Do Different Doctors Have Different Levels of Risk?

Do different doctors have different levels of risk? 

I attempted humor, suggesting surgeons are the only ones hanging around the doctors lounge because they see 1/3 the patients and charge 5x as much. Suggesting they have plenty of time to watch TV and eat free food in the lounge. A reader (physician?) responded:

They kind of take more risk though. Let them sit back and chill. I would never want to be in their shoes. I love my safe little clinic...

"They kind of take more risk though".  I disagree with that assertion. I don't think any physician, who is trained in their scope of practice, takes on anymore risk than any other physician, regardless of what field of medicine they practice in. In the current malpractice market we know as American medicine, I see an irrational linking of bad outcomes with bad medicine. Higher rates of bad outcomes does not mean that more bad medicine or more negligence is occurring. Or that there is more risk involved. It is simply the nature of the disease process or the limitations of the procedural/surgical intervention when bad outcomes occur.

Yet, physicians are charged accordingly on their med mal insurance rates. More bad outcomes? Higher insurance, regardless of the natural disease process.

Let me give you several examples. Neurosurgery has some of the highest malpractice rates, especially cranial privileges. In some parts of this country, you cannot find a neurosurgeon on call for cranial trauma because of malpractice coverage rates. If you are in a car accident in the middle of the countryside, sometimes you have to bypass major population centers because neurosurgeons have given up their call in favor of elective outpatient based interventions.

Let's say you are thrown from a car because you are drunk and you weren't wearing your seat belt. Let's say you have a large intracranial hematoma in urgent need of intervention. Let's say you make it to a neurosurgeon, who does everything right but the patient turns into a vegetable anyway. Let's say the patient develops a rebleed two days later and dies.

Compare this with an outpatient internist who is managing a patient with heart failure and chronic kidney disease. Treatment with potassium, lasix, ACEi, beta blockers, digoxin, statin. The patient presents to the ED in a sinusoidal heart rhythm as a direct result of life threatening hyperkalemia due to progressive renal failure from medication, diet, and natural progression of the disease process.

In both cases, the physician has performed their duties appropriately and both patients have died despite appropriate care from vastly different patient experiences.

The question I ask now is, who carries the greater risk? Is a neurosurgeon, practicing within their scope doing anything more risky than an internist practicing within theirs?

No. Both patient populations carry a risk of death. Both patient populations carry a chance of bad outcomes. So how can you define one as more risky than the other?

Risk is me practicing neurosurgery or a neurosurgeon practicing internal medicine opportunities. Practicing medicine you are not qualified to handle is risky. Doing what you are trained to do, despite bad outcomes is not. Yet we continue to link outcomes with risk.

If bad outcomes was a measurement of risk, then doctors who specialize in palliative care should have the highest malpractice premiums of all, as their chance of bad outcomes, defined by death, approaches 100%.

This is another reason why I contend the RVU system is a sham. Part of the payment of the RVU system (relative value unit) is the a malpractice RVU component. One RVU is worth about $35 according to Uncle Sam. For every encounter, a small number of RVUs are paid based on the perceived malpractice risk of the encounter. Every encounter I face has risk as long as I am not practicing sound medicine. Now, how many RVUs does Medicare pay for a 74 minute critical care patient, on their death bed with severe septic shock?

1/5 of 1 RVU in my community. About 0.2 RVUs. About $7.

How many RVU's does medicare pay for a craniotomy?

over 5 RVUs. About $175. This is more than the 74 minutes of critical care time I spend on a patient with severe septic shock and multi organ failure. A surgeon gets paid more just in malpractice expense than I do in all my efforts, even though their risk of a bad outcome is no different than mine, and in many cases, far less.

I contend that the Medicare payment model of risk, is in no way linked to the actual risk involved, and instead is being paid for on the basis of perceived risk driven by a backward malpractice legal system that self sustains the perception of risk. When in fact, minimal to no risk actually exists (as witnessed by the low rate of med mal payouts.)

If you are practicing sound medicine within your scope of practice, the risk is zero. Unfortunately, our entire med mal system is built around an irrational perceived risk that does not exist.

And this perceived risk has created an irrational standard of care that feeds irrational medicine and creates standards that are not achievable, even based on sound scientific principles.

With that said, my risk as an internist/hospitalist is no different than the risk of a neurosurgeon. The perceived risk is however, what matters. And that has driven entire insurance industries and med mal lawyers that self sustain themselves if for no other reason than to perpetuate their massive fraud on physicians and the general public at large.