Medical Education

What traits would you like to see in your doctor? This deceptively easy question haunts medical educators every day. Medical school admissions ideally must screen for but academic ability and ethical behavior. A recent editorial from England suggests that cognitive ability is a better predictor.

As we have noted previously, medical schools in the United States have very small attrition rates, particularly compared to law schools. Having done both I am hard pressed to see any reason to account for this discrepancy except the obvious conclusion- medical schools do not effectively “eliminate” inappropriately chosen students. Instead they are promoted and graduated.

I applaud the English proposal. Anything to improve the quality of medical school entrants should improve the quality of the product.

Ask your doctor where he/she went to school. Ask how long it took him/her to graduate. It’s your health- take care of it.

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.

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.

Residents and Errors

I’ve mentioned before that academic medical centers offer some benefit to some patients. That benefit comes at a substantial cost. You should ask your physician who will you see everyday in the hospital and how much responsibility will that person have? There is now evidence that a majority of medical errors occur due to inadequate resident supervision. That same resident who is providing you with “care” may also be fatigued. This likely increases the risk of you becoming a statistic.

I have worked in many hospitals over the last twenty-five years. Hospital policy varies greatly. Some hospitals require the attending surgeon (the one who will send you a bill) to be in the operating room during every case. Other hospitals have a more “relaxed” approach allowing relatively unsupervised residents to operate, well… unsupervised. I personally applaud the hard-nosed approach that these former institutions take. As more hospitals link CEO pay to overall hospital performance and safety I hope more hospitals will put patients first and ignore self-centered physician demands.

Academic physicians claim that their residents “need” to make a few mistakes. In fact Keith B. Armitage, MD, president of the Assn. of Program Directors in Internal Medicine. “You can’t learn without some autonomy.” The data certainly indicates residnts are expressing their autonomy and making mistakes. This is little more than a boondoggle by academic physicians to escape legitimate patient-care responsibilities. It is frankly flawed reasoning used to justify abdication of real patient-care responsibilities. Academic physicians cannot point to a shred of evidence indicating that autonomy improves resident learning. They cannot show a scintilla of data that adequate supervision is in any way detrimental. Occasionally the physician justifies the lack of presence or supervision by saying “I won’t charge for it.” Inadequate, unsupervised care amounts to fraud regardless of the cost.

Hospitals are frequently complicit. The hospitals allow “relaxed” supervision rules for surgery and medical procedures by only requiring that the attending physician be “available.” Somehow this justifies allowing a resident to operate unsupervised without actual privileges. The supervision rules are clearly stated in the bylaws and rules and regulations of every hospital. You should request and read these before you choose your hospital. Further you should commit to writing your understanding of the care you will receive from your physician and who will participate.

It’s your health. Take it seriously and protect it.

Should I be here?

Every hospital has things it does well. Most of the time the hospital does patient care well. There are, however, many hospitals that don’t provide adequate care. They don’t for a variety of reasons. Some of these reasons may directly affect your health others affect it indirectly.

Physician Privileges
As indicated in prior posts, no medical school prepares a physician for the actual practice of medicine. Medical school prepares a physician to study to care for patients. Then, after completion of a prescribed course of study a physician is eligible to take a certifying exam in a specialty.

Each hospital maintains a set of requirements that a physician must meet in order to have privileges to practice at that hospital. Sometimes the criteria are rigorous and strict sometimes they’re relaxed. Sometimes the bar is set so low that they’re virtually nonexistent. Essentially every certifying board in the US states emphatically that passing the exam indicates only that the physician has met a minimum level of training and skill. Yet many hospitals allow physicians who cannot achieve even the minimum level of skill to have privileges. You should re-read that again- hospitals allow physicians to practice who cannot meet minimum training and skill levels. You read that right. That’s what is means to have a physician who is not board certified. (There are a few legitimate reasons not to be board certified. But usually it means more than the physician just doesn’t pass the exam.)

Common examples are trainees who are allowed to “moonlight” in emergency rooms (ER). The hospital wants to have an emergency room so that local physicians can send patients. Yet local physicians are unwilling to staff the ER, or even pay to have qualified physicians cover shifts in the ER. Additionally, hospitals use the ER as a “gateway” to admission. This is good for business since every admission represents profit (the hospital would close if it could not provide inpatient services without financial loss). Thus when you are most vulnerable and have the least choice in your physician you are most likely to have an unqualified physician who may actually kill you.

Another common example is using inadequately skilled physicians from other specialties. Perhaps the most common is tertiary-care hospitals that use family practice physicians as the primary ER physician. While a family physician may do great care in the office I certainly don’t want one taking care of me during my heart attack or after a car wreck or gunshot wound.

Finally, hospitals may simply allow physicians to have privileges that are counter to community values. Would you want a recovering drug addict or alcoholic as your doctor? How about a child abuser? Many state boards of medicine maintain an on-line database of physician discipline. These databases can be checked. Even states without a database will respond to a written request for information (sometimes a small fee applies). Wouldn’t you like to know if your doctor had sex with an underage patient? Wouldn’t you like to know if your doctor kept inadequate records? How about a requirement that he not drink (ever) or that he only see patients with a chaperone?

