstract:
One hundred patients aged 14 to 19 years underwent LAGB. Preoperative average weight was 136.7 kg, and median body mass index was 48.7. Comorbid medical conditions were common. Five reoperations were performed for port site bleeding, hiatal hernia repair, possible intestinal obstruction, and port slippage. Eighty-seven patients were followed for a minimum of 6 months. Average weight loss at 6 months was 12.4 (range, 33.2 to 16.2) kg, and average change in body mass index was 4.4 (range, 11.8 to −5.6).Beyond the fact that their results are mediocre (12 kg weight loss over 6 months), I'm more concerned about the moral implications of the report---that somewhere in this country there are pediatric surgeons at major academic centers sitting down with parents and their 14 year old child, trying to convince them that they ought to consent to implanting a device that has known poor results. I mean, 14 years old. It's ghastly, really.
Wednesday, April 13, 2011
Poem of the Week
The Best of It
However carved up
or pared down we get,
we keep on making
the best of it as though
it doesn't matter that
our acre's down to
a square foot. As
though our garden
could be one bean
and we'd rejoice if
it flourishes, as
though one bean
could nourish us.
-Kay Ryan
However carved up
or pared down we get,
we keep on making
the best of it as though
it doesn't matter that
our acre's down to
a square foot. As
though our garden
could be one bean
and we'd rejoice if
it flourishes, as
though one bean
could nourish us.
-Kay Ryan
Sunday, April 10, 2011
Portal Venous Gas and Cecal Bascule
Most cases of cecal volvulus involve the twisting of a redundant, poorly fixated cecum around its ileocolic pedicle. Cecal bascule is a weird variant of cecal volvulus wherein its anterior wall folds over on itself oddly. I can't describe it in words very well. The first picture above may or may not be helpful.
Anyway, I operated on this lady recently who presented with portal venous gas and had peritoneal signs on exam. A deep fold in the anterior wall of the cecum delineated the extent of the gangrene present, isolated to the anterolateral aspect of the cecum. We did an ileocolectomy and she ended up doing well. Then I went home and looked up the word "bascule", because it sounded so stupid. Sure enough, I found it is a French word meaning "seesaw" or "balance". Drawbridges operate on a similar principle. My daughter loves seesaws. There's a park around the corner from where we live that has one. She makes me ride it with her for longer than I would normally enjoy.
Wednesday, April 6, 2011
It's Time
I was asked to see a 95 year old lady with severe abdominal pain a few weeks ago. She had been admitted to the hospital with complaints of fatigue and chest palpitations. Suddenly one morning she developed severe, sharp abdominal pain. Her heart was racing in the 130's. The Xray technicians were just leaving her room when I arrived. Now I know what you're thinking: 95 years old, what the hell is a surgeon doing on the case? But this was a sharp old broad, entirely in control of faculties. She grabbed my ID to make sure she heard my name correctly. "I'm in a hell of a lot of pain doctor", she said.
Her code status was DNR-CCA, meaning that, in the event of cardiac or pulmonary arrest no invasive life saving maneuvers were to be done. When I pushed on her belly the diagnosis was clear enough. She had peritonitis, likely from a perforated ulcer or perhaps diverticulitis. The x-ray eventually confirmed free air. I quietly informed the lady of her predicament. She told me to hold my horses, as her daughter (POA) was on her way in.
I spoke with the daughter on the phone to prepare her. I told her that her mother had sustained a catastrophic intra-abdominal event. I further told her that time was of the utmost importance; we had to determine how aggressive we were going to be, ASAP.
We met at the bedside. The daughter looked understandably strung out and stressed. Her eyes were raw red open wounds. She had seized her mother's pale hand with two of her own, as if she was fervently praying. "I think she wants you to do the operation", was the first thing the daughter said to me. Her voice trembled. She wouldn't let go of her mother's hand. She looked like she had run up the four flights of stairs to get here.
