JC, MD – Brain Blogger http://brainblogger.com Health and Science Blog Covering Brain Topics Wed, 30 May 2018 15:00:03 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.6 Managed Care Kills a Provider’s Reputation http://brainblogger.com/2008/10/05/managed-care-kills-a-providers-reputation/ http://brainblogger.com/2008/10/05/managed-care-kills-a-providers-reputation/#comments Sun, 05 Oct 2008 20:26:04 +0000 http://brainblogger.com/?p=1632 One of the difficult things about having a career in medicine is that reputation is paramount. It is quite precious and is easily shattered. There are not many industries where interpersonal interaction is more important. From interactions between a provider and his patients, nurses, ancillary staff, and other providers, the professional reputation of a doctor is made. Sometimes it is fair, sometimes it is not. It’s an industry where subjective opinions of others dictates the volume and quality of referrals a doctor can get.

Whether the technical or intellectual skill of a physician is good or bad often does not matter. If the nurses on a floor like you, they will undoubtedly tell their friends and help develop your reputation in that institution. Similarly, the way you treat patients will directly affect what they say about you to their families and colleagues.  In this day and age of online reviews of doctors, you can never be sure whether what you say or do will show up online.

In this era of managed care where providers cannot spend much time with patients, it is even more important for physicians to develop good rapport with patients. Unfortunately, the system is set up so that a provider cannot make ends meet unless he sees patients at least every fifteen minutes. If you have ever visited a doctor, you know that fifteen minutes is barely enough time to go over one complaint, let alone multiple things that will likely affect you as you age. Thus in order for physician’s to stay financially solvent, they must limit the time they spend with their patients. As you can imagine a doctor’s reputation declines from this type of behavior. Thus it is the rare physician who is able to make his patient feel that he has spent adequate time with the patient when the reality is that he has not.

There have been many efforts to rate doctors objectively. Those have all been failures. There are no good metrics by which to compare physicians. Those measure that have been used have been formulated by insurance companies aimed at cutting costs.

One could argue that managed care kills a provider’s reputation. Perhaps it has already killed a provider’s reputation so much that doctor’s are going to work for Kaiser or other managed care organizations where reputation does not matter. In those organizations a patient does not have much choice and thus the doctor’s reputation is not at stake. He will have patients to see no matter what.

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HIPAA Doesn’t Exist For Doctors http://brainblogger.com/2008/09/15/hipaa-doesnt-exist-for-doctors/ http://brainblogger.com/2008/09/15/hipaa-doesnt-exist-for-doctors/#comments Mon, 15 Sep 2008 23:29:59 +0000 http://brainblogger.com/?p=1511 Recently a very popular colleague of mine was hospitalized. He happened to be hospitalized at the facility where he works and thus you can imagine he was inundated with visitors and friends wanting to wish him well. Unfortunately, the terms of his hospitalization were emergent and thus he did not have a choice in where he went for treatment. His frequent visitors coming into the room began to hamper his recover and his family was forced to try and enforce privacy rules and HIPAA.

This only worked on the surface. When the hospital was called, they did not reveal that my colleague was in the hospital. They also did not reveal his room number. But upon scouring the hospital and connecting with nurses people started locating his room and once again started dropping by unannounced. Imagine the nurses trying to protect the privacy of the patient from a bunch of doctors wearing white coats!

HospitalUltimately, his family insisted on a premature discharge in order to protect their privacy.

What do you do in this situation? Well it turns out that the physician did not want his colleagues to know about the extent of his condition because he planned to return to practice after recovery. Surely one can appreciate the damage rumors can do to a physician? For example, would you go to see a physician if you knew he had a pre-existing medical condition that might affect your treatment or perhaps affect him during a surgical case?

My colleague actually told me that his family had to scold the nurses because his physician friends who were not on the treatment team were perusing his medical record. This is clearly a HIPAA and privacy violation and should not happen.

While this scenario may exist in the case where a celebrity is hospitalized, it is most problematic when a physician is hospitalized. Unfortunately HIPAA applies to the average everday patient but not to doctors in their own hospitals.

