A few weeks ago a friend who I will call Tom was scheduled for cataract surgery. As it happens, we share the same ophthalmologist, who I will call Doctor X. (Tom recommended Doctor X to me about 8 years ago.)
Dr. X told Tom that he was developing cataracts a couple of years ago, and a few months ago, he explained that the time had come for an operation on each eye. Dr. X planned to do one eye at a time.
Tom was about to go on a long business trip, so he didn’t schedule the operation immediately, but when he came back, he made an appointment with Dr. X who checked his eyes again, and showed him a video of how the surgery done. Doctor X also sent him for a cardiogram.
A few weeks ago, it was finally time for the operation on the first eye. Then, the day before the surgery, Dr. X’s office called three times—each time rescheduling the operation for a different time the next morning.
Exasperated, Tom finally said: “Let’s just cancel it.”
Since we had been talking about the operation and about Dr. X, he called me. “I feel like an idiot, canceling at the last minute,” he said. “I’m not afraid of the operation—these days it’s pretty simple, but there’s something about Doctor X . . .”
I couldn’t help but agree. Over the years, I have found Dr. X annoying. His waiting room always is crowded; it is not unusual to wait 1 ½ to 2 hours to see him. It struck me that he was trying to see too many patients, but when I mentioned the long waits he blamed “my genius office staff" for over-scheduling him.
Dr. X has two or three younger doctors working for him, and they too
seemed harried, racing from one examining room to another. His office
also sometimes calls to cancel appointments that have been set up
months earlier because he is going to be out of town. He seems to
travel a lot; the office usually explains that he’s going to
conferences where he is giving a speech. I took this as a sign that he
was an expert in his field. Later it occurred to me that pharmaceutical
companies might be paying him to make presentations.
When I was writing my book, Money-Driven Medicine, I interviewed Dr.
X, and he complained about how he was making less money than he had
twenty years ago. Earlier in his career, he said, he always flew
first-class. Now, sometimes he flew coach.
He was particularly angry about the fact that so many CEO’s earned more
than he did. He knew that they hadn’t gone to school as long as he had,
and he suspected that most weren’t as smart. So why should they be
making the big money? He compared them to athletes, commanding
multi-million-dollar salaries, “when they can barely sign their name on
a football.” He also lamented the fact that patients aren’t as
“grateful” as they used to be.
Dr. X is usually a charming raconteur. But in the interview, he seemed
simply sour. I was disappointed, and didn’t quote him in the book. But
that didn’t seem a reason to stop seeing him.
That is, until a couple of months ago, when I went in for an eye exam.
I knew I needed a prescription for new eyeglasses. After dilating my
eyes, Dr. X kept me waiting for more than two hours. Then, when he
finally examined me, he seemed very uncertain about the prescription.
Apparently the new prescription he was writing didn’t match up with the
last prescription he had on file. He said that the optician should
call him before making the lenses.
He also told me that my glaucoma was suddenly much worse—the pressure
on my optic nerve and the blood vessels that nourish it had shot up,
and he prescribed two new, very expensive eye drops.
All of this made me uneasy. I bought the new eye drops, but rather than
filling his prescription for new lenses, I decided to go for a second
opinion. I know I have a very difficult prescription and I want to make
sure it’s right. ( I still haven’t done that, I’m embarrassed to
say—I’ve been too busy blogging.)
In the meantime, Tom had scheduled the cataract operation. It
surprised me when he told me that he was still driving at night. He
drove back from Boston to New York on a night when it was raining; I
asked him whether that wasn’t risky, but he said he had no problems.
So when he canceled the surgery, I had a feeling that he had done the
right thing. Something is wrong with Doctor X, I thought, maybe he is
getting older. . .
I then contacted a doctor who is a friend, and he gave me the name of another ophthalmologist. About two weeks ago, Tom saw Doctor Y. He told Tom that he did not see
any reason for an operation—not on either eye. Because he had already
dilated Tom’s eyes, he asked him to come back in a few days so that he
could check his vision when they were not dilated.
The results of that second check-up were astounding: In one eye, Tom’s
vision is actually 20/20; in the other eye, the doctor told him that
his vision is “very good.” If Tom hadn’t been irritated by the
constant rescheduling of the surgery, it’s likely that he would have
had two unnecessary operations. And while cataract operations are
quite safe, there is always the possibility that something could go
wrong.
Still, who would think of going for a second opinion if a doctor tells
you need cataract surgery? In fact, cataract surgery is elective
surgery. If a doctor tells you that you need an appendectomy, you have
no choice. By contrast, when it comes to cataract surgery, it’s up to
the patient—and normally, the deciding factor is whether his eyesight
is interfering with his functioning. Is he having a hard time reading
in low light? Does he have trouble driving at night? Does the glare of
oncoming headlights bother him more than it used to? But most patients
just follow their doctor‘s recommendation.
