Doctor Disgruntled

Ron Paul's alien supporters

2007-09-06T10:21:00.000-04:00

I am generally sympathetic to libertarianism, although I have a broad view of the legitimacy of pre-emptive violence in self-defense and am NOT an isolationist. But reading a discussion about the RonPaulian craziness and seeing his devoted supporters spam all of these online polls gave me an idea for a label for all those types:

RONULANS!

As in, "Captain! There are Ronulan warships off the port bow! Fire photon torpedoes!"

DD

Update: 9/7/07. I googled "Ronulan." There are about two billion hits for that already. I'm an idiot. Or a really clever but slow person. So let's call it "independent discovery," then. Ack. DD

Overlawyering? OH REALLY?

2007-09-06T09:44:00.000-04:00

Via instapundit: From JACK GOLDSMITH'S book, The Terror Presidency: Law and Judgment Inside the Bush Administration:

"In my two years in the government, I witnessed top officials and bureaucrats in the White House and throughout the administration openly worrying that investigators acting with the benefit of hindsight in a different political environment would impose criminal penalties on heat-of-battle judgment calls. These men and women did not believe they were breaking the law, and indeed they took extraordinary steps to ensure that they didn't. But they worried nonetheless because they would be judged in an atmosphere different from when they acted, because the criminal investigative process is mysterious and scary, because lawyers' fees can cause devastating financial losses, and because an investigation can produce reputation-ruining dishonor and possibly end one's career, even if you emerge "innocent."

Doc Disgruntled says....OOOOOOOOHhhhhhhhhh, REEEEEEEEALLLLY?

*92% of New York Ob/Gyns have been sued at least once.
*44% of New York Ob/Gyns report FOUR OR MORE CLAIMS against them in their career.
*51% of New York Ob/Gyns were sued at least once DURING THEIR RESIDENCY. (source: pdf of ACOG district II 2007 press release)

Doctors also find themselves judged in a different atmosphere, in an investigative process that is mysterious and scary, with high lawyer's fees (in our case, malpractice insurance premiums, recently increased 12% in NYS and now reaching as much as $180,000/yr- so 70 deliveries just to pay for your insurance), and under the threat of reputation-ruining dishonor even if you "win." I just hope the anti-terrorism guys don't quit the way ob/gyns seem to be...we really need them.

DD

Gardasil and HPV

2007-03-07T21:38:00.000-05:00

For all of those who are concerned that young women will become promiscuous just because there is a vaccine against the virus that causes cervical cancer and genital warts - get a load of this!

http://www.cafepress.com/hpvirus.114560436

I laugh out loud.

2006-12-26T12:39:00.000-05:00

Ah, the good old New York Times, on medical progress. New vaccines! New technology! New drugs! New cures! And a new world view!

"At the time, anyone who went into preventive medicine and public health was assumed to have graduated at the bottom of the class. A shingle on Park Avenue was the measure of success, not saving lives in poor countries. Now students are eager to study global health."

L.O.L. !!
DD

Release your information, stat!

2006-12-04T14:06:00.000-05:00

So you want to be a doctor? OK. Just agree to release all of your history and records to the scrutiny of an unlimited number of third parties, which you also agree to indemnify against any damages to you that may be caused by such an investigation. Or you could not accept any insurance - I hope you live somewhere where there are lots of rich people who agree to pay cash and who will choose you over the 1000 other doctors who accept what their insurance pays. Good luck!

"I understand and agree that, as part of the credentialing application process for participation, membership and/or clinical privileges (hereinafter, referred to as "Participation") at or with each healthcare organization indicated on the "List of Authorized Organizations" that accompanies this Provider Application (hereinafter, each healthcare organization on the "List of Authorized Organizations" is individually referred to as the "Entity"), and any of the Entity's affiliated entities, I am required to provide sufficient and accurate information for a proper evaluation of my current licensure, relevant training and/or experience, clinical competence, health status, character, ethics, and any other criteria used by the Entity for determining initial and ongoing eligibility for Participation. Each Entity and its representatives, employees, and agent(s) acknowledge that the information obtained relating to the application process will be held confidential to the extent permitted by law."

"I authorize the following individuals including, without limitation, the Entity, its representatives, employees, and/or designated agent(s); the Entity's affiliated entities and their representatives, employees, and/or designated agents; and the Entity's designated professional credentials verification organization (collectively referred to as "Agents"), to investigate information, which includes both oral and written statements, records, and documents, concerning my application for Participation. I agree to allow the Entity and/or its Agent(s) to inspect and copy all records and documents relating to such an investigation.

Authorization of Third-Party Sources to Release Information Concerning Application for Participation. I authorize any third party, including, but not limited to, individuals, agencies, medical groups responsible for credentials verification, corporations, companies, employers, former employers, hospitals, health plans, health maintenance organizations, managed care organizations, law enforcement or licensing agencies, insurance companies, educational and other institutions, military services, medical credentialing and accreditation agencies, professional medical societies, the Federation of State Medical Boards, the National Practitioner Data Bank, and the Health Care Integrity and Protection Data Bank, to release to the Entity and/or its Agent(s), information, including otherwise privileged or confidential information, concerning my professional qualifications, credentials, clinical competence, quality assurance and utilization data, character, mental condition, physical condition, alcohol or chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing on my qualifications for Participation in, or with, the Entity. I authorize my current and past professional liability carrier(s) to release my history of claims that have been made and/or are currently pending against me. I specifically waive written notice from any entities and individuals who provide information based upon this Authorization, Attestation and Release.

Authorization of Release and Exchange of Disciplinary Information. I hereby further authorize any third party at which I currently have Participation or had
Participation and/or each third party's agents to release "Disciplinary Information," as defined below, to the Entity and/or its Agent(s). I hereby further authorize the Agent(s) to release Disciplinary Information about any disciplinary action taken against me to its participating Entities at which I have Participation, and as may be otherwise required by law. As used herein, "Disciplinary Information" means information concerning (i) any action taken by such health care organizations, their administrators, or their medical or other committees to revoke, deny, suspend, restrict, or condition my Participation or impose a corrective action plan; (ii) any other disciplinary action involving me, including, but not limited to, discipline in the employment context; or (iii) my resignation prior to the conclusion of any disciplinary proceedings or prior to the commencement of formal charges, but after I have knowledge that such formal charges were being (or are being) contemplated and/or were (or are) in preparation.

