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Only a few months ago, I was a practicing physician, specializing in anesthesiology.  Thirteen years prior, when I initially graduated from residency and entered the big, bright world of private practice, the world of medicine was a vastly different playground.  Computers played a minor role in patient care.  For example, physician’s notes were handwritten/scribbled in patient’s charts in frequently undecipherable scrawl.  Autonomy was nearly absolute, as doctors had very few people looking over their shoulders and questioning their judgments.  There weren’t many governing or unifying rules, except some loosely defined common notion of ‘standard of care.’  Doctor’s behavior was often abhorrent – some acted like arrogant, sexist cowboys, while others behaved like self-entitled Gods.

“You call it, Mr. Wilson.
Heads — surgery, Tails — angioplasty.”

The picture I paint of medicine barely more than a decade ago sounds ugly – like the lawlessness of the Wild West.  Actually, back then, medicine was fun.  Doctors were able to make judgment calls based upon their education and experience.  Just because one doctor did something one way, and another physician chose a different approach, as long as a safe outcome was achieved, it didn’t matter.  I remember being trained with the motto, “There’s more than one way to skin an anesthesia cat.”  Therein lies the beauty of that era and part of the attraction that so many felt toward a career in medicine.

Hide that bag of Fritos in your drawer!

During my thirteen years as a practicing physician, a vile plague began to seep its way into our careers.  First, JCAHO came into existence.  A governmental entity manned by people who worked behind desks to come in and tell those of us in the trenches how to best proved patient care.  In reality, JCAHO was a joke.  The hospitals had fair warning when the regulation Nazis would be showing up.  In fact, they’d announce “Code Gold” overhead, indicating the assault of minions with no clinical experience was imminent.  For that day, we didn’t eat or drink in the OR, we wore eye shields, and time outs were done with the utmost diligence prior to the beginning of a procedure.  Hallways that were chronically clogged with racks of hospital equipment were temporarily cleared out.  The next day, when the coast was clear, we would all saunter back into the OR with our Styrofoam cups of coffee in one hand, donut in the other, and Sudoku puzzles tucked under our arms.  The presence of which had no impact on patient care.

As the years passed, the insidious regulations became more stifling.  For example, preoperative antibiotics had to be administered to the patient within 60 minutes prior to incision.  Note that this does not mean that the drugs were actually injected into the patient within the dictated time frame, but the documentation made it look as though it were the case.  The bottom line is that many of these rules weren’t taken seriously – perhaps in part resulting from sheer protest by physicians being stripped of their autonomy.

“I can’t wait to leap off this lady’s bag,
jump 10 feet through the air,
and kill the patient.”

In the months prior to my departing the world of syringes and endotracheal tubes, a rule came down the pipeline that anesthesiologists would no longer be able to carry their personal bags into the OR.  For gas passers, our portable suitcases are often a lifeline.  We cram them with special equipment, useful textbooks, and medical journals that can all be retrieved in a heartbeat if needed.  The reasoning for the ban on our bags?  Germs.  Although my stethoscope came from the outside, as did my shoes, my jewelry, and my pen – all of which were much more likely to come into direct contact with a patient – these were not the targets.  Our bags that sat against the wall of the OR, at least 10 feet from they patient, were the source of evil, infection, morbidity, and mortality.  There was no study to substantiate that claim.  Just another idiot bureaucrat with a wiry hair very far up their backend.  Not to mention they forced us to leave our bags carrying our personal computers, cell phones, money, and other valuable belongings in an empty and unlocked office.

 

Which brings me to the million-dollar question.  What will happen to the world of medicine as more bureaucracy infiltrates every aspect of patient care?  If a patient has suspected appendicitis, will the attending physician only be able to write orders from a preprinted form?  Will there be any tolerance or allowance for personal variations?  Will doctors ever have to use their minds again?

Poof! And it’s gone forever!

This obliteration of physician autonomy causes the allure of medicine to evaporate like steam from a teakettle.  I envision the day when doctors will be reduced to robotic drones, not to mention being overworked and grossly underpaid.  So what will happen?  Will there be a mass exodus, as many have recently predicted?  Perhaps.  But the hard reality is that there are very few options for physicians looking to get out of medicine.  Some may successfully transition into law, hospital administration, or pharmaceutical and medical device positions.  However, such transitions are not easy, not quick, not cheap, and not in huge supply.  The sad truth is that many physicians will quickly realize that they are imprisoned by a career that they dislike – chained to a profession by mountains of student debt and non-transferrable skills.  And these are the individuals that will be taking care of our children, our parents, and ourselves.

 

I pray for good health.

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I’ve recently run up against a wall.  A mountain of naysayers who claim that physicians’ assertions of high malpractice premiums coupled with their perceived threat of litigation is a fairy tale.  The cynics’ argument is that it’s not that there are too many malpractice suits, but there are too many instances of medical malpractice.

I’m not denying that medical malpractice occurs.  It does.  It happens every single day throughout our country.  Patients are harmed, and sometimes killed.  It’s tragic and sad.  My heart goes out to every one of those patients and their loved ones.  This article is in no way intended to belittle or deny their suffering.

But, if you can, please take a step back and look at it from the physician’s perspective.  We face daggers at every turn.  Hospital administrators and government pencil pushers scour our charts, looking to reprimand us for any indiscretion.  In many cases, these transgressions have little if any impact on patient care, but in a court of law, they will be used by malpractice lawyers as one of the many nooses used to hang us.

Additionally, there is the threat posed to us by our own.  Doctors are their own worst enemies.  Some come in the form of hired guns – highly compensated expert witnesses that will testify to the most outlandish claims for the right price.  Others are in our own institutions and communities.  By nature, doctors are extremely judgmental of one another.  Whether in the form of peer review committees or conversations within back hallways, we tend to blame each other first and seek the truth later.

