Sunday, May 30, 2010

Preparing for the MCAT – Not Your Father’s Exam

Remember the MCAT (Medical College Admission Test)?  This is the examination that determines if pre-med students will become actual physicians. This is an extensive examination covering an expansive amount of information that is not clearly related to the practice of medicine.   It reminds me of the government and insurance industry’s emerging quality initiatives.   Like the MCATs, these programs measure what is easy to count; but what really counts, can’t be easily measured. 

If I were asked to submit MCAT questions, as a practicing physician, I would bring a real world flavor to the examination. 

Whistleblower MCAT 2.0 Sample Questions!

Test Your Knowledge! Amaze Your Friends!

Let the Games Begin!


Medical Knowledge Section

You are in the hospital recovering from ankle surgery after a fracture. After pain medication is prescribed, you develop some constipation and abdominal discomfort. The orthopedist’s physician assistant orders a CAT scan of the abdomen to evaluate the new symptom.

The biggest risk that you face from this recommendation is:

Choose the best answer.

(1) Radiation from the scan
(2) Injury to the ankle during transport to the radiology department
(3) Worsening constipation from the oral contrast. This could lead to a stampede of scope-wagging gastroenterologists into your hospital room resulting in physical and emotional trauma
(4) Finding an incidental 3 mm lower lung nodule, which will initiate a medical cascade of testing that will torture you for 2 years.
(5) The radiology tech confiding that the your orthopedist is quietly known as Defendant of the Year.

Whistleblower Note: Are you wondering why a laxative wasn’t recommended instead of a CAT scan?
If so, then you need to travel to Washington, D.C. to testify before Congress as a medical expert STAT!

Medicolegal Section

Disclaimer: Nothing in this exam purports to offer any legal advice to any examinee, or to their relatives or pets. The question is hypothetical only. Any attempt to use test materials, either purloined or memorized, to further one’s legal advantage is strictly prohibited.  Lucky for us, there is no federal tort reform legislation so can sue at whim.


Which of the following statements about the medical liability system is true?

Choose the best answer.

(1) The current medical liability system reduces medical malpractice.
(2) Democrats receive substantial financial support from trial lawyers, but this does not influence the legislators’ hostility toward tort reform.
(3) If physicians were more careful, conscientious and communicative, then they would never be sued.
(4) Tort reform is a political straw man, another example of a vast right wing conspiracy.
(5) The current system targets many more innocent physicians than negligent practitioners.
(6) If a baby is born imperfect, then something must have gone wrong.
(7) Depositions are fun and physicians should learn to enjoy them.

Doctor-Patient Communication Section

Which of the following behaviors contribute to a successful therapeutic partnership?

There are two correct answers.

(1) Patients asking for a treatment, not a diagnosis. “I need an antibiotic, doctor.”
(2) Physicians who practice TIER medicine, aka Texting In Exam Room.
(3) Patients who call for medication refills after office hours and on weekends.
(4) Patients who call for test results 2 days before their office appointment.
(5) Patients who say thanks.
(6) Physicians who start questioning about ‘stress issues’ after  the CAT scan and laboratory results are normal.
(7) Physicians who call patients a few days after appointments to check on their progress.

Please record your MCAT answers in the comment section below, along with your own sample test questions. Humor, sarcasm and bone dry wit are encouraged.

Sunday, May 23, 2010

Tort Reform and Frivolous Lawsuits: Show Me The Money!

Several months ago on this blog, I informed readers that I was a defendant in a medical malpractice case. I offered no specifics, as I didn’t want my attorney to fire me as a client, in case he discovered the post. Although the plaintiff was granted two 45 day extensions to troll for an Ohio physician to sign an affidavit of merit against my care, none could be found. My lawyer had reviewed every syllable of the medical record, and couldn’t divine an allegation against me. My lawyer and I were groping guests in a Chamber of the Absurd - trying to figure out what allegations the other side might concoct.

