More Education?

A committee of the Federation of State Medical Boards recommends that physicians applying for re-licensure show additional self-assessment and learning.

As readers might guess I am a believer in the need for physicians to engage in life-long learning for the benefit of their patients. The problem is that I don’t think that state medical boards can effectively promote and enforce such requirements. I believe that the consistently worst physicians will meet the requirements easily. They will simply do as they always have- engage in bogus efforts or lie to the state medical board. A good case can be made that quality physicians will have additional obligations without perceptible improvements in patient care.

It is essentially a case of unequal information. Bad physicians would be out of business if every patient had access to quality databases that were properly maintained. A free market requires ready access to information. Instead of legislating more educational requirements states should permit you, the readers, access to reliable quality data and force hospitals to collect and report such data in an aggressive fashion. Then we can have a free market.

You deserve safe health care. Take an active role and ask questions. demand answers.

More Ethics

The Liaison Committee on Medical Education accredits medical schools in the US. LCME consequently sets the minimum standards for content in medical education. Every medical school must offer some training in medical ethics. As you might guess the training is variable. The retention of ethical principles as well as the use in practice are more variable still.

Since 9/11 and the declaration of the war on terror the role of physicians in armed conflict, including the treatment of prisoners and detainees, has received increased attention. Military medical ethics is rarely taught in a formal manner in civilian medical schools. But then why should it be? Few practicing civilian physicians really need to know specifics of the protections offered by the Geneva Conventions.

For the military physician, however, the issue is fundamentally one of identifying primary role. For example: if a military physician is first soldier who happens to have a medical degree then the expectation might reasonably be that he/she act as a soldier. Yet if he/she is actually a physician in uniform the perhaps healthcare ethics should control behavior. Over 2000 years ago it was recognized the no one can serve two masters. The “dual responsibility” is largely a fiction.

The World Medical Association seems to implicitly accept this fact when it prohibits physicians from participating in “practice of torture or other forms of cruel, inhuman or degrading procedures… .” No provision is made for the possibility of a military physician.

Conflicts of interest may extend into civilian medical care. Insurance plans may allow higher compensation for physicians who use less laboratory testing and fewer referrals. The entire industry devolted to “cardiac care” is poorly supported by objective data. Yet few physicians will reveal economic arrangements that may compromise care and fewer still cardiologists will reveal the medical management is equivalent to interventional cardiology (stenting) or cardiac surgery for coronary artery disease. Why would this be? These simple conflicts of interest can’t possibly be based on lack of information since the information is readily available even in the lay press.

You should always discuss your physicians conflicts of interest.

There you have it…

In case some readers still need to be convinced that the American healthcare system may be detrimental to your health, a recent study finds that physicians don’t police themselves adequately even when required by law to do so. The study by the Institute for Health policy indicates that physicians seem to be quite comfortable violating the law and allowing potentially dangerous mistakes or poor care to go unreported.

As a test, next time you have to go to the hospital stop by the medical staff office and ask these questions:
1) How many physicians have been involuntarily removed from the medical staff in the last 2 years?
2) How many physicians have been reported to the data bank in the last 2 years?
3) How many physicians have had privileges restricted in the last 2 years?
4) How many physicians have had their privileges “non-renewed” in the last 2 years?

I can tell you now that the answer to every question will probably be NONE. Now you have to ask your self: Is it possible that every single physician on this medical staff is really that good? Are the standards too low? Could it be both?

Every state in the US has a medical board that licenses physicians. Every state medical board has as the fundamental reason for existence the protection of the public. Take for instance this exerpt by Donald Patrick, MD, JD in my own state of Texas, in which he notes that the purpose of the board is “safeguarding the public through professional accountability.” The state medical boards do not exist for the benefit of physicians. To his credit Dr. Patrick has begun disciplining physicians who fail to report misconduct. I think that’s an excellent move.

Yet the study clearly indicates that state medical boards have poorly influenced the willingness of physicians to meet simple requirements of the law. It’s a pity. I had higher expectations of my colleagues.

