Oct 16, 2010

Warnings and Witch Hunts

An addition to our ongoing series on Incompetent Doctors:

If one of your patients asked your opinion of another doctor whom you know to be incompetent what would you tell your patient?
Incompetence in a physician is a scary thing! Doctors deal with problems of life and death and try to heal you with dangerous tools. A doc that isn’t competent can be seriously dangerous.

But how do you know who’s on their game
and who’s falling down on the job?

It’s tricky for patients because they often don’t know enough about medicine practice to judge competency. This makes putting your body under the care of any doctor scary.

So scary, in fact, that an entire malpractice industry has sprung up to reassure patients that incompetent doctors will be severely punished. Unfortunately malpractice usually ends up a witch hunt that can burn good doctors at the stake and let bad ones go free.

“I saw Goody Doctor D dancing in the woods with the Devil!”
“Tis true! One of his patient died!"
"It can only mean he dabbles in the witchcraft of incompetence”


Wouldn’t it be nice if you had someone who understands medicine who could tip you off on the bad ones?

Yes, but it’s a complicated thing to ask your doc if another doc is incompetent or not.


Judge Not, Lest You Be Judged
Competence is not always as black and white as you might think. There is a good bit of gray and ambiguity involved. The real world practice of medicine involves a lot of educated guessing and trial and error. Even the best doctors occasionally make mistakes or use unorthodox treatments.

The real dangerous doctors are the ones that recklessly disregard patient safety and don’t even care about doing things right. And yes, unfortunately there are lots of doctors like this.

Incompetence may be common, but it is hard to prove. Doctor D occasionally sees signs of suspected incompetence in patients that have been treated by other docs. An incorrect diagnosis or an unorthodox treatment that seems way out of the expected margin of error and puts a patient at risk.

But these clues in the crime can be misleading. Sometimes Doctor D will see something and say to himself, “Self, what this doctor is doing makes no sense. I wonder if he is incompetent?” Later I met the doc only to find that he had an excellent reasoning for what he did, and was obviously acting in his patient’s best interest.


The Medical Gestapo
But there are some doctors that are all too happy to accuse their colleagues of incompetence. These docs believe there is only ONE competent way to practice medicine, and it is the way THEY practice.

These doctors want to be the to secret police who keep medicine in line. They are typically jerks with a massive god-complex. They gleefully tell every patient who will listen which doctors they think suck.

Doctor D has had encounters with the medical gestapo. They shoot first and ask questions later. They see the world in black and white. There is no gray area for them.

“Doctor D you didn’t follow the protocol! Are you thinking for yourself? Are you adjusting the protocol for individual patient's situations? Off to the firing squad!”



Dealing with Dr. Danger
Witch hunts both from within and without medicine have soiled the names of a lot of good doctors. So Doctor D is always careful about fingering another doctor as a dangerous doc, even when he has his suspicions.

I currently know a doc who I am about 70% certain is a walking public health threat. I’ve seen a pattern of “WTF?!” medical decisions that make me highly suspicious that this dude either doesn’t know what he’s doing or doesn’t care.

How certain do I need to before turn Dr. Danger over to be burned at the stake? Well 100% actually.
"We still only have circumstantial evidence, but let's burn him anyway!"

I’ve been a target of the Medical Gestapo myself, and I know how damaging misguided doctor purges can be. I’m not blowing the whistle on Dr. Danger unless I know beyond a shadow of a doubt that he’s really what I think he is.

I’ve only been 100% certain one time before and that time I blew the whistle as loud as I could.

Subtle Warnings
Although I’m not absolutely certain he’s incompetent, I wouldn’t want any of my family seeing Dr. Danger. It would be too much of a risk!

I can’t flat-out denounce him publicly, but I do want to steer patients away from the danger I suspect.

