The old joke in medicine goes, ‘don’t get sick on July 1st.’ That’s because it’s the day when new resident physicians, freshly graduated from medical schools across the land, begin their training programs. Although they have spent four years in undergraduate school and four years in medical school, it’s residency where physicians are made from the raw material of knowledge-rich, experience poor high achievers.
However, even in residency physicians are seldom told the entire story of how the practice of medicine, and their lives, will look and feel as their careers evolve and they enter the medical work-force.
Since our profession changes from year to year and administration to administration, it seems a good time to mention some of the things upcoming young physicians will face. Sadly, these are things seldom mentioned by pre-med advisors or academic medical educators.
You see, physicians are struggling. Due to falling reimbursements and the ongoing federal mandate to see non-paying patients on call, it is increasingly difficult for physicians to cover costs like malpractice insurance, licensure, professional memberships and office overhead. (Well, if they want to have a house, family and food, that is.)
Many physicians are Read more »
*This blog post was originally published at edwinleap.com*
I graduated from medical school in 1985, am board certified in EM and practiced 25 years—mainly inner city/trauma/teaching centers. However, the last 5 years were in a rural 25-bed hospital, 60 miles from a shopping mall or hospital with higher capabilities and specialists. My hourly rate was competitive and the hospital provided benefits included: malpractice, health, dental, & vision insurance, prescription coverage, paid vacation/CME allowance, and pension contribution.
Palliative Medicine (intensive symptom management for chronic or serious illness, coordination of care and clarification of patient/family treatment & life goals) is a subspecialty in urban settings but is lacking and most needed in the rural community setting. The chronically ill patient who is also typically elderly may present to the ED and be denied hospital admission after an ED physician evaluation. The doctor can “request” admission from an at-home Utilization Review nurse who checks the admission guidelines and if not met, reports the patient is to be sent home—even if it is over the objections of the physician who has evaluated the patient. There is no systematic follow-up of these patients, and they are told to “contact your primary care physician.” No one is making sure this happens. Some do not have primary care physicians and may be unable to obtain a timely appointment. The hospital does not have a social worker to coordinate care or provide assistance in the confusing navigation of insurance/appointments/outpatient testing, etc. There is no 24-hour pharmacy. Many of these patients do not have transportation or no longer drive and often live many, many miles from the hospital relying on neighbors, church folk, or county ambulance when they become ill.
In 2010, I opened Read more »
Emergency physicians are in a dilemma. Risk missing a diagnosis and be sued, or be criticized for overtesting.
Regular readers of this blog, along with many other physicians’ blogs, are familiar with the difficult choices facing doctors in the emergency department.
The Associated Press, continuing its excellent series on overtesting, discusses how lawsuit fears is a leading driver of unnecessary tests. Consider chest pain, one of the most common presenting symptoms in the ER:
Patients with suspected heart attacks often get the range of what the ER offers, from multiple blood tests that can quickly add up in cost, to X-rays and EKGs, to costly CT scans, which are becoming routine in some hospital ERs for diagnosing heart attacks …
… and the battery of testing may be paying off: A few decades ago insurance statistics showed that about 5 percent of heart attacks were missed in the emergency room. Now it’s well under 1 percent, said Dr. Robert Bitterman, head of the American College of Emergency Physicians’ medical-legal committee.
“But you still get sued if you miss them,” Bitterman added.
The American Medical Association’s idea of providing malpractice protection if doctors follow standardized, evidence-based guidelines makes sense in these cases. Furthermore, it can also help reduce the significant practice variation that health reformers continually focus on. Read more »
*This blog post was originally published at KevinMD.com*
When my six-year-old daughter heard that I was going to write about President Obama’s speech to the American Medical Association in Chicago, she offered me this insight: “He’s not a doctor! He isn’t supposed to tell people what to do when they’re sick; he’s supposed to rule the world.” Yet, regrettably, doctors do need his help and it was with great interest that on June 15, the medical community listened.
