Board Certified?

First, in the interest of full disclosure I have several board certifications. One of them, The American Board of Legal Medicine is not recognized by the American Board of Medical Specialties.

So what does it mean to be board certified? Fundamentally certification is supposed to assure that a physician has completed a defined course of post-medical school training in a particular area of medicine. Further that the certified physician has completed an approved examination on the specialty material. Most of the boards that issue certification are recognized by The American Board of Medical Specialties. The content of the actual training is assured by The Accreditation Council for Graduate Medical Education (ACGME).

Certification in an ABMS recognized specialty means that the physician should have, at least, nominal competence. It’s the lowest bar. It’s assured mediocrity. So why is that important. It’s important if your physician isn’t certified. In fact if your physician isn’t certified you should probably find another. Don’t you deserve a physician who can demonstrate he or she is at least mediocre? Don’t you deserve someone who can meet minimum standards of competence?

It’s your health. Take it seriously and take care.

Connecticut Heath Care Sucks

In a supreme act of abject poltroonery, the Connecticut legislature bowed to the hospital lobby. Prior legislation required hospitals to publicly report adverse outcomes. New legislation eviscerates the requirements allowing hospitals to deny potential patients valuable information regarding institutional and physician performance and outcome.

Since the new legislation has taken effect reports of adverse events have fallen sharply. I strongly suspect that it’s not because the doctors or hospitals got better. Records of adverse events are difficult or impossible to find. Hospital lawyers hide them behind “peer review privilege.” Now, more than ever you need to ask critical questions and get answers in writing.

The changes appear to benefit no one except the hospitals. My suggestion- flood your legislators office with complaints. Next take your business outside the state if you live in Connecticut (it’s a short drive- not like you live in central Texas). Specifically boycott hospitals named HERE.

It’s your health. Take it seriously. Take charge.

Wrong!

A Rhode Island hospital recently made the news due to a higher than expected frequency of wrong-site surgery. Rhode Island Hospital, located in Providence, will pay $150,000 and install video cameras in all of its operating rooms after performing its fifth wrong-site surgery since 2007, according to the state’s Department of Health. You can find additional stories here and here. Now the hospital’s home page has a video of the president talking about safety.

Rhode Island Hospital- have you been here?

I could ask “why did it take so long to discover this?” Or better, “why is the hospital still in business?” Or “what about the doctors?” The sad reality is that many hospitals neither report such occurrences, as required by state and federal regulations. Many do not report the physicians or nurses involved as required by many state agencies. Many simply attribute it to some “system” error.

A colleague related an experience at a tertiary care children’s hospital. In a particularly egregious occurrence the surgeon made the wrong incision for the planned procedure. He hadn’t reviewed the chart before the operation. He had refused to participate in the required “time out” designed to prevent such occurrences. His response afterwards, “no harm, no foul.” He was not disciplined by either the state medical board or the hospital. At another institution a gastroenterologist performed a procedure on the wrong patient- he was subsequently made the division chief. The entire discipline from the state medical board- 10 hours of additional education in medical record keeping.

Such occurrences are wholly preventable. That’s why insurers and the government refer to them as “never” events. Patients should not pay for these occurrences. In fact normal liability limits should not be applicable since these occurrences in most cases result from extreme negligence or recklessness not simple medical negligence.

The bottom line- ask your doctor if (s)he has ever had such an occurrence. Check your state medical board for your physician’s record of disciplinary actions. Ask the medical staff office at your local hospital how many such occurrences there have been.

It’s your life. It’s your health. Take care and take charge.

Three Strikes?

Here at Safer Health Care we are obviously interested in safer health care. However Florida has instituted a trial-lawyer backed constitutional amendment which may not further the legitimate interests of injured patients. The amendment allows the state to revoke or deny initial licensure to any physicians who has three malpractice judgements against him/her.

The constitutional amendment seems beneficial until you realize that some physicians may not be willing to work in Florida anymore. Further, shoddy physicians may simply settle to avoid a “strike.” In essence, poor physicians with substantial but nor necessarily serious ongoing acts of negligence become protected. This might conceivably allow Florida to become a haven for poor providers. A truly ironic twist.

The amendment is being challenged in court.

Reform

Health care reform is a must. The ability to have health care regardless of expense or demonstrable value to patients is irrational. Mr Franken makes good points but it raises the question “why should health care be the only thing we can’t go bankrupt buying?” Unless we accept that health care is some kind of national entitlement then it’s simply a commodity or service. If we make it an entitlement then we have essentially nationalized it as a right.

In any case it’s fun to watch Mr Franken take on an insurance industry shill.

Vaccines and Quackery

A letter to the editor in the Columbus, Ohio Dispatch warns about the dangers of H1N1 flu vaccine. The letter is disappointing in several respects. First, it’s author Dr. Phillip Demio, is in fact a board certified emergency medicine physician. Unfortunately, that does not qualify him to practice the treatment of autism. Demio’s website indicates that his practice offers an amazing number of non-therapies such as vitamin A treatment for persistent measles (it doesn’t work). His patients will be pleased to know that Dr. Demio recently purchased two hyperbaric oxygen chambers to allow him to separate desperate parents of autistic children from dollars they could better spend on legitimate therapy (hyperbaric oxygen has no role in the treatment of autism). He also touts the use of “far infrared sauna” for treatment of patients. His use is not supported by quality clinical studies. It’s only supported by his “extensive clinical experience.” It’s bogus snake oil.