Release from Liability. I release from all liability and hold harmless any Entity, its Agent(s), and any other third party for their acts performed in good faith and without malice unless such acts are due to the gross negligence or willful misconduct of the Entity, its Agent(s), or other third party in connection with the gathering, release and exchange of, and reliance upon, information used in accordance with this Authorization, Attestation and Release. I further agree not to sue any Entity, any Agent(s), or any other third party for their acts, defamation or any other claims based on statements made in good faith and without malice or misconduct of such Entity, Agent(s) or third party in connection with the credentialing process. This release shall be in addition to, and in no way shall limit, any other applicable immunities provided by law for peer review and credentialing activities. In this Authorization, Attestation and Release, all references to the Entity, its Agent(s), and/or other third party include their respective employees, directors, officers, advisors, counsel, and agents. The Entity or any of its affiliates or agents retains the right to allow access to the application information for purposes of a credentialing audit to customers and/or their auditors to the extent required in connection with an audit of the credentialing processes and provided that the customer and/or their auditor executes an appropriate confidentiality agreement. I understand and agree that this Authorization, Attestation and Release is irrevocable for any period during which I am an applicant for Participation at an Entity, a member of an Entity's medical or health care staff, or a participating provider of an Entity. I agree to execute another form of consent if law or regulation limits the application of this irrevocable authorization. I understand that my failure to promptly provide another consent may be grounds for termination or discipline by the Entity in accordance with the applicable bylaws, rules, and regulations, and requirements of the Entity, or grounds for my termination of Participation at or with the Entity. I agree that information obtained in accordance with the provisions of this Authorization, Attestation and Release is not and will not be a violation of my privacy.

I certify that all information provided by me in my application is current, true, correct, accurate and complete to the best of my knowledge and belief, and is furnished in good faith. I will notify the Entity and/or its Agent(s) within 10 days of any material changes to the information (including any changes/challenges to licenses, DEA, insurance, malpractice claims, NPDB/HIPDB reports, discipline, criminal convictions, etc.) I have provided in my application or authorized to be released pursuant to the credentialing process. I understand that corrections to the application are permitted at any time prior to a determination of Participation by the Entity, and must be submitted online or in writing, and must be dated and signed by me (may be a written or an electronic signature). I acknowledge that the Entity will not process an application until they deem it to be a complete application and that I am responsible to provide a complete application and to produce adequate and timely information for resolving questions that arise in the application process. I understand and agree that any material misstatement or omission in the application may constitute grounds for withdrawal of the application from consideration; denial or revocation of Participation; and/or immediate suspension or termination of Participation. This action may be disclosed to the Entity and/or its Agent(s). I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release and that I have access to the bylaws of applicable medical staff organizations and agree to abide by these bylaws, rules and regulations. I understand and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original.

Clausewitz, defensive medicine, and teaching the residents

2006-01-12T15:06:00.000-05:00

Karl von Clausewitz was a famous 19th Century Prussian military strategist, whose writings on War (On War) are broadly applicable to all situations in which strategic planning is required. One of my favorite of Clausewitz's observations is on the subject of "friction" in the chain of command. He notes that "countless minor incidents - the kind you can never really foresee - combine to lower the general level of performance, so that one always falls short of the intended goal. Iron will-power can overcome this friction; it pulverizes every obstacle, but of course it wears down the machine as well."

Recently, with one of my residents, I was performing what was expected to be a fairly simple laparoscopy on a young woman on the residents' service (ie, a patient in whom the residents are expected to have the primary role in management). Due to massive intrapelvic adhesions between the uterus and pretty much everything else in the abdomen and pelvis, the procedure took over three hours. When we closed there was some disseminated capillary oozing from the raw surfaces we had separated, but nothing that in my best judgement would put her at risk.

However, what I thought to be insignificant oozing might actually turn out to be worse, so I asked the resident to admit this woman overnight & obtain both an immediate blood count and a repeat count the next morning, in order to demonstrate objectively a stable blood count.

Normally, I take the "iron will-power" approach described by Clausewitz, and I am very strict with the residents, incurring the pros and cons as noted by old man Karl - the job gets done my way, obstacles be damned, but at the cost of wearing down the machine: the House Staff, who have to do it my way despite not being me, and me as well, as I continually have the same conversations about how I don't really care if they are "busy," the tests still need to be checked, the patients still need to be seen, etc.).

In this case, I tried a different approach: give the Chief some latitude - I was confident this situation wasn't risky, and I had been pretty explicit about my orders (how could they screw that up?). It isn't July, the chiefs have three years and six months of on-the-job experience and in just over another five months they'll be unleashed on the general public as doctors.

So I restrained my iron willpower and didn't micromanage the team. But I had operated on this woman and I am morally obligated to continue to care for her (not to mention legally obligated). Late the next day I checked in with the chief resident, and here's how it went:

Me: "So I assume Our Patient was fine and was discharged without trouble?"
CR: "Yep! She had some pain but felt better and went home."

I notice the CR didn't mention the blood count. I'm compulsive, remember? Can't let that slide -

Me: "Great!....and, uh...I take it her blood count was the same?"
CR: "...Actually it dropped from 37 yesterday to 30 this morning."
Me: (pause)
CR: "...uh...but her urine output was fine and her abdomen was soft, and the drop was consistent with the estimated blood loss at surgery."

I would have repeated the test again, given a falling blood count in a patient I was already monitoring for blood loss, even with the reassuring signs mentioned, but I suppose someone with more confidence in their clinical judgment could explain that drop as noted. But I didn't get angry. I just tried to make that teaching point.

Me: "...so what you're saying is, in your clinical judgment she was fine and the drop was explainable?"
CR: "Right."
Me: "Ok...(walking away down the hall)...but I still would have repeated it at 12:00 before I discharged her." (The blood test is generally taken at 6-7 am).

And that's when the icy hand of Clausewitz threw some Friction our way.

CR: "...Ah...Well...I actually didn't get the result of the first test until 12."

Now this is unacceptable. The test should be drawn on morning rounds, first thing, and be back by 10 am at the latest. Iron willpower wakes up:

Me: "I would have been compulsively checking for the results since about 10 am and then finding out why they weren't in the computer by 11."
CR: "...I did...but the specimen was 'lost' on the way to the lab...the patient even had a band-aid on so I know it was drawn this morning..."
Me: "...ok...I guess that explains your timing, but still, I would have kept her and repeated it at 3 pm just to be 100% safe."

And that was that. The patient turned out to be fine, as expected, but in my attempt to prove this I ran into precisely the kind of "countless minor incidents - the kind you can never really foresee - [that] combine to lower the general level of performance, so that one always falls short of the intended goal" as described by KvonC:

The specimen was drawn in the morning but lost
Friction in the system is so bad that the CR is used to drawing inferences like "she has a band-aid, the blood must have been drawn," because we have to expect our orders will not be followed. This means we spend half the day just finding out if the things we want done are actually getting done.
The specimen was then redrawn but the results were not available until late in the day
The combination of the time delay and the low-risk nature of the clinical situation led the CR not to fulfill her orders, as she judged the cost of time and effort outweighed the clinical benefit.

So big deal, right? The patient was fine - why even care about this?

Two reasons. First, it's all too possible for this situation to end with "the patient was not in fact fine and had been bleeding internally all morning." That happens. That's why I wanted her to be checked.

