Sunday, November 24, 2013

Should Doctors Apologize to Patients?

I had thought that apologizing was a straightforward act, but I now realize that it is a nuanced art form.  We’ve all heard the ‘mistakes were made’ version, usually issued by politicians who attempt to insert a layer of passive voice insulation between themselves and their screw ups.  There is also the ever present conditional apology which by definition falls short of complete responsibility acceptance.  The template here is: “I’m sorry for my oversight which wouldn’t have happened if….”

The Gettysburg Address - Silly Remarks?

There have been several apologies in the news recently.  First President Obama offered a faux mea culpa with regard to his indisputable and repeated ‘misrepresentations’ on his broken promise that we could all keep our own doctors and health insurance plans.  Here’s what he said on November 7th.

“I am sorry that they are finding themselves in this situation based on assurance they got from me.”

Finding themselves?  Really?  I grade this as beyond lame on the apology scale.

CBS’s flagship and enduring news magazine 60 Minutes apologized for using a source on a Benghazi piece who was a liar.  “We were wrong to put him on the air,” said Lara Logan a few days prior to airing a formal apology.  The latter included: “It was a mistake to include him in our report.  For that, we are very sorry.”  While some have criticized this apology as inadequate, I am more lenient here.  They admitted they screwed up, apologized and didn’t blame anyone for their mess up.  Sure, they could have fallen harder on their sword or fired a few folks, but I think they crossed the minimum standard for contrition and acceptance of responsibility.  

Recently, a newspaper issued a retraction for comments published 150 years ago.  The Patriot-News, a Pennsylvania newspaper earlier this month issued a retraction for referring to Lincoln’s Gettysburg Address as ‘silly remarks’.   Their recent editorial included the statement: “The Patriot-News regrets the error.”   I congratulate them on reaching this belated, enlightened position.  They certainly cannot be accused of a rush to judgment.  Let’s look for other retractions from them for other errant opinions they published in the 19th century.

Martin Bashir, issued 2 minute on air apology on MSNBC for a diatribe against Sarah Palin that shattered the network's already low threshold for decency and fairness.  While the apology seemed genuine, most of us would have lost our jobs for similar behavior.

What should doctors do when we make a mistake?  Of course, from a moral perspective, there is no controversy .  We should  do what we expect others to do.  When we err, we should admit it and apologize for it.  Of course, some errors are trivial and do not require us to march into the confessional.  If a patient receives liquid diet when a soft diet was ordered, the world will continue to spin.  No foul here. But substantive errors must be disclosed. 

The dilemma for physicians is fear that admission of error, which is morally required, may be used as a cudgel if the physician is sued for medical malpractice, which is an unfair arena.  Personally, I believe that this concern that apologizing will increase legal risk  is exaggerated and that a genuinely contrite physician may reduce legal vulnerability by explaining candidly what went wrong.  It should be self-evident that an adverse event or a mistake is not tantamount to medical negligence, but so many misunderstand this.  Nevertheless, physicians should choose their words carefully when disclosing medical errors to patients and their families.

Many states have physician apology laws that state that expressions of regret are not admissible in  medical malpractice trials.   These laws are narrowly crafted.  If the physician’s statement goes beyond expressions of regret and empathy, it is admissible.

 Inadmissible:   “I’m very sorry that this complication occurred and that a second surgery will be necessary."

Very Admissible:  I’m sorry that I nicked the spleen and I had to remove it.”

So, how was this post?  Verbose? Self-serving?  Tedious?  Factual errors?  Arrogant?  If so, don’t blame me.  Sometimes, mistakes are made. 

Sunday, November 17, 2013

Medical Overtreatment: Why Doctors Like to Slay Dragons

Saint George slaying the dragon. Bernat Mortorell, 15th century

I’m sending a patient downtown to see a pancreatic expert.   He’s a young man who didn’t fully appreciate the health risks of a former alcohol addiction.  He’s been sober for well over a year, but alcohol toxicity can be unforgiving and permanent.   We don’t fully understand why some alcoholics develop cirrhosis and other complications while others seem to skate by without a scratch.  While I want folks who have the strength to conquer addictions to regain lost health and opportunities, many life choices lead to irreversible consequences.   Life is often an unfair mystery.  We witness this in medicine often.  Some smokers live well into their 80s, while others become tethered to oxygen tanks or contract cancer.   Trim athletes who eat seaweed salads seasoned with probiotics keel over while obese Whopper-swallowers wallow their way into old age. 

