Stuck between administration and the drug seeker

Doctor, I am in a lot of pain!!! The worst pain I have ever been in and I think I might die. I am allergic to ibuprofen, tylenol and anything else without opiates in it. Well the doctor has seen this drug seeking behavior 100's of times and it plays out in a similar fashion on a daily basis in the emergency department. The doctor can give the patient some morphine or other opiate and quickly get the patient discharged until they need another fix, but doctors generally do not like to enable these patients.

Now it get's complicated. If the doctor takes a firm stance and calls the drug seeker to the carpet the drug seeker can often (not always) become enraged and aggravated, yelling and causing a huge scene which requires a lot of other employees to get involved like security, nursing staff and others. Also emergency physicians have patient surveys that the patients fill out and describe how satisfied they were with their doctor. Was the doctor nice? Was the doctor non-judgemental? DId the doctor treat you with respect? There are other questions about patient satisfaction and a nice area for patients to write in their complaints or compliments.

You can imagine what the drug seeker writes on these surveys when he/she does not get their drug of choice. Sometimes it seems that the drug seekers who have been refused are the only patients who take the time to even fill out these surveys. As you can imagine the jilted drug seeker can get pretty creative in their complaints in these surveys. Who cares? Well, these surveys are filed in the doctor's employee file and at some hospitals tie the doctor's pay and bonus based on the patient satisfaction reports. These surveys can influence promotions or even lead to termination. A negative report / survey is filed as a negative report regardless of it credibility. The administration does not know the survey was filled out by a scorned drug seeker or a patient who was truly treated unfairly by the doctor. A negative survey is a negative survey.

What would you do? Give the patient the morphine or drug of choice? Call the patient out and refuse to enable the patient? Choice one gets the doctor out of having a negative survey and may even get him / her a positive survey and gets the patient out of the emergency department in a quick manner requiring less staff and less drama. Choice two gets an outraged often belligerent patient that requires lots of staff time and gets the doctor a negative survey and may even get the doctor in a meeting with the administration and disciplined for a negative survey in his / her file.

I see it play out every shift. Many of these same patients do not pay their bills and often are more likely to sue as well. Obviously I am making generalizations and there are many patients who truly are not drug seekers in similar scenarios but I am talking about the repeat patients that are easily identified as drug seekers not the patient's with a kidney stone in true need of pain control.

Here is a parody video that some ER doctor made and although funny I have seen this exact type of patient many times.

http://www.xtranormal.com/watch/5864157/

A Malpractice Solution

If you read my previous post then you know I promised that I would post about a possible solution for the malpractice issues that have mostly fueled the out of control costs of "defensive medicine". If you did not read my revious post then read it first here:

http://jjmedicalschool.blogspot.com/2009/12/medical-reform.html

Here is a thought: If a patient wants to sue a doctor the patient should have this right but if the patient's lawsuit is lost or deemed frivolous then the patient should be required to pay fr the associated costs that the doctor and the doctor's malpractice insurance has incurred in defending itself. I recently was in a meeting with some doctors and their malpractice insurance representative and they explained to me that in a recent frivolous lawsuit that was thrown out by the judge. However it cost the insurance company / doctor $200,000.00 to defend themselves. Even though the lawsuit was thrown out the doctors still pay to defend themselves. It costs the doctors lots of money even when they win the lawsuit just to defend themselves and this fuels more defensive / expensive medicine.

We all know that even if you required the patient who sues the doctor to pay the costs of the doctor's defense if the patient loses or the lawsuit is thrown out as frivolous that the patient will not have the funds to pay these costs and will ultimately not pay the costs. I imagine the number of frivolous lawsuits would decline if patients knew they would be responsible for all the associated costs if their lawsuit was lost.

We create a system of healthcare banks that specialize in funding a line of credit to patients who have a lawsuit against a hospital or doctor. These healthcare banks will have a comitee made up of doctors, attorneys, healthcare administrators, investment managers and patient advocates who approve or deny this line of credit. A patient with a lawsuit would not be allowed to file a lawsuit until a line of credit that was large enough to cover all associated costs of the lawsuit if the patient were to lose the case or the case was denied for being frivolous.