This is where subtlety comes in handy:
I might say "Dr. Danger does some really unorthodox things." Or I might just fail to praise him, while my facial frown indicates I might not be totally cool with Dr. Danger. Or I could just change the subject and suggest you see Dr. Awesome instead.
This is how we doctors subtly steer you away from potential danger.
But you have to read between the lines, because if you flat out ask, “So Doctor D are implying you think Dr. Danger is a totally incompetent fuctard who has no business practicing medicine?” Doctor D will smile and say, “Oh no, Dr. Danger is a delightful person! You have totally misunderstood me!” Then D will give you a wink.
Doctor D puts the B in subtle!

What do you think?

Docs and Nurses: How do you manage doctors whose competency you doubt?

Patients: Do you think you are able to pick up subtle cues from your doctors?

Should Doctor D go gestapo on Dr. Danger?

Any ideas for a better process than this ridiculous system of innuendos and secret winks to keep patients safe? I'm sure there has to be something better.

17 comments:

jadedchalice said...

i feel awful for not responding to your actual post, and instead asking at totally unrelated question, but you are the only person I can ask.

Can you tell me anything about malabsorption and the anorexic? Do you know anything about how serious the problem is? I hate to be graphic but i have had both white and floating stools lately plus no matter how much i eat during this refeeding process i am so exhausted it and everytime i eat my stomach is swollen like hell. I feel like hell lol.

Anyway short of going to a doctor which i cant do for a couple of more months, can you recommend how i may address the possibility of malabsorption or how likely it is that i may have developed "whipples disease" during my 16 years with anorexia.

jadedchalice said...

ps sorry if i sound like a hypochondriac

Anonymous said...

"The only right doctor is the last one."

Remember how things look very different as a disease progresses, more details are available, etc.

Maha said...

There's a surgeon that works out of my hospital whose patients keep coming back to emerg with grotesque complications. He is a mean bastard who doesn't listen to anything other docs, nurses or patients have to say. Did I say he's a mean bastard? Because he will try to rip you a new one if you even dare to criticize him. So now anytime a patient gets referred to the surgery team, the emergency staff doc will give not so obvious warnings if Dr. Bastard Surgeon is operating and try to refer them to another surgeon.

Anonymous said...

Here's a subtle scenario:

Patient: What do you think of Dr. so and so?

Doctor: (pause) well.....um.....

The lack of enthusiasm is all I would need. My question was answered.

But in Maha's post where she gave an example of the patient being assigned to a terrible doctor in an emergency setting, is really worrisome. Hats off to the advocates on the inside that would attempt to steer the patient away from a possible calamity.

Amanda in Calif.

Doctor D said...

JADEDCHALICE: I appreciate that you are involved with the blog, but when you have questions that are totally off topic for the post it would be best if you just emailed me directly. My email is in the right hand column. I get back to every person who emailed me although it sometimes takes a while.

I really don't know much about changes to the GI tract after years of Anorexia. I imagine a GI or Anorexia specialist could fill you in. Also I'm sure there are free resources on-line that can describe the best things to add to your diet.

Anonymous said...

There is a doctor in Delaware who got away with molesting children FOR YEARS because those other doctors and professionals around him, while highly suspicious, were not 100% sure that this abomination was occurring. Tough call. There are cases of wrongful accusation that ruined people's lives - and yet there are all those children. I appreciate that this is a delicate thing - yet - there has to be a better way.

Amanda said...

Unfortunately I tend to be rather literal when folks talk to me unless I know them really really well, so the subtle approach doesn't work with me.

Annoyingly, I recognize this issue. I just can't do much about it. Yep, it's a pain. As situations permit, I prefer to bring someone with me to appointments for exactly this reason LOL.

Elizabeth said...

When I go to the doctor, I'm like Amanda, I tend to take everything the doc says literally and seriously. I think, therefore, the best approach would be to downplay Dr. Dangerous and really recommend/highlight Dr. Awesome.

badturns said...

