What is Toxicology?

I completed a 1 month rotation in clinical Toxicology. So what is toxicology? Like everything else in medicine it is a complicated question. A clinical toxicologist usually completes medical school and then completes a residency in emergency medicine (3-4 years) followed by a 2 year fellowship in toxicology.

A clinical toxicologist will usually work as an emergency medicine physician part time and then work as a consultant in toxicology where they get consulted on cases where a patient has overdosed or taken a poison (intentionally or accidentally). The toxicologist will come in and see the patient and make recommendations on how to treat the poisoned patient. These consultations usually come from emergency medicine doctors or the poison control.

The clinical toxicologist will also usually be professor tied to an academic teaching hospital and will spend some of their time teaching about various toxic exposures that occur to patients. Their job includes several different roles which makes it an interesting field.

As one toxicologist told me; "Everything in medicine is tox related"

I matched at my #1 spot

In order to keep some anonymity I will not post my actual place of residency. Those who know me like friends, family and others will already know the location.

However, I am very excited and will say that I did match at my #1 choice. That is great and I feel blessed as there are many this year who did not match and some of the program directors of the residency programs were saying that this was the most competitive year they have seen, meaning that they received many more applications for the spots this year than they had in prior years.

I feel like everything lined up and I was fortunate enough to not only match but get my top choice. Like I said, I was blessed.

I Matched

Today at 10:50 am I received and email stating the following:

Congratulations! You have matched.

This means on Thursday I will get an envelope with a letter in it telling me where I matched. It looks like I will be starting my first job as a doctor in emergency medicine in July. We just need to know where.

I will post.

Where have I been?

No excuses! I have not posted in a while. I will play some catch up. I finished 3 rotations in emergency medicine in very different emergency settings. Inner city, Suburban area , and a Urban area (not inner city but not community or suburban setting). All of them were great and the experiences re-confirmed my choice to pursue emergency medicine for residency.

I interviewed at 14 programs and ended up ranking 12 programs total. If you have read my past threads about the match this will make sense to you. There was a lot of traveling involved in going to each of these residency programs and interviewing and checking out what they had to offer for training. The bottom line in emergency medicine is that most programs if not all of them in the USA will get you trained to run a busy hectic emergency room and handle all the procedures you need to be able to do. There are very strict guidelines and rules that the residency must adhere to in order to stay accredited. Wherever you train you will get the procedures down and the skills it takes or at least be provided the opportunity to gain those skills.

As an applicant it come down to where do I want to go and what will be best for me and my family. I have some highly regarded programs as my top choices and I certainly hope to match at my #1 choice but I would happily go to any of my choices on my list.

Last month I completed a 1 month Radiology rotation and worked with a famous Radiologist who really focused on the important areas of emergency medicine with regards to radiology. I learned a ton of ultrasound and how to maneuver the probe to enhance certain exams and procedures done in the ED. I also got a great amount of CT reading and Xray training in. It was hands on and focused. I felt like I got 4 months crammed into 1 month and it was extremely high yield for me.

Currently I am on a toxicology rotation and I will dedicate some future threads to this rotation as I am only 1/2 way through it. I absolutely love it. It is all about poisonings; intentional, accidental, drugs of abuse, alcohol, drug interactions etc. Very fascinating and a great part of emergency medicine.

Next week is a big week for me. On Monday 3/15 I find out "if" I matched. I will get an email at about 11:00 am saying one of the following:

1. Congratulations, you matched.

2. You did not match.

3. You matched to a PGY1 position only.

4. You matched to a PGY2 position only.

Mine will hopefully be: congratulations, you matched. Options 3. and 4. do not apply to me as I did not apply to any programs that would only accept me for a 1 year position or a year 2 position.

Then on Thursday 3/18 at 11:00 am my entire class will meet and receive our individual envelopes. I will open mine and see "where" I matched. Then the celebrating and panic can begin as I get ready for the next phase, residency.

This is the last summer of my childhood.......

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.