Peer review may require random over-reads

“Let’s kill all the lawyers.” It’s every doctor’s favorite Shakespeare quote. And if you’re giving a talk to doctors there’s no better way to get the audience on your side than by starting with a lawyer joke.

But perhaps we shouldn’t be too hasty about killing all those lawyers. As recent commentary about the Mark Midei case makes clear, modern medicine doesn’t know how to police itself. And until medicine does learn to police itself and protect patients from incompetent or greedy or just plain self-deluded practitioners, we will still need the lawyers as a last safeguard, even acknowledging the many, many shortcomings of the current legal system regarding malpractice.

But of course there’s more involved here than just malpractice. At first glance it appears to be only a simple case of greed and arrogance, the story of an interventional cardiologist who made a lot of money by performing procedures on patients who didn’t need them. On further examination, however, the story runs much deeper, striking into the heart of the way medicine is practiced today. Before modern medicine learns to police itself, it will first need to change its culture.

When I first wrote about this case in January, and when I revisited the case last week by posting a guest comment on the case by Robert Wachter, I asked a number of acquaintances — interventional cardiologists, Baltimore-area cardiologists, and others — what they knew or thought about the case. Most of course did not want to speak on the record, but the responses were really quite interesting.

I don’t know whether I just got lucky or if Midei was a really sociable guy, but as it turned out just about everyone I asked knew Midei. Most even said they liked him, and they all expressed sorrow for Midei’s family. Several of my respondents also talked about the heated medical politics in Maryland, and the nasty feud that has embroiled St Joseph’s hospital and its relationship with Midei’s former group practice, MidAtlantic Cardiovascular Associates. (Even before Midei split from MidAtlantic, something was deeply amiss in the local medical culture. Back in 2005 Midei and a cardiac surgeon lost a $5 million lawsuit for fraud. You can read all the gory details in an article in the Baltimore Sun.)

But what I didn’t hear from any of my sources was serious doubts about the current accusations. All agreed that Midei had a right to tell his side of the story, but time and again I heard that they were aware that things were wrong. One interventional cardiologist told me about a colleague in that group who always felt befuddled at the cath conferences “because he said he could never see the lesions before a stent went down the coronary artery.” Another cardiologist, who had sent patients to Midei, told me he had reviewed angiograms that looked like a 50% narrowing but had been labelled 80-90% narrowing by Midei before performing the procedure.

So it appears that at the very least there was widespread suspicion that something was wrong. These days in New York City the motto is: “If you see something, say something.” But apparently for a long time a lot of people in Maryland saw something and didn’t say anything.

Here’s my question to the cardiologists and healthcare professionals who read this blog: what have you seen? Is there a physician out there who you would warn a family member against seeing? Have you reported this physician?

Here’s the problem: it’s not easy to rock the boat. In the case of a Midei, or the earlier, equally egregious case in Redding, California, there’s a powerful incentive for administrators to look the other way. No one wants to kill the cash cow. As one of my sources noted, “I suspect that many were aware but at all levels were too intimidated for fear of loss of job, professional rebuke, or some other form of ‘retaliation’ for questioning his practice.”

To help prevent a case like this, Wachter proposes “random over-reads of a sample of catheterization studies.” That strikes me as a good start. But it won’t be enough to prevent other types of abuse. There are innumerable roads to incompetence. Something needs to change so that a permanent, ongoing, peer review process becomes a standard part of the medical culture. Until then we need to keep the lawyers alive. Alas.

Larry Husten is a writer and editor of CardioBrief.org.

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  • jsmith

    If you don’t do peer review, watch out for lawyers. If you do peer review and nail a crappy doc, watch out for lawyers. And of course your practice expenses roll on relentlessly while you’re looking over someone else’s paperwork.
    Peer review usually doesn’t pay, financially or otherwise. Doctors who do it do it out of the goodness of their hearts. If you pay them enough , they might do it. If you mandate that they do it, they will manipulate the system (cf. continuing medical education).
    The idea of docs outside the group, preferably from outside of town, who have some legal mandate, doing the peer view has some merit, although of course who will monitor the reviewers?

  • http://www.drjshousecalls.blogspot.com DrMaryJohnson

    “Modern medicine does not know how to police itself.”

    Modern medicine isn’t really trying. JCAHO would rather label the physicians who would talk on-the-record “disruptive”. The AMA would rather hold onto its seat at the Congressional kiddie table – and eat the crumbs Obama might throw. Medical Boards are merely politically-appointed fiefdoms. State Bars are black holes of wink & nod corruption. And healthcare “reform” did not even touch peer-review or much-needed whistle-blower protection.