I think subtle works ok. Honestly, without knowing details I might actually see it as a sign of unprofessionalism if my doctor had a habit of really badmouthing others. I also think it might be good to know what docs you LIKE and who you would want to refer your patients to. Maybe if you don't know someone off hand you can offer to do some footwork and ask around for your patient. My doc does this and I love him for it.

I gotta say, to the anon commenter about the doctor who was molesting children in Delaware - I didn't get the sense that criminal predatory harm was meant to fall under the characterization of "incompetence" Dr. D was talking about here. I might be wrong but that's something pretty extreme, something *well* beyond "maybe he's a 'fuctard'". The eye closing that happens with molestation is a whole other kind of bad.

Anonymous said...

Huh. Very interesting post, especially as someone who has seen many specialists. I've really had some good referrals and luck in seeing some excellent doctors. My trouble has always been when to realize it's not working, and to move onto someone else. After all I'm a social worker and I think about communication and relationships.

So one thought that might just be different in my profession, is if I have suspicion that a child is being abused, I have to report it. Because by default CPS are the experts who do the investigation and really decide if there is a problem. Is it like that with licensing boards too? It's tricky, isn't it.

I think I would get the subtle approach. Sometimes I've had some bad experiences with doctors, and in these situations I've often found that other doctors that I've trusted while the couldn't completely go into details will often agree subtlely.

Melissa

Mo said...

Conversation with my GI doc:

ME: I need to find a good GP, someone suggested Dr. High & Mighty. What do you think?

GI Doc: crickets chirping....dead silence.

ME: Your silence speaks volumns.

Conversation with my Doctor regarding the care of my Mother:

ME: Hey Doc what do you think about Dr. Mrs. Sour Face? I have lost confidence in her.

DOC: crickets chirping.....She has very nice hair.

I think a trusted doctor will give a silent clue regarding a bad Doctor, a mean Doctor, an uninterested or incompetent physician.

I have multiple chronic illness, and I need to have the finest medical care I can find. I am very lucky that my good doctors have pointed me in the right direction for fabulous specialists.
You Guys know the good ones from the bad ones. The patients also need to know. Kudos to any doctor that helps their patients find a physician that meets their needs, and personality.

Mo

beyondanomie said...

Great article, highlighting one of the more delicate conversations doctors have with patients. I totally agree with the subtle approach to gently nudge and guide without making any direct statements which one cannot fully substantiate. That's the best balance between professional courtesy and listening to one's instincts about a colleague.

The trouble is that some patients just don't "do" subtle and won't read between the lines. But there's only so much one can do within the limits of professional courtesy and in the absence of absolute proof and I prefer to tread very very cautiously in these matters.

Anonymous said...

I found both of my specialists through the advice of other doctors--both were recommended highly and both are simply fantastic. I was seeing a quack (he told me I had congestive heart failure when I actually had pneumonia), and the quack was recommended by someone I work with. Moral of the story: trust your doctors, they know best!! (for the record I asked both specialists about the quack and got complete silence from both of them).

drottematic said...

As a resident, I make a lot of mistakes. I also know a lot of fresh stuff.

With a patient who winds up having some bizarre test, on some medicine they don't need or that's causing them harm, or having been told something contrary to what Science says is currently accurate, I pause.

I usually say "oh, well, I'm not sure why Dr. So and So would have ordered that. I bet he had a really good reason, but since you've come to see me today, here is what I am recommending and why." I hope that the patient lets me move on.

Doctors all have different styles and I know, for the most part, that a lot of consideration goes into any choices made.

I will admit that I criticize safety issues with other doctors, once the patient has left the clinic, like "I don't like working with So and So as a preceptor, because look at this clearly unsafe thing they did!" or "I always get Dr. X's patients with blah disease on regular blah medication, which is toxic to their such-and-such organ. Hmmm."

For me it goes beyond the fact that the patient is being harmed - I am an impressionable young resident and might start doing things that other doctors teach me to do. In fact, that's the idea of Residency! I'm not always smart enough to filter the good tips from bad.

