Physicians Concerned About Their Career Choices

I read the blog titled "Young Doctors Worry About Career Choices" By Bruce Japsen on the New York Times - Health - Prescriptions.  I like it.  The blog article comments on the reults of a Merritt Hawkins' survey. 

It starts: "Even though young doctors still receive a lot of job offers in one of the worst markets in decades, nearly one-third would select another profession if they had to decide on a career all over again, according to a new study out Thursday."

This is significant, very significant.  Why?  Because it is the opinion of those who are just starting their medical career.  According to the article "... a growing number of these hot employment prospects still regret their choice of profession, citing large medical education debts, the changing economics of health care, and the health care law and how it might affect their future practices and profession."

Is this opinion related to their limited experience, and the reality is not that bad?  Or is it an indication that those are smart enough to understand that there are problems, even before getting into the career?  I favor the latter explanation, and I am impressed.  I am impressed that such a remarkable proportion of young physicians are doubting their decision to be in the career of their choice because of the factors cited in the article (debts, economics, and the impact of the health care laws on their practices and profession).  They were able to recognize the importance of those issues.  But, those are not even the worst worries that are out there.  There are actually other more profound reasons that they probably were not made aware of, and that can make the most resilient to eventually regret being a physician.  Here are things that come to my mind.

1.  Physicians lost a lot of autonomy because of the tremendous regulation that is happening now.  Doctors working in hospitals (whether as independent contractors or as employed physicians) are monitored in a way that no other profession to my knowledge is.  Even though that is in part due to the high standard required of being a practicing physician, the monitoring is actually not used to improve performance in a collaborative way, but rather to judge who need to be axed.  Essentially, there is an atmosphere of deep skepticism against physicians.  The excuses to start an investigation and end up with a disciplinary action have such low standards of fairness and impartiality that, essentially, almost any physician can be a victim.  Only with the grace of being connected, politically correct, and fitting in, that anyone can be reasonably confident that they will not be subjected to elimination.  If you do not fit in from so many aspects, there is a very good chance that sooner or later you will be ruthlessly eliminated.

2.  Physicians lost respect as leaders.  They actually are low down in the hierarchy of effectiveness in a hospital setting, unless they also hold political power, or are liked by those who hold such powers.  Some of the physicians who climbed the power ladder became more of bureaucrats and sometimes anti-physician executives than being part of the general community of doctors.

3.  Physicians are the only career that I know of where, once you become a victim of a disciplinary action of severe magnitude, no matter how unfair the process was to you (and there is nothing that guarantees, even remotely, that the process will not be heavily tilted against you as a physician), your reputation will be ruined by a mandatory reporting to the famous National Practitioner Data Bank, effectively destroying your career.  You'll be ostracised, marginalized, and you'll lose the ability to find an employment or obtain privileges or be credentialed.  I think most surgeons have felt threatened or actually became victims unless they are among the selected, or too young in their career that they have not yet been touched by malpractice claims, peer reviews, anonymous complaints, etc etc.

4.  If you dream of opening your own private practice, be aware that the current structure is evolving into an environment that is both economically and politically unsupportive (dare I say hostile?) to the independent physician.  Eventually the solo will seek a hospital employment.  If that has been your dream and aspiration when you went to medical school, congratulations!

Entering into a career of practicing medicine in the US is a gamble.  It is a profession that can break the heart of the best physicians.  It is merciless for some, and too forgiving for others.

URL of the article under discussion:
http://prescriptions.blogs.nytimes.com/2011/10/06/young-doctors-worry-about-career-choices/?smid=tw-NYTPrescription&seid=auto

Will You Attend the United Whistleblower Meeting Sept 18, 2011 in DC?

United Whistleblower Speak Sept 18, 2011:

"Americans must be free to practice their trade and to tell the public the truth."
 http://internationalwhistleblower.org/


Submitted by James Murtagh

WASHINGTON, DC – This September 18, the whistleblowers and persons of conscience will hold the fifth annual gathering on Capitol Hill. As the Nation's budget crisis continues to grow, lawmakers must look to corporate and federal whistleblowers to stop out of control spending. The united message is the nation’s top priority must be to protect whistleblowers so that truth-tellers can protect the public, the public’s health, and our national security.

Five years of concentrated advocacy led to this meeting. Dr. Jeffrey Wigand (aka, “The Insider”) helped to found, guide and shape the International Association of Whistleblowers (IAW). Other Advisors include Coleen Rowley, Reuben Guttman and Cyrus Mehri. Our ranks are growing stronger everyday.