Then there are the attorneys.  I challenge anyone to turn on the television for an hour and not see a commercial by some lawyer fishing for patients.  Defective vaginal mesh, bad joint replacements, and dangerous birth control pills – we’ve all seen the ads.  They promise money to compensate for a patient’s pain and suffering.  It’s debatable whether or not these ads actually encourage patients to sue, but they do heighten the physician’s anxiety that medical litigation is practically inevitable.

Last of all, there are the patients.  Just like most doctors are decent, honorable and virtuous, the majority of patients are as well.  But society in general has become more litigious than ever before, and that includes patients.  Another factor is that today’s patient population has become sicker, and their expectations have become higher.  So many patients present with comorbidities, including obesity, diabetes, hypertension, high cholesterol, sleep apnea, peripheral vascular disease, coronary artery disease, and emphysema.  Every one of these diseases increases a patient’s risk of complications.  Yet, the expectation is that every outcome will be perfect.  It’s a setup for dissatisfaction and disappointment.

I have no false illusions that this post will change the attitudes of anyone who has already formulated an opinion of the subject.  Hopefully, though, it will allow the rest of the world to see the threat of medical litigation through the eyes of a physician who isn’t afraid to be honest.  Numbers and studies can be found to support anything.  In the end analysis, they only have meaning to those whose ideas are reinforced.  The reality is, for physicians, the threat of being sued is real.  The degree to which it alters each individual doctor’s practice depends upon the individual.  But to deny that it doesn’t play a role in medical practice is to discount the opinions and fears of the very ones providing care.

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Note: Sherry Gorman, MD is the author of the highly-acclaimed medical thriller, “It’s Nothing Personal,” which is based on her own experience with a high-profile medical malpractice suite.  Formerly publishing under the pen name, Kate O’Reilley, and publishing the blog, katevsworld.com, Sherry has decided to present her real self to the world.  For a no-hold-barred insider’s look at medicine, please visit Sherry here at the thewritemd.net.  For a wittier more sarcastic side of Sherry, please check out her blog nittygrittydoc.com.

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It’s anyone’s guess as to what will happen to health care in the United Stated over the next few years.  Whether Obamacare becomes a reality or not, our healthcare system is unequivocally in dire straits.  We have patients who are uninsured or underinsured who put a tremendous strain on the system and its resources.  Even among the insured population, many Americans burden the system with diseases they have brought upon themselves through poor choices.  Medical knowledge has improved to the point where we can keep nearly anyone alive.  But at what cost?

Whenever the topic of rationing health care comes up, there’s always someone with a heart-wrenching story about their Aunt May.  Poor Aunt May, who was in a coma for six months and, just before the doctors decided to “pull the plug,” she woke up, completely neurologically intact.  I’m not saying the Aunt Mays don’t exist, but the truth is that they are few and far between.  The harsh, and admittedly cruel, reality is that if Aunt May hadn’t survived, the amount of money and resources used during the six months she was in a coma would have been wasted.

As we inch closer and closer to being a bankrupt nation, we need to put our emotions aside and make some tough choices.  Many other industries already do so, and no one bats an eye.  The life insurance companies, for example, decide who is a good candidate and who is not.  If you drink, smoke, have high blood pressure or are obese, you are inherently a less desirable candidate.  You either get no coverage or it costs a fortune.  The pharmaceutical industry rations potentially life-saving drugs every day.  If you can’t afford the cancer drug that may give you an extra six months of life, too bad — you die early.  But when we put it in terms of affording a ventilator and ICU care for six months instead of a drug, people balk.  Don’t forget, the end result is the same.

As a physician, I see our resources going places where it doesn’t make sense.  Take orthopedic surgeons, as just one example.  I know many who are booked solid with patients scheduled for joint replacement surgery.  Many of these patients are poor surgical candidates.  For instance, a majority of them are obese.  In fact, it’s their obesity that largely contributed to their joint problems.  Obese people tend to have a litany of other health problems, including diabetes, hypertension, sleep apnea, and coronary artery disease.  Additionally, their sedentary life style does not predict positive physical rehab results post surgery.  I’ve personally seen numerous of these patients post-operatively, and many of them do poorly.  They have peri-operative heart attacks, they acquire infections, or they develop blood clots in their legs that shoot up into their lungs.  Even those without major complications tend to have prolonged hospital stays. In a world of limited resources, is this cost effective?

Another factor to consider in this discussion is that of personal responsibility.  As a whole, we Americans seem to have lost grasp of this concept.  We think we can do whatever to our bodies – smoke, drink, overeat, not exercise – and there’s a pill or a surgery or some other medical intervention that will fix it.  Smoke two packs a day for forty years and end up with a tumor in your lung?  That’s okay, just get it resected.  Eat like a pig and sit on your ass until eventually you weigh three hundred pounds?  No problem, that’s why they invented gastric bypass.  Pound down a bottle of scotch every day for years on end and finally wipe out your liver?  Liver transplantation to the rescue.

As difficult as it is for most people to accept, effective health care reform will need to include holding people accountable for their life styles.  Why should those of us who have the self-discipline to work out, eat right, avoid excessive alcohol consumption and refrain from smoking have to pay to fix those who make less healthy choices?  Part of rationing health care needs to take this into account.

The difficult part about rationing health care is that it’s easy to make tough choices, until it’s you or a loved one who doesn’t fall on the “approved” list.  Unfortunately, I think until we are able to put our emotions aside and look at the problem logically, our health care system will remain what it is today.  A disaster.