MD Whistleblower

We have spent many dinner discussions with our kids discussing plagiarism. This infraction was verboten even when I was student back when, according to our kids, ‘I used to take the dinosaur out for a walk’. While I don’t think the offense is more serious today, it is much more prevalent. Educators report that there is an epidemic of it in our schools and universities. Perhaps, the practice even crosses national boundaries, which might mean that we are in the midst of a plagiarism pandemic. Unlike ‘swine flu’, there’s no vaccine available for this disease. Of course, the offense is so much easier to commit today, with expansive information on any imaginable subject available with a keystroke. I’m sure I could cut & paste a 10 page term paper on nearly any topic during half-time of a televised football game. Some of these rule-bending kids grow up to be adults who still misunderstand the importance of owning work that appears under their name. Joe Biden, historians Doris Kearns Good

Consider this hypothetical vignette. Tiger Woods accepts my challenge to play 18 holes. Obviously, the gallery would be packed with golf enthusiasts who would cancel job interviews, vacations and even worship services in order to witness this historic competition. Spectators would be permitted to place bets at even money. Perhaps, my mother would bet on me, but no other sane person would. They would properly conclude that even my best performance against Tiger’s worst would be inadequate. There is nothing I could do to change the outcome. All of my efforts would be futile. Futility cannot be proved with mathematical certainly. After all, Tiger could develop acute appendicitis on the fairway and have to forfeit. He could be arrested. Lightning could strike. Killer bees could take him down. Nevertheless, the overwhelming odds are that I would be vanquished and humiliated. Medical futility is a more serious issue that exists in every physician’s office and hospital in the country. Example

Medical politics has dominated the news for months. Each day, we read about the machinations of various congressional committees and our legislators who are dueling over health care reform. We learn about deals that the president has forged with various medical industry stakeholders. We watch as many liberal Democrats angle to put the ‘Blue Dogs’ in a secure kennel. We read about town hall meetings across the country being disrupted by folks who are accused of being right wing tools. Too much politics and too little policy. There is another genre of medical politics that is not covered by the press, but should be of interest to every one of us who seeks health care. This is the politics that exists in every doctor’s office and directly affects your medical care. I was never taught about any of this during my medical training. I learned about it on the job, and much of it isn’t pretty. As a younger doctor, I assumed that physicians chose consultants for their patients based on their med

The concept of medical excess is very difficult for ordinary patients to grasp. The medical community has worked hard for decades teaching them that more medicine meant better medical care. The public has learned these lessons well. Physicians who sent their patients for various diagnostic tests or specialty consultations were regarded as conscientious and thorough. Patients approved of doctors who prescribed antibiotics regularly for colds and other viruses believing that something beneficial was being done for them. We can’t expect a patient to know if a CAT scan a physician orders is medically necessary. From a patient’s perspective, a test is medically necessary if the doctor orders it. However, physicians, with professional training and experience, know whether medical testing is urgent or optional. Isn’t that our jobs? Of course, the practice of medicine often resides in the murky gray area where there is no single correct answer. In these instances, there can be several rational

About 10 years ago, my dad was to see his general internist. I have always refrained from giving medical advice to my family, for all of the reasons why doctors should not treat or advise their relatives. But, on this occasion, I did give Dad some unsolicited advice, particularly as I knew that his physician fired the diagnostic testing trigger readily. “Dad, please make sure that he doesn’t check the PSA (prostate specific antigen) test.” Dad indicated that he would convey my concern to his doctor, who ran the test on him anyway. Apparently, he includes the PSA test as a matter of routine on all men over a certain age. Twenty-five years ago as a curious, but skeptical medical student, I learned about prostate cancer. I learned that every man will develop it if he lives long enough. I learned that most cases of prostate cancer remain silent and never interfere with the individual’s life. I learned that the treatment for these cancers involves either major surgery or radiation, both of

Over the past week or so, I have been engaged in a colloquy with a presumed lawyer on tort reform on KevinMD’s blog. It has been a frustrating and unsatisfying exchange. I have had many discussions with attorneys over the years, and I am always struck by the gulf that separates us on this issue. I regard myself as a fair-minded individual. I believe that I can separate my own self-interest from the public interest. Indeed, many Whistleblower postings take aim at my own profession and have generated some spirited responses from my colleagues, some of them delivered offline. Although I am a gastroenterologist, I will not defend the value of colonoscopy when a better option for patients emerges. I admit and write that our health care system is riddled with excesses and inefficiencies and that we physicians deviate from evidence based medicine regularly. Lawyers, at least those who I’ve spoken with, express an unwavering fidelity to the tort system. This is why the dialogue between the pr