With a little Googling , I discovered that there is a debate in the
medical community as to how many unnecessary cataract operations are
done in developed countries each year. Doctors perform the surgery
earlier than they used to; they no longer wait for the cataract to
“ripen.” But in some cases, if the patient had waited, he might never
had needed the surgery at all.
Going back to Dr. X, I can only wonder how many unnecessary operations
he does. Does he do it for the money? Is he merely incompetent? But he
didn’t just make just one mistake: he told Tom that he needed surgery
in both eyes on three separate occasions. Dr. X also performed cataract
surgery on Tom’s brother. His brother liked Dr. X so much that he then recommended him to Tom.
Tom has asked me to help him figure out how to report Dr. X.
Here is my question: how can I persuade someone to take a close look
at Dr. X’s practice? I could report him to the state medical board,
but I know, from past research, that medical boards are not very good
at policing doctors. And I have no proof except Dr. Y’s second
opinion. Would Dr. Y want to become involved? Probably not.
Dr. X is extremely articulate, confident, and successful. Listening to
his conversations, I know that he has many patients that he has been
seeing for years. Not long ago, a doctor’s wife was ahead of me in line
when I was “checking out”; the office assistant told her there was no
charge—her exam was a “professional courtesy.” Dr. X is outgoing,
gregarious, and is probably well known in the medical community where
he would have many supporters.
Finally, if he has done unnecessary cataract operations on other
patients, my guess is that there would be no evidence. Once the
surgery is done, I’m assuming that there would be no way to tell
whether it was needed.
I have thought about calling the surgical center where Tom was
scheduled to have the operation. Perhaps someone there has noticed
something is amiss.
I realize that our suspicion—that Dr. X is knowingly performing
unneeded surgeries—is a serious charge. And I certainly don’t want to
cast a cloud on someone’s reputation without good reason.
Still, the fact that Tom can see so well, combined with the second
physician’s opinion is compelling evidence. I feel that I have an
obligation to at least report Dr. X to the Medical Board, though unless
there have been other complaints, I’m afraid my statement will wind up
in a circular file.
Does anyone have any suggestions?
This seems to be a common problem. From today’s NY Times
State Watch for 2 Percent of Doctors
http://www.nytimes.com/2008/05/07/nyregion/07doctors.html
Maggie,
You could consider reporting this incident to the hospital where the physician is on staff and performs his surgeries. If enough complaints have been generated against a physician either by colleugues, staff or patients, then the hospital will be able to deny admiiting privielges to the doc if they find he is performng inappropriate surgeries. This is a reportable event to the national practitioner data bank and raises a red flag for other hospitals as well since a doc removed from one hospital for disciplinary purposes could often move on to another hospital without them knowing of this past action. The Data Bank has certainy made this more difficult.
As to whether any action will be taken by the hospital depends on the quality of oversight. since hospitals often can generate significant revenue off of a busy, though unscrupulous physician who brings alot of patients into its facility, there is a tendency to give the benefit of the doubt where a physician has significant financial clout. A good hospital will want to protect its reputation and does not want physicians performing unnecesary surgeries with the potential risk of being dragged into lawsuits.
Reporting to the state medical board is indeed hit and miss, but is still worth doing. It is the only way this behavior will be stopped since there is very little other incentive for physicians or other personel to get involved.
I would expect quicker action from the insurance industry than from the medical board, since they have more incentive to prevent unnecessary low risk surgeries. The state board would be unlikely to do anything unless there was gross evidence of harm…numerous bad outcomes. If this surgeon truly were performing unnecessary procedures, his stats as far as bad outcomes would probably look MORE favorable than average, and unlikely to raise any concerns with a state medical board beyond a cursory review of data.
I would expect a physician who performs unnecessary surgeries to fall far outside the bell curve in regards to per capita reimbursement. This perhaps is not always appearent unless a random audit is performed or someone specifically files a complaint with medicare or his/her respective insurer. If it were me, and I was truly convinced unnecessary surgery had been recommended, this is the route I would go. I might even try to see if I could find data on medicare reimbursment for the particular physician in the public domain.
If a pattern of unnecessary surgeries could be demonstrated by medicare or a private insurance company, then I could see a state board taking action. But I don’t see them doing the leg work to determine this…I would expect those with the bigger finacial stake to do more detective work.
Don’t underestimate the medical boards, usually the attorney general does there investigation, but medical records are often untelling, in this case however you will have the record of repeated recomendation for surgery and the second opinion (which I would include in the complaint) which will show a normal exam. Granted the board is not in the business of substituting judgement, but when it is blatant they have no choice but to act. If action is taken, that becomes public record and thus you are welcome to publicize it, possibly bringing more complaints out of the woodwork.