After a few months, I was dropped from this case that should have never been filed in the first place. Years ago, as a younger and more idealistic gastroenterologist, I was kept dangling on a lawsuit for a few years. I endured the light hearted amusement of the discovery process, including expert witnesses outside of my specialty who claimed in their written reports that my care was negligent. The deposition was so much fun, that I was disappointed when it ended. “One more hour, please”, I begged, After the ‘experts’ reviewed my testimony, they recanted, but I wasn’t formally dismissed until a few days before the trial date. Nearly 20 years later, the memory of this unfair experience still lurks in a dark recess of my mind. Lawyers don’t get this, as they don’t appreciate how deeply personal malpractice litigation is for physicians. For them, win or lose, they close their briefcases and move on to the next case.

Had the plaintiff’s attorney reviewed the record prior to suing me, he would have concluded that my care was proper and that I should not be targeted. Although in Ohio, an affidavit of merit is required to sue a physician for medical malpractice, judges will extend leniency to plaintiffs and grant extensions, as occurred twice in my case.

On March 31, 2010, I received a letter from my medical malpractice insurance carrier. Although the letter was marked PERSONAL AND CONFIDENTIAL, in all caps, bold and underlined, I feel I can share it with loyal Whistleblower readers.

Here is an excerpt:
Many physicians wonder about the magnitude of the expenses incurred in defense and/or investigation. In this case, they were $9,120.85.
Where was the rush to sue me? The statute of limitations was far in the distance. Because I was named as a defendant from the outset, with no supporting affidavit, nearly $10,000 was incinerated.

I am sure that this scenario occurs in all 50 states every day. Imagine what the aggregate financial cost is of defending innocent physicians, or doctors like me who should never been defendants in the first place. The costs of the discovery process, which I escaped, are orders of magnitude higher than my costs were.

The inarguable facts, disputed by plaintiff attorneys, are that the current dysfunctional medical liability system fails to:

  • Narrowly target negligent physicians
  • Capture most patients who have been victims of true negligence
  • Improve medical quality
I have no idea how many tens of millions of dollars or more are being vaporized in the medical malpractice crucible. With a health care system that is sagging under escalating costs, couldn’t we find a better use for this money?

Keep in mind that the actual costs of litigation are but a fraction of the costs of the medical liability system. Sure, my case burned up 10 grand, but, I will spend much more this year ordering tests and consultations that are as much to protect me as they are to protect my patients. Sad, but true.

Failing to include any real tort reform in the Patient Protection and Affordable Care Act, the health care reform panacea, is legislative malpractice. Hey, that gives me an idea. If I can get one citizen to sign an affidavit of merit attesting that our representatives breached the community legislative standard, defined as what a reasonable legislator would do, can we sue them? We wouldn’t need a judge to grant an extension. Millions of Americans are ready to sign this affidavit yesterday.

Sunday, May 16, 2010

Why Do Dentists Prescribe Prophylactic Antibiotics So Often?

Because they can.

Why am I dissing my dental colleagues? Because I can.

Perhaps, this is a simple case of Dental Envy, since their profession remains within secure borders far beyond the health care reform line of fire. Consider these dental incidentals:

• Not a syllable in the ~2000 page health care reform law that affects dentists. Every filling is still worth its weight in gold.
• Dentists recover every dime they bill. If their fee is a gazillion dollars, and your generous dental insurance, covers fifty bucks, guess what? There will be a very large cavity in your bank account.
• No middle of the night runs to the emergency room, a drill that we physicians endure
• No hospital work, which for many physicians has become an inefficient hassle which became the root of a new medical specialty
• Dentists don’t need an attorney on retainer, or caps on non-economic damages, as their malpractice situation is calm.
• We still call them, ‘doctor’.

Dentists prescribe prophylactic antibiotics (ATBs) with routine recklessness. Of course, we physicians are also culpable of antimicrobial mania. We all prescribe too many antibiotics for too many days for too many viral illnesses. It has been a tough slog to teach our profession to prescribe antimicrobial agents more judiciously. In fact, it’s been like pulling teeth. Entrenched physician habits and patient expectations are hard to change. Look how long it took for Americans to accept and practice seat belt safety. When I was a kid, I remember my parents buckling the belts behind them so they wouldn’t hear the annoying warning buzzer. It took a generation of intense education to change cigarette smoking behavior.

