Thursday, September 06, 2007

Ron Paul's alien supporters

I am generally sympathetic to libertarianism, although I have a broad view of the legitimacy of pre-emptive violence in self-defense and am NOT an isolationist. But reading a discussion about the RonPaulian craziness and seeing his devoted supporters spam all of these online polls gave me an idea for a label for all those types:


As in, "Captain! There are Ronulan warships off the port bow! Fire photon torpedoes!"


Update: 9/7/07. I googled "Ronulan." There are about two billion hits for that already. I'm an idiot. Or a really clever but slow person. So let's call it "independent discovery," then. Ack. DD

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Overlawyering? OH REALLY?

Via instapundit: From JACK GOLDSMITH'S book, The Terror Presidency: Law and Judgment Inside the Bush Administration:

"In my two years in the government, I witnessed top officials and bureaucrats in the White House and throughout the administration openly worrying that investigators acting with the benefit of hindsight in a different political environment would impose criminal penalties on heat-of-battle judgment calls. These men and women did not believe they were breaking the law, and indeed they took extraordinary steps to ensure that they didn't. But they worried nonetheless because they would be judged in an atmosphere different from when they acted, because the criminal investigative process is mysterious and scary, because lawyers' fees can cause devastating financial losses, and because an investigation can produce reputation-ruining dishonor and possibly end one's career, even if you emerge "innocent."

Doc Disgruntled says....OOOOOOOOHhhhhhhhhh, REEEEEEEEALLLLY?

*92% of New York Ob/Gyns have been sued at least once.
*44% of New York Ob/Gyns report FOUR OR MORE CLAIMS against them in their career.
*51% of New York Ob/Gyns were sued at least once DURING THEIR RESIDENCY. (source: pdf of ACOG district II 2007 press release)

Doctors also find themselves judged in a different atmosphere, in an investigative process that is mysterious and scary, with high lawyer's fees (in our case, malpractice insurance premiums, recently increased 12% in NYS and now reaching as much as $180,000/yr- so 70 deliveries just to pay for your insurance), and under the threat of reputation-ruining dishonor even if you "win." I just hope the anti-terrorism guys don't quit the way ob/gyns seem to be...we really need them.


Wednesday, March 07, 2007

Gardasil and HPV

For all of those who are concerned that young women will become promiscuous just because there is a vaccine against the virus that causes cervical cancer and genital warts - get a load of this!


Tuesday, December 26, 2006

I laugh out loud.

Ah, the good old New York Times, on medical progress. New vaccines! New technology! New drugs! New cures! And a new world view!

"At the time, anyone who went into preventive medicine and public health was assumed to have graduated at the bottom of the class. A shingle on Park Avenue was the measure of success, not saving lives in poor countries. Now students are eager to study global health."

L.O.L. !!

Monday, December 04, 2006

Release your information, stat!

So you want to be a doctor? OK. Just agree to release all of your history and records to the scrutiny of an unlimited number of third parties, which you also agree to indemnify against any damages to you that may be caused by such an investigation. Or you could not accept any insurance - I hope you live somewhere where there are lots of rich people who agree to pay cash and who will choose you over the 1000 other doctors who accept what their insurance pays. Good luck!

"I understand and agree that, as part of the credentialing application process for participation, membership and/or clinical privileges (hereinafter, referred to as "Participation") at or with each healthcare organization indicated on the "List of Authorized Organizations" that accompanies this Provider Application (hereinafter, each healthcare organization on the "List of Authorized Organizations" is individually referred to as the "Entity"), and any of the Entity's affiliated entities, I am required to provide sufficient and accurate information for a proper evaluation of my current licensure, relevant training and/or experience, clinical competence, health status, character, ethics, and any other criteria used by the Entity for determining initial and ongoing eligibility for Participation. Each Entity and its representatives, employees, and agent(s) acknowledge that the information obtained relating to the application process will be held confidential to the extent permitted by law."

