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.
Thursday, April 28, 2011
Friday, April 15, 2011
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.
Friday, March 25, 2011
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.
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.
Saturday, March 19, 2011
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:
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:
Monday, March 14, 2011
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:
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:
I think this could be one more hospital on the radar screen to see if it targets "undesirable" doctors.
Concerns about Valley Medical commissioner remain | Letter
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
I think this could be one more hospital on the radar screen to see if it targets "undesirable" doctors.
Sunday, January 9, 2011
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.
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.
Thursday, January 6, 2011
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.
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