I took care of a lawyer the other day

Lawyers are (probably) people too, and they get injured like the rest of us. I made a comment a while back on Kevin, MD (which I’m too lazy to search for right now) that, IMHO, lawyers are reticent to announce that they’re lawyers in the ED.

A few months ago saw a patient with a small laceration on a digit; after a digital block I left to do something else, then returned once the finger was good and numb to close the wound. I like to chat with patients during suturing; it is mildly distracting to the patient, and me (suturing is dull after the first thousand lacerations or so):

The conversation, as I remember it:

  • me: So, how’d this happen, again?
  • pt: Caught it between a dresser and the wall; I’m moving (out of state).
  • me: Aah. Moving for a new job?
  • pt: No, same job, different headquarters; kind of a promotion.
  • me: Good for you. What do you do?
  • pt: …I’m a lawyer…an Oil and Gas Lawyer, I don’t do any medmal.

That last part shot out of the patient’s mouth so fast, and loud, the patient in the cubicle across the hall started laughing.

We both laughed mutually, at the humor of the discomfort of his statement, and that his reaction caused laughter in others.

The finger was closed, and that was the end of the interaction, but it was amusing. And I probably won’t be sued by an Oil and Gas lawyer; at least, not by him directly.


Comments

  1. Why other day?

  2. Every lawyer I’ve ever taken care of has also been pretty quick to disavow his medmal/PI colleagues; it is almost comical. When they mention they’re a lawyer, I always give them a raised eyebrow and an expectant “really?”

    The immediate reply is virtually always “Ummm… I’m a patent attorney,” or “I do corporate mediation, no medmal.”

    I did take care of one of our local ambulance chasers (one of those guys with billboards all over town). I knew who he was, and I’ll be damned if I was going to be faced down in my own ER, so I walked in the room and cracked a joke about how much shorter he looked in person compared to his billboards. He looked at me for a second and then started to laugh… he actually turned out to be a pretty personable guy.

    It’s natural to be intimidated when you’re in their environment, under oath, and being grilled… but don’t be intimidated in your own house.

  3. My best comment from an attorney I was treating was “I’m a medmal attorney — but I do DEFENSE WORK ONLY!”

  4. It’s funny. Almost like he were embarrassed for his profession drumming up so many lawsuits that many docs have changed the way they practice to avoid getting sued.

  5. Actually, he was more scared that the physician would refuse or give him substandard care simply because he had a law degree.

    And Grunt, the lawyer doesn’t sue you – the patient does. The lawyer never “sues you directly”.

  6. Actually, he was more scared that the physician would refuse or give him substandard care simply because he had a law degree.

    I wondered how long it would take for CJD to show up. How are you these days, Matt?

    Grunt wouldn’t have refused the attorney care in the ER… and you know it. Neither would he have been foolish enough to provide substandard care to a malpractice attorney (any more than he would for ANY patient). I’ve taken care of multiple murderers and child molesters… how could I refuse to take care of a Medmal attorney?

    Now… in an outpatient setting? In a private office? I’ve known many physicians who declined to care for the local PI/Medmal king. I know of once instance where the attorney in question actually had to drive 60 miles to see a physician, as none of the local physicians in his city would have anything to do with him absent an emergency ER call.

  7. I’m well, but busy, thank you.

    You wonder why a lawyer might be worried about your refusal to care for them? Didn’t a medical association propose a rule stating they wouldn’t care for medmal attorneys just a year or so ago, when you were all whipped up in a frenzy by your insurance carriers? Maybe this will refresh your memory:

    http://www.usatoday.com/news/nation/2004-06-13-med-malpractice_x.htm

    I don’t understand why you wouldn’t care for someone in need, regardless of how they make their living. That’s supposed to be one of the differences between a profession and a job. Just like I have a duty to represent someone I may not agree with, I would think you would have the duty to treat someone you may not agree with. Since we’re giving such responsibility, and the people who can do what we do is so limited, we are expected to do more.

    But maybe you don’t see it that way or are into that higher calling stuff. I’ll admit, it’s tough when you’re grinding it out on a daily basis to make a living.

  8. TheNewGuy says:

    I’ve never turned away a patient who needed me, Matt. Have you ever turned away a client who needed you? How about one who was drunk, swung at you, puked on you, then threatened to sue you for legal malpractice?

    After all, why wouldn’t you represent someone in need, regardless of who they are, or how they make their living? I mean, even if they can’t pay, like a huge chunk of GD’s patients… right? How much pro-bono work do you do again??

  9. Note I didn’t say anything about can’t pay. I’m referring more to the fact that a judge can order me to represent someone, but also yes, to the fact that I have a duty to represent the indigent.

