Do Physicians Lie?

Yes.  Professions that heretofore enjoyed public admiration for pursuing noble work and reputedly insisting on the highest ethical standards have been exposed.  The Catholic Church could write a few blog posts on this.   Police officers, journalists and even teachers have also shown us that they are members of the human species and are subject to its weaknesses and frailties.

George Washington Cannot Tell a Lie

The fallacy is to expect certain professions and professionals to be more irreproachable than the rest of us.  We are all vulnerable to experiencing a fall from grace.  Staying straight and true is a struggle, at least for me. 

Yes, physicians lie. 

Sometimes, we rationalize a falsehood because it serves a patient’s interest.  We 'adjust' a diagnosis so that the medical test is covered by insurance.  Explain to me please why this is not stealing?  Is this different than shoplifting?   Why should the offense change depending upon who the victim is?   Many folks believe that stealing from the phone company or insurance companies isn’t really stealing.

Sometimes we physicians massage the truth in order to sanitize a grim prognosis.  While I’m not ready to brand these physicians as liars, this tactic falls somewhat short of the truth.  I have been culpable of this.  It’s not as easy as it sounds to get this right.  How much information do we divulge?  Does it all need to come out in the first conversation?   Are we always so sure that the patient before us won’t respond to treatment, even if the medical data suggests an ominous road ahead?    How many patients have we heard of whom were told they had 6 months to live and proved the doctors wrong?   How did these folks feel each day they woke up beyond the 6 month marker? 

This past week, I heard of a physician whopper that broke the record.  A consultant was asked to see a patient in the hospital.  This patient already had an active relationship with a different consultant in the same specialty. ( If a cardiologist, for example, is asked to see a patient in the hospital and discovers that the patient already has a cardiologist, the first cardiologist should step aside and notify the patient’s true cardiologist that the patient needs his medical services. This act would be included in the category called, Doing the Right Thing.) When this consultant greeted the patient, she asked to see her own consultant and even presented her own consultant’s business card to the doctor.  The physician told the patient that her consultant did not have attending privileges at the hospital and did not even perform the procedure that was being contemplated.  Both of these assertions were demonstrably false.  After the patient was discharged and followed up in the office with her consultant, the matter was exposed.  The patient has filed a grievance.

Of course, there are rogue elements in every occupation and institution.  We should not permit an entire profession to be sullied by aberrational behavior.   Sure, some teachers have helped students cheat on standardized tests and some cops have planted evidence.  But most folks, I hope and pray, are doing the right thing.

We are all vulnerable to temptation, greed, ethical erosion, self-righteousness and tortured rationalizations to justify our problematic behaviors.   The ends often don’t justify the means. My point is not to tarnish my own profession, but to present it as a human endeavor.  We physicians are human and need to struggle to do right just like everyone else.  And that’s no lie. 

Government Wants Patients to Report Medical Mistakes - Is This a Mistake?

I’m all for enhancing patient safety.  Count me in on reducing medical errors.  I acknowledge that medical mistakes harm patients and many can be prevented.  The medical profession should promulgate and support any initiative that accomplishes these objectives.

The public has become suspicious of the medical community who seem to circle the wagons when external scrutiny of its actions is threatened.  Yes, sunlight is the best disinfectant, but many of these shining lights are murky shadows that do not illuminate as intended.

Murky Sunlight

Copyright Christopher Down

The government and insurance companies are now providing financial penalties if certain medical quality benchmarks are not met.  While this sounds attractive and overdue when it is expressed in a headline or a slogan, the true motivations and capability of these efforts have been questioned.  Is it really about safety? 

I have tried to expose throughout this blog the fallacy that the medical malpractice system serves as a deterrent and improves medical quality.  I reject this lame claim and maintain that this unfair medical malpractice system diminishes medical performance and harms patients.  For those, who dare to enter this chamber of horrors, I invite you to bravely peruse the posts that are securely stored in the Legal Quality category of this blog.   I have commented on various plaintiff attorneys’ blogs and I’m always struck how so many of them feel that the current system is well designed,  fair and provides necessary justice to their injured clients.  I regard much of this as self-serving ideology that crumbles through gaping credibility cracks.   Would we regard a physician as credible who vigorously opined that our health care system needs no reform?

Our government has a new initiative to protect patients.  In this pilot program, patients would notify the government of suspected medical errors by doctors, pharmacists and hospitals.  An investigation would ensue.

