Performance goals for hospital CEOs discourage change

A big problem with changing the focus of healthcare in the United States is that hospital chief executive officers are incented to produce profits for their institutions.

This chart from Kaiser Health News shows that the goals for most of the CEOs of major hospitals and health systems are profits. Growth and more specifically, admissions growth, are also mentioned.

It also lists CEO compensation figures, which are quite impressive. In addition to their hefty salaries, most CEOs also command large performance bonuses based on meeting financial goals.

According to Becker's Hospital Review, CEO pay has risen over 4% per year since 2009 with an increase of 4.8% this year.

All this in the era of the $546 charge for 6 liters of saltwater and the $73,002 charge for an emergency department visit for a urinary tract infection.

If you were a hospital CEO, why would you want to emphasize preventive care and outpatient services when your bonus is tied to profits, admissions and growth?

Everyone is entitled to make a living. And for sure most doctors do very well. But doctors are being squeezed on many fronts—declining reimbursements, need to purchase expensive and time-sucking electronic medical records software, more ICD codes, rising overhead to name a few. They are being forced to sell their practices to hospitals. Once the majority of physicians become hospital employees, their incomes will no doubt be squeezed further.

The public is demanding more accountability and transparency from hospitals and more emphasis on keeping people well rather than treating the sick.

Yet those who run hospitals have no reason to stress wellness and every rea$on not to. Don't look for anything to change soon.

On the horrific story of a Texas neurosurgeon and why it could happen again

If you are interested in patient safety and medical errors and haven't read the story in the Texas Observer about a spectacularly incompetent neurosurgeon, you should. It is long but worth it. As I tweeted last week, it will make you cringe.

The story includes many details about operations done poorly and patients suffering paralysis and death at the hands of Dr. Christopher D. Duntsch.

The Texas Medical Board is over-worked, slow to act and apparently toothless when it comes to disciplining doctors. Despite many complaints, it took them more than a year before it temporarily suspended his license on June 26, 2013.

However, the author of the piece, some Dallas area lawyers and at least one blogger are mistaken when they blame the malpractice monetary cap in Texas for contributing to the delay.

Yes, Texas has a cap on non-economic damages. Is that really the problem? Or is it what I and many others have written, that average duration of a malpractice suit is well over 4 years, with many cases lasting much longer than that?

If the only way this doctor could have been stopped was by malpractice litigation, he would still be operating today.

This dreadful situation was created by a number of factors.

As background, note that Dr. Duntsch has a remarkable curriculum vitae in that he graduated from medical school summa cum laude and was inducted into Alpha Omega Alpha, the med school equivalent of Phi Beta Kappa.

In addition to an MD degree, he also received a PhD and did two research fellowships and a minimally invasive spine fellowship. However, according to the website of the American Board of Neurological Surgery, Dr. Duntsch was not board-certified.

In the Observer article, a general surgeon who assisted him on his first operation in Texas immediately recognized that Dr. Duntsch did not have good technical skills. The general surgeon said, “His performance was pathetic . . . He was functioning at a first- or second-year neurosurgical resident level but had no apparent insight into how bad his technique was.”

After another disaster, his operating privileges were suspended for 30 days after which time he was to have been supervised by another neurosurgeon at every procedure.

But the hospital Duntsch worked in, Baylor Plano, did not enforce that sanction and he continued to operate until he finally caused the death of a patient from bleeding.

He resigned from that staff and obtained privileges at Dallas Medical Center, which claimed that Baylor Plano said there were no issues with Duntsch's performance. Of course, there were issues. And resigning from a medical staff while under restriction of privileges or even under investigation mandated a report, which apparently was not sent, from Baylor Plano to the National Practitioner Databank.

At Dallas Medical Center, two of his first three cases ended badly. One patient died, and the other suffered a major complication.

A surgeon who was brought in to reoperate on the patient with the complication could not believe what he found and called the Medical Board himself. He was told it would take time to process the information and investigate.

Although Dallas Medical Center "fired" Duntsch, he still was operating at two other hospitals. How he obtained privileges at those two was not explained.

At one, a patient woke up with both vocal cords paralyzed after a cervical spine fusion, and at the second one, the OR team had to "physically restrain" Duntsch from continuing a procedure that was going badly.

After another more detailed complaint by the general surgeon who had helped Duntsch with his first case, the Medical Board finally suspended his license.

There were four chances to have stopped this doctor sooner.

One, as many commenters on Reddit wondered, how was this surgeon allowed to graduate from his residency program? It is unlikely that he suddenly became a terrible surgeon after completing his training, although the medical board did find that he was impaired by drugs or alcohol.