Second, there's the issue of Defensive Medicine. Clinically speaking, the CR was probably right not to bother with the test again - we were just looking for confirmation of the myriad signs that the patient was ok and not really expecting contrary information. But my desire for an "extra" blood count, and "extra" hours of hospitalization for this healthy young woman was DEFENSIVE, intended in part to prove with explict evidence what I "knew," that when I let her go home she was fine.

Why? Because a list of signs and suppositions a mile long can easily be cast into doubt by a malpractice lawyer who after the fact will say, "OBVIOUSLY your judgment was wrong, since she came back 12 hours later bleeding severely!" (Even if it weren't obvious, that's what they'll say). And a stable blood test is my trump card: "The blood count was 30, and 12 hours later it was 30. And that, in addition to everything else, was why I let her go home."

So Clausewitz's observations are a daily experience for me. Even being the iron will can't fix these problems, unless everyone else is also an iron will, but what truly rankles is that the everyday friction is exacerbated by the omnipresent hanging fear of litigation, which requires us to fulfill a standard often not supported by the clinical requirements of our patients, but by the emotional and evidentiary standards of a "jury of our peers."

DD

Your Government in Action

2005-12-20T20:53:00.000-05:00

At the office today, I provided a little patient with a vaccine for travel, since her parents were planning to take the family to the Caribbean for a vacation. The patient's mother is a college graduate; they have private health insurance from the father's job. The insurance gives me a cut-rate, but I jovially offered instructions for travelling with children, tips on plane rides, etc.

At the close of the visit, the mother provided me with a form to continue her eligibility for WIC, a Federal Government program that provides free infant formula and food. I suppose I have only myself to blame, because I was one of the founders of this program, in the 1970's, when I arranged for its beginning in the South Bronx, a poverty area of well-deserved repute.
In 1978, I was the single largest purchaser of infant formula on the Eastern seaboard.

The trip that this educated, middle class family is planning to take is during peak holiday season. Why should they receive any subsidy from the taxpayer? I'd rather spend the money on defense. (See "Where I was when everything changed" 9/13/05).

Where I was when everything changed.

2005-09-13T14:00:00.000-04:00

Thanks, Dr. Charles (www.drcharles.blogspot.com) for inspiring me to write this:

9/11: I was at the office when the news came in over the radio. We went to the roof of the building (50 stories) and looked south, and with my own eyes I saw the WTC on fire, huge clouds of smoke everywhere. While we were up there, someone with a radio said "They hit the Pentagon," and I realized even more than before, that things were deeply, deeply, wrong.

I went to the ER, waited for casualties that never came in. I went home and hugged my wife, who was crying because a few of her friends, thirty year old financial analysts who worked in the Towers, couldn't be found. They never would be. I went back out to the ER. Still no casualties. I went home again. What else could we do? A day later, I went to Bellevue, where my med school buddies were running the trauma service - nothing to do there except look at a wall a mile long, with paper flyers showing the smiling faces of a thousand people who would never come home. Same thing at St. Vincent's, about as close as you could still get to Ground Zero at that time.
!#$& murderous savages. Death is too good for them. There won't ever be enough vengeance for me.

Back on the blog.

2005-08-30T14:15:00.000-04:00

It has been awhile since I've posted. I read something over at http://www.doctornos.blogspot.com that inspired me. He wrote about how patients are very poor at answering questions. What's the deal?

Me: "What's the problem, Mrs. Patient?"
MP: "It hurts when I do this."
Me: "And how long has this been bothering you?"
MP: "Also, my friend said she thinks it might be..."
Me: "I'm going to cut you off there, Mrs. Patient - I was asking how long has it bothered you?"
MP: "A long time."
Me: (deep breath) "A long time means different things to different people...I'm looking for a unit of time, here, Mrs. Patient...as in 'a day, a month, a year'...."
MP: "Eh?"

And so on...

Orac Knows?

2005-06-07T09:36:00.000-04:00

Orac, at www.oracknows.blogspot.com, recently posted about the tendency of doctors, nurses, et al. to refer to patients by their diagnosis (or room number), as in "the diabetic in room 3 would like to speak to you." Here's my reply:

You know, Orac, you're absolutely right about that - it is somewhat dehumanizing to refer to patients as "the ectopic" or "the pre-eclamptic in room 3" etc., but I've always thought that a small part of that is cognitive efficiency (laziness?) and also focusing on the most relevant part of the many things that are important about your patient(s). I mean, I'm not supposed to care if Mrs. Smith is married or an unwed mother, if she is rich or poor, if she is beautiful or ugly, if she is kind or cruel, but I'd better care a lot about whether she's anemic, hypertensive, exsanguinating, etc. So the shorthand may reflect a failure to consider the "whole person" but it also reflects the obligation doctors have not to let the social or even physical attributes of our patients (consciously) influence our treatment of the disease.
Thus, I don't care if you're a Democrat, a Vegan, a Right-to-Lifer, a bricklayer, or a CEO - on the table, it's me against the disease, so maybe I can be forgiven for targeting my skills at the one part of the person that is most important in the professional sense...
Respectfully,
Doctor Disgruntled

Post Call, My Thoughts

2005-05-24T12:20:00.000-04:00

Here's the post: http://redstatemoron.typepad.com/red_state_moron/2005/05/post_call_.html

RSM asks why are we treated the worst, even though the whole thing depends on our labor?

I'll tell you why, RSM:Because the whole system has been set up to take advantage of your goodness, your skills, your compassion, your education, your committment to doing the right thing.
Lawyers wouldn't do it. Bankers would just laugh. But you're expected to do the work you do, without the help you need, without anyone really caring at all about your needs, your sanity, or even honestly your effectiveness in your job. (The same people who administrate the system that demands you work these hours will be the first to point their fingers at you when there's a "mistake" and say you should have known you were too tired to work. Or whatever they say.)
They are taking advantage of your character - they know that you'll do whatever it takes to get the job done right, even without the support you *ought* to have, because you care too much not too. You're a hostage to your own moral code.
It's why you make less money per hour than people in other professions with comparable education, and why you're sued but still agree to work. Because you care too much about doing the right thing, instead of the profitable thing.
Doctor Disgruntled

The Horrible, Horrible System is Mean!