I’ve seen all of these requirements. You will too if you look.

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

Who are these people- residents?

Medical school doesn’t really prepare students for anything except more school. Modern medicine has become sufficiently complex that essentially no one is able to graduate and begin to care for patients without additional training. The additional training is so important that very few states will even license a physician without it.

Residents are graduates of medical schools who are pursuing this additional training. The Accreditation Council for Graduate Medical Education (ACGME) is the body responsible for defining specialties and the required training for a physician to be called a specialist. Most residency training positions are filled in an arcane process known as “the match.” The match is run by the National Resident Matching Program (NRMP), an organization simultaneously reviled and lauded.

While still in medical school most students decide on their career in one of a large number of training programs and specialties. Subsequently the student typicall applies and interviews with the selected programs. After the residents and programs have all made their super-secret choices then the choices are fed into a giant computer. Magically, one day in March of each year the results are disclosed. On that day depression is mixed with elation as the students find where they’ll spend the next 3-7 years of their lives and more important what they’lll be doing. This is more than just residency and location selection. In a very real sense this is career selection. On the fateful day would-be orthopedic surgeons find out that they will in fact be pathologists, dermatologists find they will be internists, surgeons find they will be psychiatrists unless they are able to change programs at a later date. OK, so I’m exagerrating a bit. The match will only match what students and programs have offered as possibilities.

Resident physicians are so called because the used to “reside” in the hospital. After all medicine is a calling. The last twenty years have seen enormous changes in work conditions and hours for residents. The ACGME prohibits residents from routinely working more than 80 hours per week. Regulations further limit the number of consecutive hours a resident may work. Despite stiff penalties some prgrams continue to ignore the 80 hour work limit. Always ask the resident when he/she last slept. If the answer is more than 12 hours ago consider sending him/her away. After all if you’d been up for 20 hours and had been working for 70 hours in the last 6 days would you use a power saw or other dangerous equipment? Why would you let someone you don’t even know risk your life or health? These people are so fatigued that they can’t even drive why would they think they can make life or death decisions? Some residents are so horribly misguided, foolish, or egotistical as to believe that fatigue and sleep deprivation can “condition them.” They are wrong.

A resident’s scope of care is defined by the training program and institution. Generally each must work under the direction of a fully-trained attending physician. Under most circumstances the resdent’s entire scope of practice is further lmited by the attending physician’s supervisions and scope of practice. In essence the resident acts as an agent of the attending and all authority is delegated by the attending.

Unfortunately many attending physicians are frankly irresponsible, stupid, uncaring, or some combination of all three. In such circumstances you may find yourself having an operation at 3:00 am from a resident who has already worked 70 hours in a week and has been awake continuously since 7:00 am the prior morning. Can that happen you ask? Yes. It can. In fact depending on the hospital the resident may do so without the supervision, presence, or even the knowledge of a responsible, fully-trained surgeon. In fact some attendings are sufficiently self-serving that they will cloak their laziness in “educational concerns.” That is simply bovine excrement. Yet, it happens everyday, somewhere. Don’t let it happen to you. There is no need to be a victim of your own health care.

So why would you go to a hospital that has residents? The care is frequently better. The hospitals tend to be tertiary-care centers with large numbers of specialists who can rapidly diagnose and treat you. The residents, paradoxically, spend more time with patients than attendings (back to that caring and responsibility thing again).
The value of resident care is, however, completely dependent on hospital rules and the competence and diligence of the attending physician.

So what should you do? Ask what residents can do. Ask everyone who enters your room to identify him/herself. If a resident oprders medications, tests, or therapy ask if the attending knows and approves. Make sure that your attending physician visits everyday. If you are to have surgery ask your surgeon who will do the actual surgery. Ask what the resident’s role will be in the operating room. Do not sign the surgical consent until you see your surgeon preoperatively. Make your surgeon commit. Document your agreement in the chart and consent as to duties of the attending, resident, and medical students. Do not let them put you to sleep until/unless you see your surgeon in the operating room with you.

Similarly, if a resident is preparing to perform a minor procedure on you or a family member be equally aggressive. Assure yourself that your attending is aware or physically present, as you desire. You have the right to determine who performs what procedures.

I recall several years ago my son cut his finger while working on a ranch. The cut was not huge but needed a couple of stitches. He went to the emergency room of a university-afiliated, tertiary-care hospital. A resident closed the wound and did a nice job. A few weeks later I got a big fat bill from the hospital and a big bill from an emergency-room attending physician. Interestingly, my son had mentioned already that he only saw the resident. I called and asked for the documentation of the attending physician’s participation in the care. The hospital was unable to produce any such documentation. When I asked if they were aware that sending a bill for services not rendered was a federal offense they put me on hold. A few minutes later another person came on the line and informed me that I could ignore both of the bills and thanked me for my patience. The point is that some attendings are irresponsible, uncaring, and occassionally, frankly criminal. Residents may actually do fine work. But they are only trainees. If you let them work unsupervised you may not get the best care. In some cases you actually get inferior care that jeopardizes your health.

Residents may improve your care but it’s still best to think of them as “advanced medical students.”

It’s your health. Take care of it.