Good idea?  Sure, the concept is reasonable but how would it be implemented?  Realize that most of the reported ‘errors’ would not be mistakes at all, just as most lawsuits against doctors are ultimately dismissed as no true negligence was present or could be proved.  Many of these ‘errors’ would be recognized complications of medical treatment which are blameless events.  Other complaints might relate to perceived inadequate physician communication or indifferent bedside manners.  Other true errors might be too minor to warrant reporting such as a patient’s IV (intravenous) line had to be inserted repeatedly or a patient was given the wrong meal which resulted in no untoward effect. 

Medical records would have to be reviewed in every case and medical personnel interviewed to try to ascertain the facts.  Where would we summon the manpower and the resources to investigate the gazillions of complaints that would be forthcoming once sick folks and their families are encouraged to serve as medical quality officers with a duty to report to serve the greater good? 

Even in a medical malpractice case, it is vexing to discover the truth after months of intense medical record scrutiny, discovery and depositions.   How would this new system aim to get to the truth after a cursory review of the circumstances?

One way to encourage physician support of such as effort would be if the facts and opinions that are uncovered would be kept confidential and privileged from use by the plaintiffs’ bar.  With this provision, then we would know that safety is the priority objective.

Finally, I think that medical error reporting should be reported to hospitals where the alleged errors occurred, and not to the federal government.  The hospital is much better suited to provide review and oversight of its own patients and personnel.  They know the players and are better positioned to evaluate the situation thoroughly and efficiently. I recognize that there is a conflict of interest here and that there would need to be independent voices participating to assure that there is no cover up or slanting of the facts to protect those who have erred or the institution.

Does this post agitate you?  Have I strayed beyond the Bloggers Code of Ethics?  Have I made a mistake here or even been negligent?    Your role is clear.  I am a practicing doctor.  You think I have erred.  Now, do the right thing.  Report me.  

New Indication for Colonoscopy: High Value Target Captured.

This past week, I had a once-in-a-career event.  Indeed, if I didn’t already author a blog, this episode would have been the catalyst to begin one.   As I write this, I am not certain which category label to assign to this post.  I will likely include it in General Whistleblowing rather than create a new category called Search and Rescue.

Gastroenterologists are not just healers of the alimentary canal.  Yes, we are consumed with issues of mastication, salivation, rumination, trituration (GI power word), secretion, digestion, propulsion and elimination.  But, we are so much more than this.  We are poised to serve humanity in so many ways beyond medicine.

  

The colonoscope is mankind’s Holy Grail. 

Please study the photograph below carefully.  When we were medical students peering at a chest x-ray while the attending physician hovered behind us, we were told that “the answer is on the film”.  Of course, we always missed the diagnosis.  We would focus on the heart and lungs and ignore a lesion that was in the shoulder bone at the periphery of the film.  So, dear readers, study this photo.  As a gesture of extreme generosity, I will disclose that this is a photograph of the cecum, which is the blind sac at the upper part of the large intestine where the appendix originates.  “The answer is on the photograph”.

Three weeks before this individual enjoyed the pleasure of colonoscopic intrusion, he swallowed an item that was of great personal value.  How valuable?  Valuable enough that this man strained his stools during this period with the hope of capturing the buried treasure.  Nice visual, huh?

An astute nurse, who knew the lost item’s identity, thought that what is seen in the above photograph was a bulls-eye.  The excitement in the endoscopy suite was a crescendo.   Was this stowaway in the cecum a piece of food or something far more desirable?

I then relied upon decades of medical experience for guidance.   I elected to retrieve the item and subject it to strict scrutiny.  I passed a gastroenterologist’s version of a miniature butterfly net through the colonoscope and performed a successful extraction.

Once we cleaned it up a bit, it was easy to recognize this man’s porcelain dental crown.  Once he awoke, he was joyful to be reunited with this evasive escapee.

I’ve removed thousands of polyps from the colon.  I’ve taken thousands of biopsies from all kinds of lesions.  I’ve seen worms wriggling inside a colon that became their new home.  I’ve used the colonoscope to investigate bleeding, diarrhea, bowel issues and abdominal pain.  But, with this man, I enjoyed a singular accomplishment.  It was my crowning achievement.

Photos published with permission.

Reduce Hospital Readmission Rates or Else!

I attended a medical staff meeting recently.  These are required meetings and attendance is taken, as was done when we were in kindergarten.   While some folks are interested in these meetings’ content, many are not and simply sign the attendance sheet and then slither out in a stealth fashion.   Sly doctors grab their pagers and then leave hurriedly pretending that they were summoned to an urgent medical situation, when they are actually heading for Starbucks.  

One of the community hospitals I attend initiated a dastardly procedure when administrators would not post the attendance sign-in sheet until the conclusion of the medical staff meeting.   Under the threat of picketing, a massive walk out, letters to the local paper and other unspecified measures, the evil decree was rescinded. Who says that physicians have no power today?

