Monday, September 24, 2007

Close, But No Cigar

Professional courtesy causes people to make a lot of assumptions. We assume that, just because someone is a doctor, that person is a sympathetic soul with good bedside manners. We assume that, just because someone is a doctor, that person has strong professional ethics and honorable intentions. We assume that, just because someone is a doctor, that person is acting in the patient’s best interests. We assume that, just because someone is a doctor, that person has good communications skills.

Unfortunately, such assumptions are not always valid. Read the news and you will learn about physicians who were convicted of fraudulent billing practices, physicians who operated on the wrong patient (or body part), physicians who breached patient confidentiality -- even physicians who have abused and raped their patients while the patients were sedated on the operating table!

With each new report, we stop and ask ourselves: How could that physician’s actions have gone undetected and unreported? How come no one said anything? Didn’t anyone notice? Didn’t anyone care?

Earlier this year, while undergoing treatment for elevated pressure in my left eye, I had the kind of experience that really makes one question the wisdom of the powers that be. Having been bounced from one ophthalmologist to another, I landed in the waiting room of a physician who specialized in treating herpes simplex of the eye. This was the doctor I needed to see. And, because he was associated with a teaching hospital, the doctor had a resident under his wing who was asked to perform my initial history and physical.

It didn’t take long for me to realize that this resident had no idea what she was doing. Although she had my chart in her hand, she kept asking questions which made no sense. No matter how many times I told her there was no pain in my eye, she kept asking me about the pain in my eye. Even with the dates in front of her, she could not comprehend the chronology of my problems. She was completely clueless. When the time came to examine my eye, she was all over the place.

“Are you a resident?” I inquired. “Oh, yes,” she proudly replied. “I’m the chief resident!”

Upon entering the room, the mentoring physician quickly sensed that something was wrong and took over the examination. As soon as he had dismissed the resident, I brought the proceedings to a halt. It took a lot of guts to say what I had to say, but I figured that I had nothing to lose.

“I may be stepping way out of line here, but there’s something you really need to understand,” I told the physician. “As you know, I own a medical transcription service. Several of our clinics have rotating residents who are just learning how to dictate. But that woman can’t process information. She couldn’t even make sense out of my history. And until she learns how to do that, she’s not going to be a good doctor.”

There was a tense moment of silence before I continued.

“I want you to be very clear about the reason why I’m telling you this. It’s possible that someone is either protecting this resident or doesn’t want to be the one to tell her that she doesn’t have any talent. But as a physician, she’s a risk management time bomb just waiting to explode. So, regardless of whether or not I become your patient, I’m telling you this so you can’t say no one ever told you.”

The doctor slumped back in his chair. “Well, you’ve certainly hit the nail on the head,” he sighed. “There have been violent arguments about her and you’re right. She can memorize anything she reads and regurgitate it, but she simply can’t apply it.”

In the course of further discussions I learned that this ophthalmologist had been stuck with a “rotating” resident. He and his ophthalmologic colleagues were painfully aware of the severity of this resident’s limitations. What made the situation worse for him was that the resident’s father was a very powerful and influential colleague in Los Angeles who was “just the nicest man imaginable.”

The social promotion of interns and residents who do not -- or cannot make the grade is as questionable a practice as the social promotion of school athletes who can neither read nor write. As a patient who is also a medical transcriptionist, I feel a distinct duty to scream as loudly as possible when “The doctor has no clothes.”

Here’s why. The dumbing down of the American education system is hardly limited to students at the elementary and high school levels. There are many physicians who get through medical school because someone is helping them pass. Whether their wives, husbands or significant others help them do research -- and/or write their papers -- many medical students graduate without always learning what they need to learn. Some emerge from medical school with acute language and communications problems. Some lack critical thinking skills. Others graduate with a slight amount of functional illiteracy.

I’ve listened to the doctors who make up drug names that don’t exist. I’ve listened to the surgeons who rotate “left” and “right.” I’ve listened to the doctors who can’t spell their way out of a paper bag. I’ve listened to the Asians who, because they may not be used to gender-specific pronouns, rotate “male” and “female.” And I still shudder at the memory of the orthopedic surgeon who dictated “What am I trying to say? Idon’t know what I’m trying to say. YOU know what I’m trying to say. Why don’t you just put it in, okay?”

In his 1999 State of the Union Address to the United States Congress, President Clinton stated that as part of his Education Accountability Act “all schools must end social promotion. No child should graduate from high school with a diploma he or she can't read. We do our children no favors when we allow them to pass from grade to grade without mastering the material.”

There is no reason to expect that we can institute educational accountability in the lower grades without demanding it in professional circles as well. Recently, I cringed when the attorney who became President of a local business association introduced an important Bay area politician as “the most physically responsible member of the Board of Supervisors.” Being physically responsible means that you wipe before you flush. Fiscal responsibility is quite another matter.

If medical transcription service owners must break the unhappy news to aspiring MTs that they cannot be hired because they lack the combination of skills and talent necessary to succeed in the job, then perhaps we should carry the action further up the professional ladder. The settlements of many medical malpractice lawsuits place a gag order on the plaintiffs which effectively allows a physician to keep making the same mistakes. Within medical circles, a tendency to look the other way -- combined with a conspiracy of silence -- can allow a colleague to keep practicing medicine at the risk of patients who may suffer medical neglect, misdiagnosed symptoms or wrongful death.

My frustration with doctors who cannot clearly communicate information which must be placed in a patient’s medical record is shared by many MTs. One woman, who entered the hospital for minor surgery, asked to see her history and physical as soon as it had been placed in the chart. After reading a boilerplate paragraph of her history that was totally inaccurate, she hit the roof. “These are lies!” she screamed. “None of this is true.”

Yet nothing in her medical record was changed.

For many years I have felt there should be a means by which medical transcriptionists can anonymously report a physician whose dictation is so incompetent that the quality of his reports poses a distinct threat to patients. Whether this is done at the level of a state medical association or through the JCAHO, there needs to be some means by which MTs -- who are charged with the accuracy of a patient’s record -- can blow the whistle on such doctors. Even when their work contracts forbid MTs from having any direct contact with a dictating physician, someone needs to be alerted about this phenomenon.

Because many medical transcriptionists are functioning as independent contractors, there is a great -- and understandable-- fear of losing one’s primary source of income by reporting a doctor whose poor dictation could jeopardize patient care. But this is a situation where peer review by other physicians is clearly not working.

The sad truth is that the resident who examined my eye soon rotated to another specialty and will eventually become a doctor. I certainly would never want to be her patient -- and would hope and pray that she be restricted to working in pathology or radiology. But why should I care? I’m only a medical transcriptionist. I’m going to follow the advice recommended by doctors everywhere.

"Don't worry. Be happy!"

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