America knows what is said about whistleblowers. This conference is a chance to hear from the whistleblowers in their own words. A spectrum of statements include:

• NSA whistleblower Thomas Drake, recently revealed on 60 Minutes that 9/11 could have been prevented. The IAW demands an end to counter-productive policies that make America more vulnerable to future attacks:

"If recent history is any guide, coming forward with the truth and blowing the whistle on evidence of gross waste, fraud, abuse, wrongdoing, corruption, malfeasance, illegalities or dangers to public health and safety within public or private institutions is increasingly viewed as a criminal act. In so doing, whistleblowers not only risk their personal lives and professional careers they are often relentlessly and maliciously dismissed, victimized, hounded and even prosecuted out of reprisal, retribution, and retaliation for speaking truth to power - a clear and distinct 'shoot the messenger' syndrome. Whistleblowers are often the only witness to wrongdoing where they work. Existing laws are simply not sufficient to protect whistleblowers. http://www.whistleblower.org/blog/31/1128

• Navy whistleblower Kirk Wiebe vigorously supports the IAW message:

Whistleblowers are not a threat to government or to any organization, rather they seek to ensure integrity of service to the people they serve. The IAW Conference provides an excellent platform for whistleblowers to find their voice and to meet one another in a positive environment of mutual support. http://www.whistleblower.org/blog

NSA whistleblower Randy Kelly amplifies:

These are sad and dark days in the history of America. The American taxpayer has little or no confidence in our elected officials or government in general. The American people should be outraged at the level of corruption and criminal activity within the federal government and politics in this country. It is easy to understand why many members of the Senate and of the House of Representatives do not want any level of whistleblower reform. Too many politicians fear they themselves will become publically exposed as to the atrocities they condone by being unwilling to take any action against the prevalence of fraud, waste and abuse within all levels and sectors of our government. All honest citizens are affected by government fraud, waste and abuse. These are intentional and criminal acts that benefit but a few. And, they are taking place to the detriment of, and at the expense of, the honest and hard working citizens of this country. It is the 'whistleblowers' that are trying to right the wrongs. Yet the term 'whistleblower' remains painted with a dark and sinister image. The American people must come to realize that the 'whistleblowers' of this country are some of the true patriots of America. Now, more than ever, whistleblowers need the understanding and support of the American people!

• Bill Binney points out the Constitutional issue:

When our Constitutional form of government does not function, that is, when Congress does not have effective oversight of the agencies of the executive branch, those agencies set their own agenda and spend money accordingly. That is exactly what has happened at my former agency (NSA). Over the past 30 years, my former agency has made acquiring money the main objective - not solving operational problems. Their vision statement over these years has evolved into "Keep the problem going, so the money keeps flowing." In other words,
don't solve the problem use the problem to keep getting more and more money. This is and has been a disservice to our people and country. In effect, these agencies are trading our security for money.

• Mike McCray, co-chair of the IAW agrees:
Starting today, every agency and department should know that this administration stands on the side not of those who seek to withhold information, but those who seek to make it known.

We encourage all 264 organizations and corporations that signed the Whistleblower letter to join us! We are already bonded by a shared principle that "whistleblower protection is a foundation for any change in which the public can believe. It does not matter whether the issue is economic recovery, prescription drug safety, environmental protection, infrastructure spending, national health insurance, or foreign policy."
The IAW is independent, transpartisan, and non-aligned. It is united by a single principle: that Americans deserve to be protected by the truth. Only truth-telling patriots with extraordinary courage to tell truth to power can stop the barrage of preventable disasters that beset America. We are uniting to lobby Congress, and we will be heard. Every whistleblower will tell their story, and will be interviewed for U-tube. An extraordinary archive of these American and International stories will be collected.
All citizens who want to make America truly stronger are invited to:

Contact today Atlanta Whistleblower

INTERNATIONAL ASSOCIATION OF WHISTLEBLOWERS (IAW)
CAUCUS IN WASHINGTON September 18, 2011
DC Public Library - Martin Luther King Jr. branch
Room A-5, 901 G Street, NW, Washington, DC 20001
(202) 727-0321

Peer review victims: Are your helpers doing a good job?

Do you have any stories about businesses that claim or advertise helping victims of peer reviews but not actually helping? Not delivering? Doing a lousy job? Only interested in the victim till the victim signs up for the services then they do not follow through?

Please keep those stories coming. Confidentiality and anonymity will be strictly respected.

You can contact me through the comments on this blog.  Your communication will not be published, since comments are moderated.  Your communication will come to me as a message. I will not post it online if you want it to be confidential.
You can also message me on facebook http://www.facebook.com/find-friends/#!/profile.php?id=100001893544204

Statistics of Physician Elimination - Career Destruction

Out of curiosity, I visited the National Practitioner Data Bank's (NPDB) website, and I found the "NPDB Summary Report" at
http://www.npdb-hipdb.hrsa.gov/resources/reports/NPDBSummaryReport.pdf
It is actually a good source of information.

The NPDB Summary Report starts by stating: "The following is a summary of reports submitted and accepted into the NPDB for each professional category. This data covers the period from September 1, 1990 through April 2, 2011. Professional categories which were not available for the entire time period are noted."

Then there is a "Data Disclaimer": Reports of adverse clinical privileges and professional society membership actions against practitioners other than physicians and dentists, (e.g., chiropractors, psychologists, podiatrists) are submitted voluntarily.

I pointed my attention then  to the column "LICENSURE,CLINICAL PRIVILEGES, PROFESSIONAL SOCIETY MEMBERSHIP, AND PEER REVIEW ORGANIZATION REPORTS.  I chose some categories just to have some idea as to how many individuals in which professions are subjected to that career assassination.

