Dec 28, 2009

Why Do Incompetent Doctors Flourish?

Last week Doctor D answered this question in a way that made him sound like a frickin' hero:

How do doctors deal with colleagues that they know are incompetent?
Now that you all think I'm awesome, I have to make a confession: I have looked the other way a lot more often than I have saved the day.

Doctor D has known some bad doctors over the years. I don't mean doctors that make errorswe all do that sometimesbut doctors that flagrantly disregard patient safety and don't give a damn about right practice. And Doctor D usually kept his mouth shut.

The code of silence started early...

Doctor D's first run-in with reckless care was as a first year med student. D was working with Dr. Subethical who happened to teach the medical ethics class. Dr. Subethical who seemed so cool in class spent most of his clinic time screaming at patients and dictating physical exams he didn't perform. Lowly Medical Student D thought that this didn't seem right, but he never confronted Dr. Subethical or filed any complaint. Young D figured he must have just misunderstood the situation. Also Dr. Subethical was an honored professor while D was just some lowly student who didn't want a target on his back.

MD's usually have more power and more knowledge than their patients and other healthcare providers. This often keeps patients, med students, and nurses from confronting doctors. So it falls on other doctors to keep an eye out for bad care among our colleagues.

Unfortunately, we doctors do a terrible job policing each other.

Young D always kept his mouth shut in medical school, but he told himself that when he got that MD with some power and knowledge he would set the world right. He would stamp out crappy care and save the world from low-life doctards! Yeah, well old habits stuck around. D's been out of medical school for a long time now, and has seen quite a few doctards, and his number of confrontations thus far is a grand total of... one! To be honest, Doctor D only whooped some doctard ass at Crayzee Clinic after having incompetent care shoved in his face month after month till he couldn't ignore it anymore.

So in this anonymous blog Doctor D confesses:
"Hi I'm D, and I have turn a blind eye to bad medical care."
Doctor D's readers all gasp and shake their heads.

"But wait, I can explain!"

There are lots of reasons good doctors are always letting the bad ones off the hook:

  • Nobody Likes Tattletales: You might assume that Doctor D's heroic battle with Crayzee Colleague looks good on his resume. Nope! D has a big FAIL stamped right across his forehead. Nobody wants to work with a goody two-shoes who rats out his buddies when they break the rules. Even the excellent docs got kinda distant while I was fighting Crayzee Colleague. If I called out bad doctors wherever I worked before long I wouldn't have a job.
  • Nobody's Perfect: Our culture expects perfection from doctors. Of course, we all make mistakes, and many of us live in dread of errors. We want people to forgive our mistakes so we are willing to accept that other docs make errors too. Now there's a big difference between understandable human error and the doctard who makes a habit of flagrantly and willfully doing stupid shit. Unfortunately, this unspoken "culture of forgiveness" in medicine protects the guilty as well as the innocent
  • Everybody Hates Lawyers: Every MD lives in constant fear of a malpractice case, which is a professional and personal catastrophe. We usually keep our mouths shut about bad care because discussing possible malpractice is taboo. If you accuse a colleague of malpractice you might as well send the poor schmuck in front of a firing squad. There just isn't any safe environment where we can confront other physicians. It's ether shut your mouth or throw your colleague to the dogs.
  • There's More Than One Way To Skin A Cat: Every doc remembers that abusive attending in medical school that yelled that there was only one right way do do medicine, which happened to be his way. Later we learned there are a lot of different right answers in medicine. Every doc has a different treatment style. Nobody wants to grow up to be that jerk that attacked others' legitimate care because it wasn't the way he did it. So sometimes when we see obviously bad care we shrug and say, "Well that's not what I would do, but maybe it's just a different approach?"
  • Second Hand Information: Most of the bad care I know about is hearsay. I usually don't have time to sit around and watch my colleagues practice. I hear things from patients or read charts that sound concerning, but I wasn't there. I tend to give other doctors the benefit of the doubt: "Maybe there's a good explanation for this?"
  • We Expect Lawyers To Do Our Dirty Work: Every good doctor can probably think of an incompetent doctard who they secretly hope will get destroyed in a malpractice lawsuit. (Yep, Doctor D is thinking of one right now.) Malpractice is horrible, but some doctors deserve it. Why should we waste our time confronting bad care when lawyers will take out the garbage for us? Unfortunately, this is a total cop out. Malpractice does a terrible job policing medicine. First of all, the lawyers and juries don't understand medical care very well. Second, lawyers don't bring malpractice cases to improve medical care. Lawyers bring malpractice cases to hit the jackpot. The malpractice system creates a mad scramble where big money gets awarded or denied based on the lawyer's cleverness or the jury's mood, rather than the doctor's competence. Good doctors are often screwed while bad doctors get off on legal technicalities. Malpractice doesn't really improve medical care—it just makes doctors afraid to discuss bad care.

