I am called before the inquisition board: Welcome to modern medicine

Today I had the displeasure of sitting in judgment before a modern inquisition at one of the hospitals I attend. Although the grand inquisitor lacked the trappings of a monsignor or bishop, and without a physical executioner in the room, I was subjected to  round after round of questions regarding my apparent disregard for system wide medical and post surgical protocols. Such protocols have been adopted by CMS (which oversees Medicare) and a large amount of money is tied to their proper implementation.

There are protocols pertaining to prevention of venous thromboembolism (VTE), antibiotic use in surgical patients, removal of urinary catheters along with a few others which rarely are an issue for me. The principal point of concern for the Inquisitors was my use (or apparent lack of use) of pharmacologic agents for VTE prophylaxis. Specifically, I had not used Lovenox in 3 patients who had undergone major surgical procedures.

One of the patients had a re-do open hiatal hernia repair with a tiny nick in the spleen, another was an elderly lady with a complex medical history and carcinoma of the colon who underwent a laparoscopic right colon resection and the third had exploratory laparotomy for a small bowel perforation with generalized peritonitis and systemic sepsis four days after laparoscopic hysterectomy. In each of these cases I determined that there was more than the usual risk for bleeding and that anticoagulation, even with low dose Lovenox, increased this risk. Each patient was treated with sequential compression devices (SCDs) and none developed a deep venous thrombosis (DVT) or any other complication.

Before going before the inquisition I reviewed some of the literature on VTE prophylaxis in the general surgery patient. The incidence of DVT in this population is reported to be in the range of 6-7% without any prophylaxis. Using sequential compression devices alone reduces the incidence to about 3% and pharmacologic prophylaxis with subcutaneous Lovenox, heparin or something similar reduces it to around 1%. The tradeoff with the anticoagulants is an increased incidence of bleeding complications. In each of the three cases cited I made a medical decision to accept a slightly higher risk of developing a DVT while minimizing the possibility of post-operative bleeding.

At this point I should point out that I cannot remember the last time I had a patient develop a DVT. My standard approach to DVT prevention is to use sequential compression devices on nearly all my patients intraoperatively and post operatively. Pharmacologic agents are used whenever the risk is acceptable. Aggressive early ambulation is also employed. The last DVT I can recall was in a patient who had an uneventful laparoscopic cholecystectomy with a surgery time of about thirty minutes, discharge on the same day as the procedure, but readmission five days later with a DVT which involved the superficial femoral vein, but did not extend to the common femoral or iliac veins. This patient would not have needed any VTE prophylaxis under the current protocol, although he was treated with SCD’s during surgery.

Armed with my research I entered the arena to face a grim panel of inquisitors. Memories of my fraternity initiation passed through my mind as I took my seat near the head table.

“Do you have anything to say about the cases under review before judgment is passed?” the grand inquisitor queried. I must add that the “committee” had reviewed the cases under question the previous month, in my absence (I was unable to go to the meeting because I was in surgery). It was only after I protested their arbitrary ratings, particularly a level 4 (worst rating possible) for the patient with peritonitis and small bowel perforation, that the chairman of the committee invited me to address the eminent council.

“Yes, your eminence” I started. “I take great exception to your scoring, particularly on the first case …” I then went through each case and explained my reasoning behind the medical decisions which were made.

“You are living dangerously,” the grand inquisitor admonished.

“You’re careening down the highway out of control and will undoubtedly crash,” counseled another inquisitor. “Patients must have Lovenox or they are doomed … doomed.”

“It is heresy and blasphemy,” shouted the grand inquisitor, pounding his fist on the table and tearing his clothes. (Not really, but it would not have surprised me if these words had been uttered.)

I don’t know what the outcome of this inquisition will be. I’m sure a certified letter will arrive in the near future and I will be commanded to do 10 hours of penance by taking some sort of CME in surgical care improvement project (SCIP) and write “I will use Lovenox” a thousand times on a blackboard as part of SCIP detention.

But should it be that way? Shouldn’t I, as surgeon on a case, be the best individual to decide the risks and benefits of each therapeutic intervention, particularly in the immediate postoperative time period? It should come down to judgment, weighing the risk of bleeding relative to the risk of DVT or pulmonary embolus for each particular patient.

“Which would you rather have, bleeding or pulmonary embolus?” was one of the questions I was asked.

Of course, the answer is neither. But, it was presented as if it had to be one or the other, a flawed statement according to the laws of logic, but that is a whole different subject.

And, if my judgment regarding the risks of different therapies is not necessary, then why do my Medical consultants constantly write orders such as “Lovenox 40 mg SQ daily, if OK with Dr. Gelber?”