I think the way of insurance companies/CMS is the way to go if you want your concerns investigated. See, this is just an example of the big gap left by a total lack of oversight and governance…by a regulatory agency that is fair and unbiased (vs the “crony-ism” of Medical Boards.)
You should still cc the State Medical board, I’ll tell ya, I suspect if you contact the hospital where this doctor has priveleges he’s going to get a “Hey, guess what” phone call, so I wouldn’t, it’s very unlikely they’re going to investigate anything, if he IS performing unnecessary surgery then he’s bringing in revenue, probably getting bonus’ to boot.
Your friend Tom did the right thing by simply opting out of treatment offered by a doctor he wasn’t comfortable with. Since this is a consumer issue, our State Attorney General’s should be addressing issues like these as well
Maggie,
I am sorry for you friend’s experience. I agree with much of what is already posted. A busy surgeon can be a significant “rainmaker” for an institution and there is often a reluctance to look too closely into situations such as these. The problem is compounded in the case of cataract surgery, where the “evidence” (the presumably diseased lens) is destroyed in the course of the procedure. Moreover, the situation is worse at most free-standing surgery centers, where the high-volume physician may also be an owner and relatively free from any real oversight.
That being said, if a hospital was involved, it might still be worth bringing this to the attention of the VPMA (or whatever physician has ultimate oversight authority for quality in that institution). Also, the organization’s acceditory body (ie JCAHO) can bring some significant pressure to bear.
If it is an outpatient surgery center, direct reporting may well be futile.
I have never seen a private insurer get involved in anything but haggling over price, but a Medicare (CMS) investigation terrifies most physicians and healthcare organizations. As most cataract patients are of Medicare age, this may be the most effective route.
Thank you all for your suggestions.
I suspect you’re right about the surgical center–and that he is a rainmaker. (He’s not on staff at a hospital).
CMS does sound like a good route–and I’ll definitely
also get in touch with the state board because there is always the chance that others have complained . . .
Thank you all for your suggestions.
I suspect you’re right about the surgical center–and that he is a rainmaker. (He’s not on staff at a hospital).
CMS does sound like a good route–and I’ll definitely
also get in touch with the state board because there is always the chance that others have complained . . .
Thank you all for your suggestions.
I suspect you’re right about the surgical center–and that he is a rainmaker. (He’s not on staff at a hospital).
CMS does sound like a good route–and I’ll definitely
also get in touch with the state board because there is always the chance that others have complained . . .
Thank you all for your suggestions.
I suspect you’re right about the surgical center–and that he is a rainmaker. (He’s not on staff at a hospital).
CMS does sound like a good route–and I’ll definitely
also get in touch with the state board because there is always the chance that others have complained . . .
Maggie:
I have background information and basic explainations that you may find helpful. Feel free to contact me.
The simple fact is that you CANNOT stop “rogue doctors”. PriceWaterhouseCoopers just released an analysis (the latest in a long line of reports of this type) to the effect that FIFTY PERCENT of all dollars spent on health care are WASTED (i.e., the money is spent on services that neither advance nor even maintain health). I am aware of various specialists who routinely generate over $10 million annually from their practices, the majority of which constitute unnecessary procedures. Their patient charts are fiction, written only to support reimbursement from payers. I have personally sat in meetings where: (1) the OIG of the DHHS (Medicare fraud); (2) our states Attorney General (Medicaid fraud); the OPM (FEHBP fraud); (4) the fraud task force of Blue Cross; (5) a prosecutor from the DOJ and representatives from several private health plans. We all sat around a conference table at our local FBI headquarters discussing certain physicians. That has happened on numerouse occasions. Nobody’s in jail yet. Nobody’s been censured by the state board yet. Nobody has even slowed down their practice styles yet.
The simple fact is that we have various –ologists who think that every artery needs a stent (but only after a 64 slice CT Scan and an angiogram; every woman over 30 with a uterus is considered surgically deprived; every pregnant woman is a target for induction and then a caesarian due to her “failure to progress”; every child needs ear tubes; but, prior to that, we need weekly ultrasounds since all women are now “problem pregnancies”; and every one with sore joints needs a squeaky new ceramic hip.
UM, by itself, is of no value. They know how to play that game.
We need panels of honest physicians protected by defenses against litigation for their honesty. They need to do the tests over again BEFORE the procedures and determine if they’re truly necessary.
The other alternative is to just eliminate third party payers altogether so we’re paying for everything ourselves. However, the affluent (or creditworthy) among us would STILL be the victims of unscrupulous providers because they would lie and we would believe and meekly permit ourselves to be surgically raped.