This is where the art of medicine comes into play. I have made the mistake of operating in this situation before, when I was a less experienced surgeon. I used to think it was enough to objectively present patients/families with the options, like a mechanic at a oil change shop. Option A, operate with certain complication rates, including the possibility of death. Option B, palliative care with death to ensue sometime soon. It's your decision. I will support whatever it is you decide. And then to step back, put the onus of responsibility on their shoulders. Sometimes the choice is too overwhelming. The patient is suffering. Please just do whatever will make the pain stop, she pleads to her daughter. What if the pain medications dont work they wonder. Maybe she will be one of those rare patients who survive the surgery and get better. After all, Mom just had lunch with me yesterday at Olive Garden. And so doubt begins to creep in. Doubt about advanced directives and code status orders. It's one thing to fill out end of life documents in an abstract, detached manner years beforehand. It's quite another when actual life rears its unyielding head and strikes at you with its ferocious inexorability. And so adult children of these dying elderly patients will ask----can you save my mom?
I have saved a few. I remember one 89 year old guy I operated on for toxic megacolon. He miraculously survived the subtotal colectomy and was sent to a nursing home. I remembered him as a personal triumph, a transient victory over the brute relentlessness of death. I may have even blogged about it, I can't remember. The story didn't have a happy ending though. I got consulted to see him 8 months after that miracle surgery. He was in the ICU with sepsis from a decubitus ulcer. His granddaughter told me he never really regained his mental or full physical faculties after the surgery, despite the intense rehab. The ileostomy was a constant source of stress and irritation. He had slowly withdrawn into himself and rarely left his bed. He had become a living ghost of the man she had grown up with. He died shortly thereafter.
Sometimes you have an obligation to present a patient's options in such a way that sort of pushes them in one direction over the other. Call it paternalistic if you will. I call it humane.
I told her that an operation would be very difficult (she had had numerous previous surgeries over the years and had an obvious large ventral hernia). I told her that it's certain she would leave the operating room intubated and highly likely that she might never get off the ventilator safely. I told her that many of her organ systems were already starting to fail and that often that process was irreversible, especially in someone her age. I told her that aggressive pain control was an intervention in itself, that she ought not to consider simple pain alleviation as "doing nothing". I told her I would support their ultimate decision....but a surgery would be very tough for her to tolerate.
Well, I've never been one to drag things out, she said. Get me some pain medicine. I don't want any surgery. What are you crying for, she said softly to her daughter. When it's time, it's time.
I sometimes forget how courageous human beings can be if you give them the chance.
Her code status was DNR-CCA, meaning that, in the event of cardiac or pulmonary arrest no invasive life saving maneuvers were to be done. When I pushed on her belly the diagnosis was clear enough. She had peritonitis, likely from a perforated ulcer or perhaps diverticulitis. The x-ray eventually confirmed free air. I quietly informed the lady of her predicament. She told me to hold my horses, as her daughter (POA) was on her way in.
I spoke with the daughter on the phone to prepare her. I told her that her mother had sustained a catastrophic intra-abdominal event. I further told her that time was of the utmost importance; we had to determine how aggressive we were going to be, ASAP.
We met at the bedside. The daughter looked understandably strung out and stressed. Her eyes were raw red open wounds. She had seized her mother's pale hand with two of her own, as if she was fervently praying. "I think she wants you to do the operation", was the first thing the daughter said to me. Her voice trembled. She wouldn't let go of her mother's hand. She looked like she had run up the four flights of stairs to get here.
This is where the art of medicine comes into play. I have made the mistake of operating in this situation before, when I was a less experienced surgeon. I used to think it was enough to objectively present patients/families with the options, like a mechanic at a oil change shop. Option A, operate with certain complication rates, including the possibility of death. Option B, palliative care with death to ensue sometime soon. It's your decision. I will support whatever it is you decide. And then to step back, put the onus of responsibility on their shoulders. Sometimes the choice is too overwhelming. The patient is suffering. Please just do whatever will make the pain stop, she pleads to her daughter. What if the pain medications dont work they wonder. Maybe she will be one of those rare patients who survive the surgery and get better. After all, Mom just had lunch with me yesterday at Olive Garden. And so doubt begins to creep in. Doubt about advanced directives and code status orders. It's one thing to fill out end of life documents in an abstract, detached manner years beforehand. It's quite another when actual life rears its unyielding head and strikes at you with its ferocious inexorability. And so adult children of these dying elderly patients will ask----can you save my mom?