"I authorize the following individuals including, without limitation, the Entity, its representatives, employees, and/or designated agent(s); the Entity's affiliated entities and their representatives, employees, and/or designated agents; and the Entity's designated professional credentials verification organization (collectively referred to as "Agents"), to investigate information, which includes both oral and written statements, records, and documents, concerning my application for Participation. I agree to allow the Entity and/or its Agent(s) to inspect and copy all records and documents relating to such an investigation.

Authorization of Third-Party Sources to Release Information Concerning Application for Participation. I authorize any third party, including, but not limited to, individuals, agencies, medical groups responsible for credentials verification, corporations, companies, employers, former employers, hospitals, health plans, health maintenance organizations, managed care organizations, law enforcement or licensing agencies, insurance companies, educational and other institutions, military services, medical credentialing and accreditation agencies, professional medical societies, the Federation of State Medical Boards, the National Practitioner Data Bank, and the Health Care Integrity and Protection Data Bank, to release to the Entity and/or its Agent(s), information, including otherwise privileged or confidential information, concerning my professional qualifications, credentials, clinical competence, quality assurance and utilization data, character, mental condition, physical condition, alcohol or chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing on my qualifications for Participation in, or with, the Entity. I authorize my current and past professional liability carrier(s) to release my history of claims that have been made and/or are currently pending against me. I specifically waive written notice from any entities and individuals who provide information based upon this Authorization, Attestation and Release.

Authorization of Release and Exchange of Disciplinary Information. I hereby further authorize any third party at which I currently have Participation or had
Participation and/or each third party's agents to release "Disciplinary Information," as defined below, to the Entity and/or its Agent(s). I hereby further authorize the Agent(s) to release Disciplinary Information about any disciplinary action taken against me to its participating Entities at which I have Participation, and as may be otherwise required by law. As used herein, "Disciplinary Information" means information concerning (i) any action taken by such health care organizations, their administrators, or their medical or other committees to revoke, deny, suspend, restrict, or condition my Participation or impose a corrective action plan; (ii) any other disciplinary action involving me, including, but not limited to, discipline in the employment context; or (iii) my resignation prior to the conclusion of any disciplinary proceedings or prior to the commencement of formal charges, but after I have knowledge that such formal charges were being (or are being) contemplated and/or were (or are) in preparation.

Release from Liability. I release from all liability and hold harmless any Entity, its Agent(s), and any other third party for their acts performed in good faith and without malice unless such acts are due to the gross negligence or willful misconduct of the Entity, its Agent(s), or other third party in connection with the gathering, release and exchange of, and reliance upon, information used in accordance with this Authorization, Attestation and Release. I further agree not to sue any Entity, any Agent(s), or any other third party for their acts, defamation or any other claims based on statements made in good faith and without malice or misconduct of such Entity, Agent(s) or third party in connection with the credentialing process. This release shall be in addition to, and in no way shall limit, any other applicable immunities provided by law for peer review and credentialing activities. In this Authorization, Attestation and Release, all references to the Entity, its Agent(s), and/or other third party include their respective employees, directors, officers, advisors, counsel, and agents. The Entity or any of its affiliates or agents retains the right to allow access to the application information for purposes of a credentialing audit to customers and/or their auditors to the extent required in connection with an audit of the credentialing processes and provided that the customer and/or their auditor executes an appropriate confidentiality agreement. I understand and agree that this Authorization, Attestation and Release is irrevocable for any period during which I am an applicant for Participation at an Entity, a member of an Entity's medical or health care staff, or a participating provider of an Entity. I agree to execute another form of consent if law or regulation limits the application of this irrevocable authorization. I understand that my failure to promptly provide another consent may be grounds for termination or discipline by the Entity in accordance with the applicable bylaws, rules, and regulations, and requirements of the Entity, or grounds for my termination of Participation at or with the Entity. I agree that information obtained in accordance with the provisions of this Authorization, Attestation and Release is not and will not be a violation of my privacy.