Two, the doctors who knew of the bad cases could have been more vocal in opposing his applications for staff privileges at the area hospitals. They may have held back because of fear that they would be sued for libel or slander.

Three, the hospitals in the Dallas area could have been more diligent in investigating his past record, but neurosurgeons are cash cows so maybe his problems were glossed over.

Four, the Texas Medical Board could have been more proactive in the face of such serious allegations against the doctor.

All four of the above would have been much quicker and more efficient than any malpractice suit. The fact is that while too late to help several patients, the Medical Board suspension occurred in well under 2 years, still faster than any lawsuit would have been resolved.

This is key, "Every year the board is overseeing many more doctors and bringing in more money. But it doesn’t get to keep much of it: In fiscal year 2013, the board sent almost $40 million to the state’s General Revenue fund, of which it got about $11 million back. (Like other state licensing agencies—the Pharmacy Board, the Nurse Practitioner Board—the Medical Board operates at a surplus for the state.)"

As is true in many states, medical licensing fees are essentially a tax on doctors. Instead of going for better policing of the profession, the states use the money for other things. The doctors who assist with Medical Board investigations are unpaid volunteers.

Here's a very telling passage from the Observer article. "Why does it take so long to investigate a doctor? The process for resolving complaints is slow and painstaking, set up in statute to guarantee doctors the maximum legal protection."

And who writes the statutes? The majority of legislators are lawyers, certainly not doctors.

Regarding the investigators, the article says, "They know if they try to discipline a doctor, the burden of proof will be on them. A poorly put-together case can mean months or years of expensive litigation. So the board members tend to act conservatively."

I would wager that even a well put together case could mean months or years of expensive litigation too.

So the lawyers, who will tell you that they are the champions of patient safety and the salvation of mankind, are also the biggest stumbling block to rapid resolution of the problem of disciplining bad doctors.

By the way, If you google Dr. Duntsch, you will see that he still has many outstanding ratings from various websites, including 4½ stars of a possible 5 from HealthGrades.

And check out the first couple of minutes of this video from March of this year produced by his public relations people for the "Best Docs Network."

Among the many interests listed in Dr. Duntsch's LinkedIn profile are "Mentoring the Next Generation of Scientists" and "Medicolegal." In the future, I'm sure he will get few chances to do the former but many for the latter.

I feel for the patients and families who were harmed by this surgeon.

Texas is no different than most other states. This could happen again just about anywhere in this country.

UPDATE 12/18/2013

On 12/6/2013, Dr. Duntsch agreed to give up his Texas medical license and further disciplinary proceedings were dropped.

Is it a blog or a post?

Sometimes in the throes of temporary insanity, I call a blog "post" a "blog."

Luckily I have Twitter followers to set me straight. They have called me to task on several occasions for this linguistic gaffe. 

You see, calling a post a blog is like calling an article a  magazine. And it tends to upset people who are the arbiters of what is right and wrong on line (or is it online?).

For example, Paul Hutchinson, who posts blogs at the cleverly titled "Paul Hutchinson's Blog," says he is "getting very annoyed" at what he sees as a redefinition of the venerable (since 1999 when it was coined from "weblog") word "blog".

There's Kristen Havens, who wrote an interesting blog on semantics, at her "Writing and Editing" site. Using just 485 words, Kristen mentions different ways to use post and blog correctly and incorrectly. This particular blog of hers originally appeared on a site called MySpace, whatever that is.

But the real winner is Forrest Wickman writing in Slate's Culture blog. In a blog entitled "This is a blog post, not a 'blog,'" he excoriates people like Arianna Huffington and late Roger Ebert for using "blog" when they should have said "post."

Wickman says, "I hit my breaking point a few weeks back with—who else?—Amanda Palmer."

Who else indeed? I will save you the trouble of googling her name. She is some kind of singer and performer who gave a TED Talk, which actually is pretty interesting. She drove Wickman to the breaking point by calling a post of hers a blog! Can you imagine?

Suitably censured, she now calls her blogs posts as you can see on her website. 

I hope you enjoyed this blog post.

Discrediting the paper about discredited practices

According to a study in the August 2013 issue of the Mayo Clinic Proceedings, 146 papers appearing in the New England Journal of Medicine over the first decade of this century contradicted medical practices previously thought to be effective.

The paper's findings were widely publicized. There was talk in the New York Times of inertia hindering change and allowing ineffective treatments to continue for years.

The full text of the paper and a supplement containing a brief summary of all 146 discredited practices are available on line.

I decided to see for myself if any practices relating to general surgery were included in the paper and found 11.

Two of them seemed somewhat debatable to me.