2005-03-01T08:50:00.000-05:00

From Grand Rounds, (this week at http://www.intueri.org/index.php?p=1302) I came across this post at "Totheteeth." It is nice that people want to provide health care as charity, but I have to agree that the bashing of the free market system is really unwarranted. (my comments below the link)

http://totheteeth.blogspot.com/2005/02/grassroots-medicine-for-community-just.html

"In a lot of ways our system of medicine is so corrupt in its values around money instead of taking care of patients." said Ziwasimon.
...um...I'm not sure what Ziwasimon means by the "system" being corrupt, since the "system" isn't really taking care of patients and I am. And I do it in exchange for money. If I didn't get money in exchange for taking care of patients, I couldn't really continue to do it. Certainly "the system" cares a lot about money - for example, I paid in the neighborhood of $120,000 out of pocket and with loans (not donations, I had to pay them back with interest) just to become educated enough to take care of sick people. (I'm going to leave aside the economic analysis of my postgraduate training years where I earned $7.85/hr while trying to pay back those loans).
To echo Pogo, bravo if you want to do charity. We live in a country that gives us the freedom to make those choices. But asserting that I have less of a right to profit from my expertise than any other person leads down a road where we don't have an American health care system, and instead of merely a problem with health care for the indigent, you end up with problematic health care for the majority.
DD

Professionalism, JCAHO, and A Few Good Men Again

2005-02-17T10:37:00.000-05:00

I have been thinking about this a lot recently, and a recent post at Medical Grand Rounds inspired me to get it down.

The Joint Commission on Hospital Accreditation is pretty much a joke, in my misanthropic view. Recently a circulating nurse told me she had to leave the room to get a medication I wanted to inject during a surgical case, because due to the JCAHO visit, they moved all of the meds out of the OR........... uh......... because we wouldn't want actual medications to be near actual patients, now would we? Next they'll tell us we have to keep the scalpels somewhere else, in case someone is trying to steal them or for our own protection or some other BS. Every hospital I've ever worked in goes bananas trying to get a good rating from the JCAHO and usually by making it impossible to get any actual medical care accomplished (hide the meds! put away the needles! memorize the Mission Statement!).

Where this gets to professionalism is that the institutions that control much of a doctors life and livelihood are often highly inane, capricious, capable of massive unprofessionalism, and largely beyond they oversight of the people they govern.

The AMA says it's wrong to take $$ from drug companies, but they have no problem taking it themselves. They have no problem making $$$$$ selling CPT codes in partnership with the government (on the backs of the doctors they supposedly represent). Professional? I think not.

When I took my Board exam, I was required to grant a blanket indemnity to the Board if one of their employees misused my personal information (which I was required to open to them). Usually this kind of indemnity (also generally required by Medicaid, Medicare, HMO credentialing and Hospital Privileging Departments) includes the words "if in good faith" or something, but not the one I had to sign for the Board. Was I going to make an issue of it prior to being certified?

When the Bulletin they printed contained massive internal contradictions in the instructions and was barely comprehensible as written English, what recourse did I have? How "professional" is that?

In the film A Few Good Men, the Nicholson character is asked if he's aware of the regulation forbidding the practice of a "Code Red." He says, "I submit to you that the man who issued that order has never faced the working end of a Soviet made AK47...but let's put that aside for now." (That's my recollection). And similarly, the rules I work under are mostly written by people who don't have the "professionalism" to consider their practical and ethical implications.

So I have to struggle to do my job in the face of bloated and often hostile organizations with barely a thimbleful of actual professionalism, and on top of it my behavior (actually, my personality) is subject to the scrutiny of people who themselves are usually petty, artibitrary, and incapable of working under the kind of pressure I face almost every day.

I'd love to make the rules myself, but I'm too busy taking out people's dysfunctional organs and when I finish with that I like to see my family, so I'll skip the committee meeting, thanks very much.

Parallel Processing

2005-01-06T10:12:00.000-05:00

Another recurring problem at the hospital is the total inefficiency of most of the recurring processes we perform. I'm thinking here specifically of the operating room.

I've counseled my patient, often they have signed consent, and they and I both know what we're planning to do in surgery. Nevertheless, the procedure will not be set into motion unless I am physically present at the bedside. Once I'm there (for no real reason), then the anesthesiologist will see the patient and the room will be prepared (yes, it should be done in advance but realistically it takes twice as long if you're not hovering around in a vaguely disapproving way). Then they bring in the patient and anesthesia will get going. It takes usually about 30 minutes to get the patient on the bed and then intubated, and then we have to position the patient for surgery. So I have to arrive and then stand around doing nothing for basically 40 minutes every morning waiting for everyone else to do these things.

I can't depend on the residents to get it done, because they're totally unreliable and might not even show up. When they do show, they don't usually have the weight to push the nurses and anesthesiologists to get the case going.

Parallel processing would allow the room to be prepared and the patient to be prepped by anesthesia in advance of the start time.

During the course of the operation, I'm usually faced with the same problem - I'll ask for a scope and the circulating nurse, if she hasn't left the room for some reason (WHY? Where else do they go while we're operating on the patient?) - will unpack one. If when I come to the room I ask if the scope is in the room and opened, I'm being unreasonably demanding- "Relax...all in good time" is the attitude I get.

This reminds me that while you might think the OR is a place where people just get the job done, in reality, it is just like many other workplaces. If I don't ask "nicely" for a clamp, the scrub tech gets huffy and will complain that I hurt his or her feelings. And the administration will always take their side. Never mind that the patient is bleeding and I'd really like the instruments handed to me a little more quickly...if I suggest that the tech is slow they're INSULTED. I have to overlook the fact that a nontrivial percentage of the time they don't even know all of the names of the instruments, so when I call for something, there's a delay while that's translated into something comprehensible to them.

Infuriating.

The Pain, The Pain

2004-12-14T08:00:00.000-05:00

I've been thinking recently that being a parent is making me a better doctor, and in this week's Grand Rounds, (http://emeritus.blogspot.com/2004/12/grand-rounds-12-welcome-to-12th.html), a post at The Cheerful Oncologist echoes my thoughts somewhat.

For me and most of my cohort at medical school, life has been comparatively easy. I enjoyed the benefits of a stable home growing up, "child-centered" parents, a safe community, and an excellent quality of education. I had the privileges of a very expensive education and then medical school. All of this was not without its hard work and sacrifices, but mostly in comparison to my classmates along the way who worked less hard, studied "easier" things where there aren't necessarily right and wrong answers to find or avoid, and who went straight into the workforce at age 21-23 without all of the exams and overnight calls.

Now I have a little girl, who is the light of my life, and even the slightest threat to her well-being, emotional or physical, causes me to become nearly paralyzed with a gnawing, tearing, chest-pain.

And yesterday after I operated on a very nice 70-ish woman (for benign reasons), I went to tell her middle-aged sons that Everything Is Going To Be OK, and I could see their palpable relief, and appreciate it in a new way. I got to be the agent of destiny that showed up with good news.

All of this makes me more sympathetic. Not that I was unsympathetic before, but now I can really empathize with the stress and fear that come with medical hardship in a way that I don't really think I did before.

Unnecessary C-Sections and VBAC

2004-12-07T09:39:00.000-05:00

Just a short post on this, since I think it has been done to death elsewhere. I love how in these articles about vaginal birth after caesarean they talk about how many "unnecessary" c-sections are performed. Um...exactly how do the reporters, critics, insurance companies, and other rock throwers know that these c-sections were "unnecessary?" Somehow I doubt they were sitting there for six hours reading a vaguely non-reassuring fetal heart tracing and examining a woman whose cervix is dilating but edematous, and who is screaming every 2-4 minutes at the top of her lungs because the epidural isn't working that well.

