Tuesday, September 18, 2007

Don't Ask, Don't Tell

In February, I boarded Carnival’s M/S Ectasy for a sorely-needed vacation along the Mexican Riviera. Although, at the time, I was a new member of the Gay & Lesbian Medical Association, I did not sit in on the continuing medical education courses being offered to physicians attending GLMA’sAqua U.” I did, however, manage to catch an excellent lecture about the latest news on sexually-transmitted diseases that was being offered to interested passengers by a urological surgeon.

Alas, old habits die hard. As I sat there listening to new ways to rupture one’s colon, I found myself counting in silence as the lecture progressed. Understanding that you can take the formality out of a surgeon (but a surgeon should have no excuse for ignoring certain basic formalities), I waited until the presentation concluded before approaching the speaker. After introducing myself as a medical transcriptionist who had recently joined GLMA, I asked the good doctor if he was open to some constructive criticism that might improve his lecture. “Of course,” he responded. “Well, then, you might want to run the slides in your Powerpoint presentation through a spell checker because I caught at least ten mistakes,” I suggested.

In sharing the story of my encounter with colleagues, I was astounded to hear one MT state that, because of the sheer superiority of his education, she would never put herself on an equal basis with a surgeon and dare to correct him. Her response typified certain types of co-dependent behavior which are frequently fostered and continue to fester within the medical workplace. My reaction to her statement is best summed up by Florence King, who wroteIf you feel like screaming, tearing your hair, and rending your garments over ignorance, incompetence, semi-literacy, and the curious pride so many Americans take in all three, you have Tourette’s Misanthropy.”

The author of such wonderful books as Confessions of A Failed Southern Lady and With Charity Toward None, King is the kind of writer who can’t stop herself from screaming that the Emperor has no clothes. Whether skewering bad writers or two-faced politicians, her writing is bright, tight, and strikes with surgical precision. Some of her essays show remarkable insight when explaining how Southerners can and will talk all around an issue in their determination to avoid saying what is obvious to everyone in the room.

The concept of a conspiracy of silence was boldly brought to life in Gentleman’s Agreement (which won the Academy Award for Best Picture of 1947). Written by Moss Hart, directed by Elia Kazan, and with a cast headed by Gregory Peck, John Garfield, Dorothy McGuire and Celeste Holm, this award-winning film exposed the subtle social gestures with which anti-Semites could prevent Jews from gaining access.

There are so many conspiracies of silence at work in the world of medical transcription that failing to correct a physician’s spelling is small potatoes. While reviewing videotapes of a technical seminar held by MTIA in October, 2001, I was struck by an industry expert’s advice to those MTSOs thinking of using deferred speech recognition never to tell their doctors that speech recognition is being used to process dictated reports. I became more alarmed upon reading a posting on MTDesk.com in which an MT described being approached by an Indian businessman who wanted her to be a front for an offshore transcription firm. Suspecting that something about his proposal sounded fishy, she asked whether the clients he had mentioned allowed their work to be outsourced overseas. “No, they absolutely do not want it to go to India,” he replied, “but how would they know if they are sending the check to you?”

Thanks to whistle blowers like Representative Henry Waxman and Enron’s Sherron Watkins, conspiracies of silence have been making headlines this year. The GAO has sued the White House in an attempt to determine who met with Vice President Cheney’s task force on energy policy. And the media has had a field day trying to determine how corporate honchos like Kenneth Lay and Jeffrey Skilling can brilliantly manipulate markets one day and then dissemble and profess to know almost nothing about accounting the next.

Since September 11th Americans have become painfully aware of breaches in security. It doesn’t matter whether such incidents involve passengers carrying undetected guns and knives past airport screening personnel or the INS mailing student visas to two of the hijackers who perished in the attack on the World Trade Center some six months following their deaths.