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Some Funny Stories From the Trenches http://brainblogger.com/2008/09/09/some-funny-stories-from-the-trenches/ http://brainblogger.com/2008/09/09/some-funny-stories-from-the-trenches/#comments Wed, 10 Sep 2008 02:55:09 +0000 http://brainblogger.com/?p=1226 I read with a smile the post by Dr. Sajid Surve about the lighter side of medicine. It reminded me of some funny things that happened to me as a student and resident. I thought I would share these silly stories in the hopes of bringing someone a chuckle:

1. On one of my surgery rotations with an orthopedic surgeon specializing in shoulder surgery, I was scrubbed in as the first assist. The case was going well. I was holding the hand and following commands well such as “internally rotate” or “externally rotate”. Everything was going well until he said “drop the arm” — I dropped the sterile arm and the hand fell to the floor! A few expletives later, I apologized and he said “You really should learn the difference between the hand, forearm, and arm!”

Finger2. On a trauma surgery rotation we were responsible for all trauma that came to the ER. We typically did a trauma physical exam while the trauma team cut off the patient’s clothes and rolled the patient. The intern was usually the lucky one that got to do the rectal exam. After doing the rectal we were supposed to describe our findings such as “no gross blood. normal sized prostate.” One early morning at a trauma I did the rectal exam on what I thought was a male patient and yelled “no gross blood. normal sized prostate.” Then the trauma nurses informed me that it was a female patient!

3. On my first day at OB/GYN I was assigned to labor and delivery. I had not prepared that well for the rotation. But I was lucky enough to have an attending that let me delivery my first baby. Unfortunately, he played a prank on me. During the labor, he asked me to put my hands out under the patient to catch the baby. There was no head showing or anything but he said that if I put my hands out there I would definitely catch something. A few minutes later I caught a bunch of poop in my hands! After that I found out that it is a common thing for women to have bowel movements during labor. Unfortunately I learned the hard way!

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Medicine and the Law – Part 6: Third Party Liability http://brainblogger.com/2008/08/24/medicine-and-the-law-part-6-third-party-liability/ http://brainblogger.com/2008/08/24/medicine-and-the-law-part-6-third-party-liability/#comments Mon, 25 Aug 2008 05:21:52 +0000 http://brainblogger.com/?p=1070 Health and Healthcare CategoryOur series on Medicine and Law is starting to wind down. We’ve covered lots of topics including contract and consent, malpractice, causation, informed consent, and abandonment. Now we will talk about third-party liability.

Third party liability means exactly what it says — that a different party other than the physician or the patient hold liability for an outcome. The most common form of third party liability in the medical profession is when a patient is denied coverage by the insurance company for a recommended procedure. I’m sure many of you have seen the Matt Damon movie where he plays a lawyer and represents a patient with cancer whose insurance company repeatedly denied a bone marrow transplant. That movie summarizes the main issues with third party liability.

TankMany states now have laws that guarantee the right to appeal an insurance company decision in the form of an independent review. Often times physicians wonder if they should get involved in a patient’s fight with his insurance company to get a needed procedure. I feel that physicians should encourage their patients to pursue every avenue of appeal and to document the entire appeal process.

There is however controversy about the extent a physician is legally or ethically obligated to be involved in the appeal process. One example is when a physician must discharge a patient from the hospital because the insurance company will no longer pay for inpatient stay. Some states have found doctors negligent for in that type of situation. Other states have found that doctors have no legal obligation to advocate for the patient.

One reason that a physician may not want to advocate for a patient against an insurance company or managed care organization is for the fear of retaliation by the insurer. If the insurance company were to drop that physician from its list of approved carriers it could harm the physician’s practice. Some states have passed laws that explicitly protect physicians from retaliation. However, not every state has such policies.

As you can see, when a third party is involved in liability, the physician-patient relationship can be tested significantly. Not every state has the same laws and thus if you are a physician you should know what view your state holds. Similarly, if you are patient, it is important to know this information as well to get a better idea of how your physician may or may not be able to help.

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Malignant Medicine http://brainblogger.com/2008/08/20/malignant-medicine/ http://brainblogger.com/2008/08/20/malignant-medicine/#comments Wed, 20 Aug 2008 12:33:29 +0000 http://brainblogger.com/?p=1170 There is a culture to medicine that I alluded to in my previous post about how everyone in the hospital is your boss. In essence, medicine is a profession like no other where “scutwork,” “malignancy” and “bad-mouthing” colleagues is standard practice. In the academic world this continues on in full force even after becoming an attending. In the private medical world it still exists. There is always a “Chief” or “Chair” of the department or division in which you practice. Most professions have hierarchy or levels of the ladder on which people sit. In medicine, I submit that the personalities are very strong due to the history of malignant medicine.