As usual, after the fact, everyone's an expert in what should have been done, but there really aren't that many people who are actually willing to put their minds and hands into service just to be judged the day after that what they were doing wasn't really necessary.

My final note on this: the women who are outraged that they are being denied the "right" to VBAC can solve this problem in many ways (most obviously, by finding a doctor and a hospital that is willing to make a blanket guarantee that they will permit a VBAC- good luck) - I think the best way would be for them to learn how to deliver babies. Then they could all give each other whatever rights they think they deserve, and sue each other when they have bad outcomes.

You can't handle the truth

2004-12-02T09:57:00.000-05:00

Via Luskin's www.poorandstupid.com, I was directed to a Times of London piece by an author named Janen Ganesh (http://www.timesonline.co.uk/article/0,,3284-1371830,00.html), in which he remarks upon the negative treatment of the US Armed Forces by the media. The Jack Nicholson monologue from the film A Few Good Men ("You can't handle the truth!") is referenced.

I've always said that along with my co-blogger, I'm one of the only people in America who watches that film and roots for the Nicholson character. My experiences as a doctor have generally strengthened this view.

Nicholson is doing a difficult and stressful job, a vital job, protecting American lives. He describes the rigorous training and discipline needed to execute his responsibilities. There is little margin for error. Most people don't really want to know the bloody details about the pain and suffering that he and his colleagues are going through ("Ever put your life in another man's hands, or ask him to put his in yours?"). If they're doing their jobs right, the general public won't want to know about it. ("Deep down in a place you don't talk about at parties, you want me on that wall...you need me on that wall.")

Of course, the minute something goes "wrong," someone dies, some outcome that is not anticipated comes to pass, suddenly everyone and their uncle is howling all over the place, "How could this happen?" and "What has been going on here!?" and is more than willing to judge in retrospect what ought to have been done.

Sound familiar?

As Nicholson says in the film, (I'm paraphrasing I think): "I'd rather that you just said 'Thank You,' and be on your way."

My frustration as a physician with the way my work is analyzed and judged retrospectively mostly by people who aren't capable of doing it themselves is one thing, but to put it in perspective, the military has to do all of that stuff, plus people are trying to KILL them while they do it.

(I'll just say "Thank You" and be on my way.)

More than I can say

2004-11-08T13:13:00.000-05:00

At the National Review, there's a great piece on the implications of the national election for tort reform, that lays out in greater detail than I can a lot of good news. Check it out.

http://www.nationalreview.com/comment/copland200411080818.asp

Thank God.

2004-11-04T16:01:00.000-05:00

I'll guess that the only obstetricians in the United States of America who are not relieved to find that George W. Bush has been re-elected are the ones who live in North Carolina.

Is it time to go home yet?

2004-10-07T09:28:00.000-04:00

I've never understood why doctors don't hold the "support" personnel who are crucial to the delivery of medical care to the same demanding standard of work intensity and time commitment as the one to which we are held.

When they tell me a patient needs to be seen, I don't say "I'm on my break." I don't leave the operating room after 5 hours because my shift is over.

And it may be controversial to say this, but my impression is that nursing organizations (ie, unions, lobby groups) are always making a big deal about how their contributions are crucial. And they are! But they are also notable for the fact that their hours are governed by union contracts. They are shift workers, who except in rare circumstances go home when the whistle blows (almost no matter what is going on at the time). There are times when I have had three full and completely different teams of operating room personnel come and go during a single case. This isn't good for the patient under anesthesia, and it isn't helpful to me.

Everyone wants to share the credit.

And yes, I know they get paid less (they also get trained less), but I think it would be more appropriate if they recognized that what they are doing is supporting doctors, while they are also helping their patients.

Helpers

2004-09-10T19:21:00.000-04:00

I recently had a dispute with a patient. I learned, after a satisfactory medical outcome, and a good doctor-patient relationship, that her insurance would not pay the bill; the policy having lapsed before the date of service. Immediately upon receiving this information from me, the patient switched to another MD, and requested her record be faxed to her. She received a fax within 48 hours.

The patient, however, seeking a justification for not paying the bill, sought to create an uproar to end the relationship. She refused to admit that she had received a fax in return for her faxed request. (My office fax produces a receipt.)

The patient reported her inability to produce records to her new MD, and the office staff called my office on her behalf several times; insisting on being connected directly to me, and succeeding.
She reported me to the Medical Director of the Hospital where I am President of the Medical Staff (a voluntary position), and she received encouragement and instructions on how to contact the Dept. of Health and file a complaint of non-professional conduct, despite the fact that there no hospital care was involved. The Medical Director called and informed me of the patient's rights.
The Dept of Health, Division of Professional Conduct, Office of Records Access, contacted me, and also advised me of her rights.
She filed an additional complaint with the insurance company that had not paid the bill to begin with, and personnel from this company contacted me to complain on her behalf.

I resolved this (I think) by offering to send an additional copy of the records to the Dept. of Health; they agreed to send me proper release forms.

In summary, the patient was able to marshall pwerful forces against me: Her new MD; and an additional MD working for a hospital; the State; and an Insurance company. She had, it should be noted, received exemplary care, and she was satisfied until she learned that she would have to pay for it (a relatively small sum, actually). I, on the other hand, had been subject to theft of services, medical supplies, and the fradulent use of an insurance card. However, not one of the people who spoke on her behalf was willing to listen, or to take any action concerning what was due to me.

The RNC

2004-09-07T11:24:00.000-04:00

Many of my friends (all of whom vote Democrat) have been asking me how I can support President Bush due to his positions on the economy, the Federal Judiciary, abortion, religion, and whatever else - on many of these subjects I disagree with the President. (Though I suspect on fewer of these and to less of a degree than my friends suspect).

Until recently, my answer has been that the overriding issue for me has been terrorism, and the war on Islamofacism, and that I can't trust the Democrats to do what's necessary. Fortunately, the RNC made it clear that there are issues other than the war upon which I can claim 100% agreement with the Republican Party:

Republican Senate Majority Leader Senator Doctor Bill Frist: "you can no longer be pro-patient and pro-trial lawyer.' and "Another reason health care costs too much is our abused medical liability system. The culprits are personal injury trial lawyers.
We oppose these predators. We must stop them from twisting American medicine into a litigation lottery where they hit the jackpot and every patient ends up paying."

Republican Vice President Dick Cheney: "Under this president's leadership, we will reform medical liability so the system serves patients and good doctors, not personal injury lawyers. "

Republican President George W. Bush: "As I have traveled our country, I have met too many good doctors, especially ob-gyn, who are being forced out of practice because of the high cost of lawsuits. To make health care more affordable and accessible, we must pass medical liability reform now. And in all we do to improve health care in America, we will make sure that health decisions are made by doctors and patients, not by bureaucrats in Washington, D.C."