Many dentists irrationally prescribe ATBs before teeth cleanings and other procedures. It’s more than irrational; it’s a reflex. Here’s a sample patient questionaire that dentists use to determine if prophylactic ATBs are necessary. Answer ‘yes’ to any question, and get ready to swallow some potent germ killers.

Have you ever been told of a heart murmur?

Does your puppy have a heart murmur?

Do you want live to see your next cleaning?
The vast majority of  prophylactic ATBs that dentists prescribe are unnecessary. The theory is to protect the patient’s heart from becoming infected by bacteria that are released into the blood stream during a dental procedure. The missing piece is the absence of a shred of science supporting this practice. Keep in mind that live humans release bacteria into the blood stream during routine tooth brushing and defecation, but I doubt that heart murmur patients are advised to pop penicillin each time they are about to engage in either of these two high risk behaviors.

When physicians and dentists prescribe unnecessary ATBS, there are many adverse consequences. Here is a sampling.

  • Money is wasted.
  • Resistant bacteria emerge that can be more difficult to treat.
  • It teaches patients to expect and demand ATBs when they are not indicated.
  • Potential of serious side-effects and drug interactions.
For example, there is a condition called pseudomembraneous colitis caused by the germ Clostridium difficile, affectionately known as C. diff. The primary cause of this diarrheal disease is ATBs. There isn’t a hospital in the country that is not struggling with this stubborn and serious disease. Some of these patients have died or had their entire colons removed.  Once the germ is present in your large intestine, or colon, it can be impossible to eradicate. I see a case of C. diff at least every week. For some of these unlucky folks, C. diff becomes a chronic disease.

I have seen many C. diff cases that developed from brief courses of antibiotics prescribed by dentists and physicians. Some of these patients now have an incurable gastrointestinal affliction caused by just a few ATB pills. I help these folks as best I can. I don’t think it helps them for me to share that they never needed the ATBs in the first place. This inconvenient truth would be too hard for them to swallow. I wish that their ATBs had been too hard to swallow.

The next time that your dentist, or your physician, recommends an ATB – or you demand one – think again. Is it worth the risk of beating your colon into a pulp?

Sunday, May 9, 2010

How Do Physicians Choose Consultants? Looking ‘Under the Radar’

Professional sports has never been a dominant personal interest, although I admit that I become more engaged if my town’s teams reach the post season. Here in Cleveland, folks assign a priority level to sports that is just a notch below breathing. I do make it a point to know enough of what is happening within the various stadiums and arenas so that I am not ostracized or placed in a stockade in the public square to serve as a deterrent. If the Cleveland Cavaliers do not emerge as national champions this year, then northeast Ohio will sink into the Sea of Melancholy

There is an aspect of professional sports that I greatly admire. This transcends the athleticism and skill of the athletes, the work ethic, coaching expertise, teamwork and the thrill of the game. This is one of the only institutions that is a pure meritocracy. The philosophy is simple and not blurred by arguments for diversity or massaging the qualifications for admission to serve another agenda. Coaches, managers and owners want the absolute best performing individuals for the job. And so do the players. I wish this ethos were contagious to the rest of us.

The practice of medicine is not a meritocracy, either in the manner that students are accepted into medical schools, or in how we physicians practice. For example, what criteria do physicians use when they select a consultant? The ideal response is self evident. A consultant should be chosen because that specialist is the best qualified and is readily available to serve the patient. Medicine, however, is not an ideal universe. Consultants are not routinely selected solely for clinical skill. In my experience, availablity trumps clinical acumen for many referring physicians who want their patients seen expeditiously.

These points apply to all physicians who consult colleagues, but primary care physicians are the primary source of specialty consultations.