Sadly, most of these meetings have nothing to do with making us better doctors.  The agendas are full of medical coding and billing issues. Hospitals are hyperventilating over an increasing burden of mandates issued from Mount Medicare to preserve reimbursement.   At present, if physicians and hospitals somehow make it through the labyrinth of hoops intact, they will accrue a very modest increase in revenue.  In the near future, failure to comply will result in punitive financial confiscation. 

Physicians who make it through get paid more.  

Every hospital is armed with utilization personnel that are trolling through the wards scouring charts trying to verify that the medical documentation supports the highest reimbursement possible.  I don’t fault the hospitals for this.  We follow a similar path in our office.  The hospital hoops we are forced through are described as a palladium to protect patients, although I continue to argue that the motivation is to control costs.

This blog has several posts that argue that the government’s Pay-for–Performance initiatives are scams that ironically decrease medical quality, rather than enhance it as promised. 

At this recent medical meeting, the speaker was instructing us that if patients with certain diagnoses are discharged and then readmitted within 30 days, that the hospital would be financially penalized.  Obviously, there are many legitimate reasons that a sick patient would need to be re-hospitalized within a month, but this issue warrants a separate blog post.

Here’s what I learned.   If a patient returns to the emergency room within 30 days of a hospital discharge, all personnel will be notified that this is a ‘patient of interest’ (my term).  Every effort will be made to choose any pathway, except admission, for reasons unrelated to medical quality.  In fairness, once patients are discharged, medical professionals will stay engaged with them to verify they are complying with medical appointments and medications which should prevent disease recurrence and readmission to the hospital.

I found it galling that strong effort would be undertaken to restrict admission of only those who were recently discharged from the hospital.  Shouldn’t stringent hospitalization criteria be used for every patient seen in the emergency room?  Is it a wonder why cynicism is metastasizing widely? 

This is but a single example of how the medical profession is being forced to game the system to comply with a punitive financial penalty system that is poorly disguised as a medical quality initiative.  Hospitals are ‘teaching to the test’ so that they and physicians look good on paper so more cash will trickle in.  However, medical quality means more than checking off certain boxes required by an army of officials who don’t practice medicine.

The public would be horrified how much time and resources are devoted to feed this bureaucratic beast.   Is any of this making me a better doctor?  This is easy to determine.  Let me see if this box is checked off. 

Boston Marathon vs Terror: Boston Wins

Ohio Stands With Boston

I called my son, a Tufts sophomore, hours after the Boston bombs exploded.  I already knew that he was ok, but a horror in your own neighborhood reaches deep into your gut, as I learned when senseless evil descended upon the small town of Chardon, Ohio a few years ago.

I couldn't reach him on his cell phone.  Later, he explained that cell phone coverage was blocked in order to prevent a phone from being used as a detonator.  This seemingly innocent comment demonstrates the shattering of innocence that has affected us all.

Yes, our society knows fear and anger more than ever before.  We stare evil directly in the eye and wonder if it is lurking beyond our view.  But when it strikes, resilience, fortitude, selflessness, bravery and love have prevailed every time, as we saw in the great city of Boston last week.  While the pain of those who suffered directly is unimaginable, the actions of good people are as real as it gets.

Hail to Boston.

Medical Office Efficiency - The Times They are a Wastin'

Medical practices, particularly private businesses like mine, strive for efficiency. This has become more necessary as medical reimbursements inexorably decline while overhead and other expenses rise. This may be the point in this post when a reader will jump to the comment section below and carp how I and every other doctor are only in it for the money. Not so fast here. Yes, I would like to make a living and I believe that I deserve a decent one. In my case, I do not seek, and have never sought wealth. For small private medical groups, particularly in northeast Ohio, we are aiming to survive more than to thrive.

These days wasted time during the work week can be the tipping point that buries a private practice.

Where are the time sinkholes in medical practice?

