May 16th, 2007 by Dr. Val Jones in Medblogger Shout Outs
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Superstar medical blogger KevinMD calls today (May 16, 2007) “Black Wednesday” – the day when two of the Internet’s most popular blogs were officially closed. Both Flea and Fat Doctor were forced to shut down their blogs due to privacy concerns. The two bloggers had been posting anonymously – in order to protect themselves and the privacy of the people they wrote about. It seems that Fat Doctor was outed by a co-worker, and Flea… we don’t know what happened exactly, but he was in the middle of a malpractice lawsuit, and was revealing the unsavory details of how the trial was going.
And this news is timely, coming on the heels of an interview I did with USA Today about blogging and patient privacy.
This seems to me like a wake up call for medical bloggers – there is no such thing as true anonymity. Your identity can only be hidden for so long.
I have never blogged anonymously – and I recognize that anything I post can be read by anyone, anytime, anywhere. This knowledge has resulted in extreme caution in posting information that could even remotely be linked to a real patient. And yes, I have also refrained from blogging about issues and events that I sure would have liked to because of the associated risks.
It may be time for us medical bloggers to create and adhere to a code of conduct to protect ourselves and our patients from harm. I had actually proposed this to Dr. Rob a few weeks ago…
What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 20th, 2007 by Dr. Val Jones in True Stories
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An elderly woman had had a
cardiac arrest and was resuscitated long after a lack of oxygen had permanently damaged her brain. Her daughter remained at her side day in and
day out in the Medical ICU, keeping watch on a hopeless situation.
Many staff had encouraged her to go out and get some fresh air, to take
care of herself… but she was compelled to stay with her mom 24-7 for reasons I will
never know.
I spent some time gazing at the patient’s face – it was delicate
and quite beautiful, with flowing white hair framing fair, soft skin. I wondered what she was like when she was
herself, if she had a gentle disposition, or a fiery wit. I wondered if she had loved her husband, and
if she had had a happy life… I wondered why her daughter was clinging to her,
barely able to leave her for bathroom breaks.
The situation continued for a few weeks – I was a medical
student, and wrote some very bland and unenlightening notes about the patient
each day, describing her unchanging condition.
I felt sad as I watched the daughter slowly come to realize that her mom
was already gone.
One day the daughter looked at me and said, “I think I’ll go
out for a bite.” I smiled, knowing that
this was a turning point for her, and gave her a hug. “I’ll watch her for you,” I said.
As it happened, the patient was on the “house service” –
assigned to the teaching attending of the month. She didn’t have her own doctor, so she was
followed by a team of rotating residents and attendings. The new team started this day, and were
somewhat unfamiliar with her case. I
dutifully updated them on the history and events over the past few weeks.
As I stood there with the team, rounding on the patient –
they noted that her lungs were becoming harder and harder to ventilate. “ARDS,” they said. “She’s going to code any time now.”
And then the unthinkable happened. The new attending, who was a bit of a cowboy,
said “let’s just end this madness. Turn
off the ventilator, it’s done.” The
residents looked at one another – one protested, “I don’t think we should do
that.”
“She’s already gone – look at her! Her oxygen is dropping, she has no pupillary reflexes,
she’s on maximum pressors…”
“But wait,” I said, “Her daughter would want to be here.”
“It’s better for her not to have to go through this,” he
said. And he turned off the machine.
I gasped. “What will
we tell her daughter when she comes back from lunch?”
Annoyed by my persistence he snapped, “Tell her she coded
when she was out.”
Thirty minutes later the daughter came back to the ICU. As she walked towards her mom’s bed, the
residents scattered. Frightened, I
approached her. She could see from the
look on my face that something bad had happened.
“She’s gone,” I stumbled… “it just happened after you left.”
She looked at me as if I had convicted her of the crime of
abandonment. At that moment, her
greatest fear of leaving her mom’s side had come true – she wasn’t with her
when she died. She ran into the room,
saw that the machines were off and all was quiet. She fell to the floor and screamed.
That scream still haunts me to this day.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 9th, 2007 by Dr. Val Jones in True Stories
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In my last post I described how VIPs don’t necessarily get better medical care. In this post I will describe a case study of a bully whose behavior wasted endless resources and time. This is a true story.
The son of a business tycoon experienced some diarrhea. He went to his local emergency room immediately, explaining to the staff who his father was, and that he required immediate treatment.
Because of his father’s influence, the man was indeed seen immediately. The physicians soon realized, however, that there was nothing emergent about this man’s complaints. After several blood tests and a stool sample were taken, he was administered some oral fluids and monitored for several hours, they chose to release him to recover from his gastroenteritis (stomach flu) at home.
The man complained bitterly and said that he wanted to be admitted to the hospital. The physicians, with respect, explained that he didn’t show any signs of dehydration, that he had no fever, his diarrhea was indeed fairly mild (he had only gone to the restroom once during the hours of his ED visit – and that was when he was asked to produce a stool sample). The man’s pulse was in the 70’s and he had no acute abdominal tenderness.