Of course, we could just put all the providers on a salary and remove the incentive.
Don’t blame the honest physicians. They don’t want to get sued.
A report to the OIG – CMS may have some results, perhaps a RAC audit.
Medical necessity is a tough call, and it is likely that Dr. X is within the bounds of clinical necessity.
Poor office management and being a jerk are different issues.
Best policy, tell everyone you know about Dr. y.
Caliche-Pit–
You are absolutely right–we need to pay physicians for caring for patients, and for better outcomes, not for how much they do to those patients.
Most doctors do, I think, truly believe that what they are doing is medically necessary. But fee-for-service creates perverse incentives to “do more.” And that, combined with other pressures, is bound to lead to overtreatment.
We need to reward hospitals and doctors that, as a group, manage to get better outcomes while “doing less.” This means less suffering, fewer
side effects and healthier patients.
Dear Maggie,
I agree with Keith Sarpolis advise to complain to the hospital first. That’s what I did when I was badly treated by a resident and an attending. The hospital’s physician-administrator was a kind and caring man and took my complaint seriously.
Ten years ago, I saw an ophthalmologist at a teaching hospital in the Greater Boston area. I was first examined by a resident, the usual procedure at this institution. The resident was verbally abusive, bullying and threatening. He accused me of “not cooperating with him”, because I could not move my eyes as fast as he wanted. I have congenital nystagmosis and congenital esotropia, along with that very unusual sign–I can’t move my eyes nearly as fast as most people. I was very upset at how I was being treated. I asked the department secretary, who was a very kind woman, if this man had a history of behaving badly towards patients. She told me, “this is not the first time he’s been cruel to patients.” When I saw the attending (who had to re-do most of the clinical exam, because of the resident’s incompetence and/or inexperience), I complained about this man’s behavior. She did nothing. She did not offer an ounce of sympathy. In fact, she allowed the nasty resident to enter the exam room after the exam, when she was discussing her findings with me. I asked her to tell him to leave unless he was going to apologize. He didn’t apologize, nor did the attending order him out. When I left, the secretary saw that I was even more upset, not because of my diagnosis, but because of how badly I had been treated. asked her for the names of the supervisory physicians for both the attending and the resident. I also asked her if I could mention her in my complaint letters as someone who had known of other incidents similar to mine. She said, “Go ahead”. So I made sure that she received a copy of the complaint letter I sent to the supervising doctors. I will gladly go back to that hospital. The chief of the residency program told the nasty resident to either quit or be fired. He quit. The chief sent me a very kind letter apologizing for the behavior of his resident (obviously not reviewed by a lawyer). I do not know if the attending was formally disciplined, but I am sure that she was invited to attend an informal closed-door meeting about this incident. Even though I had a bad experience at this hospital, I would go back there in a heartbeat because my complaint was taken seriously. I had the unfortunate luck to run-into two bad doctors practicing in a hospital that really does take pride for providing world-class care to medically complex and interesting patients.
When I told my PCP what happened, he wanted me to file a complaint with the Board of Registry in Medicine. Unfortunately, at that time, Massachusetts had the worst record for disciplining its doctors. My complaint, against both the resident (for abusive conduct) and the attending (for not properly supervising a problem resident) landed in the circular file.
The medical profession needs to do a better job at screening-out potential physicians who are not psychologically fit for the profession. In the case of the really nasty resident, I’d bet that many doctors involved in training this man knew that he had a very poor bedside manner. I’d bet that he had serious psychological problems that made medicine not a suitable profession. We require our policemen and firemen to go through a thorough psychological screening before beginning training, in an attempt to weed out problem people. Why don’t we do the same for those about to enter medicine and it’s allied professions?
Tom–
Thanks for your comments.It’s an interesting story, and it shows how perseverance pays off. It also indicates how secretaries, nurses and other who see how physicians perform on a daily basis can be a patient’s ally.
The fact that the resident was forced to quit may seem harsh. But I agree with you when you write:
“The medical profession needs to do a better job at screening-out potential physicians who are not psychologically fit for the profession. In the case of the really nasty resident, I’d bet that many doctors involved in training this man knew that he had a very poor bedside manner. I’d bet that he had serious psychological problems that made medicine not a suitable profession. We require our policemen and firemen to go through a thorough psychological screening before beginning training, in an attempt to weed out problem people. Why don’t we do the same for those about to enter medicine and it’s allied professions?”
I think you’re right. In medicine, compassion is essential –unless perhaps, you’re going into forensic medicine and will only meet cadavers.
(There are also reserach positions for those who have trouble dealing with patients, though I suspect that people who lack the imagination to be compassionate may, in many cases, also lack the imagination to feel empathy.)
I agree: doctors, nurses and others should report interns, residents or physicians who treat patients abusively.