Dentists: 20,239
Nurse Midwife: 94
Nurse Practitioner: 921
Hospital Administrator: 0
Licensed Practical or Vocational Nurse: 78,421
Nurse Anesthetist: 337
Osteopathic Physician (DO): 8,129
Osteopathic Physician Intern/Resident (DO): 153
Physician (MD): 82,683
Physician Intern/Resident (MD): 588

So, the safest on that regards is to be a Hospital Administrator.  Interesting.  And, being a trainee resident or even an intern is no reason for mercy.  Career destruction and elimination based on arbitrary criteria is just the way it is, no matter how junior or advanced in the career someone is.

Breakdown of MD by State, from highest to lowest number of physicians (MDs) whose careers, livelihood have been threatened with career capital punishment. 

CA    10,019
NY    6,561
OH    4,414
TX     4,111
FL     3,885
IL      3,647
VA     3,411
PA     3,004
AZ    2,591
MI    2,525
NJ    2,481
GA    2,262
CO    2,088
MA    2,074
MD    2,025
WA     1,877
NC    1,832
KY    1,661
LA    1,399
MO    1,377
TN     1,299
AL     1,152
OR    1,116
IN    1,107
MN    1,021
OK    979
WV     972
SC     958
WI     936
IA    918
CT    897
MS    751
KS    748
NV    606
UT     565
AR    539
NM    523
ME    429
DC     393
NE    381
ND    376
NH    354
AK    343
RI     334
VT     296
ID    285
HI    278
WY     178
DE    164
SD     149
PR     44

Notice that these are raw numbers. To transform those into meaningful statistical values, in the very least I need a denominator.  Actually deciding what the denominator should be is not easy.  Is it the population of the state? The population of a certain age? The number of practicing MDs? If so, the current number of MD"s, realizing that the data cover from 1990 till 2011, so, which MD population would be used, etc. 

Regardless, for someone to become a physician, one endures a lot that is well known to everyone.  And not too many really would be willing to pursue that route if they know that more than 90,000 were kicked out.  And they were not kicked out by an objective, fair or impartial process, but were eliminated and destroyed by a flawed process that is open for exploitation and abuse, executed by their peers and called  the"peer review".  There is nothing Holy about it.

Peer Review Reform (1) - Need objective criteria for Career Capital Punishment

All the discussions everywhere indicate that we have a very flawed medical peer review system that lacks so much that it could be more harmful than beneficial.  Coupled with the National Practitioner Data Bank, the combination draws the picture of an unpredictable monster.  Let's start thinking of reforming the process, and finally having a set of guidelines that can be promoted for a proposed solution.

First of all, I do not know if there is anyway any set of hospital bylaws, policies and procedures can strike the right balance between the interests of the public in being protected from the rare dangerous provider, and being fair and impartial to the provider.  In fact, I do not think that any set of bylaws can be ganging-up proof.  Let's face it, even when a hospital clearly breaches its own bylaws, it takes so much litigation, resources and time to seek remedy that the victim may become exhausted or ruined while justice is taking its slow-paced process time.  The victim may succumb before any remedy.  Then there will be appeals, counter-appeals.  Essentially, even winning entails so much loss.

Therefore, my biggest idea for today is that a reform should set rules as to the exact conditions under which the extreme measure of restricting or diminishing a physician's privileges should be considered.  That is my one focused idea for today.  The subjective criteria do not work too well.  For example, what could be not acceptable by the one medical staff in small hospital A (eg, for financial or reputation reasons) and portrayed as being a danger to the patients, may be very well a reasonable expectation of the average practice in hospital B.  Hospital A may be essentially protecting its financial bottom-line by discouraging its providers from treating sicker patients (who normally would have higher incidence of complications by nature of their disease) under the disguise of quality and avoiding complications.  So, hospital B should really not be bound by an adversarial decision against a physician whose privileges are revoked or reduced in Hospital A.  Hospital B should be willing to accept that physician to practice, particularly he/she is willing to and is experienced in treating more complicated medical problems .  But, the reality is that once Hospital A made their decision, and that is reported to the National Practioner Data Bank (NPDB), the regulators in Hospital B system (not the professionals aka physicians) may not even give that physician a chance to be considered.  In essence, a physician's fault may not be what she/he did, but where that physician practiced.  This is because really there are no critera as to when to apply the death penalty (career capital punishment) to a physician's career.

So, my plea is that the major career-destroying disciplinary actions must be considered as serious decisions and therefore there has to be clear and objective (not subjective) criteria before applying them to a certain physician as a last resort.

Should Studying Law Be Mandatory for Physicians?

My understanding is that medical school is supposed to prepare medical students to be good doctors.  That has translated to teaching basic sciences, clinical sciences and clinical applications of the knowledge.  Also included is exposure to the healthcare system and its delivery, some medico-legal aspects, and medical ethics.  That indeed has prepared generations of fine physicians to the challenges of clinical medicine, where the challenges Time has changed.  The knowledge and skills taught in medical school do not give the prospective physician a clue as to many real challenges.  Not the challenges that will intrigue the clinical abilities, but challenges that will threaten the career entirely.  The environment of practicing medicine in the US is morbidly so highly litigated, that the legal aspects are making a very significant part of the mental energy, time and financial resources of physicians and their practices.  I dare say that the MD or DO degree alone is not sufficient to be a good doctor.  A good doctor has to be able to survive legally against many odds.  I believe that extensive exposure to the law, even with a modified JD degree, would be the least that is necessary to bring some sanity.  A disadvantage is that you will have doctors who know some of the law and may over-estimate their knowledge and legal capabilities, and get themselves in trouble.  But, I think there will be a big advantage in knowing the basics, to be able to navigate some of the witch-hunts against doctors.  Every doctor needs to learn law.  But, in case their are legal issues, still retaining counsel is absolutely necessary.  But, then, the physician will be a well-informed customer.