Meanwhile, not far from where the World Trade Center once stood, an outsourcing scandal has taken on a peculiar relevance for those involved with medical transcription. Like several states, New Jersey has been using electronic benefits transfer cards which offer recipients of welfare and food stamp benefits the kinds of electronic conveniences often associated with a debit card. Until February, the contractor providing the technology had used APAC Customer Services (a call center in Green Bay, Wisconsin) to handle calls from New Jersey’s welfare recipients. But when eFunds transferred the account to a call center in India -- where workers using fake Americanized names answer the calls -- the move triggered a peculiar chain of political events.

Objecting to the fact that taxpayer money targeted to pay for services in a welfare-to-work program was instead being used to send work overseas, Milwaukee’s Representative Tom Barrett wrote to Secretary of Health and Human Services Tommy G. Thompson (Wisconsin’s former governor who is noted for his welfare reform efforts) to complain about a practice that he felt was “technically not illegal, but wrong” -- a phrase that has frequently been used to describe Enron’s financial deceits.

“It's beyond outrageous. It's scandalous!” insists state Senator Shirley K. Turner of Trenton, New Jersey. “Of course we would prefer the jobs in New Jersey, but certainly we'd rather have them in Wisconsin than in Bombay. This is another example of privatization victimizing people. They're using tax dollars to take jobs out of this country."

When those charged with critical watchdog responsibilities are exposed as having been dangerously asleep at the wheel, it makes me hope that more Americans will begin to question authority. Therein lies the core of an ethical dilemma. Should New Jersey pay the lowest price it can get to staff a call center by letting a contractor outsource the work to India if doing so undermines the state’s own welfare-to-work program? Or should taxpayer dollars be used to pay people in India to fill entry level jobs that could have put New Jersey’s unemployed back to work? Senator Turner has introduced a bill which would require that state contract work in New Jersey be done by U.S. citizens or legal aliens. Not only is she confident that her bill will pass, she has an interesting legal precedent. The Aviation and Transportation Security Act of 2001 (ATSA), which President Bush signed into law on Nov. 19, 2001, requires that all airport security screeners in the United States be U.S. citizens.

What do you think would happen to the medical transcription industry if a law was passed requiring anyone who handles confidential medical information to be an American citizen? Such a law would surely throw a kink into the marketing plans of offshore transcription vendors.

Such questions -- strange as they may sound -- force us to confront the ethical dilemma facing our industry. Is the pressure to cut costs so great that we have no choice but to send work offshore (especially when the cost and downtime spent editing and correcting reports that were transcribed overseas may negate any anticipated savings)? Or is our responsibility to the health and security of our patients so great that we should show the same passion in our commitment to protecting their confidential medical information as we do in confiscating nail clippers from airline passengers? After all, vigilance costs money. Are we willing to pay that price? Or are we just giving our patients a lot of lip service?

On one hand, you can argue that the professional responsibilities of airport security screeners and people who answer phones in a call center do not require the same level of training as medical transcription. You can further argue that the people performing such jobs must be alert and oriented to each person they encounter. In the case of airport security screeners, you can even argue that the ATSA is necessary to save lives.

Which brings us back to “Don’t Ask, Don’t Tell.” The events of September 11th resulted in approximately 3,000 casualties. Yet it took less than ten weeks to get a bill signed into law requiring that airport security screeners be U.S. citizens. Current estimates claim that approximately 98,000 Americans die each year as a result of medical mistakes. But, hey, who’s counting?

Insisting that the Emperor has no clothes takes a lot of courage. But amazing things can happen when someone breaks a conspiracy of silence by broadcasting an ugly truth that won’t go away. What happens when the so-called authority is nothing more than corporate propaganda being churned out by a company’s marketing department? Or a hospital’s stubborn inertia?

The Leapfrog Group recently made news for its work with medical experts in identifying problems and proposing solutions that it believes can improve hospital systems that can break down and harm patients. The organization -- which is comprised of more than 100 public and private organizations providing health care benefits to over 31 million health care consumers in the United States -- is able to effect change because of the impressive clout it derives from its buying power. Although critics may resent Leapfrog’s strong-armed tactics (which are aimed at protecting its consumers), I would love to see Leapfrog flex its muscle over the conspiracies of silence gripping the medical transcription industry.

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