Thursday, November 13, 2008

Health Train Security Alert


Like all professionals, we physicians need to be policed. There are some of us  (not me)  who are impaired, drug dependent, and present a risk to patients.. Certainly today with 'transparency' as the new  buzz word it is now expected that consumers will have a seat on the medical board as reviewers and decision makers.

This blog is transparent and read by physicians, administrators, pundits and yes, even 'consumers' (I prefer patients).

In California the administrative functions of the Medical Board have changed drastically in the past year. Enforcement issues have been taken away from the Medical Board.  It was found that the 'diversion program'  for physicians who are impaired was flawed and inadquate to guarrantee patient protection. The diversion program has been terminated.

In California all licensed providers receive a quarterly report about disciplinary actions against providers, including podiatrists, allied health care licensed providers.  I don't see dentists, or optometrists on this list, so they are most likely policed by a different agency.  They are held to a different standard, although they now provide many medical functions dispensing medications.  Is the system prejudiced against MDs?

When this "brochure" arrives I rush to open it and scan it for people I know or have known. This month I was shocked to find two colleagues who I know fairly well.  One is an anesthesiologist who attended to almost all of my patients I operated on as an ophthalmologist for over 15 years.

I never had a problem with him, my patients in fact would always comment how he made them feel secure.  His anesthesia techniques were very good. If I had a problem or he had a problem he usually noticed it early on.  I know because I had a year or so of anesthesia training before I opted out to specialize in ophthalmology. (I was a late bloomer, who enjoyed it all, and could not make up my mind).. A problem for many students who are forced to chose early because our post graduate system no longer has flexible internships with exposure to general practice in the first post graduate year.  I digress.

Apparently after 30 years as an anesthesiologist he retired and took several years off.  He became a physician for the corrections department.  Of course his general medical skills needed updating.

After he was hired he was offered remedial training and also the opportunity to take an evaluation.  He was not told that his employment would depend on his passing this test.  As it turned out he did poorly on the  test and it was determined that his skills were not up to caring for prisoners....I do not know if he was offered supervision or time to have remedial CME.  His medical certificate was revoked.  I also noted that it is no longer called a 'license', but a certificate.

A second colleagues's name appeared in the list.  This doctor was a psychiatrist who I knew for over four years.

His back ground was impeccable, and he devoted his career to poor patients, either in the medi-cal system or indigent.  He dealt with patients who had serious mental illnesses, ranging from bipolar disorder, to psychosis, alcoholics, and drug dependent patients. Among his patients the ones in question were among the most ill, with poor outcomes and chances of improvement.  They were very time intensive. He developed a social and sexual relationship with one patient, and expert testimony determined that this was not a predatory behavior for him, but a circumstance that developed out of this patient's serious physicial illness.  The event ocurred out of the office, and he was seduced during a period of extreme stress arising out of a recent divorce, severe financial problesm from a failed investment in an imaging center.

He was also accused of keeping poor medical records.

This psychiatrist trained in the days where psychiatric history's were sacrosanct. Psychiatrists were taught to be very careful in what they documented in the patient's chart. This was a habit he carried with him throughout his career.  He practiced in a private setting as well as a county mental health center for many years without this being an issue.  It became an issue for 'the system' when he was supervising an 'intern' who complained about 'inadequate record keeping'.. (who was supervising who?)

He was also accused of not giving adequate informed consent.


Informed consent implies that a patient can understand what he is told or reads.   The times I saw him as a patient to deal with my own stresses he gave me a yellow sheet which outlined the reactions, side effects, and drug interactions.  Even as a physician, I had difficulties understanding some of the material.

Was this determination based upon a patient complaint, or what was not in the chart?

How would an impaired psychotic or drug dependent patient understand and be truly informed??  Dr P worked with severely ill patients,  in a very busy mental health clinic with time constraints limited by the 'system'  He barely had time to evaluate a patient, document the visit, write the prescriptions, give informed consent and get it signed.  He had minimal if any assistance, and most of the  time did not have a psychologist to deal with issues he did not have time to complete.  The county however, had no difficulty providing administrators and clerks to process financial paper work for billing and other issues.

Perhaps he should have complained to his supervisor or the county.  He would probably have been terminated.  Government never accepts their portion of accountability for anything.

The county, state or federal system lives on bureaucracy and paper work.  Many of these patients are on ten or more medications for medical conditions as well as psychotropic medications. Physicians are policed and reviewed to be certain their records are complete, so why wasn't this caught well before he faced administrative or board discipline?

Yes, physicians need to be accountable and live up to a higher standard than 'ordinary people'.  Physicians have the duty to put their patient's welfare before their own.  At times this places them in a compromised position.

These issues become more critical and more prevalent with the increase in rationing, decreasing reimbursement, increased patient loads and the real world time constraints resulting from the growing crisis in health care delivery.


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