Another potential shortcoming is if the curriculum is designed to program the future physician to promote the current miserable state of affairs without actually preparing them for the real dangers (bad medical staff bylaws, lack of constitutional rights for physicians, etc).  Therefore, the course needs to be carefully designed to prepare the student to practice in the jungle of healthcare in the US, and to give a strong sense as to which areas need reform.

Article: How Courts Protect Unjustified Hospital Peer Review Actions

I have recently read a very inetersting article that I wanted to share with you, and you can reach at: http://www.jpands.org/vol16no1/kadar.pdf
Published in the Journal of American Physicians and Surgeons - Volume 16 Number 1. Spring 2011.

How Courts Are Protecting Unjustified Peer Review Actions Against Physicians by Hospitals
The author: Nicholas Kadar, M.D., J.D.

"Nevertheless, courts have consistently misinterpreted the legal effect of HCQIA’s presumption of immunity as increasing the physician’s burden of proof, and as creating an almost insurmountable obstacle to prove that the hospital’s actions did not meet the standards of § 11112(a). For example, a panel of the Third Circuit, which included future Supreme Court Justice Samuel Alito, declared: “The HCQIA places a high burden on physicians to demonstrate that a professional review action should not be afforded immunity.” This is simply not true. A physician’s burden to rebut the presumption of immunity is the lowest known to the civil law -

For the full article, go to: http://www.jpands.org/vol16no1/kadar.pdf

Nicholas Kadar, M.D., J.D., LL.M. is a gynecologic oncologist and member of the New Jersey Bar.

More Suicides Among Surgeons Aged 45 and Older

On April 4 I tweeted: Depression and suicide among physicians — Current Psychiatry Online http://t.co/yZ9q4Yk

Now a new article on the website of Physician's Weekly reports on a recent study from the Archives of Surgery. 

The members of the American College of Surgeons were sent an anonymous cross-sectional survey in June 2008. The survey included questions regarding SI and use of mental health resources, a validated depression screening tool, and standardized assessments of burnout and quality of life.

“We know the lifetime risk of depression among physicians is similar to that of the general population, which suggests factors other than depression may be contributing to increased risk of suicide among physicians,” Tait D. Shanafelt, MD, tells Physician’s Weekly. “The influence of professional characteristics in forms of distress and depression, such as burnout, has been largely unexplored.”

Physician's Weekly reported that "According to Dr. Shanafelt, in addition to burnout, there appear to be occupational risks for having suicidal thoughts: A three-fold increased risk for suicidal thoughts was reported for surgeons who made a recent major medical error."

Rules of Commenting on Shammed Doc Blog

I am receiving comments that I need to moderate, in order to publish in my blog comments' section.  I value everyone's input and am particulary grateful for the interest in my blog and taking the time to comment.  I think this is time for me to make some observations.  Also, I thought I should post some general rules for comments, which will keep evolving as time goes by:

Preamble: I am not a member of, I am not affiliated with, and I am not friends with, any , society, center, association, or organization.  The only reason I publish here articles that are authored by others who belong to societies, centers, or organizations is that I found the content to be worthwhile, and adding value to the readership.

Using the "Blogger" platform, I cannot edit a comment before publishing.  A comment has to be rejected in its entirity if only one sentence does not conform.  A comment that is rejected will have to be re-submitted after complying with the rules and spirit if the interested individual desires to do so.

1.  The "Comments"section is meant to educate and increase awareness with the issue of the abuse of the current hospital peer review system, provisions, and immunity afforded.

2.  The "Comments" section would achieve the above through being an open forum for discussions focused on this issue, with freedom to be anonymous if needed.

3.  The blog, and the "Comments" section, are not to be exploited to advertise any business, whether directly or by making claims of achievements or favorable results in helping peer review victims.  If any entity has solid data to publish, including substantiating their own claims of achieving results in helping peer review victims, I am always looking for value content and will be willing to publish those data only if they meet a high standard of credibility and only under the full responsibility of the person who authors the article or data.  The Shammed Doc blog is not a platform for advertising, even under the name of helping shammed peer review victims.

4.  Any personal attacks against any individual person will lead to an automatic rejection of a comment. This does not limit whatsoever the pure discussion of ideas, thoughts, concepts and innovative approaches.

Enforcing the above rules for posting on the "Comments" section will start immediately with the new submissions which I will review, and I apologize in advance for any rejected comment.  All comments have great elements in them, but it is the elements that violate those common sense rules that lead to rejection of an entire comment. When I have the time, I will go back in retrospect and remove any previous comments that do not follow the same rules.