I have never seen such a profession where co-workers harbored such hatred towards each other. I have witnesses this at all levels of the medical spectrum from student to resident to attending. In the surgical field it is more predominant that in other fields of medicine but it exists in all realms of medicine. I have come to the conclusion that there are only a few reasons why doctors are so mean to each other.

MedicineFirst, I believe that many people are unhappy in their choice of career. Thus, when they see others doing better than they are or enjoying life more than they are, they do whatever they can to keep those people down. This is what I call the crab theory of medicine — that one crab won’t let another escape and will drag him down, causing both to die. Another reason for malignancy is that many physicians are really not mature individuals with many life experiences to give them perspective for their work. For most doctors, being a doctor, resident, or medical student is the first and only job they have ever had. Things get a little hazy when you do not have different perspective.

The “God complex” also still lingers in the medical profession. This is the notion that the doctor thinks he is the healer and can do and say (yell) anything he wants. Perhaps the most compelling reason that explains why doctors can be maligant is that medicine is a demanding field in terms of hours and energy and sacrifice. Proper coping mechanisms are difficult to develop when your environment is filled with similar people suffering the same affliction. It could be argued that in medicine there is no room for error and thus this stress causes doctors to behave badly.

Despite the malignant medicine practiced today, things have gotten better over the years. As the profession progresses like other industries, the medical environment will be healthier for all of us doctors. Some of us cannot wait.

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Conflicts of Interest Among Physicians II http://brainblogger.com/2008/08/12/conflicts-of-interest-among-physicians-ii/ http://brainblogger.com/2008/08/12/conflicts-of-interest-among-physicians-ii/#comments Tue, 12 Aug 2008 14:49:17 +0000 http://brainblogger.com/?p=1010 Health and Healthcare CategoryI previously posted a few times about conflicts of interest within the medical profession. A friend of a friend who reads my posts posed the simple question to me:

Isn’t the entire medical profession in conflict because it is profit driven?

This is an interesting question. After all, doctors make their living either seeing patients or doing procedures. No office visits, consultations, or surgeries then no income is generated. Thus wouldn’t doctors all benefit from making sure that patients keep coming back and that more procedures are done? Unfortunately this is true. It’s kind of like taking your car to the mechanic and asking what is wrong and for him to fix it. Of course you need a new transmission and spark plug and timing belt. Without it how is he going to feed his family and pay his mortgage? Luckily doctors take an oath to place their patients interests first. Do mechanics do the same? Maybe. Maybe not. Do lawyers do the same?

MoneyI don’t ever see a solution to this problem, unless we move to a system where doctors are all salaried and receive no reimbursement based on volume or procedures. But I don’t think that will ever happen. Physicians are entrepreneurial and that is why the private practice of medicine exists today. Granted, more doctors are moving towards working for salaries but there will always be a paying customer for specialized elective services. People will always be willing to pay a premium to have that special procedure or see that specialized physician.

So is it really a problem that doctors profit from their work? I say no. Every other profession makes money from their work AND most of those professions don’t take an oath to out the customer above all else.

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Medical Students Can Make A Difference http://brainblogger.com/2008/08/07/medical-students-can-make-a-difference/ http://brainblogger.com/2008/08/07/medical-students-can-make-a-difference/#respond Thu, 07 Aug 2008 18:52:38 +0000 http://brainblogger.com/?p=1222 It is that time of the year again when medical students start appearing on the wards. If you are a third year student you are now likely starting your clinical rotations. If you are a fourth year student you are probably embarking on away rotations to the specialty of your choice. Every physician has fond memories of being a medical student — the torture from residents and attendings, the constant pimping, the feeling of being a useless fly on the wall, the awkwardness of trying to fit in.

Every year I have a story to tell the students that I come across. It is about learning good habits as a student and learning to take the time to do a good job. It is about starting early to be the doctor that you want to be when you are a fully fledged physician.

