Caring

I teach physicians to communicate effectively. I’m not sure it works. Every now and then I am encouraged.

The two most common complaints I hear from my mother about physicians are:
1) He doesn’t listen. (Mom won’t see women physicians- no idea why.)
2) The front desk staff are idiots.

The most effective tool a physician has is her ears. The ability to take the time to listen, seriously listen, with genuine interest and compassion is rare. This is what I teach my students. That’s why the new book by Dr. Wendy Harpham caught my attention. She shares her experiences as a patient and physician.

Read Dr. Harpham’s book and change the way you think about your doctor. It’s your health care. You have the right to demand a standard of health care.

Disclaimer: I have no relationship financial or otherwise to Dr. Harpham, Amazon.com, Steve Majewski, or The American College of Physicians. It’s just a great book.

To sue or not to sue?

Adverse outcomes are frequent in medicine. Too frequent according to some experts. The problem is that medical malpractice only compensates for the negligent or intentional injuries by healthcare providers. Many years ago malpractice was prosecuted as battery (harmful touching without consent). Occasionally an adverse outcome is prosecuted as battery when the consent is so flawed as to be invalid. Equally rarely a malpractice case is prosecuted under “res ipsa loquitur,” meaning that the injury would not have occurred without negligence. As readers will recall, the attending physician is vicariously liable for the acts of resident physicians.

The problem is injuries and adverse outcomes can occur without negligence at all. Yet adverse outcomes are a powerful motivator to sue regardless of physician culpability. Frivolous and nuisance suits still arise but plaintiffs are rarely compensated. Some legitimate suits are not prosecuted because no attorney will take the case due to the small amounts at risk. Geisinger Clinic is taking a novel approach to healthcare with its 90-day warranty.

Geisinger’s approach is an excellent step towards responsible healthcare and limiting litigation and the resulting hardships for all involved.

When your physician explains complications be sure to ask who pays for the additional expense. Ask which complications result from negligence. You have a right to know.

Question Everything

Every now and then a physician goes so far out of his way to prove himself a jerk that I fear for the survival of modern medicine. When this happens I think of the old saying “Better to be thought a fool, than to open your mouth and remove all doubt.” Scott Haig should have observed this advice. Instead Haig rants bout patients who “google.”

As an aside, Haig’s by-line claims he is “Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons.” Columbia seems not to know that since he’s conspicuously absent from the orthopedic surgery webpage (yup, I googled Haig). Not that I could blame Columbia University College of Physicians and Surgeons, I’d have canned Haig for the article as well.

Modern medicine is very complex. It is virtually impossible for your physician to know everything about every disease. Actually that’s not true- it is impossible not virtually impossible. Physicians need to stop being annoyed. They need to accept that the knowledge gained in their training and held in secret is readily available to all- for free. Good physicians will learn to assess internet sources and allow their knowledeg to grow. Alternatively a skilled physician will disabuse patients of disinformation. Haig appears to prefer his patients obedient, unquestioning, and servile.

Dr. Rahul K. Parikh agrees with me. He assess Haig’s patently unprofessional comments and behavior somewhat more charitably than I do. The lay press likewise agrees with me. I believe that guys like Haig have no business in medicine. Any physician who is too busy or too insecure to respond effectively to legitimate questions need another profession.

Regardless of the internet, the information disparity in medicine prohibits a true free market. Guys like Haig prey on the ingorant and unsuspecting. They are exactly the reason that patients feel abused or misled (the same feelings that frequently generate litigation thereby driving up cost and limiting access to healthcare). They perpetuate a cloistered, arcane system that forces patients to be little more than livestock used to generate revenue.

If your physician can’t or won’t answer your questions you need a new physician. If your physician seems to indicate that “he’s the doctor and you’re the patient” you need a new physician. If your physician perpetuates the kind of paternalistic nonsense that Haig seems to yearn for then you need a new physician.

It’s your health. You can’t turn it over to guys like Haig.