Here are some reasons, beyond medical quality, why certain medical specialists are chosen.

• Reciprocity – patients are referred in both directions
• Personal relationships
• Corporate enforcement keeping consultations within the network
• Economic pressure exerted by consultants to maintain referrals.   I have seen this happen.
• Specialist willingness to do tests and procedures on request
• Habit
• Patient or family request

Even if a consultant is selected for some of the above reasons, the patient may still be ably served. For example, if a patient needs a screening colonoscopy, it does not matter that the gastroenterologist be a world class endoscopist. A simple community scoper, even one who blogs, may be sufficient.

In my experience, most patients receive high quality consultant care. However, patients are entitled to know that there may be unseen reasons why their physicians choose specific consultants. We specialists are not entirely righteous either. When we consult other physicians, we are also responding to forces that are under the radar. I personally admit to this in my practice.

When I entered private practice 10 years ago, after 10 years of a salaried position, I naively believed that conscientious care and availability would be a winning strategy to build my practice. I have learned that the dynamics between primary care and specialty physicians are more complex, and that the path to private practice success is not linear.

In sports, it's all about winning.  In medicine, it's also about how you play the game.

What’s your view?

Sunday, May 2, 2010

Sir Isaac Newton and Health Care Reform

Whistleblower readers know of my deep skepticism that the promises of Obamacare will be realized. As time goes on, my skepticism sinks deeper. The health care reform (HCR) legislation that was passed with reconciliation guarantees more taxes, more access to care for the uninsured and more government control of health care. But it fails in its promise to bend the cost curve, or does it? Perhaps, I’m being unfair and need to adopt a more literal approach to the president’s promise of cost control. President Obama’s program does bend the curve, but does so in the wrong direction. He wouldn’t be the first Democratic president in recent memory to engage in a public demonstration of linguistical gymnastics.

If health care costs continue to rise, can we expect to hear the president lecture us in 2012 during his reelection compaign with his finger wagging

“I kept my promise to bend the cost curve, and I did.”
This past month, a national and respected health care organization reported that under the president’s plan, health care costs would increase by $311 billion through the year 2019, despite the administration’s promise of cost reduction. Who made this scurrilous allegation? Was it the rabblerousing tea partiers again? Was it Sarah Palin firing up the bible belters? Were these rantings from a resurrected vast right wing conspiracy? Try again. The pessimistic projection was issued by Medicare’s chief actuary, an agent of the federal government, and not a fringe group of hyperventilating fringe partisans. So, to those who want to shoot the messenger here, you may be aiming at your own patron.

The American people agree with the government’s new analysis. An April 2010 Gallup poll reported that a solid majority of Americans believe that HCR will cost the government too much money and doesn’t address fundamental cost issues sufficiently. Is Gallup just another GOP tool like the Medicare actuary, or were we duped that HCR would really save us money?

I am not faulting the president because health care costs will continue to rise. I am chastising him and his minions for dismissing the rest of us who claimed that his plan would only bend the cost curve further in the same direction. Saving HCR dollars is tough because it violates natural law. Let’s consider the situation in Newtonian terms.

Here are Newton’s 3 Laws of Health Care Motion.
  • A health care system at rest tends to remain at rest.
  • For HCR to accelerate, it requires an external force which has more mass than the Federal government.
  • For every action applied to the health care system, there will be an equal and opposite reaction.
In other words, there is tremendous inertia in the system. Costs will be very challenging to rein in because every cost has a powerful constituency supporting it. Every example of an unnecessary medical test or wasteful medical spending represents someone else’s income. Proposals that include decreasing physician reimbursement, lowering insurance premiums, reducing medication prices, tort reform, medical rationing, increasing patients’ financial responsibility for their care and comparative effectiveness research will all be met with an equal, or perhaps greater, reaction against them.

What stakeholder in the system will fall on his sword to serve the greater good?

I suppose that Newton would support the notion that health care reform in motion tends to remain in motion. But, where is it taking us? We were told that our destination will be a promised land, but will it be a black hole instead?

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