Monday, May 23, 2011

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.