My guy has chronic pancreatitis, a known consequence of alcohol abuse.  Most of us don’t pay much attention to our pancreas, until it’s not performing well.  His is sick and is causing him pain.  He’s got a ball of fluid hanging off the tail of the pancreas, which shouldn’t be there and is not going way.  In fact, it has enlarged some as seen on his most recent CAT scan.
There are three things that doctors love to do.

Enter any orifice possible.  Why do you think that gastroenterologists, ENT (ear, nose and throat) , urologists, proctologists, gynecologists and pulmonologists are always smiling?

Stretch any narrowed tube in body.  If a cardiologist finds a narrowed coronary artery on a cardiac catheterization, the impulse to stretch it will be overpowering convinced that this has to be a good idea even if medical studies have refuted this. 

Drain Fluid.  Doctors like to do this because it’s cool and it always sounds right to patients and their families.   We welcome telling patients afterward that we’ve successfully shrunk their fluid collection by 50%.  Patients then become 50% relieved.  It sounds right that we should attack an abnormal fluid collection and that eliminating it is the ideal objective. 

Here are the unasked questions?

Does the orifice need to be violated or do we do just because we can?

Is the narrowed artery, bile duct or artery actually a medical threat that needs to be stretched, or do we widen these narrowed structures because we can convincing ourselves and others that we have averted a medical crisis?

Is the fluid we drain actually bothering or threatening a patient or should it have been just left alone?
My patient is not getting better under my care and I want the advice of an expert.  I cautioned the patient that the mere presence of abnormal fluid doesn’t mandate its removal.  I am hopeful that he will receive a sober assessment.

Sure, we all like men  of action, medical swashbucklers wielding tools and weapons to slice into our diseases and make us well.  Would we rather watch a warrior slay a dragon or a farmer plant seeds?

Sometimes, a quiet contemplative man of inaction is the true healer.  

Sunday, November 10, 2013

Why Won't President Obama Tell us the Truth about Keeping our Doctors?

Morality, truthfulness and personal integrity do not command the currency that they should or used to.  Truman’s phrase, ‘the buck stops here’ is of historical interest only.  Consider authors and journalists who admit to plagiarizing and then go on to resume their careers.  Resourceful students use modern technology to cheat on standardized tests.  Our government refuses to classify a military replacement of a government in Egypt as a coup d’etat.  Teachers strike for more money claiming that their only interest is their precious students.  Politicians deny that campaign contributions will confer any special influence by the donors. A parade of overachieving athletes over the years denies they have ingested any banned substances.  Our intelligence services are not spying on Americans.  Physicians order diagnostic tests claiming they are only for medical reasons.

Sometimes, the dishonesty is stealth while on other occasions it is transparent.  I suggest that the phrase ‘it has nothing to do with money’ signals that mendacity is just around the corner.

Reporter:  “You are suing Kellogg’s for $7 million dollars because your Rice Krispies didn’t crackle properly?”

Plaintiff:  “Yes, but this has nothing to do with money.  I’m doing this to send a message to Battle Creek and Big Business everywhere that our kids matter.”

Our then U.N Ambassador last year appeared on multiple Sunday morning news programs offering a Benghazi narrative that she knew or should have known was entirely false.  Her fate?  Promotion!
The leader of any organization sets the standard for conduct of the entire team.  If a boss plays it a little fast and loose, then those who report to him are likely to accommodate to his ‘relaxed’ style.  This is why police chiefs, school principals, spiritual leaders, coaches, department heads and editors play such critical roles.  When they set a high bar for themselves, they raise everyone’s standards.  The converse is also true.

The most important leader in the country is the President of the United States, who sets an example for over 300 million people.  Remember, when Jimmy Carter told us that he would never lie to us?  While he was honest, he wasn’t a successful president.  In 1940, FDR campaigned that “you boys are not going to be sent into any foreign war.”  Did he really believe this?    Must we choose between honest leaders and successful ones?

I am deeply troubled by President Obama’s false pledge that we could all keep our insurance plans and our doctors, when we now know that this is completely false.  I am not calling the president a liar, but I am stating that his promise was not the truth.  If he simply was misinformed or uninformed, which would demand an explanation, why doesn’t he simply admit to his error in the same manner that we counsel our children to come clean when they need to do so?  Instead, the president repeats the pledge but now makes it conditional on insurance company decisions, which is a different beast entirely.  Is duplicity and responsibility avoidance the standard he wants us to emulate?