Not About Medicine

2004-08-13T09:06:00.000-04:00

But I can't help it, I've been reading so much about the military action in Najaf, and it's been persistently frustrating. Can't we all agree that if throngs of murderers pack rifles and explosives into a "Holy Shrine" then the shrine is at least temporarily considered NOT HOLY until they can be killed? This is just ridiculous. If the killers disrespect their own holy site enough to use it as a military base, than why do we have to fall all over the place to prove we respect it?

The DNC

2004-07-27T09:23:00.000-04:00

First of all, I'm sure I'm not the only one who found it ironic that Jimmy Carter talked about serving for two Presidents of different parties who fulfilled their military obligations with honor, leading us into President Clinton's speech...

Update: I'm not: http://althouse.blogspot.com/2004_07_01_althouse_archive.html#109089036379570221

Second, when Senator Clinton said "I know a thing or two about health care," I could see one thing clearly: that between Senator Clinton's "knowledge" about health care and Senator Edwards' "knowledge" about it, what the Democrats are offering to DOCTORS (you know, the drones who actually, um, PROVIDE HEALTH CARE) is intimate knowledge of how to undermine, destroy, and otherwise dismantle Physicians - and somehow they want us to believe that is going to make the health care system better.

Moral Dilemmas

2004-07-13T16:04:00.000-04:00

I recently evaluated an elderly woman who was brought in by her home care attendant. The attendant had noted small amounts of vaginal bleeding, obviously abnormal in a woman in this age group. I think that most gynecologists would agree that an endometrial biopsy figures into the diagnosis of this problem, as there is a non-trivial likelihood of neoplasm (ie cancers or other tumors) being the responsible agent.

The problem is that this particular woman suffers from dementia, and couldn't understand the risks, benefits, and alternatives to the proposed treatment (the biopsy), which, despite its relative ease and benign nature (low risk of complications, quick and often easy to obtain, minimal to moderate discomfort for a very short duration, can be done in the office, etc.), is from a legal standpoint, surgical. Fundamentally, as simple as it can be, technically, it's surgical removal of a (small) piece of her body.

And thus, from a moral and legal standpoint, we need either her consent, or in the event that she cannot give it (if she lacks decision-making capacity), consent from someone who is LEGALLY, and we assume morally, entitled to make those decisions for her. A proxy.

In this case, that consent was easy to obtain, from the patient's daughter, and this consent was documented in the medical record just in case John Edwards and company later have a reason to review it. But what about cases where it isn't easy?

Send the patient home until consent can be obtained, even though she might have a growing cancer that ought to be diagnosed? Do the biopsy anyway, without anyone's consent (this meets the legal definition of "battery," by the way). If I send her home, and she doesn't followup, and develops advanced cancer, I can be held liable for MY failure to find her!

In an emergency, two attending physicians can sign that a procedure is medically necessary, overriding the need to first obtain informed consent. But what exactly is an "emergency?" Probably the possibility of having cancer doesn't qualify.

The health care system, and the liability system, as they are currently structured, put the doctor in a tough position in hypothetical cases like this one. Essentially, the medical and ethical reasons to perform the right diagnostic test are outweighed by the moral imperative not to do surgery on someone without their (or their proxy's) consent. From a medical and ethical standpoint, then, it may be relatively clear that not doing the biopsy is the right thing. The doctor then has accepted some degree of moral burden for hunting down this patient until she comes back with consent - now I'm on the hook for whatever happens to her, just because she came in and couldn't give consent for treatment - or until it is clear to her proxy that she is entitled not to have the proposed treatment, and that they accept the responsibility for this (see "It's Personal Responsibility, Stupid!" below).

But the legal liability isn't so clearly distributed, because as above, if she doesn't followup and gets cancer, negligence can be imputed. And while you might remember to chase down one particular patient, seeing 10-40 patients per day, five days a week, inevitably something won't get followed up correctly.

We spend big $$$ on receptionists and schedulers whose sole job is to chase these patients down and get them back in. When we can't find them, we send them certified mail and telegrams to be able to prove we have tried to get them in, so we can show the attorneys. In the clinic, the schedulers are (appropriately) told not to tell the patients the nature of the abnormal results that require them to come in (privacy regulations), so instead they just are basically scared into returning.

That's not an ideally humanitarian way to take care of people. And that's also a lot money that isn't getting spent on medicine. It's all thrown into the liability protection system. What a pity.

It's Personal Responsibility, Stupid!

2004-07-08T10:31:00.000-04:00

Recently, a young woman had some abdominal pain and went to the emergency room. They called me because she was pregnant (supposedly 9 weeks) but her hormone level and ultrasound did not conclusively demonstrate a viable intrauterine pregnancy (a small sac was seen in the uterus, but not consistent with a 9 week gestation), raising the possibility that she had a potentially dangerous ectopic pregnancy.

Even though her pain was mild and transient, and she wanted to go home, she and her family had inadvertently walked themselves into a small problem. You see, if "we" (me, the ER doctor, the Hospital, Anyone With a Deep Pocket Who Happened To Be Standing Nearby Or In the Same Legal Jurisdiction, right Senator Edwards?) let her go home, and she did end up having an ectopic pregnancy, and she had a complication from it, retroactively many, if not most people would conclude we did the wrong thing in letting her leave, even if it had been a reasonable choice at the time. Most laypeople, regardless of IQ, just aren't used to thinking about situations like that retrospectively, and it would be hard to persuade them that given the facts at the time, it was reasonable to discharge this patient. Certainly, no malpractice litigator who wants to win a case would want a jury to have a clear understanding of how looking prospectively and retrospectively at this problem could lead to different choices, and it's painfully easy for them to point to the complication and say "all of this could have been prevented IF ONLY the negligent doctors, hospital, etc., had kept this woman in the Emergency Room." (Of course, they don't have to explain that it is impossible to keep every person under 24-hour medical surveillance for an indefinitely long period of time just because something might happen to them in the future.)

But doctors and hospitals have become smarter about that, haven't we? We don't just send people out the door anymore, even if we explain to them the risks they are taking by not staying (indefinitely). So in the case of this woman I advised her to stay in the Emergency Room (indefinitely) until we could be "sure" that she was ok.

Her pain was gone. Her tests could be interpreted in several ways (ectopic, early normal pregnancy, or miscarriage at 9 weeks), some of which are dangerous, some of which are not. But even though she felt fine at this point, and probably wasn't in danger, we were not just going to let her go home. Going home became her problem.

And the underlying message we're sending to her is, "We don't want to accept responsibility for what happens to you if you go home, so we advise you to stay here."

And there is an answer, a solution for her, but I have yet to see a single patient figure it out for themselves. The answer is to say, "Fine. I absolve you of any responsibility for what happens to me if I choose to go home, recognizing that we have an incomplete ability to predict what might happen to me."