I have saved a few. I remember one 89 year old guy I operated on for toxic megacolon. He miraculously survived the subtotal colectomy and was sent to a nursing home. I remembered him as a personal triumph, a transient victory over the brute relentlessness of death. I may have even blogged about it, I can't remember. The story didn't have a happy ending though. I got consulted to see him 8 months after that miracle surgery. He was in the ICU with sepsis from a decubitus ulcer. His granddaughter told me he never really regained his mental or full physical faculties after the surgery, despite the intense rehab. The ileostomy was a constant source of stress and irritation. He had slowly withdrawn into himself and rarely left his bed. He had become a living ghost of the man she had grown up with. He died shortly thereafter.
Sometimes you have an obligation to present a patient's options in such a way that sort of pushes them in one direction over the other. Call it paternalistic if you will. I call it humane.
I told her that an operation would be very difficult (she had had numerous previous surgeries over the years and had an obvious large ventral hernia). I told her that it's certain she would leave the operating room intubated and highly likely that she might never get off the ventilator safely. I told her that many of her organ systems were already starting to fail and that often that process was irreversible, especially in someone her age. I told her that aggressive pain control was an intervention in itself, that she ought not to consider simple pain alleviation as "doing nothing". I told her I would support their ultimate decision....but a surgery would be very tough for her to tolerate.
Well, I've never been one to drag things out, she said. Get me some pain medicine. I don't want any surgery. What are you crying for, she said softly to her daughter. When it's time, it's time.
I sometimes forget how courageous human beings can be if you give them the chance.
Thursday, March 31, 2011
Over Treatment
With utter dismay I've been following President Obama's unconscionable usurpation of limitless executive power with regards to the War in Libya. And let us clear: The bombing of Libyan ground targets, the arming of rebels, and CIA presence on Libyan soil (in an advisory capacity, so they say) all represent aggressive acts of war. This is a third war we have now embarked upon in a Muslim country. Absurdly, once again, American missiles are being fired at a country that poses absolutely zero threat to our national security. And this time our Commander in Chief has committed us to war by executive fiat. No congressional approval. No meaningful debate. Not even a symbolic vote by the legislature to at least give the pretense of abiding by the dictates of Article I of the US Constitution. Everything this man campaigned on---- hope and change, the dawn of a post-partisan era, the end of the Imperial Presidency-----all a complete fraud.
I'm no foreign policy guru. I'm not there in the Situation Room. I don't presume to think that my feelings wouldn't be different if I had access to all the relevant information that the national security council has. But such a monumental decision cannot be contingent on personal feelings. It's one thing to help avert a potential slaughter, such as at Benghazi (although such rationale appears to be somewhat arbitrary; otherwise why aren't there bombs raining down in the Ivory Coast, Yemen and Bahrain?) It's quite another to unilaterally assert the right to bomb the bejeesus out of a foreign land. We are not a nation of Great Benevolent Men. We are rather a nation of laws. Believe it or not, even the President of the United States must abide.
I see parallels in this current military overreach with what is happening in healthcare. We spend 30% of a person's lifetime Medicare outlays on care provided during the last year of his or her life. We spent $50 billion of Medicare dollars last year on dying patients' last two months of life. Why are we doing this? Why has that 30% number remained unchanged for almost 30 years? Why do I continue to see consults on demented 89 year olds in the ICU who are intubated and unresponsive and suffering from multiple organ failure? And they linger for days and days. And the chart contains consults from numerous highly trained specialists, all dutifully offering the best that American health care can provide.
Is it greed? In our procedure-oriented, profit-driven health care culture, you eat what you kill. Why spend an hour doing a thorough history and physical examination, talking with family members and concluding that no further treatment is warranted when you can send your PA to do a quick consult, sign her note, and schedule the patient for a lucrative procedure the next day. Are we in Libyan merely to protect Italian oil interests? Are we there just to safeguard British Petroleum investments? Or is it truly a "humanitarian" venture?
Do we do it just because we can? Hey, we have a pulmonologist on staff. That 94 year old is dying of congestive heart failure. Send him down to the ICU, consult the pulmonologist who then orders the patient intubated based on an ABG that the nurse gives him over the phone. Then get the interventional cardiologist involved. And did you know, the hospital just recruited a new endocrinologist. The patient has a blood sugar of 356. Consult the new guy so we can tweak his insulin dosage. And on and on. Similarly, here we are sitting on the greatest military arsenal the world has ever seen. American military spending in 2010 was over $650 billion. That's 7 times more than the second highest national military budget (China). All this ordnance and materiel that, which each passing year, becomes more and more obsolete, necessitating even more spending in the future---might as well use it whenever a vaguely justifiable reason develops somewhere in the world, right?