    How much do I do? Enough to be named my county’s Legal Aid Volunteer of the Year for the last couple years. And that’s just the cases referred to me by Legal Aid. How about you?

    GD doesn’t get paid based on his collections. He has a contract with the hospital, presumably, and I’m betting it doesn’t include any terms about making sure his patients pay. You’re making a poor comparison.

  10. Matt, your presumption is incorrect. I get paid on my percentage of billing as applied to total collections. NO hospital money involved, we live on what we earn/collect.

    Oh, and last time I looked, we collect 23 cents on every billed dollar.

  11. I’m curious, can you explain that in more detail – I’m not following the “percentage of billing as applied to total collections.” Does that include the bills like I saw during my ysecond kid’s birth where it was $100 for an igloo chest of ice?

  12. And is your 23% collection rate include the amount billed the insurer, or the amount the insurer agreed to pay for the procedure up front when the contract was entered into? In other words, if you normally charge $1,000 to do procedure X but agreed to do it for the insurer for $300, do you use the $1000 or $300 to figure the 23%?

  13. I get my % of the RVU billing, from the total collected (minus the billing and management cuts, which don’t figure into the 23% number).

    And, yes, insurance ‘discounts’ are excluded (from your example, we’d have used the 300 number).

    Wish we could bill by the hour. Heh.

  14. TheNewGuy says:

    I likewise receive no money from the hospital… it’s strictly what we bill. We also collect less than 30% of billed charges… and that’s a pretty common percentage.

    In simpler terms, almost 50% of the patients I see are medicaid or self-pay (ie. no-pay). I treat them the same way I treat all my other patients.

  15. You can bill by the hour, just find a hospital that would allow it. It’s stunning to me that you guys don’t have more variety in your billing arrangement. Why do seemingly intelligent people keep doing things they think are causing them to lose money, are you guys just that poor at business? Particularly when you’re so unhappy with what you have. Or maybe you’re not that unhappy, but you just like to complain? After all, given the system you hate, it’s still a pretty good living on average.

    NewGuy, if they’re medicaid, you’re still getting paid. If they’re “no pay”, I’m not sure why you’re not pursuing them for the balance, setting them up on payment plans, etc. Do you get credit when the collection companies your hospitals outsource debt collection to ultimately collect?

  16. Most of our self-pay patients have nothing to take… no assets, no job… nothing you could put a lein against. A very few pay, but most of those bills go unpaid. Medicaid has lousy reimbursement, and most of my consulting docs don’t accept it, so getting patients followed-up can be quite difficult. The hospital bills separately from us, and there’s no fee-splitting or kickbacks involved (illegal), so we don’t get any credit/money from them.

    Also, lawyers may bill by the hour, since that’s how the legal profession works, but I can’t bill by the hour with most insurances… they simply don’t work that way (some psychiatrists bill by time). Insurances and various payors reimburse by diagnostic code, and that’s generally it. For instance, to use an example from one of my colleagues, Medicare pays X dollars for a surgical procedure (like an appendectomy), and it doesn’t matter how long it took the surgeon to do the case, how much extra post-op care they require, or how many follow-up visits they need… that’s ALL INCLUDED in medicare’s reimbursed amount. Like it or lump it.

    My physician reimbursement goes by level of visit (1 to 5, from least emergent to most emergent), and critical care is the only area I can think of where time spent with the patient changes anything.

    Ever wonder why some doctors try to crank through as many patients as possible? It’s because they’re financially penalized for spending too much time with one patient. That’s how the reimbursement scheme rewards them… in volume (eg. number seen), not in time spent. I don’t imagine it’s very dissimilar to why some attorneys pad their hours… because that’s how they get paid.

    The current medical payment system has tremendous organizational inertia, and I think you’re giving us credit for waaay too much power when it comes to making changes. Those with the gold make the rules, or rest assured there are many things physicians would change.

  17. sultan of swage says:

    Kudos to you, Matt, for your accolades as one of your county’s outstanding individuals. But you will have to forgive any of us if we are hesitant to allow you to draw a direct comparision of the work you do and that which we do. Here’s the deal: we do not choose or select in any way the people we devote our ability and empathy to. Professional emergency physicians open their places of practice to anyone and everyone who even has the slightest thought that they may need medical help, regardless of the true nature of their complaint, station in life, or any other consideration. Not to be melodramatic but when we rush the 34 year old HIV patient with respiratory failure back to the resucitation room so that we can quite literally save her life, we bypass every wealthy and/or insured minor complaint in the waiting room as if they were not even there. We do not ask for your praise or your appreciation as this are the circumstances we all agreed to work under and we are proud to do so.

