Trust must be earned, no matter what letters follow one’s name

In the last couple of days, I read two articles about health care delivery which had a great deal to say about the quality of care across the medical world. As a physician for over 25 years, I literally felt sick to my stomach as I read these descriptions of substandard healthcare. It would be very easy for me to criticize the ethics and professionalism of the various medical services discussed in these articles. But then, I could be challenged in return as to my qualifications to make such judgments.

This is one of the reasons why I am such a strong proponent of data collection, constant digital monitoring of medical practice, continuous data analysis to identify negative trends, and electronic medical record systems [EMRs] that take a very active role in how physicians deliver care.

The first article began with a single line statement that reflects a very dangerous practice in emergency rooms [which were the target of the study]. The first article, which appeared in the journal Academic Emergency Medicine, stated as follows: “only 22% of reproductive aged female patients had pregnancy tests performed before being prescribed potentially teratogenic medications”.

To explain this statement, imagine the following scenario. A 25-year-old woman presents to the emergency room complaining of discomfort when urinating. She is asked if she is pregnant and she says no. After speaking further with the young lady and performing an examination, the physician decides that this is a case of a urinary tract infection which requires antibiotics. The patient states that she is allergic to a number of medications and that she has taken one antibiotic in the past that did not cause her any problems. The name of the medication is Ciprofloxacin. The doctor writes the prescription and sends the patient on her way.

When someone asks me what it takes to be a good physician, my answer is always the same: be conscientious. Despite what you may believe or have heard from others, you do not need to be particularly bright to be a good doctor. Of course, you do need the mental skills to be able to absorb and remember all of the pertinent information with regards to managing your patients. But especially in this day and age, when encyclopedias of medical information are a mobile phone swipe away, it is far more important for a physician to always be thinking “Did I check for everything? Did I rule out all of the potentially dangerous conditions? Did I explain myself sufficiently well to the patient so that he or she knows what to do if something goes wrong?”

The scenario I described above of the young lady with an infection seems to be without issue. But there is a problem. During a physician’s training, he or she is taught to take a detailed history from the patient but then question every component of it. This is not because physicians are being taught to distrust patients. This is simply because patients may forget certain important clinical points, or they may confuse the names of the medications they take or they may totally misunderstand a medical question such that they can give a totally incorrect answer. The classic example is when a physician asks a young lady if she takes any medications. Many young women will say no. Then, the physician should ask, “are you on the pill”. And many women will answer yes.

When the physician challenges the patient as to why she did not initially say yes, the answer in return is that the “pill” is not a medication. In the patient’s mind, medications are only something a person takes when they are ill. The contraceptive pill is something that a woman takes when she is feeling perfectly well. Knowing that a woman is on the pill can make a major difference in her assessment. That is why a good doctor is the one who is conscientious enough to ask the additional question to make sure that all of the information necessary for a diagnosis is available.

The same kind of issue arises when a physician asks a woman of fertile age whether she is pregnant. Without going into details, every doctor has at least one story of a woman who swore up and down that there was no way that she could be pregnant, but in fact was. For this reason, when a doctor treats a female patient in a way that could be harmful to a young fetus, the medical recommendation is to do a pregnancy test. In this way, there is no need to question the patient and then to rely on suspicion and intuition to determine if in fact the patient is pregnant.

now, one can understand how serious it is that so few women are tested for pregnancy even when they are prescribed medications that could severely harm a young fetus. It is simply irresponsible not to do the pregnancy test. If the doctor does not know that the test should be done, then this is a very serious case of incomplete knowledge.  And when a doctor is lacking in basic parts of their clinical knowledge, you begin to wonder  what else they do not know.

None of this would be an issue if the physician was using an EMR that did not allow the Dr. to order the problematic medication unless there was some indication in the EMR as to the pregnancy status of the patient. In the event that there was no evaluation of the patient’s pregnancy status, then the EMR would not allow the Dr. to order the medication until a pregnancy test was done and the result was recorded as negative. In this scenario, I simply do not rely on the physician to remember  the protocol and to implement it.  There will be doctors who find this kind of digital intrusion to be upsetting and even unacceptable. My return answer to such physicians is that far too many studies demonstrate recurrent basic errors in these types of medication ordering situations. And it seems that no matter how much is published on the issue, nothing is changing. Therefore, the time should come that computer systems simply  do not allow doctors to “misbehave”.

The second article I read had to do with differences in medical costs between different regions of the United States. This article focused on the large group of elderly individuals who would spend the winters in the south of the United States [Florida for example] and then return to their more northern homes [New York for example]. Many of these individuals experienced an extremely unpleasant situation when they sought care in the southern regions. The article focuses on a number of cases where the price of care in the south was dramatically higher than back home in the northern USA. More so, the article describes a number of people who were being firmly pushed into additional testing for problems that did not require a workup. Fortunately, a number of the individuals discussed in this article contacted their regular physicians back home, and after the phone call, confidently told the physicians in the South that there was no need for the extra testing along with its cost and occasionally its invasiveness.

On reading this article, my initial reaction was the same as the author and most people reading the same text. The message  is clear: the doctors in the south take advantage of their location and the concern of their elderly patient population to make extra money. If all of the details are true as they are described in this article, it seems that quite a number of these doctors in the south could be charged with fraud. once again though, I find myself in the situation where I cannot make such a judgment without more information. The southern doctors could easily argue that the patient’s conditions changed from the time that they were last seen by their own doctors back home. And the southern doctors could argue that medicine is an art and that there are differences of opinion as to how much of an evaluation is appropriate when the patient is not feeling well.

This brings me back to the same conclusion as I had after reading the first article. We need data. We need to be able to assess the health of the individuals noted in this article, both when they were home and when they were down south for the winter. Only by comparing a [long] list of health parameters, can one legitimately state that there was no basis for doing more testing [and charging more money] while these individuals were in their southern retreat. With the appropriate data, it would be possible to challenge the southern doctors and to even formally charge them with fraud, and at the very least with behavior unbecoming of a physician.

Both of these articles have the same basic message. As much is it pains me to say it, it seems that many doctors – far too many doctors – cannot be trusted. They cannot be trusted to follow protocols. They cannot be trusted to order appropriate testing. They cannot be trusted to control their own greed even in the face of potentially harming innocent people. Basically, the message in both cases is that these doctors have no business being doctors. They should be stripped of their degrees and cast out. The only other option, is to impose a system which is impartial. And the only impartial system I can think of is one that is driven by zeros and ones. When a doctor in the south decides to order a test, he or she would need to justify why. And at any point in time, these southern doctors could have their ordering statistics reviewed and challenged. Only in this way could one hope to enforce proper practice across the entire medical world.

I very much appreciate how harsh my statements are in this post. But I take the practice of medicine very seriously. It is a noble profession  and it should be practiced by people who respect that fact. It seems though that until computers are watching over physicians’ every step, it may not be possible to trust those healthcare providers who should be above reproach. And that is very sad.

Thank you for listening

My website is at http://mtc.expert