Residential Space A creative outlet during residency, turned ongoing virtual soap box

Posted on Friday, March 21st, 2008 at 2:57 pm. About Health Care, Ramblings.

Leave Doctors Alone

Okay, it’s been too long – it’s time for another post reminding everyone that, despite what the 24-hour news media and the Law & Order tv series would have you believe, doctors are good people who don’t deserve to be crucified when they cannot meet superhuman standards. Not to sound too much like Chris Crocker here (of “Leave Britney alone!” fame), but please – leave doctors alone.

Case #1: John Ritter’s death – unfortunate and untimely, yes, but is the right response really to have gone after a radiologist and a cardiologist? Ritter’s widow, Amy Yasbeck, went after these two physicians and wanted $61 MILLION in damages. The jury disagreed and did not find the physicians negligent – but only after the hospital had settled with Yasbeck for over $10 million. Apparently, the story goes something like this: John Ritter had a random full-body scan several years ago (I’m so against randomly ordering tests screening for nothing in particular for no reason, unless a good randomized blinded controlled trial shows a meaningful benefit to patients – ie, the colonoscopy), and evidence of coronary disease showed up. The radiologist told Ritter to follow-up with a primary care physician for management, and he never did. Then, he presented to the ER the night he died with chest pain, and apparently was being managed the way one would manage a myocardial infarction rather than going immediately to surgery for an aortic dissection. Yasbeck’s attorney argued that Ritter would be standing here today, making us laugh, if the proper diagnosis had been made and he had gone to surgery. I find this slightly ridiculous – if it was a severe enough dissection to have killed him so quickly, there is not a guarantee he would have survived surgery. Maybe he would have. Who knows. I think it is unlikely the physicians were grossly negligent though – chest pain is a very common presenting ER complaint, and one does the best he or she can to properly diagnose and treat the cause. Sometimes we give antacids and if it goes away, we assume that it was severe reflux. We don’t sent every single patient with chest pain through a cardiac catheterization or inject IV contrast for a CT of the chest and abdomen to evaluate for an aortic dissection. In following this case, my response has been: thank goodness I’m not practicing in Southern California and having to regularly treat wealthy celebrities. I have always driven myself to provide the best patient care I am capable of providing, but the constant fear of being sued leads to excessive diagnostic testing. I am relieved that the jury believed that physicians are typically decent HUMANS (not superhumans) trying to do the right thing with the knowledge they have spent many years acquiring. 

Case #2: Again, in Southern California, a transplant surgeon is ordered to trial for a patient’s death. He is accused of hastening the death of a patient in order to recover his organs for donation. The story on this case goes something like this: the patient was in a coma with a terminal disease and was going to die, but in order to be an organ donor, one must be declared brain dead. There are a large number of patients who will die a cardiac death prior to achieving brain death, and for a long time they have never been eligible for organ donation because they did not meet brain death criteria. Therefore, hospitals are starting to pursue options for “donation after cardiac death.” From what I know about this, it involves having the surgeon and operating staff ready in the operating room, and as soon as the patient has a cardiac death (cardiac arrest), the patient becomes an organ donor as soon as possible. One of the claims in this case is that the surgeon did not have experience with donation after cardiac death. My response is – most surgeons probably don’t. It’s new. It’s not traditional. That doesn’t make it wrong. Every transplant surgeon has to have his first time, and many times it will be unsupervised. This doctor has recovered hundreds of organs on patients who have not had cardiac death – is the anatomy suddenly going to change because the person has had a cardiac arrest? I would not think so. Is a 60 year old transplant surgeon who has been practicing independently for 20 years going to be told he or she has to go back through fellowship to learn to do this procedure under supervision before performing it independently? Likely not.

Here is the second reason this case is ridiculous – the transplant surgeon has nothing to do with the care of the patient prior to the patient becoming an organ donor. There is no clear consensus on what actually happened. There is the argument that the patient received morphine and ativan prior to cardiac death. Most terminally ill patients who are expected to die soon receive these drugs – there are entire order sets called “Comfort Care Orders” that are completed when the decision is made by the patient’s family to be on “Comfort Care,” usually meaning the goal of care is comfort only – no heroic efforts to preserve life, only to preserve comfort. I don’t find the administration of morphine or ativan to a dying patient unusual at all, regardless of whether he was to become an organ donor. I also find it sad that, given the shortage of surgeons in this country, one of them is having to fight these charges in order to continue practicing medicine, to keep his medical license, and to stay out of jail.

Let’s run through this one more time. In order to become a physician:

1.  First there are four years of college – and not “hanging out at the bars on the weekends” years, but studying, preparing for the MCAT (Medical College Admissions Test) years.

2. Then, there are four years of medical school, which are tough – my first year, after being in class all day during the first two years, I studied a MINIMUM of three hours a night after coming home from a full day. Exam periods were worse. I had friends who studied much more, if you can imagine. Then, at the end of the second year comes the USMLE Step 1 (U.S. Medical Licensing Exam), which is hard and expensive. But don’t worry – it’s not hard to pay for when you’re collecting tens-of-thousands-of-dollars of debt annually. The third and fourth year, you’re working like crazy in on-the-job training while caring for patients, and you’re doing this while continuing to accumulate debt because you’re not being paid. During the fourth year comes USMLE 2, which is hard and expensive, and the USMLE Clinical Skills exam, which is even more expensive. That’s okay – more loans to cover that.

3. So then comes residency – where a doctor is finally paid what society thinks he is worth, ~$42,000/year for working 60 hours/week in a good week, and 80 hours/week in a bad one. Thirty hour-long shifts every fourth day are common. Don’t forget USMLE Step 3, which is long and expensive. For three to four years this goes on for most medical specialties, but for surgeons it can be much longer – this transplant surgeon endured a minimum of five years of surgery residency followed by two years of transplant fellowship, just to have the privilege of caring for patients independently.

4. Finally, in your thirties, assuming you have gone straight through without stopping, you are ready to pay back loans and start earning a living, although surgeons then have to worry about high malpractice insurance premiums.

I apologize if I’m sounding whiny (for the record, I’m not a surgeon, a cardiologist, or a radiologist), but I really wish people would give doctors a break sometimes. What they do is intense, and the wrong decision can come at the cost of a person’s life – believe me, doctors are aware of the trust their patients have given them, and it means a lot. They value this and often sacrifice self-care for patient care as a result. They don’t expect thank you notes in return, but I can imagine it is very demoralizing to be sued for malpractice over the results of a full-body scan on a seemingly healthy young patient (one study out of dozens that radiologist looked at that day, most likely), or to have felony charged pressed against a transplant surgeon for possibly hastening the death of a patient with whom the doctor had very little interaction, if any.

 What is more harmful than anything this doctor likely did is the negative press spotlight on organ donation – how many potential donors may decide not to be donors anymore because of what they perceive happened in this California hospital?

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