An honest administration would admit that we were deeply misled and would accept the political cost of this admission.  Not only is this the proper course, but it is also the wiser one.  When they continue to fail to admit what we all know to be true, they only deepen the hole they are trying to crawl out of. 

The president offered a statement on Thursday which some described as an apology.  I don't.  Here's the statement:

"I am sorry that they are finding themselves in this situation based on assurances they got from me."

You call that a mea culpa?  What happened to clear expressions of contrition, such as "I screwed up"?
The president added that "we weren't as clear as we needed to be.".  I disagree.  The president's repeated promise that we could all keep our doctors and insurance plans couldn't have been any clearer.  Indeed, it is this clarity that keeps the anger and frustration burning.

Which slogan is operative here?  The Buck Stops Here or The Spin Starts Here.

Sunday, November 3, 2013

Has Your Health Insurance Policy Been Cancelled? Who Knew?

I feel bad for Jay Carney, the president’s spokesman.  Each day, he faces the Washington Press Corps -piranhas on the hunt – and he must dodge and obfuscate.  I am surprised that the velocity of his spinning hasn't resulted in him drilling himself a mile below the earth’s crust.  He is a human spinning tornado. Presumably, this role must be challenging for Carney, who formerly practiced as an actual journalist who was charged with ferreting out the truth.  Now, he is under orders to avoid the truth.  While I do not suggest that he openly prevaricates, withholding the truth qualifies as dishonesty, as I see it.

Tornado or Jay Carney?

Carney and all politicians leapfrog over the specific questions being asked.  Their non-responsive responses are exasperating to the questioner and to the public.  There are many rhetorical techniques that these professional double talkers use to change the subject.  Let me illustrate with a hypothetical interview.

Interviewer:  “If the vote were held today, senator, would you support it?”
Astute Whistleblower readers recognize that this is a ‘yes or no’ question’ that could be answered in a single word.

Response from Fantasy Senator #1:  “Yes.”
Response from Fantasy Senator #2: “No.”

Responses from Actual Smarmy Senators (ASS) Who Think We’re Too Dumb To Notice:

ASS #1:  “Well, what I WILL say...”
ASS #2: “Let me be as clear as I can…”
ASS #3: “The real question you should be asking…”
ASS #4: “The point I’ve been trying to make is…”

We’ve all seen and heard this spin cycle before.  When a politician of one party has behaved badly, we can expect two results.   

o         (1) The oppposing party will pile on demanding censure, public rebuke or resignation.
     (2)  Political colleagues of the offender will spin wildly with comments such as “both sides need to dial      back the rhetoric”, when in reality only one side deserves blame.

The more we learn about Obamacare, the more hostile to it the nation has become.  Even liberal Democrats are having difficulty defending what is indefensible.   The arrogance of an administration that uses the term ‘glitch’ to describe a disastrous and failed rollout of the insurance exchanges on October 1st is astonishing.  Of course, this is not merely a technical fiasco.  It is symptomatic of a government behemoth that hopefully will fall under its own weight before it crushes the country. The rollout is a preview of a program whose rotten guts are starting to be exposed.  Then veneer is fading and the public is now able to inhale the noxious aroma from its innards. 

Millions will be tossed off of their insurance plans and will have to pay more to receive the same or less coverage.   Or, they will be forced onto the exchanges; and we see how smoothly that operation is proceeding.

The news media has been reporting aggressively that the administration knew that millions will be kicked out of their plans.  This has not been just a Fox News story.  I heard hard reporting on this on CNN and NBC, which are not known to be outlets of the political right.

We all heard the president – Salesman-in-Chief – promise us the following in 2009.

“Let me be exactly clear about what health care reform means to you.  First of all, if you’ve got health insurance, you like your doctors, you like your plan, you can keep your doctor, you can keep your plan.  Nobody is talking about taking that away from you.”  

This was at worst an outright lie.  At best it is a broken promise of a core pledge that the president gave to mollify our anxieties over a government takeover of our health care system. 

When the president was pressed on this issue recently, he now says that the government won’t force anyone off their plans.  This Clintonian utterance is beyond disingenuous.   The insurance companies are baling as a direct result of Obamacare.  If the government pushes insurance companies to the edge of a cliff that has been doused with oil, who’s responsible if the companies fall over the side? 

From 1996-2002 there was a TV series called Spin City.  Spin City is alive and well today.