• No show patients – This is the ‘Wonder Bread’ of medical practices. It torments doctors in 12 different ways. Younger readers may need to Google to get this reference.
• Late Patients – While these folks are less sinful than ‘Wonder Bread’ patients, they mangle the schedule and suck up physician and staff time. Should these patients be told that they need to reschedule? How late does a patient have to be before he is ejected from the office? Should he be told to sit tight in the waiting room until all of the on-time patients have been seen? Are we comfortable playing hardball with a 90-year-old woman who hobbles in on her walker 20 minutes late?
• Delays in receiving requested medical records. Even in the electronic era, it can be mind boggling how much work is required to get a few papers faxed over. For doctors, this task becomes a competition where we gird our loins to beat the system.
• Patient Paperwork – Our new patients fill out medical surveys that our staff then uploads manually into our EMR (Electronic Medical Record) system. Although these folks are told to arrive early, it never seems to be early enough. I often find myself in solitude in the exam room while the expected patient is in the waiting room pushing paper. In time, this clumsy process will be compressed and expedited, but our practice is not there yet.
• Down on the Pharma – This is the IED (improvised explosive device) of medical practices. I cannot calculate how much time is vaporized re-prescribing medications that are not, or no longer on, the preferred list. If we guess the right medication, then we err on the number of pills permitted. If we opt for the mail order pharmacy, we learn that the local drug store was the proper destination. And, of course, if we were insane enough to memorize a particular patient’s proton pump inhibitor prescription pathway, it changes at year’s end.

There may be other reasons that challenge medical office efficiency. Perhaps, for instance, there is the rare instance when a physician is late. In this instance, any of my patients who are reading this post are invited not to comment.

Does Medical Resident Work Hour Reform Reduce Medical Errors?

One of the points I offer in this blog and elsewhere is to be skeptical to assume that something is true because we think it should be.

We’ve been brainwashed to believe that obesity is a killer, despite research performed this year concluding that a little more weight may add years to your life.  Many argue that an assault weapons ban will save lives despite the absence of social science research that supports this.  Fewer guns should save lives, right? When skeptics like me point to Chicago which boasts extremely strict gun control legislation while being a murder theme park, we are given excuses to reject the data that contradicts gun control dogma.  Isn’t the term assault weapon itself unfairly charged and loaded?  I have supported medical education reform advocating that medical residents and interns should not be worked to exhaustion and yet be expected to administer high quality and compassionate care to ill patients.  I had believed that somnambulating medical interns were more likely to harm patients with careless care.  I believed that this was true because it seemed entirely self-evident.

Two recent studies published in the 3/25/13 issue of JAMA, the Journal of the American Medical Association, suggest that I was wrong.  

What should one do when a study contradicts a long held view? Two choices to consider.

(1) Reflect, consider the quality of the new information and modify your view.

(2) Attack the study as a Big Government, Big Oil or Big Anything conspiracy and hold your ground.

The latest information suggests that interns and residents who work fewer hours commit more errors.

Reasons include:

• While residents work less at the hospital, they aren’t sleeping more.
• Residents are now required to do the same amount of work in fewer hours.
• Shorter shifts mean more ‘hand-offs’ of patients to the next crew of eager interns.

Obviously, cramming in the same amount of high-pressure work into fewer hours invites errors, particularly with relatively inexperienced physicians who may not be adequately supervised at night.  Medical handoffs are the event when interns who are leaving the hospital sign over the care of their patients to the next crew who must assume immediate responsibility for patients they may have never seen.  Hospitalized patients are complex.  The nuances of their condition cannot be seamlessly transmitted to doctors-in-training in a few sentences.  An intern may have to assume care of 10 or so new patients as he comes on shift.  Would you feel at ease if you were one of these patients?  Indeed, one of the defenses of the pre-reform system when interns were real men and worked until exhaustion was that there were fewer dangerous medical handoffs.

Now, these two studies are not determinative.  The increased error rates with shorter work shifts were volunteered by the doctors themselves, which is not scientifically rigorous.  I’m not ready to abandon my view that interns in my day were unnecessarily overworked, but it may be that the reforms that are in place left now have left us too far from a humane end zone.

Not every hypothesis needs to be tested.  Do we need a study to determine if highway driving while wearing a blindfold is dangerous?   Are we still entertaining the notion that it is better for patients and young physicians to meet when the doctor is disoriented from sleep deprivation?    Is there really a need to torture interns to buck them up for their later years in medical practice when they will likely sleep soundly through most nights? 

I’m against torture, even though I know its definition has been a matter of public debate.  Indeed, I’m pleased that my views coincide with national policy.

"We Do Not Torture"  

 "We Waterboarded U.S. Soldiers so it’s not Torture"

What if our senators and representatives had to legislate on four hours of sleep each night?  Care to predict the outcome?   Would the quality of legislation, comity and bipartisanship flourish?  One would surmise that exhausted congressmen would commit more errors, but who knows?  I say, let’s try the experiment for a year to test this hypothesis which may ultimately improve the political process.  I think there’s a reasonable prospect that congressional sleep deprivation may improve quality considering that these self-promoting, self-aggrandizing, self-serving and self-protective scoundrels have already hit bottom.  There’s only one direction they can go.  No need to sleep on this one.