I have quoted articles from elsewhere and other websites. I have also posted articles that were submitted to me and the author was given a limited privilege of being a guest for that one submission.  I am not affiliated with, nor am I a member of any organization, society, center, support group, or any similar entity, that is connected with any of those whose articles have been posted on my blog.  I do not have any "friendship" (even if on facebook every connection is called "friend") with any member of those entities. I am not a member of the Center for Peer Review Justice, the Semmelweis Society, the Alliance for Patient Safety , AAPS (Association of American Physicians and Surgeons), or of any society whatsoever, nor am I known to any member of those or any other societies or individuals.  I do not support any causes or values advocated by any of those entities to any extent beyond the limited scope of the peer review process and closely related topics.

So What Is a Sham Peer Review? A MedGenMed Article

Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1681729/

So What Is a Sham Peer Review?

Roland Chalifoux, Jr, DO, Neurosurgeon; Clinical Instructor; West Virginia University Visiting Professor

Roland Chalifoux, Jr, private practice; West Virginia School of Osteopathic Medicine.

History

One of the first notable sham peer reviews took place in Oregon in the early 1980s. The physician who took it up with the courts was Dr. Patrick, and the Supreme Court ruled in his favor. As a result of the publicity surrounding this case, the Healthcare Quality Improvement Act (HCQIA) was enacted in 1986. One of the concerns that arose from the Patrick case was a fear that no physician would want to participate in peer review if he or she could be potentially liable for a bad report. The HCQIA gave immunity to hospitals and reviewers participating in peer review.

This immunity has been abused by hospitals and physicians to harm “disruptive” physicians (ie, whistleblowers) or financial competitors. All one must say is: “Dr. Joe Blow is a bad doctor, which is my professional opinion in this peer review, and this hospital should get rid of him.” And poof! Dr. Joe Blow, patient advocate, financial competitor, is gone! And the accusing physician is immune!

A wonderful series has recently been written by Steve Twedt of the Pittsburgh Post-Gazette called the “Cost of Courage,” detailing a number of physicians who have suffered from sham peer review and the consequences they have had to pay (http://www.post-gazette.com/pg/03299/234499.stm).

So What Is a Sham Peer Review?

A sham peer review exists when a practitioner undergoes chart review during which “serious” deficiencies are determined to exist and, therefore, “the practitioner must be prevented from being a risk to the public safety.” This conclusion is obtained by either:

• Declaring that the practitioner does not practice within the guidelines of the standard of care – regardless of whether that is true. (Several examples include the panel rejecting literature to support a position and being told, “We don't care what the literature shows” and “That institution doesn't know what they are doing.” In essence, a new standard of care is established – because that is not what the victim does.)
• Commissioning an outside review with prearranged outcomes. There are peer-review firms with dubious reputations who will perform a review that reflects the desired outcome of the employer.

For the full text of this article, go to http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1681729/

MedGenMed. 2005; 7(4): 47.

Published online 2005 November 15.

Copyright ©2005 Medscape

What the Future Holds in Health Care

By Richard Willner

 The question before the legislature is should young people be required to sacrifice their civil liberties just to become a physician.

Or should these young people choose another course with …less irrational legal constraint like finance for example.

Should they be required to sacrifice family life and hundreds of thousands of dollars just to work for the momentary pleasure of some corporate hospital huckster.

Depending upon how the legislature comes down on the immunity question , The answer is pretty obvious isn’t it?

A bright future for medicine depends on creating a safe environment to practice medicine.

They take this all consuming journey to learn to take care of human beings. This is not an act of Revolt against society.

This is an act of optimism and love and dedication to the well being of our country and to the human race.

Medical education is not undertaken to take orders from the AMA or the hospital industry or to sanctify any substitute agenda besides the doctor patient relationship PERIOD.

Doctors do not become doctors to get into a battle with lawyers or corporations or insurance companies or the legislature.

Their fatal flaw is that they think that the rules of evidence that apply to medicine, the natural law, should apply to the legal environment of medical practice.

They also have the reasonable expectation that they will be judged with fairness and equanimity in the law just like any other citizen.

Currently nothing could be further from the truth. Doctors have no civil liberties.

Working as a Doctor us best compared to living in Russia under communism.

While the practice of medicine has its own politics there is nothing sacred about medical politics. There is nothing sanctified about medical politics.

So here we see in 2 extremes of medicine the good and the bad. The sanctified and the profane.

About 10% of doctors belong to the AMA close to 90% do not. Does that mean that 90% of doctors are suspect. Hardly.

So what should the legislature do to insure a bright future for healthcare.

According to the principles of the natural law they should sanctify optimism and idealism of those who are thinking about becoming doctors by refusing to rob them of the full rights of American citizenship, as the peer review process implies, just because they become doctors.

Alternatively they can choose to sanctify the peer review process over the rights of independent physicians, the agenda of medical politics and screw every doctor who chooses to practice in the state.

The answer will determine the future of health care. It is also simple and time tested.

Richard Willner directs the The Center for Peer Review Justice
http://www.peerreview.org/.
He can be reached at e-mail:   Legal@PeerReview.org

We Cause Complications

This is one of the most distressing elements of our profession.  Even when we keep our knowledge up to the highest levels, even if we use the knowledge and the skills we have with a high level of competence, we will cause a complication.  Since many aspects of applying medical knowledge are subject to different opinions and controversies, it is not difficult to locate a physician who would honestly be of the opinion that (in retrospect, of course, and with 20/20 hind-vision) a certain treatment that led to a complication is worth criticism.  For God's sake, it does not take an expert to determine that.  Everyone of us, when we think back, we can identify ways of doing things a little bit, or much, better.  Isn't this what we do everyday, no matter how experienced we are?  Otherwise, how do we improve? Is there any point in one's career that one can claim that she/he reached the level of perfection that there is nothing more to be learned, and no more need to learn from bad experiences?

