Sunday, May 26, 2013

Freedom Is Not Free

I have enormous respect for the military who have suffered the highest costs of protecting the freedoms that we often take for granted.  I have never served, but these men and women serve me and the rest of us every day.

The Whistleblower blog is not an anonymous samizdat, such as was present in the former USSR.  I criticize the president openly under my own name.  Those who challenge governments in other countries risk imprisonment or worse.

To those who protect our freedoms to write, speak, assemble, pray and criticize our leaders, please accept our collective endless gratitude, knowing that it will never be sufficient for what you have done and will do for us.

Sunday, May 19, 2013

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. 

Sunday, May 12, 2013

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.  

Sunday, May 5, 2013

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.