The tough part is deciding whether to talk to the doctor who has done something I think is unsafe. If I just do things slightly differently, no big deal - might ask them so that I can improve or change my practice if they are doing something interesting. But if they are truly Dr. Danger, should I call them and let them know?

shrinkr said...

I'm a doc too, but I'm a forensic psychologist and QME who had the misfortune to undergo TOS surgery and this narcissistic neurosurgeon stretched or partially transected the Phrenic nerve causing a permanent R sided Hemi-D. paralysis! This idiot then avoided me like the plague during the post op period. He even slipped out the back door and left when I was there to have the op site checked. I found out later why he split. He was hoping the nerve injury would resolve and he wouldn't have to disclose it.

When I asked another doc about going to this creep, he said he was technically competent. I then asked him if he loved his mom and would he send her to him? He said yes. I knew there was some political crud going on re. this surgeon in the hosp. (a world famous teaching inst..-rated third best in the U.S.) so, I asked about competence to steer clear of the other stuff.

I asked a second doc (a well known professor) about this surgeon and he made an off handed comment that was anti-Semitic and said don't go to him. Because of the nature of the remark, I did not consider the source credible. This doc later told me he made the comment like that because he didn't feel he could tell me really why I should stay away from the neurosurgeon with a bad rep.

Now, the good and bad part. I've had several pts come to me who were about to be sent to doc creepy or have him perform surgery. When they all asked me about him (and all of them asked) I scrunched up my face into a contortion worthy of a prune and let them figure out what I was thinking. I just couldn't stand by and watch someone else get mangled.

Unfortunately, the wolf is guarding the hen house re. some state med boards and doc creepy is still in practice.

We all know docs make legit boo boos. Better to man/woman up, say sorry and lets work on dealing with it. If there's true incompetence, then we need to get rid of these guys and the public needs total disclosure...and transparency. Now, wouldn't that be novel???

Anonymous said...

This post bothers me. I think 100% is a horrible standard on this. At the same time, I agree- it is very hard to know how bad the practice has to be and where to draw the line. I can say, from the patient (or parent of patient) perspective, that I wish docs did more policing of their own, and erred on the side of caution.

In my case child 1 with some congenital complications had an adverse rxn from an adenoidectomy. apparently old doc is losing his skills or particularly heavy on the cautery and my son had torticollis which took a while to resolve. Fast forward a year when child 2 has obstructive apnea and needs to have her tonsils out. Recognizing that child 1 had a complication that is within normal, i still felt more comfortable asking ped doc for a different ENT referral, and explained it was general discomfort because of the other experience. No hesitation to provide a different name- in fact, the staff who brought the contact info said they completely understood. New ENT is very familiar with the previous doc. Explaining the surgery/recovery I tell him I am aware of risks, child 1 had x complication so now I know (and can avoid emergency room visit on the weekend with pain and inability to move head) he immediately responds let me guess- Dr. Outdated did the surgery. I cover for him sometimes and that happens a lot. He's heavy on the cautery.

After I picked my jaw up from the floor I said, so it's known, the new ENT backtracked. Since then we have also found out that with a cleft child shouldn't have even had the adenoids removed.

There's no permanent damage/long term problem. I am not inclined to sue, follow up with a med board either (I don't feel I have the competence to do so), but should there be a warning? Absolutely. What is frustrating is that we went back to peds office and said that this is a known problem with Dr. Oldguy. No comment and they still have him on their referral list. Also, the treatment didn't work, and new ENT made other recommendations/changes and his drainage hearing has improved.

Buyer beware, but more responsible policing on the qualified professional side might limit some of the insurance premium issues. And, while the overall outcome was no long term damage, there are costs and risks associated with unnecessary/improper surgery. In our case, the cost of the surgery (we moved and a second ENT has confirmed that is shouldn't have been done and we are lucky that there is no hypernasality), cost of ER follow up, and unnecessary pain in a small child.

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