    I’m sure I’ve left something out.

    Those of us who have reported bad care through the peer review process (speaking “on-the-record” as the public wants us to do – but apparently not really) . . . and for our trouble were professionally crucified/black-balled by hospitals-with-economic-agendas, and pulverized/SLAPP-sued by those noble-truth-seeking (not) lawyers and have seen our stories-of-woe IGNORED/BURIED by the pandering press . . . can testify to that.

    In my case, I mean I could testify literally. But FOR SEVEN YEARS North Carolina DA has refused to even let me swear out a complaint against the two medically-clueless/morally-challenged “non-proft” executives who de-railed my life & career . . . all the while lying about what they did and why . . . and then lying some more in Court in order to save themselves some money after I fought off all the soul-sucking nasty tactics of their lawyers (who do belong at the bottom of an oily sea) and dragged them there.

    Medical peer review needs a whole lot more than “random over-reads”.

  • Reality

    Let’s not get carried away here. Modern medicine has actually done a brilliant job policing itself. Much better than ANY other industry. Take the financial industry for example, no need to explain there. How about the pharmaceutical industry, which is not self-policing but under very direct and heavy scrutiny of the government (via the FDA, etc).

    Have you ever tried to get a mortgage for a house? Did you know about the fake fees that lenders and brokers embed into the closing costs? This amounts to hundreds of millions a year and no one is watching.

    Who was watching BP when they went deep-sea drilling?

    Who was watching the Catholic church when, well, you know.

    I salute our physicians and other practitioners for being so vigilant, hard-working, and honest. Physicians are perhaps the most ethical creatures on the planet. They are not perfect, just as perfect as human being can be.

    So let’s lighten up. I know careers are made from chasing ambulances and blaming doctors for their “incompetence” and “greed” but the reality of the matter is that our medical professionals as a whole are the true embodiment of the human drive towards an ethical and ordered existence. No other profession even comes close.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    “Reality”, very respectfully, as someone who’s been on the wrong end of the jurisdictional dodge (after first being one the wrong side of “the White Wall”) . . . for over twelve years, I think you’re the one who needs a reality-check.

    The medical profession does a HORRIBLE job of policing its own – being almost as bad as the legal profession (which barely polices itself at all). As the article alludes, a whole lot of “ethical” upstanding professionals are unwilling or feel unable to testify against their own – even when patients’ lives are at stake. That’s not being “vigilant” or “honest” at all. It’s cowardice.

    A lot of that reluctance to take a stand or get involved is about fear, and economics/market share and power.

    As a young Pediatrician in public service, I was pummeled for being “the embodiment of the human drive towards an ethical and ordered existance” (in other words, intervening to stop and reporting bad care) while others-of-my-kind craned their necks to look the other way. For my trouble, I lost twelve years of my life to (so far) to the nasty/creative tactics of businessmen & lawyers-trying-to-bury medical ugly. So I’d appreciate it if you’d not tell me to “lighten up”.

    Moreover, the public knows we’re horrible at oversight. It’s the reason that healthcare “reform” did not get near malpractice tort reform. The public doesn’t trust us.

    We-as-a-profession are NEVER going to get meaningful tort reform unless we stop patting ourselves on the back for our nobility, and wake up and smell those roses. Noting the far-less-than-brilliant oversight in the other areas you mention, the general public isn’t quite so gullible as it used to be.

    And I’ve got to say, comparing the medical profession’s self-regulation to that of BP or the banks or the Catholic Church and calling what we do “brilliant” really isn’t saying much.

  • Reality

    Dr. Mary Johnson– sorry to hear about troubles. I was not referring to you when I said “lighten up.”

    I know the legal and business world very well. I’m a practicing physician but also the founder of a company. I’m in a very unique position.

    My point is that compared to the “outside” world (eg business and law), the medical profession is by far the most ethical. In fact, I can’t really think of a more ethical group of human beings. This is one of the things that makes me proud of being a physician and the reason I have not given up practicing yet, even though it makes up only 20% of my income and taking 60% of my time.

    Although I don’t know your story, great doctors, such as you, may get pushed around. Physicians are among the most defenseless group of professionals out there. They are easily taken advantage of. They are too busy taking care of patients, fighting to get paid, and avoiding frivolous lawsuits. Looking at the big picture, everyone (insurance companies, hospital CEOs, politician, even some patients) have made a habit of taking advantage of the physician community. And why not? No one really cares. Physicians are the lowest path of resistance.

    It’s very easy to target almost any physician and ruin their life. Good luck doing the same with crooked corporate CEOs. They’ll eat you alive.

