Sunday, February 26, 2012

Honesty in Medicine: Do Doctors Tell the Truth?

Did Washington Chop Down the Cherry Tree?
Courtesy of National Archives

…resolve to be honest at all events; and if in your own judgment you cannot be an honest lawyer, resolve to be honest without being a lawyer.

No need to identify the authorship of the above quotation, which should be known by all discerning readers, such as those who feast on the weekly Whistleblower offering. For those who have suffered a cognitive lapse, I will provide 4 identity clues. Take a guess after each clue. If after the 4th clue, you are still clueless, then politely request a 5th and 6th clue in the comments section, and they will be provided to you.

(1) He had a high pitched voice.

(2) He was prone to depression and melancholy.

(3) He was an ambitious and successful attorney.

(4) He was known as ‘the rail-splitter’.

Honesty in medicine is a fundamental pillar of our profession. However, physicians and scientific investigators have the same moral failings as the rest of our species. While we have moved beyond the atrocities of the Tuskegee syphilis ‘research’, we are actively combating plagiarism, fraud, corporate misconduct and ethical erosion.

Most of us believe that our physician’s exam room is a sanctuary from dishonesty. Our own doctor, while imperfect, is honest and would not knowingly give false information to us. A recent survey published in Health Affairs challenges this assumption and suggests that a new battlefront against medical dishonesty needs to be waged.

Nearly 20% of about 1800 physicians surveyed did not soundly reject that patients should never be told a falsehood. About 10% admitted to having done so themselves. We don’t know the specifics of their truth-stretching, which may have been well meaning massaging of medical facts or sanitizing a prognosis. Nearly a third of physicians did not agree that medical errors should be disclosed to patients. Keep in mind that while patients have a right be informed about medical mistakes, the current medical malpractice system is a major impediment blocking physicians from admitting error. It’s a little tougher for a doctor to tell a patient he messed up when this admission will be used as a legal cudgel against him.

I think that honesty is an absolute virtue, and not an elastic concept that can be stretched over questionable behaviors. How would I measure up? Here are examples of advice that I’ve given patients over the years.

  • Recommended fiber as a treatment for irritable bowel syndrome, although there is no scientific basis for this.
  • Ordered CAT scan for defensive purposes to minimize my legal vulnerability.
  • Placed feeding tubes in patients at the request of attending physicians when the medical benefit of this intervention is questionable.
  • Kept silent when patients were being subjected to overtreatment by me or my colleagues.
How do I reconcile my view that I am honest with the above examples? Are my honesty standards too high or is my performance too low? Although my level of honesty may be sufficient to practice medicine, according to the unnamed author of the quote that begins this post, it would surely disqualify me from the practice of law.

Sunday, February 19, 2012

Voting for Gridlock in Washington: First, Do No Harm

Inauguration Day

Presidential election seasons are always exciting times for Americans. Read the newspaper any day for a reminder of how much we take for granted here. Every four years we have the opportunity to hire, rehire and fire a commander-in-chief. Of course, our system is not perfect, and is often downright maddening. But, most of us would not trade our system for another.

The presidential election year is especially exciting when you can share it with your kids. I cannot calculate or even recall how many dinnertime discussions we had where all of us would debate the issues and evaluate the candidates. It was great fun to watch the kids engage in the electoral process. While I lean toward the political right, I tried to be a fair (and balanced) moderator during these dinnertime debates. My prediction is that 3 of the 5 will be Democrats, 1 will be a Republican (but doesn’t know it yet) and the 5th kid could go either way.

As we know, one’s political affiliations tend to change as one’s life and circumstances change. Folks tend to protect their own interests, and these interests change as they enter different phases of life. College kids, taxpaying parents raising children and senior citizens likely have different political and economic interests and may vote differently. While some folks, such as presidential candidate Ron Paul, have maintained their political views throughout their lives, most of us modify our views over time.

Remember the joke that a conservative is a liberal who’s been mugged?

The 4 remaining GOP presidential candidates all profess to be true conservatives. One is mocked as being a moderate, as if this is a scarlet letter shaming the former Massachusetts governor. Wouldn’t most of us want a president to be moderate? One is accused of espousing a dangerous nihilistic foreign policy. One is referred to as an erratic time bomb. And one is labeled as not ready for prime time.

All four compete as to who would repeal Obamacare the fastest.

“When I take the solemn oath at the Capitol, I will place my left hand on the bible and raise my right hand. And, in that right hand I will be clutching a pen so that the moment after my swearing-in, I can sign the repeal as the Chief Justice who upheld Obamacare looks on.”

Which candidate made this pronouncement?  Don’t bother Googling. I made it up.

The Supreme Court will hear arguments challenging the constitutionality of Obamacare next month. Most of us expect that the core of the plan – the individual mandate – to slip through. However, just because something is legal, doesn’t mean it’s a good idea.

While Romney wants us to accept the inevitability of his nomination, he hasn’t closed the deal. Anything can happen. Who would have predicted that a one term senator from Illinois would prevail over the Hillary Clinton machine to become the Democratic nominee for president?

If President Obama is reelected, which I expect, then brace yourself for Obamacare on steroids. The hope of those like me who think that Obamacare is bad medicine is that the GOP maintains control of Congress. Why would I actively support gridlock? Because as a physician, I subscribe to the principle, Primum non nocere, First, do no harm.

