Loss of Autonomy

I guess I do owe you, my blogspace friends, an explanation of my previous post. I am taking a sabatical from my job at "Crack City" Medical Center. Heck, I've actually already turned in a letter of resignation with the required 6 months notice, but instead have been coaxed into an indefinite leave of absence. In essence, I'm still on the medical staff just in case I change my mind. "We don't want to lose someone of your caliber" convinced the folks in my group. At any rate, I've agreed to finish out next month's schedule, since it has already been made. Then afterward, I'm outta there.

Years ago when I was but a numbskull, doe-eyed medical student, I was already well forewarned by one of my mentor attending that this day would come. I told myself that if the day ever come when I am being told by some nonclinical administrator what tests I can or cannot order for my patients, I would resign my clinical privileges at that hospital. I promised myself that the day when the Utilization Review Nazi come after me, I would quit. Justified or not.

During last Monday morning departmental meeting, I was heartbroken. A completely nonclinical administrative staff handed out a some papers with detailed statistics on how many xrays (and of what body parts), CT scans, EKGs, CBC, Chemistries, Cardiac Enzymes, etc...that each one of us in the group had ordered for the fiscal year, with a ranking of each individual compared to our peers and that of the rest of the medical staff. Though she did not explicitly state that we can't order such and such studies, the implied message was quite evident. My spirits were crushed.

Yours truly was singled out during the meeting for ordering more CT scans than the rest of the group, and in fact, more than any other physicians on the entire medical staff. I quickly asked for stats of how many patients I saw for 2006, as well as patient seen/hr. in comparison to the others. Guess what? For CT's per patient seen, my number was actually very low. Just slightly above the part time doc who only work 2-3 swing shifts a month for us, and lower than the rest of the group. I then asked for the even more important stats, the number of positive CTs, how many of them were done on trauma patients, etc... The CT Nazi didn't have the numbers immediately on hand. I then asked for the medical record numbers of all the patients on whom I ordered the CT's. She didn't have that list either. So I left the meeting right in the middle, went onto the computer and logged into our web-based medical records. For the past few days, I've spent hours and hours going over every patients I saw for 2006. And boy, I saw a lot too, ~12,000. Only second to a partner physician who works more shifts than I do. And I only work weekend nights (Fri, Sat, Sun.), with an occasional swing shift to cover any hole in the schedule! Come to find out, some of the CT's ordered were done at the request of the surgeons on call (such as the appy's that you know were appy's but the surgeons wanted a CT), many were trauma related because of mechanism of injury (such as drunk or unresponsive roll-over MVA, or drunk and unresponsive with head trauma). You gotta scan these trauma cases with significant mechanism of injury because of a lack of history. Excluding for all the traumas, the majority of CT's were abd/pelvis CT's on elderly patients and patients with kidney stones with positive rate of over 90% for pathology. Some were of the chest looking for PE's, aortic dissection, etc...but accounted for less than 3% of total ordered. I wanted the stats on which docs have diagnosed the most aortic dissections and PE's by CT scans but they weren't able to provide that for me. I would dare argue that I'm right at the top of that list. Many of the CT's done weren't even ordered by me but by the admitting physician whom I consulted. But because my name was already assigned to the patient on the computer, the unit clerk just entered the order under my name. There were also many instances where the person ordering the CT was not me but one of my partners on the same shift. This happens because when the patients hits the door and get registered, they are assigned on the computer to a physician on duty in the ED to expedite standing orders. The name of the physician on the chart is not necessarily the one taking care of the patient because there are at least 2-3 of us on duty for any given shift, except after 1AM when the night guy flies solo.

The point of it all is that I DON'T WANT ANYBODY, clinical or nonclinical, to tell me what tests I can or cannot order on my patients when I am the only one who will ultimately held accountable in a court of law! I will not allow any MBA wielding pencil pusher with no clinical experience or background whatsoever dictate what I can and cannot do for my patients! I realize that medicine is just as much a business as any other businesses, and bottom lines must be met or kept in check. But the day when a physician loses his or her autonomy at a hospital, it's time to pack up the bags and call it quits, or move on. I'm taking a firm stand on this issue!