Hospital HallwayWhen I was on my pediatrics rotation I happened to admit a young girl while taking call with a resident. As an eager medical student looking to impress I did a thorough history and physical with the girl and her mother. The girl was about 11 years old and had an awkward constellation of symptoms. However, she had been in and out of the hospital 3 or 4 times over the past several years. Each time she was admitted and discharged for one symptom that based on the medical notes did not appear to ever resolve. The resident who I was working with was on autopilot and wanted to admit the patient and do the same workup that has been done each time the patient had been admitted. I decided to look up the patient’s symptoms on the computer and found that it sounded an awful lot like a rare syndrome of which only 60 cases had ever been reported.

To make a long story short, because of my work as a medical student the girl finally got the correct treatment. She underwent an extensive workup and was found to have a cardiac condition that was associated with the syndrome. She also had surgery to fix the primary problem that she was having. I happened to see her and her mother in the hospital hallway several years later and they were so very thankful to me and to this day said that if they had not come across me that night when I was a student they would not know where they would be today.

Helping that patient as a medical student did not earn me a high grade. It did not get me any special recognition from anyone in the hospital. However, it helped out someone in need. Thus, for all of you medical students out there – you can actually make a difference. You are at a unique point in your training where you can see everything with fresh eyes. Don’t forget how important you are to your patients.

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Medicine and the Law – Part 5: Abandonment http://brainblogger.com/2008/07/27/medicine-and-the-law-part-5-abandonment/ http://brainblogger.com/2008/07/27/medicine-and-the-law-part-5-abandonment/#comments Sun, 27 Jul 2008 16:55:30 +0000 http://brainblogger.com/?p=1028 Health and Healthcare CategoryContinuing on in our series we will now talk about abandonment and terminating the physician-patient relationship. We’ve previously talked about the contract and consent. Then we moved on to medical malpractice and causation. Finally we discussed informed consent. Now we move on to abandonment.

Abandonment is the concept whereby a physician terminates the physician-patient relationship without reasonable notice at a time when the patient still has need of medical attention. This typically is prevented by giving the patient adequate time to find a replacement physician, planning for adequate post-procedure follow up, and giving the patient adequate instruction for care when the patient is not in the presence of the physician.

AbandonedAbandonment typically only comes up when a physician is treating an undesirable patient or a patient that he or she simply no longer wishes to take care of. This may be for financial reasons or simply because the patient has disease that is too complicated for the physician to take care of. It may also occur because the patient is not adherent to the doctor’s recommendations and thus the doctor notifies the patient that he plans on terminating the relationship if the patient will not follow instructions. Most often, the physician will write a formal letter to the patient so there is record of the severance. The main concept is that there must be a chain of continuous medical care that cannot be broken.

If a doctor prematurely discharges a patient or discharges a patient from the hospital without adequate follow up instructions he could be found to have abandoned the patient. If the doctor notifies a patient that he is closing his practice or moving to another location, he must allow adequate time for the patient to find another doctor. He may even refer all of his patients to another doctor to prevent any claims of abandonment.

When a patient is abandoned, lawyers typically only get involved if there were damages caused by the abandonment. However, if the physician shows that good faith efforts were made to treat the patient and the patient was simply lost to follow up, he is not liable.

I will address the ethics of severing the physician-patient relationship in another article.

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Pharmacists Really Do Have Prescribing Power http://brainblogger.com/2008/07/16/pharmacists-really-do-have-prescribing-power/ http://brainblogger.com/2008/07/16/pharmacists-really-do-have-prescribing-power/#comments Wed, 16 Jul 2008 20:34:56 +0000 http://brainblogger.com/?p=1074 Drugs and Clinical Trials CategoryI read with interest my fellow Brain Blogger’s article on pharmacists and their essential value to the medical team. While pharmacists do not have prescribing power and often get a bad rap as being “pill counters,” it is clear to me that their position in the medical team food chain is equivalent to having prescribing power.

At the very least, a good medical team or ICU team will have a pharmacist as part of the team to help with medications. This includes making sure the patient has no allergies, that there is no resistance or cross reactivity between medications, and checking to make sure the prescribed medication is clinically indicated. In this situation the pharmacist is sort of like the medical case manager. He or she “owns” the prescriptions of that team.