I certify that all information provided by me in my application is current, true, correct, accurate and complete to the best of my knowledge and belief, and is furnished in good faith. I will notify the Entity and/or its Agent(s) within 10 days of any material changes to the information (including any changes/challenges to licenses, DEA, insurance, malpractice claims, NPDB/HIPDB reports, discipline, criminal convictions, etc.) I have provided in my application or authorized to be released pursuant to the credentialing process. I understand that corrections to the application are permitted at any time prior to a determination of Participation by the Entity, and must be submitted online or in writing, and must be dated and signed by me (may be a written or an electronic signature). I acknowledge that the Entity will not process an application until they deem it to be a complete application and that I am responsible to provide a complete application and to produce adequate and timely information for resolving questions that arise in the application process. I understand and agree that any material misstatement or omission in the application may constitute grounds for withdrawal of the application from consideration; denial or revocation of Participation; and/or immediate suspension or termination of Participation. This action may be disclosed to the Entity and/or its Agent(s). I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release and that I have access to the bylaws of applicable medical staff organizations and agree to abide by these bylaws, rules and regulations. I understand and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original.

Thursday, January 12, 2006

Clausewitz, defensive medicine, and teaching the residents

Karl von Clausewitz was a famous 19th Century Prussian military strategist, whose writings on War (On War) are broadly applicable to all situations in which strategic planning is required. One of my favorite of Clausewitz's observations is on the subject of "friction" in the chain of command. He notes that "countless minor incidents - the kind you can never really foresee - combine to lower the general level of performance, so that one always falls short of the intended goal. Iron will-power can overcome this friction; it pulverizes every obstacle, but of course it wears down the machine as well."

Recently, with one of my residents, I was performing what was expected to be a fairly simple laparoscopy on a young woman on the residents' service (ie, a patient in whom the residents are expected to have the primary role in management). Due to massive intrapelvic adhesions between the uterus and pretty much everything else in the abdomen and pelvis, the procedure took over three hours. When we closed there was some disseminated capillary oozing from the raw surfaces we had separated, but nothing that in my best judgement would put her at risk.

However, what I thought to be insignificant oozing might actually turn out to be worse, so I asked the resident to admit this woman overnight & obtain both an immediate blood count and a repeat count the next morning, in order to demonstrate objectively a stable blood count.

Normally, I take the "iron will-power" approach described by Clausewitz, and I am very strict with the residents, incurring the pros and cons as noted by old man Karl - the job gets done my way, obstacles be damned, but at the cost of wearing down the machine: the House Staff, who have to do it my way despite not being me, and me as well, as I continually have the same conversations about how I don't really care if they are "busy," the tests still need to be checked, the patients still need to be seen, etc.).

In this case, I tried a different approach: give the Chief some latitude - I was confident this situation wasn't risky, and I had been pretty explicit about my orders (how could they screw that up?). It isn't July, the chiefs have three years and six months of on-the-job experience and in just over another five months they'll be unleashed on the general public as doctors.

So I restrained my iron willpower and didn't micromanage the team. But I had operated on this woman and I am morally obligated to continue to care for her (not to mention legally obligated). Late the next day I checked in with the chief resident, and here's how it went:

Me: "So I assume Our Patient was fine and was discharged without trouble?"
CR: "Yep! She had some pain but felt better and went home."

I notice the CR didn't mention the blood count. I'm compulsive, remember? Can't let that slide -

Me: "Great!....and, uh...I take it her blood count was the same?"
CR: "...Actually it dropped from 37 yesterday to 30 this morning."
Me: (pause)
CR: "...uh...but her urine output was fine and her abdomen was soft, and the drop was consistent with the estimated blood loss at surgery."

I would have repeated the test again, given a falling blood count in a patient I was already monitoring for blood loss, even with the reassuring signs mentioned, but I suppose someone with more confidence in their clinical judgment could explain that drop as noted. But I didn't get angry. I just tried to make that teaching point.