Let's look at how this could work. Example 1: "legitimate case". The patient suffers an amputation of the wrong leg and instead of losing 1 leg has to go back in and have the correct leg removed and is now legless and requires a wheelchair. This patient has tremendous mounting bills and will require many future medical costs due to this medical mistake. The patient now wants to sue the doctor. The patient will need a line of credit to file the lawsuit to assure all costs are paid for if the lawsuit is lost. The patient will present his case to the healthcare bank that will review the case with its committee of experts. They will see that this is in fact a legitimate case and a case that will most likely win a large settlement. It would make financial sense for the healthcare bank to provide the line of credit to this patient and when the patient wins the case the healthcare banks will make a small percentage for offering the line of credit to the patient. The line of credit is granted and the patient and his attorney file the lawsuit. The judge views the line of credit and allows the case to proceed. The malpractice insurance company for the doctor and the hospital realize that they are at fault and not going to win the case and decide to offer a settlement of $3 million. The healthcare bank gets a reasonable percentage for backing the case with a line of credit and the patient and his attorney get the rest of the funds. The case is closed.

The above case is an actual case that under our current system the patient was in a state that had lawsuit compensation caps and the patient was only awarded $250,000, the cap maximum. I am not sure if and how the associated medical bills were handled but the awarded amount was $250,000.

Example 2 "The frivolous case". The patient decides he wants to sue his doctor because he suffered a heart attack after smoking crack and claims his doctor never mentioned that crack cocaine could cause a heart attack. This doctor saw the patient one time for a cough in the emergency room over 1 year ago and as part of a standard medical history asked the patient about the use of illicit drugs like cocaine the patient denied ever using drugs. At that time the doctor treated the patients cough and told him to follow up with his regular doctor. The patient decides that he wants to sue this doctor and when he looks into suing the doctor he is told that in order to file a lawsuit he will need a line of credit to cover the costs of the case if the lawsuit is lost or deemed frivolous. This patient does not have the means to provide a line of credit so he would be referred to the healthcare bank. The committee at the healthcare bank reviews the case and quickly realizes that this would be a frivolous case and a bad case to back with a line of credit and denies the line of credit. The lawsuit is never filed.

The above case under our current system was a real case that never went to trial and was thrown out as frivolous but it cost $67,000.00 to defend and to get it thrown out. The malpractice insurance company pays these costs and the doctor pays with time and an increase in his / her future premiums and other intangible costs)

Obviously my suggestions above are filled with imperfections and needs a lot more thought put into it by qualified experts. It is nothing more than a naive concept by a medical student and others have probably thought of similar, if not better concepts, but I believe a variation of the idea could work in some degree. Lawsuit payout caps do not work because this leaves patients who really need large sums of money to pay for the care needed by the mistakes they suffered, out in the cold with insufficient funds even when they win their lawsuit. Some studies have shown that states with lawsuit reward caps have an increase in the number of lawsuits. The current system offers no protection to doctors even when they defeat a frivolous lawsuit because it still cost them (through higher premiums) and costs their insurance company to defend the bogus lawsuit.

This is just an idea. The system is broken and the true tragedy is that until hospitals and doctors lose the fear (whether real or not) that their ability to provide for their families is blowing in the breeze and ready to disintegrate at the next lawsuit you are going to have defensive medicine. The defensive medicine is a major chunk of the healthcare costs that are overburdening our system. It is easy to say "hey doctor XYZ do not run that unnecessary test that you know is not really needed!" and it is easy for doctor XYZ to think or say "it is not worth my license or livelihood to be the guy who has the rare case that would have been caught by the unnecessary test had I only performed it, so I am going to perform it because I am afraid that I will be sued if I don't and my career will be over!"

I am not saying the solution I proposed is perfect or even near perfect and a multitude of much more experienced and qualified individuals could tear it to pieces with the problems and holes it may have in it but it might be a start of some kind.

The bottom line is something has to be done about malpractice and all the issues around it both for the patients who really need compensation and for the doctors / hospitals / public who pay for the defensive medicine caused by a fear of the litigation. The problem is that all current "house policies" that I have read do not even mention any form of reform for our healthcare legal malpractice problems.

Medical Reform

I am sure that many people have many different opinions of the current state of our healthcare system. Most individuals probably base their opinions on how to fix or not fix our healthcare system based on what part of the system they have most often experienced. If you are a medicare patient and frustrated with the lack of doctors who will see medicare patients and the long delays to get an appointment you probably are frustrated with the inconvenience of trying to get an appointment with a doctor that will take medicare. If you are an HMO patient you are probably frustrated with all the rules and regulations that they are forced to follow and the lack of care they are allowed given all the HMO policies. I think you get the point.

