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.

Extending Doctors: Physican Assistants and Nurse Practioners

Question from a reader:

How do you feel about PAs and NPs?

So Physician Assistants and Nurse Practitioners are medical providers who are not doctors, but do doctor-like care for patients with basic problems. NPs and PAs are often called "physician extenders" or "mid-level providers." PAs and NPs don't go to medical school—therefore the care they provide has to be supervised by a physician.

How does Doctor D feel about them?

The Good, the Bad, and the Ugly:

Just like doctors, physician extenders are individuals with different styles of care. Similarly, there are good ones and bad ones. Doctor D is in favor of the good ones.

I have met some excellent physician extenders who work wonderfully with both patients and MDs to provide superb care. My own son, Little D, was delivered by a Nurse Midwife who is like a physician extender for obstetric care. It was an uncomplicated pregnancy, and I was totally comfortable with the midwife caring for my wife and son. It was one of the best deliveries I have ever seen.

Bad PAs and NPs can be trouble. Just like doctors, they can fall prey to the God-complex, which can be even more dangerous when arrogance is coupled with less medical education. D once worked with a NP who was doing some bad care. When Doctor D brought it up he said, "Who the hell are you to tell me how to practice!" And D was like, "Well actually, I'm the doctor assigned to supervise you, dude. It's kind of my job to tell you how to practice."

Just like bad doctors, bad physician extenders are the minority, but they can give all the good ones a bad name. Generally speaking, PAs and NPs are an important part of the healthcare system. Mid-level schooling is shorter which allows excellent people who just don't have the time for medical school to become medical providers.

NPs and PAs in Primary Care:

One place that you will see a lot of mid-level providers is in Primary Care. Since Primary Care is high stress with less pay a lot of medical students just aren't choosing that field. PAs and NPs are helping fill the gaps.

Something that concerns Doctor D is the idea being forwarded by some that all Primary Care can be done solely by physician extenders. The theory is mostly forwarded by politicians eager to save money and Specialist MDs who have no idea how complex Primary Care medicine can be. While there is need for PAs and NPs in Primary Care, physicians must remain intimately involved in this essential part of healthcare.

The Importance of Teamwork:

Patients who see a PA or NP are usually in good hands, but you should be aware that you are being cared for by a team.

Your mid-level provider is working with a physician even if you don't directly see that physician. This team approach has some obvious strengths: you get two providers involved in your care. Two minds can be better than one at spotting problems or unusual diagnoses. You always have the physician as a back-up if the mid-level provider feels your situation needs more advanced attention.

Of course, the flip side of this is that if either the MD or the mid-level are bad, irresponsible, or just don't communicate well your chance of problems increases significantly. Sometimes a really good mid-level provider is stuck with a bad physician. You may not even know you have a bad doctor on your team who is detrimental to your health.

If you are seeing a PA or NP you should understand how the system works, and particularly know about their relationship with the physician that supervises them. If your mid-level provider appears to be competent and has a good working relationship with mutual respect with their physician you can usually rest assured that your care will be done well.

So what do you think? Do you see an NP or a PA? What is your experience with mid-level providers? Any PAs or NPs out there who can tell us more? As always, Doctor D loves to hear your thoughts.

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 errors—we all do that sometimes—but 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!

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.

Incompetent Doctors: The Series

What is to be done about dangerous, incompetent doctors?

• The Battle Against Incompetence
  

• Why Do Incompetent Doctors Still Flourish?

• The Competency Witch Hunt!