DrugsIn most advanced hospitals these days, medicine orders are entered electronically. Even those hospitals that are in the dark ages use faxes to fax paper copies of doctors’ medicine orders. For the hospital that uses electronic prescribing, the pharmacist really does have a whole lot of power. When an order is entered it is routed through a software program that the central pharmacy manages. When something is out of whack, you will undoubtedly get a page from central pharmacy questioning the order and in many instances asking for justification of the order.

Some hospital pharmacy software programs are so sophisticated that they raise red flags when expensive drugs are prescribed when there is a cheaper equivalent. When the pharmacist pages you, it is you the physician who must double check your prescription and your order, not the pharmacist. The pharmacist is kind of like the banker on the show “Deal or No Deal”. He sits in an office overlooking the entire prescribing force of the hospital and uses his phone to corner any deviant physician!

Actually, the reality is this — the pharmacist is there to do what physicians are meant to do but that usually do not have the expertise to do — to make sure prescriptions are done correctly, dosages are appropriate, medications are cost-effective.

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Ethics 101 – It’s Beyond My Scope of Practice http://brainblogger.com/2008/07/13/ethics-101-its-beyond-my-scope-of-practice/ http://brainblogger.com/2008/07/13/ethics-101-its-beyond-my-scope-of-practice/#respond Sun, 13 Jul 2008 16:53:48 +0000 http://brainblogger.com/?p=1059 Health and Healthcare CategoryIn medicine a lot of physicians categorize their patients as “good” patients or “bad” patients. Good patients are patients whose care is relatively easy for the physician to handle. The patient is compliant with recommendations, is motivated to get better, and is thankful for the doctor’s care. Bad patients are generally those patients who do not follow physician recommendations, who behave in a way detrimental to their own health, who are extremely high demand, and who threaten litigation. Good patients are more likely to do better with treatment. Bad patients are very likely to have a complication.

Doctor's officeSome of these things are within the patient’s control. Some of these are not. Unfortunately, doctors do not always distinguish between difficult and complex medical problems and difficult and complex social problems. It is not uncommon for these patients to be homeless, poor, or with chronic health problems that are not properly cared for.

One scenario that occurs relatively frequently is when a physician passes a patient on to another physician. Often the doctor says that the patient’s medical problem is “beyond the scope of his practice.” Meaning that he is not comfortable treating the patient’s problem and that he recommends that patient see a “specialist.”

Sometimes this is a legitimate reason. Often times the doctor just does not want this patient in his practice. In the medical profession this is often referred to as “poaching” — when a doctor selects the “best” (often the ones who have good insurance) and leaves the other patients for other doctors to see.

As you can imagine, this practice is fraught with questionable ethics.

Should doctors have the right to pick and choose who they take care of? Should doctors be able to refuse care based on “scope of practice” even though the patient’s problem is a basic problem that any board certified physician must be able to handle to be licensed?

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The Curbside Consult http://brainblogger.com/2008/07/07/the-curbside-consult/ http://brainblogger.com/2008/07/07/the-curbside-consult/#comments Mon, 07 Jul 2008 13:34:04 +0000 http://brainblogger.com/?p=1068 Health and Healthcare CategoryA physician frequently gets stopped in the hall of the hospital or gets paged by another doctor for an unofficial consult. In medicine, this is called a “curbside consult.” Essentially, one physician would like some input on a case without getting the consulting physician officially involved in the patient’s care. Typically, this is done because the primary physician either knows the answer already but wants to run it by someone else. Or because he thinks the problem is not major enough to warrant an official consult. If an official consult is requested it will require the consulting physician to see the patient, write a consultation note, as well as dictate a consultation note.

PathwayThe concept of “curbside consult” often moves outside of the hospital and often involves friends and strangers consulting you for your expertise in an “unofficial” manner. Imagine going to a cocktail party and people finding out you are a pediatrician. A “friend’s” child has some odd symptoms and they want to know what you think about it and how you would go about treating it.

Most often a physician will ask who the child’s pediatrician is and recommend that they go see that person for the child’s care. If they are looking for a new pediatrician the doctor will probably tell the parent to call his office for an appointment.