For a while now, I’ve been in between lawsuits. I am now pleased to report that I am a defendant again. Such good fortune, like a lottery win, descends upon doctors without warning or invitation. Nothing else can leaven a physician’s morale more than opening that thick envelope delivered by certified mail. We should not regard a medical malpractice lawsuit as a personal legal assault, but rather as an opportunity to promote truth, justice and the American way of life. (If I had the technical skills, an audio of the Star Spangled Banner would now begin.) We physicians, through our involuntary participation and testimony, can shed light in the darkened corners of the medical world. This is no time for physician anger. This is a time to give back and make others whole. Litigation is a natural extension of our professional mission to serve humanity. When viewed from this perspective, sitting in the courtroom or giving a deposition are important opportunities to heal our injured patients. T

We’ve already had a little fun presenting ‘ tort for sport’ for your entertainment, describing a system that is nearly exclusively advocated by trial lawyers and their minions. Beyond their tendentious rhetoric, however, are the inescapable hard facts that the tort system misses most cases of true medical negligence and wounds too many physicians as friendly fire casualties. Let’s put this issue in medical terms. As lawyers so often say, ‘let’s consider a hypothetical’. A pharmaceutical company launches a new medical screening test to diagnose pancreatic cancer at an early stage when the disease is curable. The test can accurately detect the condition in only 5% of cases. Unfortunately, the test causes side effects in most patients, who experience severe fatigue, muscle aches and joint pains. These symptoms last for several months and then gradually resolve. If this screening test were widely adopted as a routine test, then 95% of early pancreatic cancer patients would be missed and m

Physicians and plaintiff attorneys have philosophically divergent views on our tort system. I know the attorneys’ views on this issue well. There are lawyers in my family who have prosecuted physicians for alleged medical malpractice. Sometimes, there hasn’t been enough antacids in our house to douse my flaming heartburn after some of our discussions. Obviously, one reason that lawyers support the current system is because it enriches them. However, there are purists among them who truly believe that the tort system, despite some flaws, is the best means available to pursue justice and to compensate injured people. They point out that the medical profession has been lax to monitor itself and to sanction incompetent physicians. Too many medical mistakes, they claim, are ‘buried’. Without aggressive legal advocacy, what recourse would negligently injured individuals have against the powerful and well financed medical profession? In addition, they argue that the system is a powerful deter

Would you be comfortable buying a house if you didn’t know the price or weren’t sure you could obtain financing? Of course not, but this is exactly the kind of purchase the government is asking us to support. This past week, the non-partisan Congressional Budget Office threw the Obamians off balance with health care reform cost estimates that were beyond the stratosphere. None of reform plans on the table credibly explain how they will be funded. The public is becoming wary of buying into their Grand Plan on credit. Credit card purchases are easy to make and can seduce us to buy more than we can afford. As many American are learning, these purchases can haunt us and ultimately bury us in debt. President Bush was rightly criticized for signing the Medicare Part D prescription drug program, which deepened our debt. Imagine how reforming the entire health care system could affect the nation’s balance sheet. First, show me the money. Then, show me the whole pie, not a different piece of it

Later today, President Obama will address the American Medical Association (AMA) in Chicago. I suppose that if the administration can make soft overtures to Iran, that it can also present its health care plan to physicians. The organization has already expressed its opposition to the president’s public option proposal, at least in its current form, which is regarded either as a panacea or a poison pill, depending upon your health care ideology. Some have accused the AMA of pursuing its own partisan agenda to protect physicians’ incomes rather than sacrificing a few dollars for the greater good. To this charge, issued by Kool-Aide drinking Obamophiles, I say guilty! Of course, the AMA supports physicians’ interests. Although I am not a member of the organization, I have always regarded it as a physician protector rather than as an advocate for the public interest. It’s history doesn’t inspire confidence that the organization is a paragon of humanitarianism. Recall that over 10 years ago

Obama’s health care reform is moving steadily forward, or backward depending upon your point of view. He has reframed the issue entirely, empowered by his political standing and Democratic majorities in both houses of Congress. It is no longer whether there will be a public option (read: government take over), but only over the extent that the government will control our health care system. The GOP are trying to cry doomsday, but their damage control efforts are drowned out by the din of the Democrats. What a difference an election makes. Senator Kennedy’s new legislative plan will provide health care to all Americans with employers and individuals making mandatory contributions. In this pay or play proposal, if someone does not purchase medical insurance, then the government would extract its pound of flesh through punitive fines. Private insurance companies, like casinos, would be required to pay out a specified percentage of their premiums as health care benefits. So much for the ‘f