Most people would agree that there needs to be some things addressed within our current healthcare system. I will briefly discuss 1 point today (there are many more); Malpractice.

Many people think that malpractice is a cost of healthcare but really only effects the doctors as they pay their higher insurance premiums and that very little costs trickle down to the patients or the system as a whole. However malpractice is probably the single largest cost and waste of money on the entire healthcare system. Doctors are going to get sued. We now have classes in medical school about how to cope with your first lawsuit. It is not an issue of if but more and issue of how often. So every doctor out there is trained early and often on how to practice "CYA" medicine (cover your ass). For example; if a child comes in who has a hit their head and it is a mild bump at best. The doctor knows the child does not really need an expensive CT scan but the doctor also knows that it is not worth a lawsuit to not scan the kids head and so the kid gets $1000.00+ of tests that the doctor would most likely not do on his own child in the same situation but because he knows of a case where 1 doctor got sued for blah, blah, blah... the tests are performed. This type of medicine is being practiced all day long in every hospital, clinic and surgery center throughout the USA. As you can imagine the CYA medicine singlehandedly cost the healthcare system billions of dollars in unnecessary tests and procedures.

I once spoke with an "ambulance chaser" type attorney and he told me that in order for him to make his $1,000,000.00 salary he needs to file 10 lawsuits against doctors and or hospitals / month. He explained that whether or not the case had any merit at all did not matter. He just knew he needed to convince 10 people to sue / month. He said it was easy to convince the people to sue because they had nothing to lose. The patient does not have to pay anything unless the case gets settled and if it did get settles the attorney took is 30 - 50% and the patient got their money. The attorney said the patients had noting to lose. "Why not sue" he said. So you go in for a procedure and are completely happy with your care and satisfied with the outcome, this attorney will take you case and find some area or way that he can create a complaint and then sue the doctor at no cost to you and then one day you get a call and he says guess what your case for the procedure you were happy with settled and you get a check for $50,000.00. I asked the attorney what would happen if they put payout caps on the malpractice lawsuits and he responded that instead of 10 lawsuits / month he would have to raise it to 30 lawsuits / month to keep his $1,000,000.00 salary and in the cases that really deserved a larger payout would no longer be eligible for a needed larger payout

This attorney actually said to me "you would be stupid not to sue, even if you are happy with the care because you may get a payout." This is why doctors have to practice "CYA" medicine. This kind of medicine is expensive! A CFO at a hospital I was rotating at explained to me that he estimates that they do $50 - $100 million in unnecessary tests and procedures / month in the name of CYA medicine. This is just 1 hospital is 1 community that has 7 other hospitals in the same community.

Ironically there is no mention of malpractice reform in any of the new healthcare reform policies. Many politicians, including our president are attorneys so it makes sense that this huge elephant in the room would be ignored in any new policies. There is big money in malpractice for the attorneys but if it were addressed properly it could literally reduce the need for most if not all of the other cost cutting solutions that have been proposed. Some of the other issues of course should and could be addressed but certainly the malpractice issue is being ignored completely.

What is the solution? I do not claim to have all the answers or maybe even any of the answers. I have an idea but you will have to wait until my next post to read about it. Rest assured though this malpractice and CYA medicine is most likely much bigger and more expensive than any other cost in our healthcare system and is not being addressed and may never be addressed, at least in the foreseeable future.

Finished up another emergency medicine rotation

Everyday I work in the emergency department I feel like at the end of the shift I have added more to my data base knowledge of disease and pathology. For example, the other day I show up on my shift and I had to perform a couple knee taps from traumatic knee injuries where the patients had bled into the joint space of their knee due to an injury from falling onto their knee. You have to drain the fluid and the blood if enough pressure builds up in the knee the you the patient will have their nerves and blood vessels pinched to the point of infarction. They can experience permanent damage if you do not remove the fluid.

You palpate the knee to find the fluid build up and then use a needle and syringe to evacuate the fluid. It can be hard to find the fluid filled space but once you get it and drain the fluid the patient immediately feels relief and is happy with your work. It is a great procedure.

So now I am comfortable with knee taps. I feel the whole education and training process is all about getting exposure to all the many different illnesses and procedures needed to be a good physician. Each time you perform a given procedure your skills improve and you knowledge advances. This part of the reason that the training requires so many years. It just takes a long time to get all of the procedures down. Some days I show up to work a shift with know real clinical knowledge of a given procedure other than reading about it and the by the time I leave I have performed the procedure and added it to my skill set.