Most often physicians do not like to do curbside consults for strangers or friends because they technically are not the patient’s doctor. There is no physician-patient relationship established. However, by giving a medical opinion, it could potentially be inferred that such a relationship was initiated. Thus, many physicians like to draw a clear line between interactions that denote a physician-patient relationship is intact versus interactions that are not.

I personally have been asked tons of times for medical advice on people who are not my patients. I am always honest and let the person know that if they are concerned they should see their own physician or go to the nearest emergency room. I do this not because of medical liability but also because I do not want to be responsible for any potentially adverse outcomes. These adverse outcomes end up being the “skeletons” in every physician’s closet.

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Going Beyond Informed Consent http://brainblogger.com/2008/07/02/going-beyond-informed-consent/ http://brainblogger.com/2008/07/02/going-beyond-informed-consent/#comments Wed, 02 Jul 2008 13:16:34 +0000 http://brainblogger.com/?p=1058 Health and Healthcare CategoryIn response to my last post about informed consent in my Medicine and Law series, several commenters made the point that informed consent is more than just getting a form signed. That ideally it should involve a dialogue between patient and doctor. That the burden of trust is on the doctor to inform the patient so that the patient actually understands what the risks and benefits are. That the doctor should empower the patient to make the choice.

These are all great points and I couldn’t agree more that informed consent does involve all of the above. It does involve trust and building of it in a patient-physician relationship. There is the medicolegal aspect that I have outlined in the Medicine and Law series, but there also is the real relationship that goes on between the patient and doctor.

DoctorDespite all these ideals that physicians strive for, the circumstances are not always conducive to this. For example, when a physician meets a patient for the first time in the Emergency Room and the outcome of the workup is that a procedure will need to be done on the patient, the doctor does not have a long history of rapport with the patient. The patient just met the doctor this visit and doesn’t have a lot to go on other than this limited reaction. Thus for the physician covering the Emergency Department with tons of patients backlogged that he needs to see, he cannot feasibly spend an hour talking with the patient about the informed consent. Generally, informed consent can be as fast as a few minutes and as long as an hour conversation that is unresolved and carries over to the next day.

To make matters worse, if the patient requires surgery, the surgeon must schedule the surgery when the operating room has availability, must find an anesthesiologist to do the anesthesia, and must make sure the patient has not had a meal in the 6 to 8 hours prior to surgery. Thus, when a patient wants to delay surgery to decide and think things over in the emergent or semi-emergent situation, then he is delaying his care.

The other issue comes with choice and empowerment. Many patients act surprised when you ask them what they would like to do. They often want the physician to decide what is best. They are not physicians and do not want the responsibility to make the decision. Often when given power to make the decision, they choose the one that the physician does not think is the best idea and leads to a worse outcome.

Physicians strive for the ideals above and that informed consent where the patient is on board and also feels empowered to control the destiny of his own health. However, from a medicolegal standpoint, at the end of the day, it is the physician that is responsible for the patient’s care, not the patient.

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Should Doctors Unionize? http://brainblogger.com/2008/06/27/should-doctors-unionize/ http://brainblogger.com/2008/06/27/should-doctors-unionize/#comments Fri, 27 Jun 2008 13:32:45 +0000 http://brainblogger.com/?p=1027 Health and Healthcare CategoryIn this time of financial strain on physicians and the government reimbursement system we once again need to address the question — should doctors unionize?

Recently, a group of physician picketed Capitol Hill to denounce continue reimbursement cuts. This results in a temporary stay of a planned 20% cut for next year. As many doctors will agree, we are facing difficult times and many physicians are looking at other ways to create income to support their practice and their families.

UnionUnions have been around for a long time. They typically are based on industry, require a percentage of income to join, and have strong leadership to negotiate salaries and benefits. Businesses have never liked unions as they increase the cost of work and often lead to such cumbersome rules and restrictions that ultimately may limit productivity.

In the medical profession, unionization could have significant bargaining power among physicians or among specialists. For example, if we take the example of ophthalmologists who take care of cataracts and do eye surgery, the unionization and collective bargaining could single handedly dictate the terms and types of care that all people in this country receive for eye care. It could result in basically monopolization and anti-trust issues in the eye care industry.