Further, the fact that he is the parent of an autistic child, does not qualify him to defy medical science with his claim that autism is related to vaccines. The simple statistical relationship between the rise in influenza vaccination and autism is paralleled by rises in cell phone use, microwave oven use, garage door openers, improved civil rights, worsening general access to health care, and airbags in cars yet Dr. Demio does not claim any of these are responsible for autism’s rise. The statistical relationship is not causation. The relationship between vaccines and autism has been studied rigorously- it’s not a cause.

More people die each year from allergic reactions than from influenza vaccine. More people die from influenza than from the vaccine. Influenza vaccines have been produced using nearly 50 year-old technology. The technology suffers from unpredictability in production schedule not vaccine quality.

Dr. Demio’s advice is simply wrong. His admonition that each of us carefully consider our health care options is, in contrast, accurate. Don’t let doctors sell you non-therapeutic “care.” Do your homework and be prepared with difficult questions.

It’s your health. Take care and take charge.

Malpractice Reform

Defensive medicine and tort reform are frequently discussed as inseparable twins. Many doctors claim defensive medicine is the systemic evil causing health care costs to run rampant. The latter, tort reform, is the holy grail of health care salvation. Both views are wrong.

Rahul Parikh, MD is a physician who largely agrees with me. In a recent article over at Salon.com Dr. Parikh addresses the fallacy of tort reform.

In contrast to many of my colleagues I attribute defensive medicine to physician incompetence or ignorance. In short, physicians practice “defensive” medicine primarily because they haven’t the knowledge to actually understand the relative likeliness of disease states in particular patient populations. From my own experience at a tertiary care childrens’ hospital I recall pediatricians ordering monthly MRI scans to follow children for “static encephalopathy.” When I inquired one day as to why the response was “just to be sure.” Disquieting. My colleagues in the primary care specialties order tests for diseases with remote, absurdly remote, possibilities. They do this so they can “be sure.” They order tests as a huge battery of unnecessary studies rather than sequentially. They order tests they can’t interpret since they had no meaningful clinical suspicion. They attribute this to “defensive medicine.” It is not defensive. It’s wasteful.

Then we have tort reform. Obama is right to decouple tort reform from health care reform. Proponents of tort reform cite decreased malpractice as the primary metric. They then theorize that decreased malpractice costs will allow health care costs to decrease. Needless to say the reasoning is flawed. There are few, if any, good studies liking malpractice costs to health care costs. In short the pundits are using the wrong metric. Until tort reform can be clearly shown to decrease health care costs then it amounts to little more than an additional route to profit for physicians and liability carriers.

These are complex issues poorly understood by most physicians.

As patients each of you can control health care costs. Simply ask your physician “what is the likelihood that I have the disease you’re looking for?” If the likelihood is very low then look elsewhere- for a diagnosis and health care. If your physician can’t explain, clearly, how (s)he will interpret the test results then look elsewhere.

It’s your health. Take care and take charge.

Sleep and Safety

I don’t want you to take care of me if you’ve been awake for 16 or more hours. It doesn’t matter how smart you are or how good you feel. There’s clear evidence that your cognitive and motor skills are beginning to deteriorate at that point. Yet medical education still refuses to admit this limitation to the delivery of modern health care.

Ironically, it’s the senior physicians, the attending physicians, who are more likely to perform well while fatigued. It probably has to do more with the better pattern recognition skills in experienced physicians rather than a lack of fatigue effect. Yet, it’s the attending physician who is home in bed while the least experienced physicians and medical students provide you with care in the middle of the night.

It’s been many years since the residents were limited in the number of hours that they are permitted to work- either consecutively or in aggregate per week. Yet no one can show a change in outcome associated with the limitation. Part of the reason is that residents in some programs are actively encouraged to “fake” the number of hours they record in their log books. In such a circumstance there would be no detectable result from a “reduction” in work hours since there is effectively no reduction.

The reductions proposed by the Institute of Medicine (“IoM”) are a welcome and necessary step for reducing patient harm. The IoM report also reiterates the need for those attending physicians to actually supervise residents. Again it’s an issue of safety.

So what should you do?
1) Ask who the “doctor” is. Is he/she a “real” doctor or just a resident?
2) Where is the attending? Will the attending learn about you and the planned care before the therapy starts?
3) Is the physician rested? Or, has he/she been working the permitted 30 (you read that right thirty) consecutive hours?

It’s your health. Take charge and take it seriously.

You’re Fat- Yes, You

A recent article in the Los Angeles Times poses the question “Are you fat because your doctor didn’t tell you?” I’ll buy the possibility that some mildly overweight patients might not actually know that they’re fat not just “fluffy.” I’ll also accept that some patients underestimate their degree of obesity.

Yet it’s impossible to put a patient’s failure to recognize obesity on the treating physician. If you’re overweight, by any amount, ask your doctor about it. But only ask if you’d like to commit to reducing your weight and gaining a healthy lifestyle. Your doctor cannot follow you around and limit your intake or increase your activity. If you can’t or won’t commit then you’ll only frustrate both of you.

It’s your health, take it seriously and be responsible.