Maybe the words are sophisticated, they way I write them, but the idea really isn't. Take responsibility for your actions. (I choose to go home, now that the MD's have explained to me the risks, benefits, and alternatives to staying or going, and therefore, I am responsible for what happens to me, provided the doctors have given me medically accurate advice.)

But patients generally don't say this. And probably don't believe it. (I expect most people would rather believe that their misfortunes can be blamed on other people who have failed to do their jobs correctly than believe that their bad luck is partially or completely their fault.)

Fortunately for doctors, hospitals, and fundamentally, for patients who would otherwise become prisoners of a health care system that refused to release them out of the fear of litigation risk, there is a mechanism for achieving this contract of personal responsibility.

The patient signs herself out of the hospital "Against Medical Advice." We advise her to stay (indefinitely), she signs saying she wants to go home, even though we've told her her life is at risk.

It's a poor solution, also it's probably easy to impeach in court, but it isn't worthless. And it formalizes the process of having a patient take responsibility for their choice. So doctors don't have to have infinite, limitless responsibility for the slings and arrows of outrageous fortune.

God Bless America, and God Help Us If Edwards Gets Into the White House

2004-07-06T09:39:00.000-04:00

From an article at CNSNews.com, citing the Boston Globe's 2003 profile of Senator Edwards:

"The Globe cited an example of Edwards' oratorical skills from a medical malpractice trial in 1985. Edwards had alleged that a doctor and a hospital had been responsible for the cerebral palsy afflicting then-five-year-old Jennifer Campbell.

'I have to tell you right now -- I didn't plan to talk about this -- right now I feel her (Jennifer), I feel her presence,' Edwards told the jury according to court records. "[Jennifer's] inside me and she's talking to you ... And this is what she says to you. She says, 'I don't ask for your pity. What I ask for is your strength. And I don't ask for your sympathy, but I do ask for your courage.'"

Add: 7/6/04; 1240 pm:

Don't miss Kate O'Beirne at the NRO, with a recap of a NY Times article about Edwards' spiel from one of his malpractice cases:

http://www.nationalreview.com/kob/kob200402050836.asp

Referencing the hour-by-hour monitor readings, Edwards told the jury, "She said at 3, 'I'm fine.' She said at 4, 'I'm having a little trouble, but I'm doing O.K.'...At 5:30, she said, 'I need out.'" His closer: "She speaks to you through me...I feel her presence. She's inside me, and she's talking to you." Edwards's clients won a $6.5 million verdict in that cerebral-palsy case and Edwards went on to win over $60 million in about 20 similar lawsuits over allegedly botched deliveries against doctors and hospitals. His share of the verdicts was typically about a third.

Ironic and Sad

2004-06-14T12:19:00.000-04:00

From the AP:

Doctor Proposes Not Treating Some Lawyers
Mon Jun 14, 7:38 AM ET Add Health - AP to My Yahoo!
By TARA BURGHART, Associated Press Writer

[clip]

You know where this goes, the doctors at the AMA went ballistic when this was proposed, and they aren't going to come close to endorsing this kind of proposal. But here's the interesting part of the story, in the last two paragraphs:

"Last week, the daughter of a Mississippi legislator said she was denied treatment by a plastic surgeon because her father opposes limits in damage suits against doctors.

Dr. Michael Kanosky said he referred Kimberly Banks to other plastic surgeons to have her burn scars removed because he had lobbied on the other side of the issue and saw an ethical conflict."

So...her father is against limiting malpractice damages against doctors...and she's having trouble finding a plastic surgeon to treat her burn scars...wait a second...I've got it! She needs to find the kind of plastic surgeon who doesn't care about being exposed to unlimited personal liability if a jury decides they've committed malpractice. I'm sure that there are plenty of intelligent men and women out there who are qualified to be plastic surgeons and who will just accept that they have unlimited personal liability when they agree to help someone get rid of their burn scars. Which, by the way, I'll point out is a totally elective, COSMETIC procedure that is freely sought and invited by this patient.

ADD (6/14/04): In an article I found about tort reform in Mississippi, "Tort Reform in Mississippi Legislature Dies, Revives and Dies Again," Earnest McBride, freelance writer for the Jackson Advocate, noted that "Jefferson County, Mississippi, has been the venue for some of the largest class action suits in the nation, including the f$14.5 billion en-phen diet settlement and the multi-billion dollar tobacco lawsuit, both with national implication."

No good deed goes unpunished

2004-05-27T13:17:00.000-04:00

A few months ago I got an emergency call from a small local hospital I cover - A pregnant woman was in advanced labor in their emergency room and they don't have Obstetrical Services. I immediately started to arrange rapid transfer of this woman to an appropriate nearby facility, while I raced to the Emergency Room in case she was really about to deliver. I arrived roughly 12 minutes after they first called me (I checked my watch, can't be too careful about these things) to find the woman in labor, basically fine, but around ten people standing around not really doing anything to help the situation.

So I fixed that. Examined her, scanned her, took a history (why couldn't any one of the other personnel there, including several MDs and assorted other "medical care providers" do this?), and made sure neither of my two patients was in any danger. I refocused the "administrative" personnel on getting that transfer going, rather than having to deliver the baby in the Emergency Room or the ambulance or something. She was term, prenatal care in another state (!) and decided to visit her aunt, then went into labor.

During the course of my examination of this woman, she started screaming at me - I examined her "too roughly," and she was angry. (Then I was angry, but I choked it back; after all, she's in labor, she's scared, all that. Maybe I was too rough? I was a bit anxious myself, trying to make sure we didn't have an impending disaster on our hands, and faced with a dead baby nobody is going to take my side and say, 'well, he didn't want to be too rough with the examination, so he couldn't really figure out what was going on.')

After a TOTALLY UNACCEPTABLE delay, we got her transferred, and she went on to deliver safely; while I was happy about that I was still annoyed that I was the target of her anger, given all of the people around her who had done nothing to take care of her other than, well, call me to come take care of her.

The hospital where she was transferred notified me the next day that her blood and urine tested positive for cocaine and alcohol.

Nice.

Cut out the cancer

2004-05-17T14:26:00.000-04:00

While travelling this week, I happened to notice that the covers of both Time and Newsweek were dedicated to the Abu Ghraib prison story. Meanwhile, the enemy (ed: "whose enemy?") by which I mean the enemies of Western Civilization, those people who overtly and covertly are trying to exterminate Western values of freedom, equality, and diversity, videotaped themselves beheading a contractor. And they're proud of it. I assume we won't be seeing front cover stories about that, instead we have to flagellate ourselves because a bunch of prison guards took naked pictures of a group of people formerly known for torture, rape, murder, and the service of manaiacal dictator. So excuse me if I don't weep openly for their "suffering." (A friend of mine actually cried, cried(!!) for their humiliation. I find it hard to imagine how she reacted to 9/11 and I didn't ask.)