I suspect that my colleagues in Chicago are the only crowd to boo the President during a speech since his election, and I think that much can be learned by examining why this occurred. Just moments before being booed, Obama received raucous applause when he acknowledged, “that some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable. That’s a real issue.” Physicians in the audience then booed the next line, “I’m not advocating caps on malpractice awards which I believe can be unfair to people who’ve been wrongfully harmed.” The President went on to offer a plan to help physicians avoid practicing expensive defensive medicine. “We need to explore a range of ideas about how to put patient safety first, let doctor’s focus on practicing medicine, and encourage broader use of evidence based guidelines.”
I do not object to President Obama’s sincere and well delivered remarks to the AMA, but found some of them to contain trite platitudes. Encouraging physicians to “put patient safety first, focus on practicing medicine and follow evidence-based guidelines” is like asking airline pilots to pay attention to safety gauges, fly their planes, and respect passengers. I found the admonition to follow evidence-based guidelines as a means to avoid medical malpractice claims a particularly naïve statement. I’m not arguing against using guidelines, I just don’t see how guidelines will protect me from a lawsuit any more than the currently used standard-of-care.
I share the President’s opinion that any individual should have the option of remediation through the court system when wronged but large, punitive settlements change the way hospitals and physicians practice medicine and have resulted in an untold number of unnecessary surgeries as well as causing the actual death of many who never had their day in court. Unreasonably large medical malpractice settlements often have consequences that reach far beyond the parties involved in the original suit. Follow the relationship between cerebral palsy and C-sections and you will understand my assertion. In 1985, then trial lawyer John Edwards won a settlement of 6.5 million dollars against a hospital and 1.5 million dollars from an OB/GYN doctor arguing that if a C-section had only been done for an unfortunate child she would have been born without cerebral palsy. This case set off a chain reaction of suits throughout the country, leading obstetricians to practice defensive c-sections. The United States currently has the highest rate of C-sections in the world, the most expensive obstetrical costs per birth, and when measuring infant mortality ranks 42nd out of 43 industrialized nations.
In 1970, six percent of births in the U.S. were done by C-section; today that number has risen to over 30% while the WHO recommended, in 2006, that the actual rate should be no higher than 15%. Yet, the last four decades have seen the cerebral palsy birth rates remain close to 2 per 1000 live births in the U.S. without change. Considering that women are 4 times more likely to die during a C section than during a vaginal birth it becomes a simple and tragic mathematical exercise. Consider that in Scandinavia the maternal death rate is 3 per 100,000 births while 13 mothers die per 100,000 births in the United States; unless you’re African American–then you count an appalling 34 dead for every 100,000 births. Furthermore, once you have had a C-section there is a very good chance that all future births will be done the same way with an increased rate of hysterectomies, post-operative infections, blood clots, drug reactions, etc.
On the other hand, tort reform has resulted in major shifts in the physician workforce. In 2003 Texas put a cap of a quarter million dollars on malpractice settlements for pain and suffering but did not place a limit on the actual economic loss suffered by a plaintiff. The limit for a wrongful death case was set at 1.6 million dollars. Since 2003 Texas has seen 18% more doctors filing for new medical licenses per year (30% in 2007) and by the end of 2007 there was a 6 month backlog for the medical board to begin processing new license requests. The increased number of physicians has helped to improve access to care. Medical malpractice reform is necessary to avoid the kind of collective defensive behaviors that, ironically, may not be in the best interests of patients.
In my next few posts, I plan to discuss various aspects of our broken healthcare system. It is imperative that we understand all of these problems to avoid making things worse. This will require a probing and honest evaluation of what is wrong today. I also intend to discuss the President’s plans for reform and while I don’t agree with all of his plans, he has put forth many ideas that I do agree with. The time for reform is here, action appears inevitable, and the moment to speak out is now.
Until next week, I remain yours in primary care,
Steve Simmons, MD