Del Meyer, MD, Pulmonary Medicine

MedInfo Health Line

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Doctors in Hot Water

Doctors are increasingly in "Hot Water." But this may not be their fault. Let me tell you about an actual case that recently happened in a hospital.

Dr Canfield, a surgeon, had an unexpected finding during an operation. It was a challenge in which he had not had a great deal of experience. He wasnít quite sure if an alternative approach to the intended operation might be better. So he did the unusual and obtained in intra-operative surgical consultation from a colleague. It took a great degree of courage for a surgeon to do this during an operation. Maybe he should have expected the unexpected, but such is the nature of medicine and surgery. Many surgeons would just have proceeded and no one would have known the difference. Thus the patient received the benefit of the consultative opinion, did well postoperatively and was discharged.

Several days later, two of Dr Canfieldís colleagues in the same specialty took him aside and told him that he should resign his surgical privileges within 24 hours, or they would "drag him through the mud." He was directed to meet with the physician health committee in the medical staff lounge immediately after office hours at 6 p.m., or they would report him to the Medical Board.

When he arrived in the staff lounge, he met one of his colleagues who pledged to be his friend and see him through the confrontation. On entering the medical staff lounge, he found himself surrounded by four other colleagues in his specialty, as well as a psychiatrist who was present in order to make it look like they were interested in his emotional health. He was given the same ultimatum to resign within 24 hours or they would use his medical records against him and he would lose hospital practice privileges, an action that would then be reviewed by the state medical board. Ultimately, the result could be loss of his medical license. He would then be reported to the National Data Bank, that attorney David Gallie has called a permanent tomb for physicians, not necessarily just bad doctors.

Professor John H Fielder, PhD, writes about a disturbing trend in medicine today which he calls "Abusive Peer Review." He cites examples in Astoria, Oregon, Oakridge, Tennessee, and Sacramento where Peer Review, which is supposed to monitor quality of care, is being used to eliminate doctors in competition. He cites reports that estimate that up to 70% of Peer Review may have nothing to do with quality of care, the very thing it was designed to do, and instead is used for economic reasons.

So if your doctor disappears from his or her practice, there is a chance that, even though he was a good doctor, he didn't have the political savvy to survive the political onslaught of unscrupulous doctors and hospitals.

A Doctor Goes to Jail

At the beginning of 2001, one of our doctors went to jail. It may have had nothing to do with the practice of medicine, but rather with law. Although there may be information that wasn't available in the papers or in the facts as he discussed them, it is important for us to understand them. Many doctors could go to jail while practicing good medicine.

This doctor had a large convalescent hospital practice. He would see these patients once a month. Many of his patients were unable to communicate with him, and the examinations were unchanged for months and sometimes year. The important thing for him to do every month was to review the medical record to see what was going on and to discuss the patient with the nurse for any problems that weren't recorded. Then as he walked around the hospital ward, his examination was focused on the primary area of disease or new items the nurse brought to his attention. These patients did not need a detailed examination on a monthly basis.

A nurse noted the lack of significant examination and reported him. Many physicians with similar practices have told me they practice the same way. In fact, most family physicians stated that this is how they practice office medicine. Only the required examination, based on the patientís complaint, is all that there is time to do. Hence, he was within the community standard of care.

In the old days from which this physician came, a doctor would charge a fee commensurate with the degree of detail of the examination. However, at this time, there are thousands of numbered codes, each representing a certain type of detail. Unfortunately, there was no number that correctly identified the type of evaluation that he did. He, therefore, used a numbered code that he felt was close to what he did. He unfortunately chose a number that reflected a degree of examination that he didn't perform, unbeknownst to him. Therefore, he was indicted and sentence for not following the letter of the law. Physicians don't make good lawyers. They don't think in legalistic terms. It has been estimated that perhaps half of all physicians breaks rules of which they are totally unaware.

As lawyers in practice and lawyers in congress control more and more of what physicians do, and put doctors in legal straight jackets, we will find physicians fending for themselves to the detriment of their patients. When doctors become lawyers and business people, then who will we have as our doctors? Then we as patients soon won't have any body on our side. We must act before it's too late.

Disabled Doctors

Doctors were once among the most dependable workers in America. However, they have been leaving their jobs in sharply rising numbers to collect disability benefits. In some instances, they are earning more on disability than in working, according to insurance executives. Insurance analysts believe that declining morale is a key factor in the growth of disability claims.

Surgeons have been encouraged to continue practicing despite arthritis and other ailments. They formerly ranked with lawyers, accountants, and architects in occupations most favored for disability coverage. Now they rank toward the bottom of the professional hierarchy, below shipping clerks, steel mill superintendents and traveling salesmen.