Sunday, February 12, 2012

Obama And Health Care Reform: Leading or Misleading?

Leadership is convincing folks to follow a new and uncomfortable path. Folks have to believe that the new direction will ultimately serve their interests, even if it feels awkward and unsettling at first. This works when there exists a foundation of trust between leader and followers. Otherwise, there will be doubt as to the motives of the leader who will be suspected of serving his own parochial interests, and not the greater good.  Consider some examples.

  • If your boss has always been stingy, it may be difficult for him to convince workers that the 'new and improved' health care plan is better for their families.
  • If a presidential candidate receives $400 haircuts, can he convince the hoi polloi that he understands the common man and his travails?
  • If a religious leader is discovered siphoning donations into his private accounts, will folks still call the ‘prayer line’ to offer a tithe?
When trust in the leader is squandered, distrust lingers and will frustrate and impede future leaders. Decades of dashed promises have created deep cynicism in our society. Want proof? Take a look at the public’s approval ratings of Congress – either party – any day of the year. With those numbers, it’s amazing that any of them get reelected, but they do, and repeatedly.

How well has Obama led on health care reform? Not as well as he could have and should have, in this blogger’s view. He deserves great credit for campaigning on the issue of health care reform and for taking it on as president. Passing Obamacare was a singular presidential achievement.

Although the Patient Protection and Affordable Care Act passed, this wasn’t a result of presidential leadership. It was the result of Democrats voting in lockstep, with the administration cheering from behind. While I’m not suggesting that the GOP would have behaved like Eagle Scouts had they been in the majority, Dems dissed the Republicans and shut them out. Real leadership, especially on an issue of paramount importance to the country, should have forged a different path forward including minority participation and respect.

I still believe that the president believes that government controlled universal care is ideal, but he still can't state this outright, at least not yet. He hopes to achieve this, perhaps in his 2nd term. Elections matter.

Did the medical interest groups, who were feted at the White House really believe that their interests would be protected as they were promised? The strategy of pitting one medical player against another is good politics, but is it good policy? Does the country win when hospitals compete against physicians who compete against insurance companies? Why is the pharmaceutical industry, affectionately known as Big Pharma, demonized regularly by the government and the press? Sure, this throws red meat to the crowd, but don’t we need these guys to deliver the next generation of cures and treatments?

The public wasn’t led, it was misled. This is why they delivered the U.S. House of Representatives back to the GOP in 2010. Polling consistently shows that about half the country wants Obamacare repealed, although interpreting and crafting polls is tricky business. By any poll, it is clear that the country has not drank Obama’s Kool Aid.

Many years ago, a man was born on this very day. He was a leader who led the nation to where it needed to go. While he was a very ambitious man, he was always guided by the nation’s interest. His goal, as he wrote in his 2nd inaugural address, was to achieve a just and lasting peace among ourselves and with all nations.  He is an inspirational model of leadership everlasting.  Can the other president from Illinois make this claim?

Sunday, February 5, 2012

When Should a Doctor Fire a Patient?

His signature is, 'Your're Fired!'.
Photo by Gage Skidmore

Rarely, I have fired patients from my practice. Why do I do this? You might think that we send out termination letters to patients who haven’t paid their medical bills. We don’t. We try to work with these folks and will keep seeing them as long as they are making the barest effort to address their financial responsibilities. If they refuse to make any payment, or won’t return our billing office’s phone calls, or are hostile to our staff. then we may withdraw as their physician, provided there is no medical urgency present. Our office will see patients who have no medical insurance so that these folks have access to medical care.
The process of terminating a professional relationship between physicians and patients is well presented in EverythingHealth, one of my ‘must read’ medical blogs.

The more typical reason why we fire patients from the practice is because of continued behaviors and actions which place them and me at risk. For example, if a patient with cirrhosis, a severe liver condition, will not keep scheduled medical appointments, we may have to cut him loose. I can’t accept the responsibility for his health or a medical catastrophe if the patient is conspiring against himself. If a patient won’t take his medicine for Crohn’s disease, and it’s not a matter of affordability, then I need to reassess whether I want continue serving as his gastroenterologist. If he ends up in an operating room to face emergency surgery that could have been avoided had he followed medical advice, could he convince an attorney with some tortured logic that my care was inadequate? I can imagine the deposition with an attorney asking me pointedly:

“Doctor, did you know that your patient wasn’t taking the medicine because he was worried it might cause side-effects? Why doesn’t your office note mention this?”

“Doctor, why didn’t you write the patient a letter after his office visit encouraging him to take his medicine? Don’t you think this might have helped? Was a 44 cent stamp to much to invest in your patient’s health?”

“Doctor, if it was so important that your patient take his medicine as prescribed, why didn’t you take 2 minutes to call him to reinforce the advice? Were you simply too busy?”

“Doctor, the patient never knew that failure to take the medication could result in a colostomy. Why doesn’t your office note specifically document this risk? Of course, had my client known this, he would have swallowed the medicine with zeal and enthusiasm.”

Of course, we care for patients who reject our medical advice. Medical care is a collaborative process and patients are ultimately charged with making the decisions, although many are happy simply to accept our guidance. This acceptable practice is distinct from, “I’m not taking any high blood pressure pills and you can't make me!”

So, there are times that we fire patients from our practices. Perhaps, some readers can offer comments explaining why patients decide to fire us.