Politicians speak out of at least three sides of their mouths. This is not just standard double talk, but represents the polished art form of triple talk. First, they tell us what we want to hear. Afterwards, they offer ‘clarifications and adjustments’ (never a flip-flop!) to their original remarks. Thirdly, they spin their views either to the right or left in order to repackage the policy for successful legislative butchering. All the while, they claim that their views have never changed. President Obama, before the election, assured us that he did not advocate the federal government taking over our health care system, realizing that most Americans would not support this policy. He offered us the safer bromides of expanding health care access, reducing costs and increasing medical quality. Who could oppose these noble objectives? However, campaign slogans such as ‘we need to create the finest public schools in the world’ generate enthusiastic support, but mask the complexity of the is

Actually, sign me up for Plan B or C instead. Many fear that Obama’s end game for health care reform is a single-payer (read: government) system, despite his denials that this is his objective. Single-payer zealots argue that if government takes over health care, that many of our intractable problems will be solved. We will save tons of money, they argue, from increased administrative efficiencies. Spiraling health care costs will be tamed under the government’s whip. Private insurance companies will no longer gouge the public with rising premiums and unfair exclusions for preexisting medical illnessess. The 46 million uninsured would be covered. Big Pharm can finally be caged by Big Government establishing price controls. And, with the government in charge, the president can submit a bill to congress simply outlawing cancer. I agree that single-payer would resolve many recalcitrant issues, but at what cost? What health care system would we be left with? A guillotine is an effective tr

There is a serious and expanding effort to address corruption in medicine. Regulators and lawmakers are addressing cozy relationships between physicians and industry to protect patients from financial conflicts of interests that may skew doctors’ medical advice. This is murky territory since not every potential conflict is corrupt. For example, is it acceptable for an orthopedist to benefit financially by using a particular artificial hip if the physician believes that this is the best product available for his patients? Does this practice become ethical if the physician discloses this financial arrangement? Are his patients entitled to know the actual dollar amount that the doctor receives? Is it proper for a gastroenterologist to receive a generous honorarium by a heartburn drug company to speak to primary care doctors about reflux treatment? Could this physician be trusted to offer truly objective information to his primary care colleagues with the company’s pharmaceutical represent

We watched the marriage on national TV. Both sides said, ‘I do’, as they faced a fawning audience of the press and government dignitaries. The couple, arm and arm, started ambling toward their parked limousine, festooned with bright Just Married signs. Newlyweds, usually wives, track many of the first events in a marriage. One of the recorded stats is the first argument. When it occurs, savvy husbands should save time and themselves by apologizing profusely and admitting shame and remorse. For most couples, this inevitable post-nuptial event occurs weeks or months after the solemn wedding vows are expressed. In the White House marriage we watched last Monday between Obama and a coalition of health care groups, the sniping started barely after they left the chapel. Wise bloggers had predicted this outcome, but I admit that I was mildly shocked at the speed that the bride pursued an annulment. What went wrong? Did that prankster Cupid dip his arrows into a vat of single-payer elixir poi

Can you feel the love? Cupid ran out of arrows in Washington, D.C. this week. On Monday, several medical industry groups including physicians met at the White House for a health care reform love fest. For as long as I’ve been a physician, the pharmaceutical industry, insurance companies, hospitals, physicians and medical device makers all viewed medical reform as a disease that needed to be vanquished. This week, these erstwhile reform antagonists are sitting around Obama’s campfire in a Kumbaya moment. These health care stakeholders pledged to reduce health care spending (read: their income) 1.5% annually over the next 10 years. What happened? Were they drugged or hypnotized? Is there a secret deal that we don’t know about? Did they drink the Obama Kool-Aide that has intoxicated much of the nation? Did they hear an inspiring sermon at their church services this past Sunday and were inspired to do the right thing for America? The correct answer, of course, is none of the above. These m

Comparative effectiveness is a new term that’s been pushed into the health care public square. Get to know it since it’s here to stay. The prestigious New England Journal of Medicine published 3 commentaries on the subject in its May 7th issue. More importantly, this new concept in medical quality measurement has also been reported by the lay press to the public. The debates and discussions that will follow in the coming months will be as calm and civilized as the gladiatorial contests were during ancient Rome. Comparative effectiveness (CE) aims to determine which medical treatments truly work and which should abandoned. The federal government will be spending over a billion dollars funding studies to try to objectively demonstrate which medical interventions are effective. It is hard to object to this mission. Nevertheless, comparative effectiveness will polarize the medical world. Opposing camps are already preparing for battle because for many interest groups, this may be an exist