    It wouldn’t be far from the truth to say that big business can get away with murder. A physician working 70 hours a week writing the wrong dose of a medication at 3AM in the morning while on call, which may or MAY NOT have resulted in the patient’s bad outcome, is only one step away from total ruin.

    I don’t want medicine to be criminalized. That would slow down progress and quality of care. We must stop pointing fingers at doctors.

    I think we should always step back and put things into perspective. Looking at how much the medical profession has evolved should be a great source of pride for all. It’s a great human accomplishment. This historical outlook can provide a better framework for judging the competence of the medical profession. Unfortunately, business and career interests of lawyers, CEOs, and a select group of so called academics has distorted the reality of how doctors think and perform their work.

  • http://nostrums.blogspot.com Doc D

    I worked in an integrated system where quality review was a part of everyday life. Every clinical service and every ancillary service had a random selection of their work reviewed. It made for some disagreements, and occasionally, hard feelings.

    But the biggest challenge was making it meaningful. Most thought it was drudgery, and some would retreat into nitpicking criticism of administrative deficiencies (like crossing t’s and dotting i’s–you know what I mean: “the time seen was not recorded in the right place on the patient’s record”, etc).

    What was needed was substantive and constructive criticism: “what was the indication for the treatment you chose?”

    Telling people if they don’t do it, the lawyers and regulators will didn’t get much traction. That was too theoretical and distant.

    I’m not sure how to guarantee this kind of internal regulation can be effective.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    “Reality” is what it is.

    Healthcare “reform” as passed will only made it worse. More CEO’s. More lawyers. More academics.

    Ethics and patient care be damned. But let’s cross those t’s and dot those eyes on all the forms/EMR’s and tell the public we’re doing something to protect them.

    That’s my perspective from the cheap seats/front lines.

  • Matt

    “My point is that compared to the “outside” world (eg business and law), the medical profession is by far the most ethical.”

    How do you figure? By what standard are practitioners of medicine more ethical than, say, architects? Architects aren’t prosecuted for defrauding the government as so many physicians are with Medicare/Medicaid, are they? Are there as many engineers practicing their professions while high or drunk as there are physicians? How about abortions – how many lawyers literally snuff out innocent life like medical practitioners do?

    Clearly, the examples above are the minority of physicians, but whenever any group starts trying to measure it’s morality as opposed to some others, it’s a dangerous comparison.

  • Marc Gorayeb, MD

    “Something needs to change so that a permanent, ongoing, peer review process becomes a standard part of the medical culture. Until then we need to keep the lawyers alive. Alas.”
    This is truly one of the most – if not the most – ridiculous conclusion regarding peer review that I have ever seen. The assertion that the legal system acts as some sort of backstop on unethical or substandard physician practice is bizarre. This writer knows absolutely nothing about the actual effects of litigation on physician behavior.

    The issue is complex, and there are many possible approaches to improving physician peer review. How about starting with the simplest one of all? Strongly encourage and incentivize patients to get a financially (and socially) disinterested second opinion before agreeing to undergo a procedure. It’s worth going outside of the local hospital community to get the opinion, and the patient’s primary care physician can certainly facilitate this.

  • http://www.drjshousecalls.blogspot.com DrMaryJohnson

    “Strongly encourage and incentivize patients to get a financially (and socially) disinterested second opinion before agreeing to undergo a procedure. It’s worth going outside of the local hospital community to get the opinion, and the patient’s primary care physician can certainly facilitate this.”

    LOLLOLLOL!!! And it is for just that kind of “disruptive” patient-focused attitude that you, Dr. Goyayeb, would be drummed out of many a small-town hospital (with their new state-of-the-art cancer or heart wing) for having . . . probably by your jealous colleagues, using bad-faith peer review.

    You KNOW you’ve got to keep “the business” local.

    And “support the parent company”.

    Meanwhile, good-ole much-beloved Dr. Happy, who is 100 years old, the town drunk and not board-certified in anything can serve as an “honorary member” of the hosptial’s board.

  • Panacea

    Reality said, “My point is that compared to the “outside” world (eg business and law), the medical profession is by far the most ethical.”

    Sorry, Reality, but I gotta call BS on that.

    As a practicing RN with 25 years of experience, I have had endless frustrating experiences with unethical physicians in multiple states who don’t hesitate to twist the system to their advantage, commit outright fraud, or just plain try to abscond on their responsibilities to patients.

    Examples: a surgeon who tried desperately to transfer a patient with necrotising fasciitis to another hospital rather than take the patient to the OR . . . because he knew he would never get paid (patient was homeless).