Of course, all these are just lame excuses. Doctors should step up and call out the bad ones who are endangering patients. Doctor D can think of a couple that need to be set straight, but after his adventure at Crayzee Clinic he isn't too eager to try any more heroics. He's keeping his mouth shut and venting anonymously on his blog.

So Doctor D has taken the first step: he admitted he has a problem. Any ideas for 11 more steps that could motivate D and the other good doctors out there to remove the incompetent doctors from their midst? I've got no answers on this one.
This is an intervention!
Your favorite blogging doctor has a serious apathy problem, but he is totally unmotivated to change. Use the comments section below to convince Doctor D why he try to be a hero again when the first time was a big fail!

Dec 25, 2009

Merry Christmas (A Friday Without Links)

Today is Friday, but it is also Christmas—so no Friday Links shall be served today.

I hope today is a day that you link to your family and friends and to the Great Physician whose birth we celebrate today. He can heal what no doctor ever will.

God bless you all and merry Christmas!

Dec 21, 2009

The Battle Against Incompetence

A while back Nurse K asked a really good question:

How do doctors deal with colleagues that they know are incompetent? Keep your mouth shut? Frank discussion with the medical director? Anonymous letter?
Doctor D has two ways of answering this question. One makes him look really awesome, and the other exposes him a part of the problem. Doctor D will start out all the heroic stuff and then tell you more in the next week:

Doctor D once worked at a place called Crayzee Clinic, because he really wanted to practice primary care in an underserved community. (What a saint! Let's give Doctor D a Nobel Prize or something!) Unfortunately the clinic came with a partner we shall call "Crayzee Colleague."

Now Crayzee Colleague was pleasant enough, but the medicine she practiced didn't even remotely resemble proper standards of care. Doctor D, being the totally nice dude that he was, thought maybe Crayzee Colleague was just behind the times and hadn't heard of the cool new stuff doctors have been doing for these last fifty years. D mentioned his concern in the gentlest possible way, but would you believe it, Crayzee went nuts! She called D a "young doctor who doesn't know shit."

So Doctor D printed out some info for Crayzee Colleague on how medical care is done in this century to prove that he isn't the only one who believes in things like vaccines, mammograms, and such. Unfortunately nothing changed about Crayzee Colleague's incompetent care.

Doctor D was worried because he shared patients with Crayzee Colleague and the stuff she did wasn't exactly safe. From time to time he sent her pleasant little notes reminding her about sensible medical care as he was cleaning up her disastrous work. After a few months of this our hero realized Crayzee Colleague had no interest in changing anything.

Since Crayzee Clinic was federally funded, Doctor D figured he should go up the ladder and speak to "The Man." The Man isn't a doctor, but he has a fancy title, sits behind a big desk, and supervises a whole lot of doctors. D figured his colleague would surely listen to The Man. So D informed The Man that he was very worried about Crayzee Colleague's care. The Man said "Doctor D you are right. Crayzee should step up her game."

And then nothing happened.

Crayzee Colleague kept providing downright dangerous care, ignoring D's still friendly but increasingly firm reminders to at least try to practice something resembling primary care.

Finally, Doctor D had enough of Crayzee Colleague doing dangerous shit to his patients. He blew the whistle as loud as he could. He warned every healthcare bureaucrat he could find, "Look, if Crayzee Colleague keeps doing this stuff that endangers patients I will resign from Crayzee Clinic and tell every patient I see on my way out that I'm leaving because the care here is a treat to public safety!" And still nothing happened.

So Doctor D did exactly as he had threatened he would.

At the end of our story The Man's bureaucracy remained intact, Crayzee Colleague was still at the clinic, and Doctor D had all his principles but no job in the middle of the Great Recession.

...but Doctor D is still proud he opened that can o' whoopass on medical incompetence as well as The Man and his Crayzee Clinic.
Please feel free to praise the fearless Doctor D in the comments section! Get his ego good and inflated because next week he has to make some confessions that will disappoint you.

Dec 18, 2009

Shuffling Links! (Friday Links)

Doctor D wishes you all came to his nifty site for his brilliant answers to your questions, but let's face it, it's Friday and you're here for the links. That's okay. D forgives you! Since this site is where a lot of you come to connect to the medical blogsphere Doctor D is going to be sure the linkage is up to snuff...