    However, for you to even suggest that any patient has their care influenced by something as trivial as their vocation makes you look a lot more ignorant than I know you are. We are quite aware that your profession is well-populated with selfless and chartible people, dedicated to improving thew world in which we live. The same goes for us too, man.

  18. It wasn’t my suggestion, read the original post. Also read the link. When physicians try to pass resolutions in their medical societies that would allow them to prohibit treating people with certain jobs, why is that so unreasonable to suggest that the care of those people might be affected?

    And I never suggested we were selfless or charitable as a group. We’ve got the same number of sons of bitches as any other profession, including myself.

  19. “The current medical payment system has tremendous organizational inertia, and I think you’re giving us credit for waaay too much power when it comes to making changes. Those with the gold make the rules, or rest assured there are many things physicians would change.”

    I agree there is organizational inertia, and I think it’s the physicians’. Every one of you has the power to refuse to sign those contracts. To simply say no. You don’t because you know it’s still a pretty good living.

    As for having the gold, few professions have the level of wealth and the unanimity of interests you guys have and could commit toward political lobbying.

  20. TheNewGuy says:

    unanimity of interests?

    You know better than that, Matt… physicians are a many-splintered group, and “the Gold” happens to be in the hands of the government, the large insurers, and the hospitals. Physicians salaries account for only a small fraction of the healthcare dollar, as you likewise know.

    As for negotiating contracts, I’ve seen physicians try to band together to get a better deal from payors, only to be sued for price-fixing and antitrust (happened to a group of orthopods I know… the insurer was UHC). If you work in an area dominated by a large insurer (like a commercial insurance, or the big blues), refusing to take that insurer’s deal gets you cut out of the provider network entirely. It can be very hard to make a living in that scenario… some doctors end up getting driven out of town.

    Physicians aren’t politicos; it’s not part-and-parcel of the profession. This is distinctly different from attorneys, as evidenced how many lawyers are in legislatures compared to physicians. Most doctors are too busy with their practices to spend time lobbying, and our “professional organizations” (like the AMA) are nothing but a shell, and apart from attempting semi-successfully to hold the line on medicare cuts, represent only a small minority of physicians.

  21. You do have a unanimity of interest in that the same things affect the vast majority of you, as opposed to say, lawyers. Don’t tell me you can’t come together for political purposes because I’ve seen you do it to the (unwitting) detriment of those injured by malpractice. You march on state capitals, testify before Congress, write innumerable letters to the editor, and propose legislation. Is that solely because you’re organized by the insurers? Where is this organization, this effort, when it comes to you annual Medicare battles? Can you only get motivated when the insurers declare a “crisis” about once a decade?

    It’s not part and parcel of most industries naturally, but they put their money together and hire good lobbyists or form good lobbying organizations. There is no reason the world’s best paid profession cannot do that. None whatsoever.

    If physician salaries account for only a small percentage of the healthcare dollar, then malpractice premiums must be miniscule!

  22. If physician salaries account for only a small percentage of the healthcare dollar, then malpractice premiums must be miniscule!

    Again, as you know perfectly well (because you’ve participated in the discussions on this very website), malpractice premiums are only a small part of the defensive-medicine pie.

    Stop trying to change the subject, and stop attempting to obfuscate the issue by bringing malpractice insurers into it.

    Unanimity of interest is not unanimity of action… because insurers have very neatly divided physicians. Look at reimbursement for procedures versus “mental” work. One gets increased, one gets decreased, and divide-and-conquer goes on. It’s 1% here, a half-percent there… the death of a thousand cuts.

    The government payors and private insurers aren’t fools. They know perfectly well that the service has already been rendered when the bill gets submitted, so the more obnoxious, labor-intensive, and byzantine they can make the process, the more bills will simply get dropped because it’s not worth the effort to collect them. The current admin-heavy system virtually guarantees that they’ll get care for some of their beneficiaries for free, because doctors will end up eating the cost. They are also famous for delaying approvals and “resubmit with X additional documentation” notices until very close to the deadline, so when it doesn’t get resubmitted in <90 days, they can deny payment because it didn’t make the deadline.

    You should work in coding/billing/insurance for a spell, Matt… I guarantee your sue-the-bastards bone would be itching in about ten minutes flat.

  23. I’ve been an insurance defense lawyer, so I know what you’re speaking of, and it’s why I won’t do that work anymore.

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  1. [...] Meanwhile, GruntDoc has been making lawyers crap their pants in the ER. There are very few things that make seasoned ER personnel nervous, but the phrase “I’m a lawyer” is enough to give just about anybody pause. However, the tables turn when the lawyer is on the table, as we can see here. [...]