Monday, July 27, 2009

The Buck Stops Here (not!)

I just did one of my pet peeves! I consulted someone for something that I could take care of, but didn't wan the liabilty.

We call it Fleaing a patient. It is based on the fact that the dying dog gets covered by fleas as it departs the world. The hospitalist who can manage the patients blood sugar consults endocrine, because the patient has a pacer cardiology is called, the patient cant fart so Gi is called. Each time the doctor does not want to be the last standing when the patient dies and the family looks for someone to blame and finds a way to consult another doctor (flea). Attorneys always ask, did they consult a specialist? So every specialist gets called. When there isn't a local specialist, they can transfer the patient to somewhere where there is one because of EMTALA and the fleaing starts again. The buck gets passed. And so it goes. (By the way, attorneys will argue that defensive medicine does not exist). It is amazing when the local specialists will suddenly decide that although they are trained in the procedures that the patient needs, they have restricted their practice and no longer perform that procedure. (limits liability) So the patient gets transfered.

Well, here is the problem. After transfer after transfer you get to the end of the line. The problem was that it was me. I have done the procedure that the patient needs in my training and once since. I know how to do it but the outcome will not be good. I told this to my patient and his familty. They have been to 4 other hospitals so far and everyone has passed the buck. They asked me what I would do if it were me or one of my family. I told them that I would try to find someone that has done the most and has the most experience. That is what they wanted. I called in every favor and pleaded and the surgeon who trained me accepted the case. He is at another center where they are self insured and make the patients sign arbitration agreements.


SeaSpray said...

This one evokes feelings. I'll come back to it when I have time. :)

SeaSpray said...

I have circled around this post trying to decide whether or not to land and for how long.

Hmmm... I am curious about something. ? You said, "I know how to do it but the outcome will not be good."

Did you mean the outcome will not be good because you have only done the procedure a couple of times or that the outcome will not be good because of the patient's co-morbidities? Or both? And how do you know for sure the outcome will not be good?

Boy..this situation is hard on everyone involved..isn't it?

I can appreciate the dilemma docs must feel... but it is certainly worse being the patient. And as they are rejected by physician after physician..their fear must be mounting because that is a telltale sign it's a big deal. Then again... it's all a matter of perspective. Reading this causes me to feel bad because I wonder if I was that patient at one time for a doctor I have the *utmost trust and respect* for. And perhaps it wasn't his decision alone.

I will say..that a good doctor should know his limits and if your doctor isn't confident he can do it and your life is involved then you really do not want that doc to do the surgery. Just logic really.

I agree with you.. you want the one with the most experience doing it. But you also want the doc who has a high success rate. If you do 20 botched ones and the other does 5 successful..I'd still want the doc with the 5 successful. I assume though that you obviously think the number of surgeries performed coincides with a high success rate.

I wrote a lot more but put it in my drafts. (Sparing you :)

Suffice it to know..I know what it feels like to be the flea patient... not to that extreme tho... and it wasn't black and white.

Bottom line..if my doc did it because he genuinely cared about my outcome.. I am grateful. If it was because he was in self preservation hurts.. but I understand. I think it was both.

In the end... *I know* physicians have to look at the big pic and they are needed to treat many more patients and can't be bogged down with a pt that they feel will hinder them. On the other really sucks for the patient who trusts their doc.

It did help me tremendously to see the surgeon who agreed to take my case was so upbeat and confident about it...even reassured me that he and his partners would look out for me in the hospital too. Of course it didn't hurt to see in a letter to my PCP he referred to me as "delightful"! :)Nah..I know his skill is more important than his opinion on my personality..but it did warm my heart. :)

Throckmorton..I was afraid to have the surgery in the 1st place, then when referred out heightened my fears even more... but of course..I'd want the best care.

That was over 2 years ago & I've managed to avoid the surgery thus far. I am hopeful that I have healed and surgical intervention won't be necessary. I'll know more in the fall... but like I said..I am hopeful. The surgeon I have is stellar and has worked hard in facilitating healing in me and I do think this last time was successful. :)

I am having a difficult time honing this comment down but it is giving me an idea for a post for surge experiences. :)

SeaSpray said...

P.S. - I am both sympathetic and empathetic to the dilemmas docs face when making these decisions. It is just difficult being on the patient end of it.

The following doesn't really mean anything but I will share a feeling.

One thing that bothers me and I observed this while working in the hospital.