Number 43 on the list was a comparison of open mesh to laparoscopic mesh inguinal hernia repair that appeared in NEJM on 4/29/04. This was the critique:

"A laparoscopic approach to repair inguinal hernias with mesh was thought to have lower hernia recurrence rates and less post-operative pain. This multicenter, randomized trial in a VA population found that the laparoscopic approach led to a higher rate of complications and a higher rate of recurrences when repairing primary inguinal hernias."

It definitively closed the door on laparoscopic inguinal hernia repair. Or did it?

In the 4/30/04 issue of NEJM, letters to the editor pointed out that the laparoscopic recurrence rate of 10% in the VA study was much higher than in other reported series, and the size of the mesh (~8.0 cm) used in the laparoscopic cohort was much smaller than the 10 cm x 15 cm that most experts recommended.

How has the VA paper affected surgeons' choice of technique for hernia repair?

A report from the American Journal of Surgery in 2012 found that as of 2008 at the Mayo Clinic, 41% of inguinal herniorrhaphies were performed laparoscopically.

Looking at national resident case logs data for 2012 from the ACGME, 35% of all groin hernia repairs were done laparoscopically.

Despite having been "discredited" in NEJM, laparoscopic inguinal hernia repair is quite alive and well.

The Mayo Clinic Proceedings paper also stated that preoperative biliary drainage for patients with cancer of the head of the pancreas was discredited by another NEJM paper for 1/14/10. Here is what they said about number 131 on their list:

"Jaundice in surgical patients is postulated to increase the rate of postoperative complications. Many surgical centers have employed biliary drainage prior to surgical intervention for cancer of the head of the pancreas, but there is conflicting evidence regarding its effect on morbidity and mortality. This multicenter, randomized trial found that routine preoperative biliary drainage increases the rate of serious complications without a mortality benefit."

Subsequent letters in the 4/8/10 issue criticized the study because patients were drained for 6 weeks prior to surgery which was not the norm of 2 weeks, patients with bilirubin levels above 14.6 gm/dL who were most likely to benefit from preop drainage had been excluded, the wrong type of stent was used and prophylactic antibiotics for ERCP were not uniformly administered.

Is preop biliary drainage still being used?

A randomized trial from South Korea in the July 2013 American Journal of Surgery showed that preoperative biliary drainage for longer than 2 weeks resulted in twice as many complications as drainage for less than 2 weeks, 25.9% vs. 9.1% respectively. This compares favorably to the 74% complication rate of 6 weeks of drainage found in the 2010 NEJM study.

In the July 2013 American Journal of Gastroenterology, a group from Memorial Sloan Kettering Cancer Center published a retrospective review of over 500 pancreaticoduodenectomy patients, 220 of whom had preop stents. The overall complication rates did not differ whether a stent was used or not.

Again despite being "discredited," the use of preoperative biliary drainage continues to be very common.

So what happened here?

The only surgeon among the authors of the 146 discredited practices paper is a third-year general surgery resident. Maybe he did not have enough experience to evaluate these papers and their impact.

Or maybe one should not necessarily base an opinion about whether a practice has been discredited or not on a single paper in one journal.

The findings about these two topics, hernia repair and biliary drainage, lead me to question just how many of the other discredited practices are really no longer indicated or used.

Surgeons behaving badly

An orthopedic surgeon from New York reportedly has 261 malpractice suits against him. He has been accused of performing "phantom" and unnecessary operations. In one case, he supposedly performed a knee reconstruction, and the patient died of a pulmonary embolism the same day. A post-mortem examination allegedly showed no evidence of a reconstructed knee.

There is also said to be evidence showing that in one day he was doing as many as 22 cases, some apparently lasting less than 8 minutes. Details can be found in a lengthy story in the Poughkeepsie Journal.

If you've been following my blog, you know that I am not a big fan of lawyers. But I have to admit that one lawyer's questions about what the hospital knew about all this and why the surgeon wasn't scrutinized sooner are good ones.

Surely the operating room staffs of the two hospitals he worked in must have had a hint that something was wrong. If he said he reconstructed a knee and didn't really do it, wouldn't the OR nurses, techs and anesthesiologists have noticed? Were there no quality assurance or risk management policies in place?

And what about the other orthopedists in town or members of his multispecialty group? They must have seen some of his patients who were dissatisfied. How could they not have spoken up?

What about the company providing his malpractice insurance. How do you get to 261 cases? I once sat on a committee of a malpractice insurance company run by a state medical society. We interviewed a surgeon who had about 10 active or closed suits against him.

When we spoke to him, he could not explain why he had so many suits other than that he had a high-volume practice. His record keeping was poor and his communication skills were lacking.

We terminated his policy on the spot. No other company would insure him. Without malpractice insurance, he could not work.

