Doctors Face Perverse Incentives and Constraints

Kevin MD’s blog provides an illuminating discussion of how hard we make it for good people to practice medicine.  The case discussed involves an MD who is successfully sued for not performing a heart cath on a patient, even though two previous treadmill tests did not reveal any problems.  (The heart cath procedure itself has a nontrivial risk of death and other serious complications.)   

The discussion in the Kevin MD illustrates the difficult incentives and constraints faced by the conscientious physician. In terms of a patient’s health, a cost/benefit analysis may imply that a medical test should not be performed, but in terms of an MD’s income, and legal liability, a cost/benefit analysis may imply that a medical test should be performed. 

Something is wrong with our reward structure and legal institutions, when MD’s who make the right medical call for the patient, are "rewarded" by earning less, and by increasing their chances of being sued.


Read the full discussion at:


For convenience, here is the opening entry in the discussion:

Saturday, June 03, 2006

Liable for not doing a heart cath on a 49 year-old

Interesting case with an unfortunate outcome:

Daniel Bettencourt was 49 when he suffered a fatal heart attack while working as a manual laborer at E.&J. Gallo Winery on Jan. 15, 2003.

An autopsy determined that the Modesto man had more than 90 percent blockage in an artery that supplies blood to the left side of the heart.

Last week, a jury found that Gould Medical Group doctors had failed to diagnose Bettencourt’s heart condition.

A 49 year-old male has recurrent chest pain. He was referred to a cardiologist and had two negative stress tests. That sounds like reasonable standard of care to me, although I probably would have done a more detailed second stress test – such as a stress-echo or MIBI. As the defense stated, you can’t cath everybody with chest pain (although if they had, this lawsuit would have been avoided – score another point for defensive medicine).

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