One problem is that the current healthcare environment in the United States is fiercely suppressing this healthy attitude.  A complication may result in a malpractice claim, in a peer review process, in an investigation, and every one of those events can have a detrimental impact on a physician's career and livelihood.  There is no single incentive to stimulate an open and healthy learning and accumulation of more experience in most hospitals.  The current punitive environment gives a clear message: every complication may and will be used against you, possibly to the fullest extent.

Ask any well-experienced and skilled physician or surgeon if the medical school and residency taught her/him every contingency that can be faced and that no complications will occur whatsoever.  This is impossible.  The best doctors are the ones who were allowed to grow and accumulate experience and wisdom with time and hard work.  In doing so, inadvertent complications do happen, and they add to the wealth of knowledge, experience and wisdom and help more and more patients.  Give me a doctor who never ever caused a complication, and I tell you, she/he either is too early in the career, has no experience yet, or avoids treating other than the most straight-forward cases.  Worse still, a surgeon who never saw a complication will probably be not as good in managing a complex situation after a complication arises.  The bottom-line, an environment that rewards perfection and punishes the normal occurrences of complications is inherently against patients' best interests.

Where to draw the line when complications are acceptable products of a healthy process, and when they are the products of an individual person's poor practice or a system error?  Only if a fair and an impartial/neutral auditing process is in place that such a differentiation may be made.  Most hospitals in the US simply do not have access to a process like that, nor do they have any provisions in their Bylaws to mandate such a thing.  Constructive auditing and constructive peer review does not exist in the majority of hospitals in the US.  The only available mechanisms are judicial or quasi-judicial, adversarial, and their outcomes are often punitive and destructive. The process is very arbitrary.

I have not read Dr. Atul Gawande's book, "Complications".  So, I have no idea how this posting will agree or disagree with that new classic.  Patients and their physicians are the victims of an environment that is obsessed with senseless finger-pointing, punishment, elimination and revenge, and shows very little desire to truly address quality issues in a constructive manner.

Recruitment to Hospital Hell

Here is a hypothetical scenario, and a possible one.  A brilliant surgeon, trained in a subspecialty on the very high tech from the best surgical residency training program in the state.  She is approached by recruiters.  Every recruitment firm gives her a list of the most attractive positions and practice opportunities.  Some are so with income guarantee to open her own practice.  Some are employed positions with a hospital.  Some are employments with a group, with the possibility of partnership in 2-3 years.  Recruiters are quite excited for her.  One recruiter spots for her the dream practice opportunity.  A nice community hospital in a small town that is a bedroom community to a city that consistently ranks high as to the quality of life.  Outdoors, indoors, you name it, it's there.  Schools, colleges, an international airport, arts, museums, galleries,concerts, a symphony orchestra, all there.  Ocean beeches, there too.  What else?  A very supportive community.  A collegial atmosphere.  The opportunity is to start own practice as a solo surgeon.  The hospital believes that reintroducing that specialty to the hospital will capture so many patients who had to be sent away.  Now they will be treated in the hospital, boosting the revenues and serving the community locally.  There are others on staff who belong to the specialty, but not very active in this hospital anymore.  So, they will not be competing.  And the financial package is competitive.  Site visit is warm and very encouraging.  The young fellow accepts.  Life is good. Then a shock: within a year her career is totally ruined.  She loses her livelihood.  All the long hours of medical school.  The loans.  The ruthless internship.  The long residency training for a full general surgery program of five years.  The two years of fellowship training.  The qualification for two specialty board exams.  All gone, just like that.  Is that possible? What happened?  Read on.

 

The hospital CEO's entire plan to recruit a surgeon with that high level of training but very little independent experience was simply that, recruit her and give her a referral basis, or at least, ED calls to start building her practice.  The young fellow in her entire training had been in the fully supported environment of a university hospital.  There are highly qualified residents, faculty, nurses, technicians, etc.  An environment where things just go so smoothly.  Being a tertiary center, the most challenging cases are treated well, and they do as well as could be.  The young fellow was realistic that such a level of support would not be duplicated in a small community hospital.  But, with a great attitude from the administration, and lots of hard work and determination, and confidence in her abilities, her practice will be the best in the small town.  She has not yet felt her way as to which cases should or should not be done in that hospital.  Being a solo surgeon, no senior partners to guide her.  She does some cases with great success.  She becomes confident of her abilities and the abilities of the hospital to support her professional needs.  She becomes somewhat arrogant and rude, just a little bit.  But that does not sit too well with the OR supervisor/director, who will from now on put that fellow under the microscope.  Also being all by herself building the new specialty service, she becomes chronically tired.  The after midnight ED calls make her chronically sleep-deprived.