Without such unionization, ophthalmologists (and all other physicians) are at the mercy of the government payer. If the government wants to decrease reimbursement then we must accept it. The alternative is for doctors to stop accepting Medicare and to fight back. For many physicians, this goes against the entire reason that we entered medicine — to take care of people. Some doctors are doing it, others are trying it out with mixed success. But one common theme emerges from these doctors — they are happier for doing so.

If doctors start doing this in mass, many patients will be left out on the street with nobody to take care of them. Are we as a country ready for this? Are physicians as a group ready to continue to accept lower payments? Should physicians unionize and collectively bargain for better reimbursements?

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Ethics 101 – Patients Who Hide The Truth http://brainblogger.com/2008/06/23/ethics-101-patients-who-hide-the-truth/ http://brainblogger.com/2008/06/23/ethics-101-patients-who-hide-the-truth/#comments Mon, 23 Jun 2008 12:45:32 +0000 http://brainblogger.com/?p=982 Health and Healthcare CategoryIn this series of posts we are examining the ethics behind medicine. This includes the entire ethical spectrum of behavior by doctors, patients, nurses, and the entire medical system. Here we present another case scenario about a patient.

A 36 year old man presents to his plastic surgeon for cosmetic deformity. He would like a rhinoplasty for his nose. This is something that he has always wanted done. His plastic surgeon asks him why he wants the surgery as he is a good looking guy who is fit with good self esteem. His surgeon asks him if he has ever had plastic surgery before. The patient says no. Thus the surgery is scheduled and both the doctor and patient agree to proceed.

A Gruber RetractorDuring the surgery the surgeon finds significant scar tissue that clearly indicates a prior surgery. This circumstance significantly lengthens the surgery and complicates the surgery. Nevertheless due to the surgeon’s skill the surgery is successful.

Clearly this is a type of unethical behavior by the patient. One that could significantly increase the risks of the surgery for both the patient and the doctor.

Is this unethical? What if the doctor has a policy of not doing revision plastic surgery and this is the only way for the patient to get the surgeon to agree to do the surgery?

Maybe some of you are thinking that this is not a big deal. What about if the patient fails to disclose that he has HIV or Hepatitis C and the surgeon has a blood exposure or needle stick in the case?

I won’t go this far but some could argue that failure to disclose could be criminal if there were harmful outcomes because of that failure to disclose.

I would be interested to hear what readers think.

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Medicine and the Law – Part 4: Informed Consent http://brainblogger.com/2008/06/13/medicine-and-the-law-part-4-informed-consent/ http://brainblogger.com/2008/06/13/medicine-and-the-law-part-4-informed-consent/#comments Fri, 13 Jun 2008 13:13:14 +0000 http://brainblogger.com/?p=960 Health and Healthcare CategoryIn my previous posts about Medicine and the Law we talked about the elements necessary for a patient-physician relationship — contract and consent as well as medical malpractice. We then went on to discuss causation and the different types. Continuing on in this series let’s talk about informed consent. Failure to obtain informed consent is a leading cause of malpractice claim.

Informed consent essentially is documented written or verbal permission from a patient to receive treatment or undergo a procedure. Typically it involves five elements:

  • A description of the illness
  • A description of the treatment
  • Risks of the treatment
  • Alternatives to the treatment
  • Risks of not having any treatment

AttorneysPhysicians can get into trouble in many scenarios regarding informed consent. Most states require that informed consent be verified by a witnessing party. Thus an informed consent form typically has three signatures — the patient, the doctor, and the witness. If a patient is unable to sign, verbal consent can be obtained or his/her healthcare power of attorney may sign. If there is no family or healthcare power of attorney and the procedure or treatment is emergent then a two-physician consent may be done. This basically is permission granted by the state to care for a patient in an emergent situation according to the standard of care.

When a patient is demented or cannot comprehend any of the requirements for informed consent, then things can get a little dicey. Often times the treating physician will obtain a psychiatric consultation to evaluate the patient’s decision making capacity. If that consultant still cannot determine the patient’s decision making capacity, he may obtain an additional consultation.

As you can imagine, getting permission from a patient who may or may not completely know what is going on is a recipe for disaster. As a treating physician this is an area where you may get in trouble if you are aggressive and treat or if you are conservative and do not treat. Ultimately it is the outcome that gets you in trouble given that most patients who sue are those who have a bad outcome.

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