Speaking of lawsuits, here's Lawsuit #9 that I'm currently dealing with, adding to the stress and insult of it all. Three years ago, I saw a patient who came in complaining of "blood in urine" with dysuria, urinary urgency and frequency. Standing orders on her had been done by the triage nurse by the time I saw her. Her CBC was normal, negative on the urine pregnancy test, U/A showed large leukocyte esterase, many WBC, and many RBC's (not gross hematuria, only microscopic), but negative nitrite. The ratio of RBC to WBC was about 2:1. It was a clear cut case, I called it a UTI and discharged her on Bactrim DS without ordering a urine culture. Her physical exam was unremarkable, no CVAT. I gave instructions to follow up with her family doctor in 3-5 days or the internist on call that day for outpatient referrals, and also to return if worsening symptoms such as fever, vomitting, etc... It's one of those lawsuit nightmares that we've all read about in the medical journals, but it happened to me just the same. 3 years later this same patient returned to our ED, now she has gross hematuria, TNTC rbc's in her urine, severely anemic with a Hgb=6 and tachycardic. A CT scan showed a bladder mass with metastatic disease to one of her kidneys. She was transfused, underwent a full cystectomy and nephrectomy for transitional cell cancer. She now has a urostomy tube. Yes, I'm being sued for a misdiagnosis. And I do feel horrible for the lady that she had a bad outcome, but the situation was completely and truely beyond my control. She had exactly 2 ED visits, the first one 3 years ago, and the 2nd one when she was diagnosed 3 years later. Nothing in between. She never followed up with anyone during the intervening 3 years, and I guess she expected me to have a magic crystal ball up my ass! She argued that when I instructed her to follow up with a family doctor, she didn't have one. The internist that I had referred her to in the event she didn't have a family doctor, she never saw because she was wallet-biopsied when she showed up at his office. But she never returned to the ED until 3 years later despite persistent worsening symptoms even after finishing the week's course of Bactrim DS that I had prescribed. The plaintiff lawyer, with his expert witnesses, claimed that had a urine culture been ordered it would have proven that she didn't have a UTI, and that had she been appropriately worked up with a cystoscopy, she would have been diagnosed earlier. Bullshit! Strongly positive leukocyte esterase, many WBC's, microscopic hematuria, with symptoms of dysuria, frequency and urgency... is text book pathognomonic for a UTI. They argued that consultation with a urologist should have been done. The plaintiff attorney also charged that I had entirely ignored her complaint to me about severe gross hematuria and back pain in the history. Bullshit again! In medicine, there's the subjective history from patients and then there's the objective findings. The latter proved that she did not have grossly bright red urine when I saw her. By their ridiculous arguments, every patient with a UTI would then need to see a urologist for a cystoscopy. Absurd!!! And also, there's the issue of the statute of limitation. C'mon, I saw her 3 years ago! But the letter of the law is rather obscure and is up for interpretation. The exact wordings on statute of limitation in this state is weird, it refers to the "time of discovery", which allows the plaintiff lawyers room for much laxity.

The straw that broke this camel's back has come. It's one thing having to put up with the Press-Ganey bullshit and having artificial patient satisfaction survey scores tied to your reimbursement, but this loss of autonomy is a devastating blow to the heart. I can't take it no more! I'm standing firm on principle. It's time to move on after 7 years at CCMC. The hospital administrators won't give a crap whether I stay or go, of course. Their contract is with the group, not me. I'm just a doc in a box and working stiff to them. ER docs are easily expendable, and that's a fact, jack. No matter how exceptional you are! They can fire our group and bring in another one at a drop of a hat. Our group's contract with the hospital expire in July anyway. Many corporate groups out there would gobble up the opportunity to come in and take over. In fact, 6 of them bidded against us for during last year's contract renegotiation. I guess I can find another job at an ED elsewhere, but this erosion of the physician's autonomy is probably gonna be the same everywhere. I hate being a hospital based physician as the position puts you at the mercy of the hospital administrators who don't knows squat about patient care. But working at an urgent care clinic would be just too boring for me.

Isn't it ridiculously ironic? The hospital is ragging my case for ordering too many tests, despite that they are justified, while a patient is suing me for not ordering enough tests, despite that there were no justification for such. Cystoscopy for a UTI, oh my goodness!

What's next for this burned out doc? I dunno. Opus? I guess I can continue to blog about the cases that I've seen in the past, like good ol' Dr. Sid Schwab in retirement. I'm still too young, though, and don't have enough $$$$ to retire yet.