So if you will direct your attention to the right of the blog just below the "followers" section you will see the new, improved link lists:
  • First of all, Doctor D realized that putting doctor-blogs at the top is probably likely to exacerbate these bloggers god-complexes. Henceforth, the links shall shuffle! Currently Patient Blogs have risen to the top. Nurses and medical students are also above the docs! The shifting lists should always bring something new to the top.
The lists themselves are also evolving:
  • Patient Bloggers: I took out a few links that honestly I'm not reading anymore. Six Until Me is a popular diabetes blog, but if you aren't a diabetic it doesn't really have much to say. Ditto with Reality of Anxiety. It's a good blog for what it is, but right now I'm more interested in blogs that explore the experience of being a patient than blogs about a particular disease. You don't need to know anything about bladder diversion to enjoy Neo-Conduit's blog or the diagnosis of unusual illnesses to enjoy Queen of Optimism. Their writings are essentially human not medical stories. I also added a very interesting blog: Coming Out Of The Trees, about a patient overcoming a history of severe abuse—heavy but fascinating.
  • Nurse Bloggers: Well with Nurse K's blog gone again I had to cut the link, but she's still there on twitter. So for D's top Nurse Blogger the award goes to MAHA! She is a new nurse fresh out of nursing school who is an very funny articulate blogger. Heck, she deserves the top slot just for this post. Unfortunately Lonely Midwife appears to have gone into unannounced hiatus, so her link is gone, but if she comes back D will return her to her rightful place.
  • Medical Student Bloggers: Ella is still D's favorite med student blogger, but a new contender is Indifferential Diagnosis. It seems to be the work of a group of medical students just teetering on the edge of sanity. God bless, those poor suckers sludging through the misery of med school! Doctor D can reasure them it gets better, but while they are somewhat delusional you can enjoy their brilliant posts like this one.
  • Doctor Bloggers: D is thinning out this category right now. Doctor Rob is wonderful despite his strange fascination with lamas, but with his blog on a semi-hiatus his link is being retired for the time being. Buckeye Surgeon is a great storyteller, but recently his blog has gotten a bit overly political for D's tastes. The Happy Hospitalist's link is also gone. Doctor D was just tired of reading so very much about so very little, and without Nurse K around to antagonized Happy what is the point? This opens up space for you to discover some of the other great doc bloggers over there.
  • Resident Bloggers: This category is getting lonely! Agraphia appears to have shut down his blog which is too bad, but understandable. Residency is a trial by fire. Only Doctor Ottematic is left. Anybody know any good resident bloggers D can link to?
  • And as an extra bonus Doctor D is adding an Other Fun Stuff section. What's in there? You guessed it: other fun medically-related stuff! Enjoy.
Thanks for coming to this week's Friday Links! I promise fewer links next week.
What do you think? Did D miss a great blog that should be in the lists or delete a blog that should have stayed? Tell him all about it in the comments!

Dec 14, 2009

Of Course, It's All In Your Head!

A patient asks me:

"Doc, are you saying this is all in my head?"
The assumption behind the question: things in the mind are not real. Doctors also display this unfounded assumption. We just obscure our prejudices by using medical jargon like "supratentorial." (First reader to define Supratentorial and use it in a sentence wins Doctor D's prize of the week!)

Every illness you ever had was "all in your head." Seriously, where else could it have been? You have never felt a symptom, whether it was a broken ankle or a broken heart, that wasn't felt in your mind. Your mind is your consciousness. Every pain, cramp, anxiety, or ache is felt exclusively in the mind. Your mind is not a part of your body. Your body—as you know itis a part of your mind.

Doctor D, has had a couple brain-dead (literally not figuratively) patients. Trust me, they never complained of anything! They never had any symptoms. They never felt bad. And their bodies didn't survive long without minds.

Many doctors hold to this absurd theory that your body is a separate entity from your mind and physicians should focus solely on the body. But the human mind keeps getting in the way and annoying these stupid doctors. Of course it does! The mind and body are completely interwoven and inseparable.

This crazy idea that the mind shouldn't interfere with the body has spread from stupid doctors and now created a stupid culture. It is tricky to actually figure out what is going on with a person because everybody now denies their mind has anything to do with their symptoms. Lots of patients refuse to answer when Doctor D asks about their feelings about their symptoms or illness. I can understand why. They're worried that Doctor D thinks they are nuts. Having a mind doesn't make you crazy, it's loosing your mind that is crazy!