You must be in charge of your healthcare.

Who Cares?

Who cares about your health? You.

Maybe your family. Possibly only you.

Your attorney cares as long as it results in payment.

Who can you trust? No one.

Recently physicians have been examining their own medical records. Some are astonished at what their own doctors have documented about them. Some physicians aparently can’t be bothered to provide acceptable healthcare to other physicians.

So your doctor does lots of tests. He must be good right? He must care, right? Wrong. Lets looks at the MRI scanner. Hospitals and free-standing centers are installing them at a breath-taking pace. Why? Do they save lives? Do they improve diagnosis? No. They make money. My veterinarian diagnosed my dog’s ACL tear in 3 minutes with simple bedside tests the same way that human orthopedic surgeons have diagnosed the condition for decades. What does the MRI add? Nice pictures and excess expense. It is generally a valueless study done to bolster the confidence of a minimally skilled physician. Don’t misunderstand, some MRIs are useful, necessary even. Many are not. For some patients the study might even be dangerous. The CT scan your doctors wants “just to look” might also be hazardous.

So what should you do? Ask your doctor what the test will be used for. Ask explicitly how it will change your diagnosis or therapy. Will the results change your prognosis and do you want to know about the change? If the test does not have real use and changes nothing it offers you no value except possibly prognosis. You should not get tests just to satisfy your physician’s “intellectual curiosity”. You are not a lab animal. Previously I worked at a hospital that had four MRI scanners. They ran twelve hours a day six days a week. The vast majority of the studies were unnecessary. Neither the radiologists nor the hospital were going to force the ordering physician to justify the studies since the radiologists and the hospital both make money from the MRI (at that hospital the MRI center was the single largest revenue producer). You should not be treated as a “revenue center.” If your doctor is not helping you- find another one.

Finally, maybe the government cares? No. A Rhode Island Hospital had three wrong-side surgeries before being fined. Why did it take three significant medical errors for the state to intervene? Why is the state allowing the hospital to operate at all? The government can’t assess hospitals well so it’s not surprising that it can’t discipline them. Make no mistake, patients suffer from this lax attitude by the government and hospitals.

Additionally, you should note that the first case was started by a resident. Readers will remember that up to 70% of errors are attributable to inadequate supervision of residents. You should always discuss with your surgeon or physician what role residents will have then commit that understanding to writing.

It’s your health. You must care. There may not be anyone else who cares.

Balls?

Many readers know that I practice anesthesia at a tertiary-care medical center. Almost daily I run across a patient who needs additional evaluation prior to surgery to determine if he/she is actually healthy enough for elective anesthesia. Indeed, I frequently find that I’m assessing the appropriateness of the surgery as well. Part of the problem is surgeons who seem to have forgotten that they are, in fact, physicians.

It seems that other physicians feel similarly about surgeons who abdicate their responsibility to properly evaluate their own patients. It is hard to know how to respond to such musings by other physicians. Clearly there are some surgeons who remain superb physicians as well as surgeons. I personally have no idea what fraction of the practicing sugeons this might constitute.

The lack of preoperative evaluation by the surgeon also means two additional things. First, the surgeon has not completely evaluated his/her patient. This raises the possibility that the surgery may not actually be necessary or appropriate. Second, the surgeon may simply be acting as a technician on the recommendation of another physician who may, or may not, have evaluated the patient properly.

There are certainly times when it’s OK for a surgeon to act a technician. However, in the majority of cases you should expect your surgeon to take a thorough history, examine you carefully, and then explain options to you. Most of the time when a surgeon offers only one choice (or two choices if you consider no operation a choice) then you need a new surgeon. The one you have doesn’t know enough or doesn’t care enough.

Finally remember, the anesthesiologist does not get paid to cancel cases. If he/she delays your surgery then it’s for your safety. If your surgeon makes a fuss about the delay or cancellation you decide who’s more concerned about your welfare.

Question. Set high expectations. It’s your health, protect it.