Is it our arrogance? As doctors, do we presume to be the arbiters of life and death? Has our power to save and extend life been corrupted by an overweening sense of infallibility and righteousness? Has the American Hegemon unequivocally declared itself the Exceptional, Indispensable Nation? Do we truly believe we know what is "best" for every other group of human beings scattered across the expanse of the globe? Has the condescension of the White Man's Burden been passed on to 21st century America?
It's probably a combination of all those reasons, to some extent. Fundamentally something is rotten at the core of our nation. We define things in superficial terms. We demonize with catch phrases and sound bytes--- i.e. "death panels" and "they hate us for our freedom". We dare not look under the surface into the complexity and confusion and unpredictability of reality. We close our eyes to the discomfort of uncertainty and nuance. We would rather wear flag pins and dress up like 18th century New Englanders and sing God Bless America and publish papers on the effectiveness of colon surgery on nonagenarians. Death and decline prey upon us all---individual and nation as a whole. Nothing lasts forever. Clinging to a platitudinous nationalism, a jingoistic pride, a sense of professional omnipotence---these are all forms of an incipient dishonesty that threatens our collective soul. Death and decline are not to be feared. We can't save all patients. We can't rule the world forever. There are limits to human achievement. There is nothing shameful about recognizing futility. It's time we summoned the courage to look a little deeper, to find a sliver of humility through self analysis, and to reconcile ourselves to our ineluctable imperfection in this fallen world.
I'm no foreign policy guru. I'm not there in the Situation Room. I don't presume to think that my feelings wouldn't be different if I had access to all the relevant information that the national security council has. But such a monumental decision cannot be contingent on personal feelings. It's one thing to help avert a potential slaughter, such as at Benghazi (although such rationale appears to be somewhat arbitrary; otherwise why aren't there bombs raining down in the Ivory Coast, Yemen and Bahrain?) It's quite another to unilaterally assert the right to bomb the bejeesus out of a foreign land. We are not a nation of Great Benevolent Men. We are rather a nation of laws. Believe it or not, even the President of the United States must abide.
I see parallels in this current military overreach with what is happening in healthcare. We spend 30% of a person's lifetime Medicare outlays on care provided during the last year of his or her life. We spent $50 billion of Medicare dollars last year on dying patients' last two months of life. Why are we doing this? Why has that 30% number remained unchanged for almost 30 years? Why do I continue to see consults on demented 89 year olds in the ICU who are intubated and unresponsive and suffering from multiple organ failure? And they linger for days and days. And the chart contains consults from numerous highly trained specialists, all dutifully offering the best that American health care can provide.
Is it greed? In our procedure-oriented, profit-driven health care culture, you eat what you kill. Why spend an hour doing a thorough history and physical examination, talking with family members and concluding that no further treatment is warranted when you can send your PA to do a quick consult, sign her note, and schedule the patient for a lucrative procedure the next day. Are we in Libyan merely to protect Italian oil interests? Are we there just to safeguard British Petroleum investments? Or is it truly a "humanitarian" venture?
Do we do it just because we can? Hey, we have a pulmonologist on staff. That 94 year old is dying of congestive heart failure. Send him down to the ICU, consult the pulmonologist who then orders the patient intubated based on an ABG that the nurse gives him over the phone. Then get the interventional cardiologist involved. And did you know, the hospital just recruited a new endocrinologist. The patient has a blood sugar of 356. Consult the new guy so we can tweak his insulin dosage. And on and on. Similarly, here we are sitting on the greatest military arsenal the world has ever seen. American military spending in 2010 was over $650 billion. That's 7 times more than the second highest national military budget (China). All this ordnance and materiel that, which each passing year, becomes more and more obsolete, necessitating even more spending in the future---might as well use it whenever a vaguely justifiable reason develops somewhere in the world, right?