Well first..let me just say that I LOVED the show Dr Welby MD. I wanted to be Consuela..working side by side with the good doctor..being supportive and helping patients. (I have found that to be quite rewarding in the past) But...after working at the hospital and discovering projectile body fluids..I was more than content to forget my idea of going into nursing and just be the receptionist, etc... but with lots of compassion and support for staff and patients. No regrets there.

I learned quickly how complex medicine is and that it is a *BUSINESS* and that reality isn't the warm fuzzy feelings you get watching Dr Welby.

Prior to working in the environment... I just never thought about any of it. I viewed docs and nurses as only serving the patients and were always warm, compassionate and that is all they had to do. Like what you see on TV.

I liked thinking of doctors/nurses as really caring about their patients. (I think most do)But when you see what goes on behind the scenes and all the stresses and all that is involved (blogging opened my eyes even more)it is also so impersonal and people are just numbers... seen as a an annoyance or threat in some way (sometimes)and..I don't just bothers me. I want to believe that med staff really care.

The reality is.. that Dr Welby in this litigious era... would probably be fleaing his patients too.

The bottom line of what I am saying is that most patients would not want to be thought of as a lowly flea.

It's just disappointing to think it comes down to these things.

I wish doctors could treat their patients with the skills they were trained for and with confidence..without having to be afraid of being sued.

I wonder how much better docs would be with having that burden removed.. thus able to focus on what is most important..*the patient* and hone their skills all the more because they aren't sidetracked with all the other BS.

And of course..there are absolutely times when a physician should refer out to another doc.

The Fleaing concept is bothersome though.'s tough on you all too.

Seems like one big game... devalues the patient though.

Throckmorton said...


Thank you for your comments and questions.

It all comes down to a level of competence. Generally, the more you do of a procedure the better the results. Some procedures by their vary nature will have a higher probability of something going wrong and some patients because of their comorbid problems may not be able to survive these complications. When you are the patient, you want your surgeon to be one who has done the procedure successfully many times. You dont want to be hist fist and second.

If you ask a surgeon to name the two best surgeons he knows of, he will have a hard time naming the other one. That being said, it is essential to know ones limits. If a case is beyond your ability, you try to get the patient to someone who has the ability. Sometimes though, it is a case where there will be no one. These are the last ditch, hail mary surgerys. One of the first questions a plaintiff's attorney will ask, is "Doctor, how many of these operations have you done." You just hope that it is more than the hired gun that they hired to shoot you with.

SeaSpray said...

Your welcome Throckmorton. Thank you for your answer. :)

You said "Some procedures by their vary nature will have a higher probability of something going wrong and some patients because of their comorbid problems may not be able to survive these complications." That is exactly why I resisted as I did. Because *I knew my doc was so concerned* ... I appreciated the seriousness of it and it became my mission to avoid at all costs..if possible.

Now.. perhaps the word "may" is the operative word. The surgery *may be* successful or *may not* be successful. I don't think I was a hail Mary patient... but I was afraid of becoming one during surgery or post-op.

Second to dying or being permanently disabled via stroking out during or post-op, avoiding sepsis post-op and having to go back in...since the surgery involved attaching something to a healthy organ that has been functioning well..i was also concerned about compromising that and then having other issues with that. I never exactly told my doc about my fears of post-op problems, as with complications that would affect my everyday life. For all I know..I have built that up to be more of a concern then it should be.

I guess I just did not want to go down these roads. I pray to God I still will not have to.

I actually wrote a lot more and put in my drafts again. Maybe I will land again with the comments. It's a hot topic for me. Especially since fall is just around the corner.

I just have to say... I feel good..but unfortunately the previous condition (I say previous because I REFUSE to own the condition :)has been *mostly* asymptomatic when a stricture is occurring. But..I am believing for the best. :)

I agree with you that it is important for a physician to know his limits.

I guess the ideal is for a surgeon to get a lot of basically healthy patients (sans a lot of comorbid conditions) on which he can hone his skills so that when the big challenging case comes..they can do it with confidence... as much as one can anyway.

You also said "If you ask a surgeon to name the two best surgeons he knows of, he will have a hard time naming the other one. "


P.S. The buck does stop with you in the OR (once you've taken on the case)and it's going to turn out one way or the other.

I think that takes a lot of courage to take on that kind of life and death responsibility. It has to be a calling.