Bogus Experts

I truly believe that most physicians are honest, decent people. (I also believe that most lawyers are honest decent people-but more people argue with me on the latter.) There are, however some physicians who are simply criminals.

Here in Texas, and across the south, lawsuits involving silicosis and asbestosis seemed to be appearing with alarming and increasing frequency. Judge Janis Jack from the Federal District Court in Corpus Christi thought this sounded wrong when the resulting mass tort case ended up in her court. Her opinion, nearly 250 pages is a scathing rebuke of Dr. Jay Segarra (Dr. Segarra has been excoriated elsewhere by lawyers as well).

Worse than the millions of dollars Segarra bilked people out of is the irreparable loss of trust. There is also the incalculable angony and expense imposed on his victims associated with additional, unnecessary testing.

Judge Jack, quite appropriately, has handed down a decision that will be a step towards improving quality of legal services and mass torts. The price may be a small reduction in access to the court. The other side though will be an improvement in the quality of healthcare as well as legal care.

Judge Jack is one of the few people actually watching out for your health.

Heart Disease, Cardiac Arrest and Death

Hospitals are dangerous places. As it turns out you’re better off having your cardiac arrest many places other than hospitals.

Heart disease in the US generally results in expensive care. Yet recent data indicate that we, Americans, are dying of preventable illness at a rate greater than citizens of other developed nations. So why is American healthcare so expensive- waste. It’s simple. Everyone wants everything all the time. There is little attention given to actual therapeutic value.

Heart disease specifically suffers from this overuse. Coronary artery surgery, angioplasty, or stents offer little value beyond conservative medical therapy. Yet some of these therapies have as much as a 20% incidence of serious complications. With no demonstrable value.

You must ask your doctor about the benefit of treatment to you. No one else will.

Dr. Gawande- redux

The December 30 New York Times has an opinion column by Dr. Gawande. In the article Dr. Gawande expresses amazement in his usual restrained style at the foolishness of the Office of Human Research Protection (OHRP). The OHRP has recently shut down funding for a Michigan program that has already reduced morbidity and cost by the simple use of a checklist.

I, unfortunately, do not suffer from the same restraint as Dr. Gawande. The OHRP’s decision is the kind of blind servility to a narrow interpretation of policy that smacks of world class stupidity and reckless disregard for patient welfare. The decision was probably made by some non-medical middle manager based on funding but cloaked in legal terms.

Please take a few moments to read Dr. Gawande’s editorial by clicking HERE.

Readers will recall that I have commented before that no one cares about your health except you. Now it appears that if you live in Michigan even the federal government is against you.

Atul Gawande, MD, MPH

Occasionally I find something that makes so much sense and is so intuitive that I whack myself on the head and wonder why it’s taken modern medicine so long to discover it. Atul Gawande has an amazing perception regarding modern medical practice and patient safety. He is not only a bright young surgeon but he has a gift for bringing medicine to life for physicians and lay persons alike. He is a staff writer at the New Yorker as well as the author of two excellent books, Better: A Surgeon’s Notes on Performance and Complications: A Surgeon’s Notes on an Imperfect Science

Recently Dr. Gawande wrote in his New Yorker column about something very simple- a list. A checklist to be exact. The checklist seems to actually prevent complications and save lives according to the research of Dr. Peter Pronovost.

Yet some physicians refuse to use such checklists because it intereferes with their “autonomy.” These physicians have forgotten that their “autonomy” should be subjugated at all times to the safety and welfare of patients. In short they let their ego override good judgement and sound science.

Checklists exist in many professions. A preflight checklist is what helps keep you commercial flight safely in the air. A pre-administration checklist helps keep your nurse from giving you the wrong dose of the wrong medication. Checklists also exist in many areas of medicine. Whenever you get ready to have a procedure you should ask your physician about the availability, validity, and use of checklists. It may save your life.

If your physician says “I don’t use checklists because it interferes with my judgement” then you know you need a new physician.

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.