Saturday, March 13, 2010

Torte Reform

Unfailingly, each time I tell somebody that I’m doing OB/GYN, the first thing that they tell me is either, “Ooh babies” or “You’re brave--the malpractice insurance.” I’m na├»ve. I chose OB/GYN because I am passionate about the field, and because of my love, I feel willing to pay the high insurance and face the threat of lawsuits. Because the only obstetricians I know are part of an academic practice that covers malpractice insurance, they don’t openly discuss, at least with me, their fear of lawsuits. Even so, I think the dread of bad obstetrical outcomes is palpable in each decision that is made on a labor and delivery unit.

I know next to nothing about the legal system. However, I think as a physician I should learn some basics as lawsuits will most likely, unfortunately, be part of my life. Many healthcare practitioners have told me “tort reform is the answer” and I just nodded my head. I have no clue what tort reform is. According to the Agency for Healthcare Research and Quality, “torts are civil wrongs where the injured person asks for monetary damages from an individual in a situation where there is no contractual relationship.” Thus, tort reform includes legislation that caps payments for non-economic damages when a patient sues a doctor and wins.

As of 2003, 23 states had some tort reform legislated into their government. There is evidence to suggest that tort reform is effective at curbing malpractice fees. For example, in California, legislation was passed in 1975 to lower malpractice costs; by 2000 their insurance premiums increased by 167% whereas in the rest of the nation, fees increased tremendously by 505% [1]. It has also been shown that in California, defensive medicine is less employed and that health care costs are 5-9% lower without significant change in patient outcomes [2].

One of my favorite blogs, Academic OB/GYN, written by Dr. Nicholas Fogelson, recently discussed the importance of change within the country’s legal system in order to produce better obstetrical outcomes over the long term. This is in response to the recent National Institute of Health’s Vaginal Birth After Caesarian (VBAC) Consensus that convened this week. VBAC is a highly contended subject; having a vaginal delivery after a previous caesarian puts a woman at a low but existing risk of the uterus rupturing from the C-section scar being stressed during labor.

Many obstetricians refuse to do VBAC because of fear of litigation due to the risk of uterine rupture. The consensus concluded that VBAC trial was shown to be a safe option for most women [3]. Dr. Fogelson suggests that the apprehension to perform VBAC might be assuaged by “mini-tort reform” in which patients sign a release that in case of a uterine rupture during VBAC, they waive their right to sue. While this is a provocative idea, requiring unlikely consensus and collaboration among a highly divided obstetrical profession, I am not informed or experienced enough to have my own personal convictions on the topic.

I am so protected and coddled as a medical student. I have no concept of what it feels like to be the final decision maker in stressful or liable situations. It is easy to be idealistically devoted to vaginal delivery for every woman who desires it, but to take a stance on the complex and heavily weighted decisions that obstetricians make would be unfair. I do feel with full fervor, however, that it is important to do what is safest and best for our patients. Letting the terror of litigation overrun an entire field of medicine is expensive and can potentially produce worse patient outcomes.

What I am certain about and can propose however, is TORTE reform. As a rich intermediary between a pie and a cookie, this is one topic that there is only one right answer: YES! Tortes are traditionally made with eggs, sugar and nuts. In this recipe, which I very loosely based on a linzertorte, I’ve reformed the composition to have a Southern tinge as a dedication to the pecan pie. The dough is made from chopped pecans and almonds, as is the filling in a pecan pie with mixed nuts spiked with brandy, and it is topped with a gooey chocolate ganache. This is one torte reform we can all agree on (unless you don’t like nuts or chocolate; nobody will ever completely agree).

Nutty Torte Reform with Chocolate on Top

For the crust
½ cup blanched almonds
½ cup pecans
6 tbsp butter cut into cubes, kept cold
1/8 tsp salt
¾ cup cake flour
½ cup powdered sugar
1 egg yolk

For the filling
2 eggs
¼ cup walnuts
¼ cup pecans
¼ cup blanched almonds
(or you could do ¾ cup pecans or use other nuts such as macadamia nuts or hazelnuts)
1/3 cup brown sugar
1/3 cup corn syrup
2 tbsp brandy
2 tsp vanilla
Pinch of salt
Pinch of cinnamon
1 tbsp heavy cream

10 inch tart pan

For the chocolate ganache
1 cup chocolate chips
¾ cup heavy cream
Splash of brandy

Preheat oven to 400 degrees. Toast almonds and pecans for crust in oven for 7 minutes or until golden and fragrant. Toast the nuts for the filling on a separate baking sheet. Allow to cool. Blend in food processor for 30 seconds or until mealy but don’t overwork or it will start to look more like nut butter. Add flour, sugar and salt, pulse a couple of times to blend. Add egg and butter, pulse until blended. With hands, gently bring dough into ball and press into disc, don’t overwork, refrigerate for at least an hour.

Preheat the oven to 300 degrees. On a floured surface with parchment paper, roll out dough. If the dough becomes too sticky, you can press it into the tart pan with your fingers. Prick dough with fork and bake for about 15 minutes. While baking, whisk together filling ingredients. Once crust has started to brown, remove from oven, add filling and bake for another 25 minutes until filling has solidified and crust is brown. Allow to cool.

Over simmering double boiler, whisk together chocolate and cream until blended, add splash of brandy and pour over top of torte while cooling. Refrigerate for a few hours and eat!

1. Hellinger F et al. Malpractice Awards on the Geographic Distribution of Physicians. 2003. US Department of Health and Human Services Agency for Healthcare Research and Qualtiy.
2. Kessler, David and McClellan, Mark “Do Doctors Practice Defensive Medicine?” The
Quarterly Journal of Economics, vol. 111, Issue 2, May 1996, pp. 353-390.