So Doctor D has some ideas for how MDs and patients can overcome our anti-mind biases and improve doctor-patient relationships:
  • First, doctors and patients both need to acknowledge that all symptoms are real. If you feel it in your mind then it is real—period. We don't say that happiness is "imaginary" because it is a mental state. We shouldn't say that any discomfort is imaginary. Fibromyalgia and panic attacks are just as real as pneumonia and broken bones.
  • Second, doctors and patients both need to acknowledge that the mind is real and it matters. I know this sound obvious, but some doctors still think only Psychiatrists should pay any attention to patients' minds. No matter what the disease, ignoring the person to focus solely on the body will lead to disaster after disaster in medicine. Patients also need to be willing to discuss their mental attitudes and recognize that the mind plays a role in illness and healing.
  • Finally, we need to understand that different symptoms need different treatments. Not every symptom needs a big work-up or a strong medicine. It is my job to help people distinguish dangerous symptoms from ones that are not. Shortness of breath that starts when your girlfriend breaks up with you merits a different work-up than shortness of breath with unilateral leg swelling and a low pulse ox. Both are real problems, but not the same problem. Understanding your mental and emotional experience of your symptoms helps me better diagnose you and avoid giving you treatments or work-ups that could cause you harm. In order to successfully negotiate these interactions a patient must trust that the doctor has taken the first and second step and isn't assuming they are crazy.

What do you think? Does it bother you when your doctor asks about your mental state when you report physical symptoms? Or does your doctor seem to be biased against the mind and imply you are crazy if you bring up your feelings? Do you think that these 3 steps can improve doctor-patient communication? Doctor D would love to hear your thoughts!

Dec 11, 2009

Friday Unlinking

It is a sad day in the medblogging world! Nurse K has pulled the plug on her blog again!

We can only assume that the illustrious Nurse K had renounced blogging out of shame! She had been promising to do a guest post for Doctor D for like a month now and never got around to doing it. Poor K! Her guilt at letting down Doctor D must have driven her to despair. And now she has closed her blog and assumed a life of quiet contemplation in order to do penance for her transgressions.

Nurse K, all is forgiven! I never really thought you'd do that guest post anyway. I knew the topic was too dull for your tastes! I forgive you the guest post you owe me. You are free to return from your seclusion. Your readers need you in these dark times!
Actually Nurse K is still cool, but her blog is down for the near future. She is missed, but Doctor D will keep her link on the sidebar, ready for her triumphant return. Until then you can get your dose of ER Crayzees at this site.

Is The Patient Crazy—Or The Doctor? (Friday Links)

Doctor D found a great blog by a patient with lots of physical maladies who used to be reporter for the Associated Press. Now she is "Sick Momma" and blogs on her life as a chronically ill mother and wife. As D was enjoying her blog and came across this post about some conditions he'd never heard of.

Apparently Sick Momma believes that many doctors suffer from a mental disorder which causes us to attribute symptoms we don't understand to a patient's mental state. Whatever!
Patients expressing unfamiliar complaints to their physicians often induce the "It's All In Your Head" (AIYH) or the "That's Impossible" response in doctors suffering from these behavioral problems and personality disorders.

Physicians fixated upon the metaphysical belief system of "If we don't know about it, then it doesn't exist" are suffering from a mental defect or psychological condition known as "Doctors with Unexplained Medical Beliefs": D.U.M.B.
Excuse me? I'm the doctor, so I'll decide what is a disorder and what isn't!

And I've never heard of these "behavioral disorders," which leads me to suspect they don't exist! Since I have no idea what put these crazy ideas in Sick Momma's mind, I shall diagnose her as depressed and put her on Prozac. I shall continue to add psychoactive medications until she learns not to challenge my god-complex!

Actually this is an interesting problem: What should be done about symptoms that make no sense? Lots of patients and doctors end up these situations.

The doc is thinking, "This doesn't sound like any disease I know about. All these symptoms are subjective sensations. Maybe it all is in this patient's head?"

The patient is thinking, "This doctor doesn't know what is causing my symptoms! What an ignorant doctor! If my doctor has never heard about this it must be something rare and horrible!"

It is a tricky impasse. Each can't help but have these impressions sometimes. We all want to prove we aren't ignorant or crazy, but then again we all want to be agreeable. Often these situations end up with either unnecessary antidepressants, unnecessary testing, or both.

We need better ways of discussing strange symptoms. Hence, in next week's reader question Doctor D shall provide some answers! (or perhaps some humble suggestions)
Until then, what do you think? Has a doctor ever told you your symptoms were all in your head? Have any of you healthcare providers ever had a patient who had nutty symptoms? Doctor D would love to hear your stories!

Dec 7, 2009

The Bad News Room

A reader asks:

On rare occasions, a doctor won't say anything while I'm on the tissue-covered table and silently escorts me to a small room with ugly upholstered furniture for a conversation. I think the idea is that this is a more "comforting" environment, but to me, it's just another strange medical space. Perhaps you could explain how your compatriots decide where to speak to patients?
Yes, some doctors have this weird idea that bad news is only tolerable when given in a sitting room with upholstered chairs and fake plants.