For years, physicians have vented anger and frustration about the changing rules of their profession. Many complain they are working harder for less money, are under increased stress and are having their medical judgment questioned by HMOs. Adding to their indignity, many critics dismiss their complaints as the whining of a spoiled elite.

Disability carriers are experiencing a drain on their earnings as doctors are incurring disability claims at about twice the number expected from all occupations. They are no longer clamoring for doctor business.

But the real question remains. Why are we allowing others to destroy our profession? To what organization are we paying our dues to be our watchdog? Maybe we need a different watchdog.

Veterans Hospitals

Here's an interesting and true story I know you will enjoy.

Joel D Wallach, DVM, MD, nominee for the 1991 Nobel Prize in Medicine, mentioned in an address that hundreds of thousands of patients lose their lives unnecessarily in hospitals. He then stated that we have two "opportunities" to give our lives for our country - once on the battlefield and once in a [government] VA hospital.

He wasnít kidding. A VA doctor tells the true story. One day during rounds, the nursing assistant complained that a patient was not swallowing. The food just keeps running down his mouth onto his shirt. The doctor looked closely at the patient and noted that he was dead.

Now isnít that something. Not only can you give your life in the VA hospital, but after youíve given your life, the staff doesnít even know that youíre dead.

As is well known, the government itself is a welfare system. It is the only employer that can employ the totally incompetent.

Or from another angle, while weíre debating physician-assisted suicide, why donít we just allow people to get admitted to a VA hospital who want to die. Then nobody will know the difference.

Hazards of Hospitalization

The Harris poll rated health care settings as slightly more dangerous than airplanes and the workplace and slightly safer than nuclear power plants. Many were speaking from personal experience. The results reflected that 40 percent of US adults have been involved personally or through a friend or relative with a medical accident or mistake while in a hospital as a patient. This is supported by the results of Lucian Leape, MD, of the Institute for Health Care Improvement at the Harvard School of Public Health, which says that errors or accidents may harm up to 20 percent of hospitalized patients. This totals a staggering three million separate incidents a year at a total annual cost of $200 billion.

The best way to avert errors when you are admitted to the hospital can be summarized in two words: Speak Up!

It may be a clichť that health care should be collaboration between patient and doctor--but it's no where truer than in a hospital. Many people are intimidated by complex hospital routines that they stay out of the way. But any doctor or nurse will tell you: The hospital is one place where it definitely pays to be involved and assertive. Ask questions about any thing you don't understand. Be polite, be pleasant, and be persistent. Try to understand the purpose and schedule of every medication or test you are given. Drug allergies may have been missed. Have personnel identify themselves before you take your medicine or are wheeled off for a test that you haven't been expecting. Always ask what it's for. If you're too shy, recruit a friend or relative to be your advocate who will ask the questions for you.

Remember the organ removed or the amputated leg can never be restored. The life that is lost can never be reclaimed.

The Cost of Hospital Oxygen

As a medical director in a hospital, I had first hand experience in how hospitals charge for their services. I'm a pulmonary doctor and was in charge of the Respiratory Therapy Department. According to the Joint Commission that accredits hospitals, the medical director was supposed to be involved in setting the charges for all services rendered.

One day, my technical director came to me and said that as he was going over the department charges, he found that the charge for oxygen had increased from 75 cents an hour to three dollars an hour without input from him or the department. This added $72 for 24 hours of oxygen to my respiratory patientís hospital bill instead of $18. We researched the mechanism and noted that our respiratory therapists entered the hours of oxygen into the patients computer account which then converted it to dollars without any of us knowing the final charge. We determined the cost of the oxygen at less than 25 cents an hour.

We then made an appointment with the assistant administrator that was in charge of our department and expressed our concern. He said that he had authorized these progressive increases and the hospital still had not determined the maximum that Medicare, Blue Cross, Blue Shield, and other insurance carriers would pay. In fact, since everyone was paying the $3, he had already authorized the next increase to $3.50 an hour.

I was told quite firmly, "Isn't getting the money in our prime objective?" It was then that I became aware that costs had nothing to do with what hospitals charged. To charge 14 times what the cost of oxygen was did not seem to the hospital to be gouging the unsuspecting sick patients, nor did they even think it unethical. They were busy building, what European doctors call, large palaces for their patients. All this extra money allowed each hospital, no matter how small, to have facilities that even the large metropolitan hospitals in other countries could not afford.