Me: " what you're saying is, in your clinical judgment she was fine and the drop was explainable?"
CR: "Right."
Me: "Ok...(walking away down the hall)...but I still would have repeated it at 12:00 before I discharged her." (The blood test is generally taken at 6-7 am).

And that's when the icy hand of Clausewitz threw some Friction our way.

CR: "...Ah...Well...I actually didn't get the result of the first test until 12."

Now this is unacceptable. The test should be drawn on morning rounds, first thing, and be back by 10 am at the latest. Iron willpower wakes up:

Me: "I would have been compulsively checking for the results since about 10 am and then finding out why they weren't in the computer by 11."
CR: "...I did...but the specimen was 'lost' on the way to the lab...the patient even had a band-aid on so I know it was drawn this morning..."
Me: "...ok...I guess that explains your timing, but still, I would have kept her and repeated it at 3 pm just to be 100% safe."

And that was that. The patient turned out to be fine, as expected, but in my attempt to prove this I ran into precisely the kind of "countless minor incidents - the kind you can never really foresee - [that] combine to lower the general level of performance, so that one always falls short of the intended goal" as described by KvonC:
  • The specimen was drawn in the morning but lost
  • Friction in the system is so bad that the CR is used to drawing inferences like "she has a band-aid, the blood must have been drawn," because we have to expect our orders will not be followed. This means we spend half the day just finding out if the things we want done are actually getting done.
  • The specimen was then redrawn but the results were not available until late in the day
  • The combination of the time delay and the low-risk nature of the clinical situation led the CR not to fulfill her orders, as she judged the cost of time and effort outweighed the clinical benefit.
So big deal, right? The patient was fine - why even care about this?

Two reasons. First, it's all too possible for this situation to end with "the patient was not in fact fine and had been bleeding internally all morning." That happens. That's why I wanted her to be checked.

Second, there's the issue of Defensive Medicine. Clinically speaking, the CR was probably right not to bother with the test again - we were just looking for confirmation of the myriad signs that the patient was ok and not really expecting contrary information. But my desire for an "extra" blood count, and "extra" hours of hospitalization for this healthy young woman was DEFENSIVE, intended in part to prove with explict evidence what I "knew," that when I let her go home she was fine.

Why? Because a list of signs and suppositions a mile long can easily be cast into doubt by a malpractice lawyer who after the fact will say, "OBVIOUSLY your judgment was wrong, since she came back 12 hours later bleeding severely!" (Even if it weren't obvious, that's what they'll say). And a stable blood test is my trump card: "The blood count was 30, and 12 hours later it was 30. And that, in addition to everything else, was why I let her go home."

So Clausewitz's observations are a daily experience for me. Even being the iron will can't fix these problems, unless everyone else is also an iron will, but what truly rankles is that the everyday friction is exacerbated by the omnipresent hanging fear of litigation, which requires us to fulfill a standard often not supported by the clinical requirements of our patients, but by the emotional and evidentiary standards of a "jury of our peers."


Tuesday, December 20, 2005

Your Government in Action

At the office today, I provided a little patient with a vaccine for travel, since her parents were planning to take the family to the Caribbean for a vacation. The patient's mother is a college graduate; they have private health insurance from the father's job. The insurance gives me a cut-rate, but I jovially offered instructions for travelling with children, tips on plane rides, etc.

At the close of the visit, the mother provided me with a form to continue her eligibility for WIC, a Federal Government program that provides free infant formula and food. I suppose I have only myself to blame, because I was one of the founders of this program, in the 1970's, when I arranged for its beginning in the South Bronx, a poverty area of well-deserved repute.
In 1978, I was the single largest purchaser of infant formula on the Eastern seaboard.

The trip that this educated, middle class family is planning to take is during peak holiday season. Why should they receive any subsidy from the taxpayer? I'd rather spend the money on defense. (See "Where I was when everything changed" 9/13/05).

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