It is amazing when you look back over a few months of many long shifts and realize how much learning has occurred and it keeps you going on the days when you feel like you are no where near the level that you need to be at to be a excellent physician. It is a day by day, hour by hour process and eventually you get there. I love it and enjoy the whole process. Even a bad day is great compared to some of my past jobs / careers.

More on the Match

This year the match day is set for Thursday March 18, 2010. All 4th year medical students get a letter 1 week prior to the match day that tells them if they did match or did not match. You hope that you get a notice stating that you matched. Then you have to wait a week to find out which of the programs on your rank list that you matched at and where you will be going. Following a week of torture all the 4th year medical students meet up at their schools on "Match Day" and everyone receives their envelopes and wait for the official signal and then tear into their letter to see where they and their family will be going. This occurs on Match Day at all of the medical schools across the country on the same day and at about the same time.

For most it will be a day of happiness and celebration but for some it will be a day of frustration and or panic as they find out they matched at a program that hey really did not want to go to or they do not match at all and have to enter the "scramble".

The residency programs get their list of new residents for the upcoming year (their program's match list) on the same day and they learn who they get at their program. This can be a happy or sad day for the residency programs as well. They may have a spot or 2 not filled or they may have drawn from the end of their match list and not matched the rockstar students they had hoped to get.

In the more competitive fields there are very few (if any) spots that go unmatched and there will be several applicants that do not match at all. These students will have to either scramble into a different (less competitive field) or take a 1 year general internship and reapply the following year. In the less competitive fields there will be several programs that do not fill all their spots and will have to try and fill the spots in the scramble or leave the spot unfilled.

Emergency medicine is more toward the competitive side on the scale of competitiveness but not as competitive as the super competitive specialties. Last year there were only 5 or 6 unfilled spots that were immediately filled before the scramble even really began. There were many applicants in emergency medicine that failed to match and had to change their specialty of choice or make a new plan. This year looks like it may even be more competitive as most of the emergency medicine program directors I have spoken with have said that they have seen at least a 10% increase in applications from last year. Some of the programs will get 800+ applications for 10 spots.

It should be interesting.

Residency and the Match

I am asked about how a medical student gets accepted to a residency program once they finish medical school. I will try to explain the complicated process here.

It is called the match. During the 3rd year of medical school you rotate through all of the required rotations for 1 - 2 months per rotation. The rotations include surgery, internal medicine, pediatrics, ob-gyn, family practice, psychiatry and some others. While doing these rotations you work as a "doctor in training" seeing patients and learning how to be a doctor. During these rotations you are supposed to figure out what kind of doctor you want to become.

The 4th year of medical school is about doing rotations in the specialty you want to go into and doing other electives that may relate to the specialty you want to pursue. There are some required rotations during 4th year as well. I want to go into emergency medicine so I have done several rotations in emergency medicine. Another strategy during 4th year is to do the rotations in your specialty of choice at programs that you are applying to so that the program can get to know you and you can see if you like the program as a potential place to train at for residency.

In the beginning of the 4th year you apply to programs in the specialty you have chosen and hope to get interviews. Depending on the specialty and how competitive it is, you may apply to a handful of programs or many programs. Once you have completed your applications you sit back and hope that you get several interviews. If a residency program is interested in an applicant they will offer an interview to the applicant. You go to the interviews and check out their residency and you try to impress the program.

Once you finish all of your interviews you submit a rank list in oder of where you want to do your residency. For example; if you have 10 interviews that you went to, you would rank these programs from 1 - 10 (1 being your top choice and 10 being your last choice. The residency programs rank the applicants that they interviewed. Often a program will interview 100 applicants and so they will rank the applicants from 1 - 100 (1 being their top choice and 100 for their last choice). On a certain date the all of the rank lists are due and processed by a computer program.

Then about half way through the 4th year of medical school there is a match day where you receive a letter with the rest of the nations medical students and you open it to find out if and where you matched. You can only match at 1 residency program and you are contractually obligated to train at the program you match at and they are obligated to take you as a resident. Every year there are many students (even competitive applicants) that do not match for one reason or another. There is a program called the scramble where residency programs who did not match all of their spots and unmatched applicants can call, fax, and email each other to try and get a spot or fill their residency program.

It is a rather complicated process but it has been used for years and seems to work well. Basically the program you rank the highest that ranks you high on their list as well will be where you match. The match day is a very exciting day because you find out where your next several years will be spent.