The orthopedist in question has surrendered his New York medical license as of September 2, 2013 but still has a license to practice medicine in Virginia. Another Poughkeepsie Journal article describes his work history since he left Poughkeepsie, a non-medical incident in Virginia and the transfer of assets to his wife's name. By the way, that might not work since it was probably done after the problems surfaced.

Of note is the fact that he has excellent patient satisfaction scores. Based on 51 responses, he gets 4½ of 5 stars from HealthGrades.    

A spine surgeon in Ohio has been indicted by a federal grand jury on 10 counts of performing unnecessary spine surgery, 5 of which involve health care fraud.

He is said to have told some patients that surgery was urgently needed, including that their heads would fall off if they were in an automobile accident "because there was almost nothing attaching the head to the patient's body."

A lawyer filed a malpractice suit against the surgeon claiming he did unnecessary operations on over 100 patients.

Although he apparently has no current hospital privileges, he still can operate at a surgical center that he owns.

His HealthGrades scores are a bit more modest at 3 stars.

I realize that only one side of both of these stories has been told. These are allegations. Nothing has been judged in court yet.

Finally, we go from the serious to the silly. A New York City eye surgeon has gone public with an offer to trade his services as rewards for dates with women. He has exacting standards however.

According to the New York Post, he went to three Ivy League schools (Dartmouth, Columbia and Harvard), Emory and has an MBA from NYU. "He wants a woman with a graduate degree or Ivy League undergraduate degree."

Police have been stationed outside his office to control the hordes of Ivy League women who are queuing up.

These are isolated stories and not representative of all surgeons. But they are disturbing to me.

What do you think?

Electronic charting, tracking and malpractice lawsuits

A recent article on amednews.com called "Medical charting errors can drive patient liability suits" led with a case involving a bad outcome after coronary artery bypass surgery. The plaintiff's attorney alleged that the doctors did not review the patient's lab results or x-rays because they did not specifically say so in the medical record.

The article quoted a defense attorney who said, "By the time [the doctors] are deposed, it's three years later and they say, 'I'm sure I looked at that,' but there's no charting to back it up.” 

Unless there is something very unusual about the electronic medical record (EMR) used by the doctors in that case, there should be a very easy way to determine if they viewed the results in question.

A feature of every EMR that I am aware of is that each time a chart is accessed, the EMR records who accessed the record, where they accessed the record from, what they looked at and for how long they stayed on a page down to the second. It is like an electronic fingerprint with time included.

When I was a surgical department chairman, I had many opportunities to see how this worked. 

For example, I was asked to review a situation in which a resident failed to call for help with a patient who was crashing in the ICU. An arterial blood gas showing severe metabolic acidosis was not acted upon on a timely way. The resident said that the nurse did not report the critical blood gas result to him after the lab phoned it to her. This could not be verified, but the EMR showed that he had seen the result some 30 minutes before calling his senior resident.

Another case centered on an allegation by a gynecologist that a consultant surgeon failed to respond promptly to a call to assist with a bleeding patient in the operating room. The EMR revealed that four days after the case, the gynecologist had altered her operative dictation to make it appear that she had called for the consultation much earlier in the course of the surgery than what actually had occurred.

A surgical resident looked at a chart of a patient who did not have a surgical problem and was not on his service. She denied having accessed the record. When it was reviewed, the EMR showed that she had looked at 9 separate sections of the chart and had spent more than 10 minutes doing so.

As is true of many reports about malpractice trials, important details about the heart surgery patient's case are lacking. But surely the defense attorneys must have known that the EMR could be searched to see if and when the doctors in question looked at certain portions of the chart.

If all medical, nursing and ancillary staff members are not aware of the tracking features of EMRs, they should be. This is the same type of tracking that catches unauthorized personnel who peek at the chart of a celebrity or other prominent patient in the hospital. 

Note the example of the recent Boston Marathon bomber who was hospitalized. Staff who were not involved in treating him were repeatedly warned not access his EMR. 

Consider yourselves informed. Big brother is watching.

Employers, health insurance coverage and PSA testing

Help me with this please.

A 56-year-old man just got a new job. As part of the pre-employment process and in order to be covered by his new company's health insurance, he had to undergo a physical examination and some blood tests. A digital rectal exam was not done.

He has no risk factors for prostate cancer or urinary symptoms and by most guidelines is not a candidate for PSA screening.

He was not told of the possible harms of the test, nor was he told to abstain from ejaculation within 48 hours of the blood being drawn.

Of course, his PSA is 5.9 ng/mL.

The cost of the repeat PSA test will be borne by the patient. There is already talk of biopsies.

Not only will the patient have to deal with the anxiety generated by the test, he is being pro-rated by his health insurance carrier. He will be paying $200 per month extra for his coverage.

Does anyone have any thoughts about this?