Wednesday, July 18, 2012

“Damned if you do…”

Here’s a little story from the early days of my first job as a chairman of surgery.

Shortly after I assumed the role of surgical chairman in a community teaching hospital at the ripe old age of 40 and having absolutely no administrative experience, I visited a mentor of mine whom I had known since I was a medical student. He had been serving in a similar role at a larger hospital than mine, and I thought he might be able to share some wisdom about how to be a good chairman.

He was dispensing sound advice for most of the hour or so I spent with him. Then he said something that struck me: Sometimes the unexpected happens and there’s no simple solution. He told me that among the challenges he was facing were two lawsuits.

One was from the family of a patient who had died after a carotid endarterectomy that had been performed by a surgeon in his department. The plaintiffs were suing the hospital and my mentor, the surgical chairman, for allowing what they alleged was an incompetent surgeon to do complex vascular surgery.

The other lawsuit was by a surgeon in his department who had requested privileges to perform carotid surgery, which had been denied by my mentor on the grounds that in his opinion, the surgeon was not adequately trained in carotid surgery.

I never heard the outcome of either case, but it certainly seemed like a no-win situation.

Although that encounter occurred some 25 years ago, the problem persists today. For example, patient advocates are concerned that pain is not being adequately addressed. Yet there is an epidemic of abuse of narcotic prescription drugs that is sweeping all parts of the country.

We also are being criticized for runaway healthcare spending and being encouraged to reduce things like unnecessary testing, while a recent jury verdict for $6.4 million in Philadelphia went against two physicians for failing to order certain tests on a man who had a fatal heart attack 3 months after an emergency department visit for pneumonia.

Some say too many CT scans are being ordered for the work-up of appendicitis with worry that radiation will cause future increased cancer rates. However, in my experience, patients prefer accuracy in diagnosis over a theoretical increased risk of cancer 30 years from now.

Not long ago I was called by an emergency physician who said he had a 17-year-old boy with a textbook case of acute appendicitis. He felt a CT scan was unnecessary. I examined that patient and agreed. I explained to the boy’s mother that I was convinced he had appendicitis and needed surgery. She said, “What about a CT scan?” After a lengthy discussion, I convinced her that the CT scan was not needed. As I made the incision, I said to the OR team, “I sure hope this kid has appendicitis.”

I can think of many more such situations. How should we resolve them?
It seems to be the mantra for modern medicine. "Damned if you do and damned if you don't."


BobbyG said...

I am acutely sensitive to this problem. One of the standard lines we use in pitching our new Nevada HIE (HealtHIE Nevada) is "reduction of duplicative/unnecessary testing." Well, [1] that represents a loss of revenue for the testing/imaging entities, and, [2] if I'm the Provider of Record (I'm not a doctor, btw) in an exigent circumstance, do I want to rely on orders and results originating elsewhere?

I will have to cite this on my blog.

Skeptical Scalpel said...

Booby, thanks for the comment. You raise good points.

DTM said...

Great post. Liability is truly a vexing problem. However, attorneys NEVER testify against doctors. Other doctors do. Many of our problems are self-inflicted. It would be nice to have professional societies that come to our aid rather than ones that fall over themselves capitulating to self appointed overseers.

Skeptical Scalpel said...

DTM, thanks. I agree that many of our problems are self-inflicted. Most professional societies are useless.

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