Is it any wonder that the HMOs and government has now clamped down on everyone in the healthcare business even though 90 percent of the gouging was done by hospital and other suppliers? The important message is that we all have to keep our eyes open to abuses. When you receive a hospital bill, be sure to check it very carefully to make sure charges are appropriate. Even better, monitor every charge while youíre still receiving care. If you don't get satisfaction with the hospital or insurance company, you may call 916-497-1434, or send a copy of your excessive bill to the address given.

Mega Hospitals

Hospitals have convinced doctors and the public that getting larger is more efficient. Many of our local hospitals are selling themselves to large hospital systems, telling the medical staff that service to them and their patients will be just as personal. Others are just getting larger under the name of efficiency and improved ability to compete. But what is being said and the effect on patient care may be disastrously different.

In our community, eight hospitals have become a two-hospital system of 5 and 3. In addition to the obvious efficiencies of larger purchasing power, the other so-called benefits may not be beneficial. For example, the medical staff services and medical transcription has been consolidated for all five hospitals in one system. Can you imagine how frightening it is to walk into your own medical staff office and no one knows you in the very institution in which you make a living? This can be horrifying.

Also, the five transcription services consolidated to an off-sight contract service. This may make the patientís history and physical report, the basis for the entire medical record, totally irrelevant. My first transcription to an off-sight transcription pool was totally unrecognizable, both to doctor and patient. It was the type of thing that occurs when a legal transcriber fills in for a medical transcriber and the words are unfamiliar. The transcription was on the chart for several days before even I recognized that it might be mine. It served no useful purpose in the care of this patient. It was not corrected during the five-day patient stay. It was still not corrected when the final summary was dictated.

Information is critical for medical decision making of life and death issues and must readily be available. When business decisions are made without medical input, patient care is compromised. We must always be on guard.

Cape Coral Hospital Fraud

The Cape Coral Hospital is now the famous "merger gone awry." This nonprofit facility which opened in 1977 became this coastal townís largest employer and favorite charity, attracting many volunteers who even had to pay to be volunteers. The townís most prominent citizens were on its board. In 1994, this profitable nonprofit hospital was on the brink of failure, losing $1 million a month putting it in danger of defaulting on its bonds. The administrator suggested that these were hard times and they would have to merge like other hospitals all over the country. . . . Same story, but this time a different verse.

It turns out the hospital administrators were using hospital funds to build luxury homes, buy diamond rings, pay for golfing trips to Scotland, and buy an island resort and a strip mall. Soon the hospital directors participated in shady deals. One even billed his insurance company for medical care he obtained free from the hospital. This would all have gone unnoticed had it not been for one director who became suspicious and suggested hiring an outside firm to examine the hospital finances. The hospital administrators all resisted. The suggested examine finally passed by a vote of 7 to 6. With one less vote, the hospital administrators and involved directors would have made off with half-million dollar homes and millions of assets that were stashed away.

Think this is bad? The IRS agent in charge of tax exempt organizations said that exploiting charitable assets for personal gain isnít extraordinary in the inbred world of nonprofit hospitals. The corruption of business leaders with doctors makes things ripe for this to happen. He said that cases linked to health care fraud are up 60 percent this year. So, when your hospital says they canít make it in this competitive world, just ask for an outside audit. Thereís plenty of money in the health care industry if itís focused to patient care.

Hospital Costs

The CEO of a large insurance company wrote a letter to the editor of a newspaper about how he was trying to reduce health care cost by cutting hospital stays. He quoted an example of sending mothers home on the same day of delivery. This was an unfortunate example since most mothers already go home in a day or so after delivery.

This may be the wrong emphasis in controlling cost. Doctors have been very successful in reducing hospitals days as safely as possible. But we're finding out it may not have decreased hospital costs.

Surgeons, for example, have developed laparoscopic techniques to remove gallbladders, appendices and ovaries through a tube inserted into the abdomen. This has drastically reduced hospital stays from, in many cases, five days to one day.

Doctors naively assumed that the hospital charge for a one-day hospitalization would be about one-fifth the charge of a five-day stay. I was shocked when my patient brought in her hospital bill indicating a $15,000 charge for taking out her gallbladder, especially since she was only in overnight. The full five-day stay under the DRG Medicare system was less than $10,000.

In our example above, the insurance CEO is making a hundred doctor's salaries by getting the doctors to risk their patients health in sending them home the same day of delivery. In the hospital example, the charges are increasing despite a false guise that they are trying to reduce costs by sending gallbladder patients home in one day. Doctors are being blamed for doing too many surgeries when, in this example, the surgery should have cost 80 percent less rather than 50 percent more. It appears that anything physicians do to decrease health care costs will be subverted by others into an increase. Itís time we put the blame where it belongs.

Disclaimer: These messages were written in the years as noted and may be somewhat dated at this time. Please consult your physician or other health care provider.