Is it our arrogance? As doctors, do we presume to be the arbiters of life and death? Has our power to save and extend life been corrupted by an overweening sense of infallibility and righteousness? Has the American Hegemon unequivocally declared itself the Exceptional, Indispensable Nation? Do we truly believe we know what is "best" for every other group of human beings scattered across the expanse of the globe? Has the condescension of the White Man's Burden been passed on to 21st century America?
It's probably a combination of all those reasons, to some extent. Fundamentally something is rotten at the core of our nation. We define things in superficial terms. We demonize with catch phrases and sound bytes--- i.e. "death panels" and "they hate us for our freedom". We dare not look under the surface into the complexity and confusion and unpredictability of reality. We close our eyes to the discomfort of uncertainty and nuance. We would rather wear flag pins and dress up like 18th century New Englanders and sing God Bless America and publish papers on the effectiveness of colon surgery on nonagenarians. Death and decline prey upon us all---individual and nation as a whole. Nothing lasts forever. Clinging to a platitudinous nationalism, a jingoistic pride, a sense of professional omnipotence---these are all forms of an incipient dishonesty that threatens our collective soul. Death and decline are not to be feared. We can't save all patients. We can't rule the world forever. There are limits to human achievement. There is nothing shameful about recognizing futility. It's time we summoned the courage to look a little deeper, to find a sliver of humility through self analysis, and to reconcile ourselves to our ineluctable imperfection in this fallen world.
Tuesday, March 29, 2011
Dentists: Patient Advocates
From the New Haven Independent 3/24:
You think this is unreasonable? You think this is just a craven power play by a State Commission to monopolize a lucrative side business flimsily related to dental health? You see a conflict of interest in that the Dental Commission is comprised almost entirely of...dentists? Are you crazy? Just wait till you see what is coming down the pike in other fields:
The American Hand Surgery Commission is considering a resolution that defines all finger nail clipping as "digital-related surgery". Early drafts of the bill would require Americans to obtain finger nail clipper licenses from a Hand Surgeon-approved weekend instructional class. (To be renewed every three years.)
Rumors have it that the American College of Dermatologists are hoping to define the application of any SPF lotion above 30 as "practical dermatology" thereby mandating a visit with your local dermatologist and a prescription prior to that summer trip to the Outer Banks.
Working its way through subcommittees is a resolution from the State Board of Pediatrics that would try to re-classify classic remedies for your kids' colds as "rudimentary pediatric medicine". So no more over the counter Vicks to your kids' scrawny chests. No more TLC. No more ginger ale without a prescription. And the only chicken soup you can administer your kid is the the leftover slop that your pediatrician fed her family the previous night.
The Bariatric Surgery Commission is close to an agreement that would deem any form of exercise as a "bariatric intervention", to be monitored by highly trained obesity specialists. GPS monitors would be placed on anyone with a BMI of over 30 to ensure that nobody obese is moving faster than a crustacean without first seeking advice from a friendly local bariatric surgeon and informed of the harmless, easily tolerated surgical options in the War on Obesity.
Finally, the American Society of Pulmonologists and Critical Care Intensivists is lobbying to regulate the way Americans breathe. It isn't just a gasp or a sigh or a mere inhale. No sirree. Just because you breathe involuntarily doesn't mean that a highly trained sub specialist shouldn't be lucratively involved in your own personal world of O2/CO2 exchange. A mechanism that complex requires close surveillance. If enough votes are garnered, citizens will be forced to see a pulmonologist every 6 months for a full assessment of his or her "respiratory mechanics".
State dentists could get a monopoly on the lucrative business of teeth whitening pending action by a commission they control.
The State Dental Commission held a hearing in December to review whether teeth whitening should be classified as "dentistry" - a move that would result in the procedure being done only under a dentist's supervision. The commission is set to vote on the issue at its May 11 meeting. If the panel rules that it is dentistry, others who provide the service in shopping malls, salons and spas could be put out of business.
You think this is unreasonable? You think this is just a craven power play by a State Commission to monopolize a lucrative side business flimsily related to dental health? You see a conflict of interest in that the Dental Commission is comprised almost entirely of...dentists? Are you crazy? Just wait till you see what is coming down the pike in other fields:
The American Hand Surgery Commission is considering a resolution that defines all finger nail clipping as "digital-related surgery". Early drafts of the bill would require Americans to obtain finger nail clipper licenses from a Hand Surgeon-approved weekend instructional class. (To be renewed every three years.)