 

The young surgeon takes a challenging case to surgery, to find that she is given a technician that is not used to work with her, and is not familiar with some of the details of those types of surgeries.  She complains to the OR supervisor, but with a vicious smile she is told that she should be able to work with that technician if she was competent enough.  Though uncomfortable, she decides to go ahead with the scheduled surgery.  She gets into a technical difficulty, but there is no back-up surgeon in that specialty in this hospital.  Working the best she could with the inexperienced technician results in the patient bleeding, suffering an injury, re-bleeding, then dying.  The exhausted surgeon is devastated.  She talks to the family and feels their pain, and she has to live herself the pain.  She manages the paper-work including calling the coroner and explaining.  Then she has to see her other patients on the floor.  She comes back to see if the grieving family have any unanswered questions, then totally drained-out she finally goes home near midnight.  Life and work in this hospital is becoming hell, but that is just the beginning.  The OR director, who herself is an unpleasant grumpy person, keeps questioning the competence of the surgeon.  She does not make it easy for her to be assigned the best technicians.  The surgeon learned a lesson about real life outside the university medical center.  She decides to be more selective accepting that her skills and professional abilities cannot grow in this hospital.  She decides that she should move to another hospital.  Read on ....

 

In the meanwhile, the OR director voices "serious concerns" about that surgeon's competence to the Quality Improvement Director.  The case is sent to an external reviewer.  The external reviewer decides that the care of that case was substandard, that is, below the standard of care.  The surgeon gets suspended from practice and an immediate investigation is started.  The surgeon is stuck.  She cannot go to another hospital now, being under investigation.  If she resigns her privileges while under investigation, she will have to be reported to the National Practitioner Data Bank (NPDB).  If the suspension remains for more than 30 days, she also has to be reported to the NPDB.  If the hospital decides to put any limitations or restrictions on her scope of privileges because of medical concerns, she has to be reported to the NPDB.  A report to the NPDB may result in the surgeon losing her career, since it will be very hard for her to be employed.  The collegial medical executive committee, being hammered by quality concerns from the OR director, fearing they lose reputation as being lax about patient safety, become hawks.  They have to protect the public.  This is what the OR director keeps reminding the key players from behind the scenes.  She also throws in, just for good measure, several other insignificant events to draw a bigger picture of alarm.  Now everyone is scared.  The potential liability to the hospital becomes the biggest anxiety of all.  They ask their lawyer, can we revoke that surgeon's privileges to be on the safe side?  Of course the lawyer tells them it is possible, and he is confident that the law is on his side.  There is immunity for the peer review process.  The young surgeon, who has barely started her career, is delivered the death sentence to that career.  All her privileges in this hospital are revoked.  Story ends.

Victimizing the Target Physician - the Next Level

The National Practitioner Data Bank (NPDB) is supposed to be a mechanism to expose those rogue monster doctors wherever they go, stigmatize them, flush them out of the profession, and kill their careers and livelihood.  As we know, the data that the NPDB promulgates, which drives those physicians to such horrendous fate, is simply derived from hospitals' disciplinary actions.  This is a huge amplification of the effects of a flawed system.  We know that most hospitals' systems in the US are not equipped with fair or impartial mechanisms.  We know that good physicians get caught in the flawed process like a mouse in a trap or a fly in a spiderweb.  No escape. No constitutional due process.  No impartiality. No fairness.  We know that the standards of the process are so low that anything can be used against the physician, with success, and immunity is enjoyed by the attackers.  A hearsay can trigger an action. A complication that can be the unfortunate consequence of treating a risky patient despite every effort would be just perfect. The NPDB entry is the Badge of Shame.  You may think that the NPDB reporting is the end of story?

Comes the next level of destruction.  "Continuous Query" formerly known as Proactive Disclosure Service (PDS).  Let that adversarial report be pushed to subscribing institutions within 24 hours.  Let everyone know, almost immediately, that a hospital has eliminated a physician.  Let the stigma stick before there is any chance to remedy.

As described on the NPDB-HIPDB website: "24 hours a day, 365 days a year. Continuous Query keeps you informed about the adverse licensure, privileging, Medicare/Medicaid exclusions, civil and criminal convictions, and medical malpractice payments on your enrolled practitioners. By enrolling all practitioners with which you interact, you receive email notifications within 24 hours of a report received by the Data Bank, and you always have access to Data Bank information on enrolled practitioners. Keep in mind that Continuous Query is only for querying on practitioners, not health care organizations.  Then there is a Note: "Continuous Query meets legal and accreditation requirements for querying the Data Bank."

Furthermore, it is dirt cheap.  Currently, the annual charge is $3.25 for each practitioner, for each Data Bank.

Shouldn't we really make sure first that we have an impartial and fair process before going to the extremes in career destruction?

Whether we acknowledge it or not, practicing medicine in the US is becoming a hostile and malicious environment, and is only getting worse.  This is NOT an exaggeration.  Be well informed.  You can easily become the next target and victim.  If that happens, you'll be surprised how vulnerable you will be, how helpless you will be, how you will be immediately marginalized by cascading events and a ripple effect, almost like a chain reaction.  And schadenfreude is so prevalent, sadly.