The man left in a huff, and called his father to reign down sulfur on the ED that wouldn’t admit him.
And his father did just that.
Soon every physician in the chain of command, from the attending who treated him in the ED right up to the hospital’s medical chief of staff had received an ear full. Idle threats of litigation were thrown about, and vague references to cutting key financial support to the hospital made its way to the ear of the hospital CEO.
The hospital CEO appeared in the ED in person, all red and huffing, quite convinced that the physicians were “unreasonable” and showed “poor judgment.” Arguments to the contrary were not acceptable, and the physicians were told that they would admit this man immediately.
The triumphant young man returned to the ED for his admission. Since the admitting diagnosis was supposedly dehydration, a nurse was asked to place an IV line. The man was speaking so animatedly on his cell phone, boasting to a friend about how the doctors wouldn’t admit him to the hospital so his dad had to make them see the light, that he moved his other arm just at the point when the nurse was inserting the IV needle. Of course, the poor woman missed his vein.
And so the man flew into a rage, calling her incompetent, cursing the hospital, and refusing to allow her to try again.
At this point, the ED physicians just wanted him out of the emergency room – so they admitted him to medicine’s service with the following pieces of information on his chart:
Admit for bowel rest. Patient complaining of diarrhea. Blood pressure 120/80, pulse 72, temperature 98.5, no abdominal tenderness, no white count, patient refusing IV hydration.
Now, this is code for: this admission is total BS. Any doctor reading these facts knows that the patient is perfectly fine and is being admitted for non-health related reasons. With normal vital signs, and no evidence of dehydration or infection, this hardly qualifies as a legitimate reason to take up space in a hospital bed. And when the patient is refusing the only treatment that might plausibly treat him, you know you’re in for trouble.
The man was discharged the next day, after undergoing (at his insistence) an abdominal CAT scan, a GI consult, an ultrasound of his gallbladder, and a blood culture. His total hospital fee was about $8,000.
Do you think he paid out of pocket for this? No. He submitted the claim for payment to his insurance company. Their medical director, of course, reviewed the hospital chart and realized that the man had no indication for admission, and refused medical care to boot, so he denied the claim.
So the son appealed to his father, who then rained down sulfur on the insurance company, threatening to pull his entire business (with its thousands of workers insured by them) from the company if they didn’t pay his son’s claim.
The medical director at the insurance company dug in his heels on principle, assuming that if he continued to deny the claim, the hospital would (eventually) agree to “eat the cost.”
In the end, the insurance company did not pay the claim. The CEO of the insurance company called the hospital CEO, explaining that it was really the doctor’s fault for admitting a man who didn’t meet admission requirements. The hospital CEO agreed to discipline the physician and eat the cost to maintain a good relationship with the insurance company that generally pays the hospital in a timely manner for a large number of patient services.
I ask you, my friends, does this seem fair? It’s because of these cases that doctors become (sadly) hard of hearing when it comes to patients who appear well, but may indeed have a serious condition.
In my next post, I will describe a true story of a baby whose life was saved because of her mother’s insistence.
P.S. There are many comments on this post, featured at Kevin MD.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 9th, 2007 by Dr. Val Jones in Opinion
2 Comments »
I’ve invited my Revolution colleagues to form a “blog fodder chain” – when we see something interesting on the Internet, or have a difficult question, we forward it to one another as a kind of challenge to write about it in our blogs.
I have to say, though – they keep sending me the hard stuff. Examples of physicians gone bad, morally questionable healthcare practices, and hot topics full of mine fields. I keep hoping for the “which puppy do you think is cutest?” question. But no such luck for Dr. Val…
Our Chief Privacy Officer challenged me again with some powerful food for thought. A recent article in the New England Journal of Medicine reports that some physicians withhold information (about treatment options) from patients if the physician objects to the options on moral or religious grounds. Med bloggers Kevin MD and Medpundit also have recent posts about this article.
Well, of course this inspires initial indignation. Aren’t physicians supposed to offer all the options, with factual explanations of their pro’s and con’s, and then let the patient decide what they’d like to do?
Well, yes, they are. But the funny thing is that time after time when I’ve tried to do that for patients, they’ve expressed annoyance at me. They say, “you tell me what I should do, you’re the doctor!” And so after hearing this over and over again, I ended up truncating my explanation of options to the most “reasonable” ones and then allowing the patient to ask for more if they’re interested. Am I allowing my personal values to determine the hierarchy of options I present? Yes, probably so.
I’ve noticed that attention spans, even when it comes to important medical decisions, appear to be fairly short. Eyes glaze over when we try to explain all the subtleties of the options, and in the end (if the patient likes you and trusts you as a human being) he or she just wants to know what you’d choose if you were in his/her shoes – and why.
Am I being paternalistic? I hope not. I want patients to choose what’s best for them, but strangely enough their choice is often to let me decide. The power that patients impart to us is an honor and a privilege – and the reason why doctors are held to a higher moral standard than many other professionals. They are right to hold us to that standard. We must not squander their trust.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