Rumors have it that the American College of Dermatologists are hoping to define the application of any SPF lotion above 30 as "practical dermatology" thereby mandating a visit with your local dermatologist and a prescription prior to that summer trip to the Outer Banks.
Working its way through subcommittees is a resolution from the State Board of Pediatrics that would try to re-classify classic remedies for your kids' colds as "rudimentary pediatric medicine". So no more over the counter Vicks to your kids' scrawny chests. No more TLC. No more ginger ale without a prescription. And the only chicken soup you can administer your kid is the the leftover slop that your pediatrician fed her family the previous night.
The Bariatric Surgery Commission is close to an agreement that would deem any form of exercise as a "bariatric intervention", to be monitored by highly trained obesity specialists. GPS monitors would be placed on anyone with a BMI of over 30 to ensure that nobody obese is moving faster than a crustacean without first seeking advice from a friendly local bariatric surgeon and informed of the harmless, easily tolerated surgical options in the War on Obesity.
Finally, the American Society of Pulmonologists and Critical Care Intensivists is lobbying to regulate the way Americans breathe. It isn't just a gasp or a sigh or a mere inhale. No sirree. Just because you breathe involuntarily doesn't mean that a highly trained sub specialist shouldn't be lucratively involved in your own personal world of O2/CO2 exchange. A mechanism that complex requires close surveillance. If enough votes are garnered, citizens will be forced to see a pulmonologist every 6 months for a full assessment of his or her "respiratory mechanics".
Thursday, March 24, 2011
Hedge Funds for Lawsuits
This is awesome. As if there aren't enough shady financial instruments out there for nefarious money making purposes. We now enter the era of the hedge fund- financed medical malpractice lawsuit.
I get it. Mounting a malpractice trial is expensive. You have to spend hours upon hours (at $500-800 per) taking depositions. You have to pay off, er, compensate whores, er, I mean, expert witnesses for their time. For a garden variety med mal case, trial attorneys can expect to spend upwards of 100 grand of their own stash. Given that physicians end up winning 70-80% of med mal cases that go to trial, this anticipated outlay of personal funds prior to a verdict can be somewhat discouraging to the less testicularly fortified litigation firms.
And this is part of the reason why malpractice lawsuits have declined over the past ten years. It doesn't have anything to do with the merits of cases; it's just simply too damn expensive to take a complaint to trial. This is the moral hazard that dissuades too many "frivolous" lawsuits. But it also hurts patients. Patients who have been injured through possible negligence may find that there are fewer firms willing to acept the case.
So what to do if you're a med mal lawyer without a fat bankroll? Contact one of these rapacious "lending firms" to front the costs of the litigation. You then pass the burden of the exorbitant interest payments on to your client. Awesome! So if you win the case, the first chunk goes towards your fee (did you think otherwise?). The second chunk pays off the interest on the loan. And whatever is left goes to the patient/client. And you aren't required by law to inform your client that you have leveraged the costs of the litigation. What a country!
I get it. Mounting a malpractice trial is expensive. You have to spend hours upon hours (at $500-800 per) taking depositions. You have to pay off, er, compensate whores, er, I mean, expert witnesses for their time. For a garden variety med mal case, trial attorneys can expect to spend upwards of 100 grand of their own stash. Given that physicians end up winning 70-80% of med mal cases that go to trial, this anticipated outlay of personal funds prior to a verdict can be somewhat discouraging to the less testicularly fortified litigation firms.
And this is part of the reason why malpractice lawsuits have declined over the past ten years. It doesn't have anything to do with the merits of cases; it's just simply too damn expensive to take a complaint to trial. This is the moral hazard that dissuades too many "frivolous" lawsuits. But it also hurts patients. Patients who have been injured through possible negligence may find that there are fewer firms willing to acept the case.
So what to do if you're a med mal lawyer without a fat bankroll? Contact one of these rapacious "lending firms" to front the costs of the litigation. You then pass the burden of the exorbitant interest payments on to your client. Awesome! So if you win the case, the first chunk goes towards your fee (did you think otherwise?). The second chunk pays off the interest on the loan. And whatever is left goes to the patient/client. And you aren't required by law to inform your client that you have leveraged the costs of the litigation. What a country!
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