Texas Medical Association and Sham Peer Reviews

http://policy.texmed.org/

130.017     Physician Rights and Sham Peer Review:

The Texas Medical Association condemns “sham peer review” and manipulation of medical staff bylaws by hospitals attempting to silence physician concerns for access to quality care at hospitals and advocates against “sham peer review,” manipulation of medical staff bylaws and enforcement of such bylaws, and other tactics that chill or inhibit the ability of staff physicians to advocate for their patients (Res. 401-A-07).

The Texas Medical Association will (1) work to assure that accused physicians are granted reasonable rights and due process for peer review and quality assessment efforts;  (2) solicit member input and address issues related to misuse of peer review process or “disruptive physicians” policies by health care facilities or peer review entities; (3) work to educate and inform members about the potential misuse of peer review; and (4) work to end the use of “disruptive physicians” policies which are extended to non-patient care issues, such as economic credentialing, failure to support marketing or business plans of the hospital or health care facility, or are used as a recourse because the physician has raised serious quality or patient safety issues regarding the facility, and their practice (Res. 406-A-07).

Comment:   
State medical associations and professional societies representing physicians should take the lead in reforming the hospital peer review process to become fair and impartial. This is what patients expect. No patient wants to see his or her good doctor being eliminated by a flawed process.

A "pro-administration" doctor goes against an "elected" physician commissioner

I think I will deviate from my usual topics, since my Google radar screened a very odd letter article.  It is from the State of Washington.  The hospital, Valley Medical Center (VMC), is apparently discussing some sort of affiliation with the University of Washington Hospital.  VMC is a public hospital (that is, a government entity) which has a democratically-elected Board of Commissioners.  One result of the affiliation would be that a bigger governing body rendering the voices of the elected commissioners (including the one the hospital administration is afraid of) less significant.  Here is the link to the article:

Concerns about Valley Medical commissioner remain | Letter

http://www.pnwlocalnews.com/south_king/cmv/opinion/letters/117775948.html#

The doctor (Terence Block) wrote:

"Sadly, elections sometimes are decided by sound bytes and political rants, rather than insight in to the persona and qualifications of the candidate."

"If the affiliation between UW Medicine and VMC comes to pass, the operations of VMC will be guided by five elected Commissioners, five people appointed by the UW in consultation with many of our elected political officials, and three representatives of the most prestigious Medical Center in the Pacific Northwest. Yes, this may dilute Aaron Heide’s influence on the affairs of Valley Medical Center. Judging by his behavior at board meetings these past 14 months, I think that may be a good result."

What?  Is it only my imagination?  Doctor Block indicates that, since the voters did not elect a commissioner that goes along with the hospital administration, the remedy is to add governing members who are not elected, to dilute the effect of that elected commissioner, and any others in the future that may be democratically-elected.  Looking further, I found an earlier letter written by Aaron Heide, which completes the picture:

 

Valley Medical commissioner concerned and calls for action regarding democratic process | Letter

http://www.pnwlocalnews.com/south_king/cmv/opinion/letters/117209888.html#

I think this could be one more hospital on the radar screen to see if it targets "undesirable" doctors.

Does Your Hospital Abuse the Peer Review Process?

Dear Doctor,

If your hospital abuses the hospital review process and tries to enforce disciplinary actions unfairly, wouldn't it be a good idea that other physicians know so that, hopefully, new physicians be careful not to become victims.  Don't stay in a rotten place.  When you leave, you'll stink.

You can reach me in one of the following ways:

1.  Follow me on Twitter, I follow you, and you can direct message me.
2.  If you have a Facebook account, direct message me.
3.  You may make a comment on this blog if you wish.  The content of any comment is the responsibility of the posting person, since I do not verify content of comments.

Questions Defying Answers

There are some things in life that bother me a lot when I cannot understand.  When laws and regulations are counterproductive and unjust, where to go?

 

• I cannot understand why regulators and lawyers in the US have put in place a peer review process that is very clearly lacking in the equivalent of an impartial jury. 
• Why competitiors and those who may have an interest in eliminating a physician are given so much unbalanced power and have the final word, in effect?
• Why is the process so highly judicial that a physician may be targeted but have no financial means to protect himself/herself and, therefore, easily removed from practice?
• I cannot understand why such a process, that is therefore open to corruption, is left untouched
• I cannot understand why the American Medical Association, the American College of Surgeons, etc, etc, have been so soft in this while seeing their own members being victimized
• I cannot understand why the outcome of an inherently corrupt and unfair process has to be reported to the National Practitioners Data Bank as if it were a fair outcome?  Isn't that defaming by definition, even though the goal was to protect patients?
• I cannot understand why a physician has less rights in defending her/his career than a criminal does in defending himself/herself
• I cannot understand why there is absolutely no mandate that an educational peer review process exist, while punitive panels are set up to sentence to death good physicians' careers.

 

There is something wrong with this picture.  Physicians in the US are under the mercy of the politics and the whims and conscience of their colleagues.  Patients are not safer in such an environment.  Since the results of those execution tribunals (peer review committees) are so devastating, the select favorites will never be subjected to them, while the solo, the foreign graduate, the newcomer, the young (essentially the vulnerable), will more likely be the target.  And the victim may even be the better doctor than the ones who are judging.  Too bad that physicians do not have representation that stands strong on issues like those.  The American medical Association is just too soft on that issue.