    An obstetrician who wouldn’t leave off his elective surgeries to come suture a hidden laceration on a post partum patient, and kept insisting on methergine even though the fundus was firm. Patient did OK, but got a totally unnecessary blood transfusion as a result.

    An ER physician notorious for cherry picking patients based on the insurance listed on the face sheet.

    A surgeon who instructed his Medi-Cal patients to report to the ER at 6am on the nights he was on call, so he could do their gallbladder surgeries as “emergent” and not wait for Medi-Cal approval.

    I see crap like this all the time. I’ve seen it in every hospital I’ve ever worked in, in 7 different states (I’ve worked as a travel nurse).

    It’s so pervasive that the only solution is to chuck the current system and start over.

    My suggestion would be to have a new Medical Board that includes members from other health care professions such as nursing, respiratory therapy, and pharmacy in order to do away with the good old boy culture that is more interested in protecting bad doctors than protecting patients.

    That being said, I would say that most physicians are ethical. But the modern medical profession is rife with corruption and an entitlement attitude that is hurting patients. And since the medical profession seems to have little interest in cleaning its own house, it won’t get cleaned until someone else comes in and does it.

  • alex

    “Until then we need to keep the lawyers alive. Alas.”

    Yes, clearly. Because every other country without our legal system is absolutely drowning in unethical physicians compared to us. Ergo our wonderful legal system must be the only thing keeping the dogs at bay.

    Seriously, is this even an attempt at making a logical argument? How can you simply ignore every other first world country on earth?

  • F Scott

    Panacea,
    Your 25 year “experience” of fraud and unethical behavior (4 examples) seems biased and one sided. You seem to have acidentally left out all the unethical behaviors by nurses that you have encountered over that time. I am certain you have seen, as I have, an entire wing of patients who have vital signs of 120/80, p=80, R=20 at 3AM. You certainly have seen charts documenting “dressing changed” when it was not done for several days, and exams listing PERRL on patients with prosthetic eyes. Nurses have documented pain meds given when they took them for themselves and “made rounds” while watching TV. I also know this is a minority of individuals, but do not call for all nurses to be subjected to a federal investigation “that includes members from other health care professions such as nurses aides, respiratory therapy, and pharmacy in order to do away with the good old girl culture that is more interested in protecting bad nurses than protecting patients.”
    If you know these events happened as you claimed, you should have had the courage to report them. Not doing so was your failure to live up to the responsibilities of your profession. It is impossible to know if the motivation to transfer a patient was purely financial or if the patient would be better cared for at a different facility w/ more resources. Likewise, hard to know exactly why a MD picked up a particular chart at a particular time was or whether the patient needed the GB surgery and was expedited by coming to the ED. Your assertions that this was only for money are only one plausible explanation for these events. If you don’t KNOW this but just suspect it, you should get the proof or keep your suspicions to yourself.

  • Panacea

    F Scott:

    It’s not that I was biased or leaving anything out.

    The subject at hand was the medical profession, not the nursing profession. I agree, there are plenty of unethical nurses who’ve done all the of the things you’ve cited. I call them on it, when I see it.

    Reality was claiming that the medical profession was among the most ethical, and it just ain’t so.

    As for reporting things; what makes you think I haven’t? :)

    The surgeon playing games with Medi Cal suddenly discovered that I was writing detailed notes of patient statements when I triaged them; everything I wrote was true, but it made what he was doing stick out like a sore thumb. Suddenly, it stopped. When a gb patient comes to the ER specifically believing he is scheduled for surgery, but is in no pain, and I see a string of these patients in the ED all claiming the same surgeon has scheduled their surgery, then it is pretty clear what is going on.

    Could I prove it in court? Probably not. But when my charting changed the behavior, it became pretty clear my beliefs were on the money.

    I called in the nursing supervisor for the OB refusing to attend the hidden laceration; when he still refused, I told him I was calling the Chief of Staff. Next thing I know, he’s calling up to send the pt to an exam room and to have a suture setup ready.

    Same for the surgeon trying to illegally transfer the guy with necrotizing fasciatis.

    And I complained about the cherry picking in the ER. I knew it was going on because patients are supposed to be seen in order of priority. When a higher priority patient with no insurance or Medicaid is ignored in favor of a low priority one with BCBS, then I know cherry picking is going on.

    I lost a job because I reported a nurse for having a sexual relationship with an inmate trustee in the prison infirmary. I was also blackballed in a two county area as a result. Being a whistleblower carries a high price, and I’ve paid it more than once.

    Thanks for playing ;)

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