Was it wrong? Sure. Should it be punished? Yes. But let's move on, and remember the bad guys don't want us to capitulate in this war. They want us to DIE.

The Catch

2004-05-07T22:24:00.000-04:00

As a pediatrician in practice, I am referred newborn patients at our local hospital. Once the infant is born, standing nursery admission orders (using my name, my license, my malpractice insurance, my hospital privileges) are initiated. Sometime within a reasonable interval, I arrive at the hospital and examine the patient. Then, I interview another patient, (the Mother, sometimes anesthesized) to obtain, and relate, information about my patient. A few days of hospital care usually follow, and may include some elective surgery (a circumcision). Then my patient is discharged, in tandem with the other patient (the Mother). And, if I'm lucky, I never see them again. My responsibility persists for 18 or 21 years, depending on which lawyer is talking.
My office then attempts to arrange to obtain some financial recompense for my highly specialized, insured, licensed and heavily regulated labor. Of course, the hospital paperwork contains only information needed for hospital billing, and although I have asked ( I am the President of the Medical Staff, for crying out loud) they refuse to obtain information relating to physician billing during any part of the registration process (like before the Mother is anesthesized) because the additional info would "confuse their billing process."
If I get any response from the Mother to our attempts to get paid, it usually consists of her informing me that I am not "in" her insurance, so I she refuses to pay me. She insists that I should have informed her about not being "in" her insurance before I proceeded to care for the infant.
So, the next time I approach an anesthesized, exhausted and worried new Mother, the first thing I have to say is "What kind of insurance do you have?" I can't give her any reassurance about her infant, because I haven't examined him yet. Most of them don't have a clue at that point which insurance plan (her's? Dad's? the one from the job she's on maternity leave from? or the job she was at when she conceived?) covers the infant.
Anyway, we're off on the wrong foot; because all I "care about" is insurance. Damned if I do, damned if I don't.
Peds10708

Anatomy Lesson and the USS Clueless

2004-05-07T10:14:00.000-04:00

I read Stephen den Beste regularly (http://www.denbeste.nu/), and I almost emailed him about this comment, but then I decided it's just the kind of nitpicking he derides, so I'm posting it here instead, for myself.

He suggested that his inability to acquire foreign languages easily was due to his type of cognition, "holistic thinking," and that he was unable to memorize long lists of words (this is "Detail" thinking rather than "seeing the forest for the trees.")

I think it's just the opposite. I barely passed Gross Anatomy precisely because I couldn't (wouldn't) memorize laundry lists of ligaments and nerve branches across the whole body, and I think I'm more of an "holistic" rather than "detail" thinker, but I find foreign language acquisition relatively easy, and always have.

If you ignore "minor details" like spelling and pronunciation, English and Spanish are 75% the same, in my view. If you get hung up on the differences between the words "Ado-LES-cent," and "ado-le-CENT-AY" then you might find it difficult to speak a "new" language.

Professional Prognosis

2004-05-07T10:05:00.000-04:00

In the doctors' lounge I overheard two old surgeons complaining to one another about an Editorial written in the professional journal of their subspecialty, which suggested that established doctors shouldn't tell medical students all of the bad things about practice, and that they should instead emphasize all of the positive things that can be found in the practice of medicine. They didn't see it that way.

I think most people have a pretty good basic idea of the positive things- that's why they're drawn to the practice of medicine. The question for young people considering the practice of medicine is, "How much are you willing to put up with in order to do this?"

I think we should travel to college campuses with large posters saying, "Want to be an obstetrician?Congratulations on your decision to spend the next four years acquiring a $120,000 tuition bill and then working four years for $35,000 a year. By the way, three out of four of you will be sued for malpractice (at least once)."

Nothing Works

2004-05-03T12:40:00.000-04:00

That's another thing that has been weighing on me recently. Almost nothing works around here. My computer: broken (I have to do this from the library). Getting someone to fix it: nearly impossible. So, access to my email, to my patient records (on the computer) - nope. I like to type my patient histories - YES, MY COLLEAGUES ARE STILL HANDWRITING THEM - because it is faster, wasting less of everyone's time. But I haven't been able to PRINT them for over a month. I have to save them to disk and then find another station in the office to get them down to the printer. This is so frustrating. And the bottom line is it makes me wonder about the context in which I work - there isn't adequate support for me to maximize my working time - instead I'm dealing with the computer. Other things in the office (the telephones, the answering service) all grind along the same way. Believe me, I'm doing what I can to fix it, but it's frustrating that I have to put any energy into it at all - why do we have a medical office at all, if not to make it easier for the doctors to see the patients? Yet nothing seems to exist to make that easier. And the rot that underlies this problem is the real problem.

Postop Day One

2004-04-30T11:01:00.000-04:00

I'm tired. The first case (the t-shirt case) took much longer than expected (which is a given), because it was actually a surgical challenge. Part of the problem was instruments - now, I know a good surgeon isn't supposed to blame the instruments, and I'm not really blaming them, just noting that the tools I had to work with just weren't well-suited to the task. We got it done, but it was much slower and much harder than it had to be. Anyway, after that we started the second case, and then it was very late. Back in the office today, two cups of coffee, and I'm still walking around with dead eyes. I had to dictate op. reports on surgeries done literally months ago, because the (unreliable) residents blew it, never did it.

Grrrrr.

Minor Cases

2004-04-29T15:11:00.000-04:00

Ohhhhhhhhhhh brother. The rage I'm feeling. Years of training, years of study. I'm providing a specialized surgical service to people who don't have that many options. And while I'm walking out of the OR waiting (as usual) for them to be ready for me (as usual), the "head nurse" accosts me: "Who are you?" (I'm new to this hospital. I guess that's why she's comfortable being that rude to me. Or maybe it's because she knows damn well that while I may be an Ivy-league educated surgeon, she's a unionized employee who is pretty much untouchable. Bitch.)

I tell her.

"It's OR policy that if you're wearing a T-shirt under your scrubs it has to be fully covered."

This is what she stopped me for. THIS is their policy?! How about a policy that every #@^&#$ surgery shouldn't start 45 minutes late? Or a policy that their scrub techs have actual competence at their jobs? Nope. T-shirt policy- no tolerance.

Does my T-shirt touch the patient during surgery? (It doesn't, it's covered by OR scrubs.) Do my OR scrubs touch the patient? (No.) What's the difference between my white T-shirt and the surgical greens? (Other than that my T-shirt was cleaned by me at home and not in a batch of industrial laundry by a cut-rate low bid housekeeping company that probably kicked back a few grand to the City Council to get the job).

Is there ANY EVIDENCE AT ALL that T-shirt bacteria pose a threat to surgical sterile technique? Through OR scrubs and through OR gowns? Fat #@!&% chance.

But that's beside the point, right? Much better to enforce the policies and to make senseless policies to enforce. It lets all of us feel like we're really valuable and really doing something for the patients. When actually, only I'm doing that.