The trouble, of course, is that patients suspect this and therefore getting moved to the little room with comfy chairs significantly worsens your already nerve-racking visit. You know the bad news is coming, so the comfy room feels like a cell where you await your sentence.

As I've mentioned before, giving bad news is always a rough part of this job. We want to be as gentle as possible, but I think the little room is more for our comfort than yours.

Doctor D believes the most important thing about news is to give it straightforwardly and in a private place. Last thing your doc needs to do is to give it in crowded ER when your neighbor is listening on the other side of the curtain. Of course, the small, busy ER where Doctor D works has lots of curtains and no cute little room. D has even been known to take people in the medicine closet for a talk when it's the only safe place to protect their privacy.

But when privacy isn't a concern, the last thing I want to do is move you somewhere where you know you are waiting for bad news. I'll tell you straight up what I'm thinking. Doctor D believes people care more about hearing news directly, honestly, and kindly than they do about the location where they are told. I have used offices or these little sitting rooms in the past, but only because the patient wanted me to tell a lot of family members that wouldn't fit anywhere else.

I start directly and tell you straight up wherever we are. I know their will be lots of further discussion and questions. I'm always glad to finish the conversation wherever you would prefer to talk.
What do you think? Would you be upset by being told in an exam room sitting on that tissue-covered table? Would you prefer to be moved to the room with the comfy chairs? Let Doctor D know if he should change his strategy!

Dec 4, 2009

Blogging Fatigue (Friday Links)

Blogging can be an exhausting thing~ Doctor D is pretty familiar with exhaustion these days between doctoring, husbanding, fathering, and blogging.

Don't worry, this isn't one of those hiatus posts. AskAnMD is still going strong, but one of the web's favorite medbloggers Dr. Rob decided to throw in the towel this week. He was always an interesting read and will be much missed. Also D will now never be able to figure out that dudes odd obsession with lamas.

Blogs don't last forever, although there is always the hope Rob's blog will have a resurrection like Nurse K's and Ella the Med Student's have.

Fortunately amazing new bloggers are always appearing:

The new link this week is Medical Moments in 55 words! Word Doc is an internist who tells medical stories in short 55 word posts. The stories are both funny and poignant, and best of all they take less than a minute to read. So go check out Word Doc. Doctor D guarantees you won't be disappointed!
I'm really impressed with the brevity of Word Doc's posts. The shortness doesn't take any power at all from her stories. Should Doctor D try to answer your questions in 55 words for a while?

Dec 3, 2009

What Are My Chances, Doc?

As you may recall from the last post, if Doctor D suspects you might be facing a lethal illness he'll let you know straight up. He brings it up gently, pointing out that any doctor's guess has a lot of uncertainty.

You do, of course, have the right to ask, "How certain are you, doc?"

But here's the secret: MDs hate answering this because we often don't know how certain we are. I'm usually pretty good at predicting what will kill a patient. How good? Results may vary...

In a few diseases there is solid data: 80% of people diagnosed with pancreatic cancer will be dead one year later. Usually, however, the situation is too complex and there isn't any research data to answer the question. Then Doctor D whips out a gut guess.

I once had patient with curable but advanced colon cancer develop urosepsis and then have a heart attack from the septic shock. His family wanted a percentage for his chances. I made one up, "Maybe a 40% chance of surviving the next 24 hours." He survived and went home.

As I said, I'm not perfect.

Percentage numbers don't really mean that much when I'm guessing, but people just like something that sounds mathematical rather than “almost certainly dying” “could die” or “maybe dying but probably not.”

Predicting death is a risky business. Doctor D once had to dodge a fist when D told a dude his dad probably wouldn't make it. (Fortunately crying people can't pull off a good sucker punch!) Doctors also don't like mentioning death because most people don't like to discuss about their own mortality. We vaguely acknowledge we all die sometime, but you don't expect "sometime" anytime soon. Then Doctor D sits you down and says, “Now might be your time.” It's never an easy talk, and it's almost always based on an educated guess.

Doctor D still thinks it is worth letting you know, even if his estimations aren't perfect. Most patients want to prepare themselves and their families if death is a real possibility. I only withhold such information if a patient told me ahead of time they don't want hear any discussion of death.
What do you think? Do you want your doctor to tell you your chances? Even if it is only an educated guess?

Some old MDs never mention the word “death” because “they don't want to take away hope.” Obviously, Doctor D takes the opposite approach. Which would you prefer? For yourself? For your family?