Physicians and patients are under more strain than ever before. Electronic medical records (EMR) won’t be a force of healing, but will threaten to divide the parties further apart. We physicians are already under more stress than ever before. We are working harder and earning less. Insurance companies dictate how much (or how little) we are paid and what medicines we may prescribe. We are crushed by an avalanche of absurd paperwork. We worry about being sued even if we haven’t done anything wrong. Patients are more dissatisfied today also. They often feel rushed through appointments without having adequate time to express their medical concerns. They want more communication and softer bedside manners from their doctors. They want more conversation and fewer medical tests. They complain that medicine has become more of a business than a profession. They admire Dr. House’s diagnostic acumen, but they still want Marcus Welby as their own doctor. All of these issues strain the docto

I am flattered that influential U.S. senators must be reading MDWhistleblower for important policy advice. Senator Max Baucus, Democrat of Montana, and Charles Grassley, Republican of Iowa issued proposals that aim to change the Medicare payment system to doctors and hospitals. Payment would be directly linked to quality, rather than to volume of services. Under the present system, if a surgeon operates on a patient 3 times to correct his own complications, he is paid more than a colleague who got it right the first time. However, as discussed in many prior postings on this blog, medical quality is very difficult to measure. One of the senators’ specific proposals receives a 5 Star Whistleblower Award for medical quality. The government will aim to reduce the excessive use of CAT scans, MRIs and other advanced medical imaging techniques that cost a fortune and create unnecessary medical cascades that chase after trivial lesions that will never cause illness. ( Click here for a related

A paperless society is approaching for all of us, which sadly will include the demise of my beloved New York Times, which I cherish each day. Our medical practice will have electronic medical records (EMR) in the foreseeable future, if we can mollify the objections of one of our technophobic physicians. There are several reasons why most physicians haven’t made the move to EMR yet. First, it is not easy to learn. This is not like getting a new e-mail address. It is a complex software system that is like a giant onion with endless layers of functions that will perform office tasks that have been successfully done manually for decades. It introduces an entirely new computerized culture into the office. This adjustment is particularly difficult for doctors who were not trained in the I-pod era. However, even for the cybersavvy, learning these complicated systems takes months. During this training period, patients, doctors and staffs become frustrated when it takes 10 minutes or longer to

The Obama administration will be devoting billions of dollars to promote electronic medical records (EMR) for doctors. Today, EMR vendors run in and out of doctors’ offices trying to hawk their software. Each one claims to be the holy grail of electronic records. I admit that the concept seems intoxicating. The promise of a paperless office is certainly seductive. The notion of physicians and patients having access to their medical records from any computer would improve medical quality and efficiency. Every doctor knows how frustrating it is to see a patient in the emergency room when the relevant medical records are sitting in the primary doctor’s office or in a hospital across town. Conversely, EMR permits the primary physician, who may not have been the hospital treating physician, to be easily updated after hospital discharge when the patient returns to his office. Many patients I see today in my office don’t know their medications and can’t recall prior illnesses or even operatio

If we are ever to prevail against the CAT scan cascade, we must understand why these tests are ordered. Here are 7 explanations of why doctors scan their patients. Talk to your own doctor and see if I’ve missed a few. While some physicians have financial conflicts of interest, most order scans for other reasons. This is not a ‘choose the best answer’ multiple choice test. Physicians often have more than one reason to scan you. The physician orders a scan to follow trivial lesions identified by accident on prior scans. A patient or the family want a medical test believing that a diagnosis has been missed. The physician orders a CAT scan hastily, without sufficient thought if it makes medical sense. The physician has a financial interest in ordering CAT scans. The physician correctly believes that the scan is medically necessary. The physician orders a CAT scan defensively for his own legal protection. The physician orders a scan to bypass a difficult discussion of a patient’s chronic co

The last few postings in the Radiology Quality category have detailed the risks of pursing trivial CAT scan abnormalities. Physicians created the term incidentalomas to describe these lesions that were discovered incidentally, or by accident. There is an epidemic of these lesions today as the volume of CAT scanning increases each year. When a scan uncovers an abnormality, the healthy patient is dragged into the medical arena. This unlucky patient may not be healthy for long. These scans are a potent accelerant that fuels the vicious cycle of unnecessary and excessive medical care. Medicare expenditure for radiologic imaging tests, including CAT scans, is exploding. John Iglehart analyzed this trend in the March 5, 2009 issue of The New England Journal of Medicine. Medicare Expenditures for Imaging Studies Year 2000 Annual Expenses: $3.6 billion Year 2006 Annual Expenses: $7.6 billion The government capped fees paid for imaging studies performed in out-patient facilities and doctors’ o