And, in the bigger picture, why am I chastised for attending to a very ill, septic, complicated patient on a Saturday afternoon, operating on her, and saving her life?

I have nothing against pharmacologic anticoagulants. The committee cited three cases out of hundreds of surgeries I had performed at that facility over the months. The cases “fell out”. All three were fairly complex cases. Certainly, in the myriad other operations I have performed I have ordered Lovenox when appropriate.

I know the answer to the questions I raise above. The answer is money. These “core measures” are tied to Medicare reimbursement. If the hospital is not compliant then it loses money. Thus, the nursing staff lives in terror lest one of them forget to contact the doctor to have him or her comply. Excellent nurses have been fired for failure to make such calls; three strikes and you’re out. Pharmacists have taken it upon themselves to discontinue antibiotics in septic patients because they are “SCIP patients.” I know of two such incidents which occurred in a span of 2 weeks, both patients suffering.

And I am called before the inquisition board to explain my heresy. Welcome to modern medicine.

Only ten years until I can retire.

David Gelber is a general and vascular surgeon who blogs at Heard in the OR and author of Behind the Mask.

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  • trinu

    This is the problem with “voluntary guidelines”; the treat them as if they are neither voluntary nor guidelines.

  • Jonathan

    Ridiculous! Good luck.

  • morebuzzkills

    Almost all politicians (as well as a select few posters on this blog) will lead you to believe that medicine can be reduced to algorithms. Critical thinking and decisive action are skills that most physicians would agree are fundamental to the effective practice of medicine. Unfortunately, these skills cannot be programmed into an algorithm. Instead of recognizing this, lawmakers chose to ignore it for the sake of convenience. It also has the added benefit of hijacking the autonomy of the physician that dares to buck the algorithm. As a result, physicians will jump ship as quickly as possible…whether it is early retirement, cash-based practices, or only accepting select types of insurance. The “have-nots” will be the ultimate losers, which is extremely upsetting. I find it kind of ironic that these policies were supposed to help those without proper access to health services. Our beloved lawmakers completely neglected the supply side of the equation…creating a massive exodus of baby-boomer physicians, which happen to be the most productive docs in the health care system. I’m sure the hardworking baby-boomers will feel extremely comfortable in the “hyper-productive” hands of Generation Y.

    • http://twitter.com/DavidGelberMD David Gelber MD

      I sometimes dream about giving it all up. the problem, however, is that I really like taking care of patients and I think I’m pretty good at it. the bureaucrats haven’t beaten me down yet. I think Paul Newman in “Cool Hand Luke” said something similar.

      • buzzkillerjsmith

        Here’s the analysis: What is the supply/demand situation for vascular surgeons in your area (by the way, you and people like you operate on very ill people in the middle of the night and few realize that you all are among our best physicians)? If it is in your favor, do what you want. If it is not in your favor and you like the area, you might have to reel in it a bit.

        A second consideration is the supply/demand situation in other areas where you might like to live. If it is in your favor, well, you know.

        A third consideration is whether you have the money to just walk away. If so, let ‘er rip.

        I like to piss off hospitals and corporate entities as a matter of principle, if pt care does not suffer, of course. I have to restrain myself from assaulting people who wear ties. But I digress… In any case, keep up the good work, doc.

        Dr. Dike Drummund had an excellent post at this blog on how to be a disruptive physician. Worth a read.

    • James deMaine

      As far as I can tell, the guidelines used by the “inquisitors” are established by doctors – not simply lawmakers. A friend aged 52 recently died from a massive PE a week post knee replacement. I don’t know the details of anticoagulant use, but there is a reason for the guidelines. It’s a pain to defend ones work in saving lives, but in the large scheme, more lives may be saved if guidelines are followed – and reasoning must be well documented when not. The golden age of doctor saying “well, in my experience”, now meets the age of evidence based medicine.

      • morebuzzkills

        I am very sorry to hear that you lost a friend. I certainly wasn’t suggesting an abandoning of evidence based medicine. I was referring to the fact that lawmakers are trying make medicine one giant algorithm. Unfortunately, people misinterpret guidelines to be guidelaws. Anticoagulant use, just like every single other pharmacological treatment, requires a risk-benefit analysis by the prescribing physician. In the author’s case, the risk of bleeding secondary to anticoagulant use outweighed the potential anticoagulant benefit. Furthermore, he initiated an anticoagulant treatment that was shown to be almost as efficacious as anticoagulant pharmacotherapy. This is called clinical judgement. If the author (as well as any physician) has to go before a panel to defend his/her use of clinical judgement, we are going to have a giant group of burnt out physicians.

        As an aside, the evidence based medicine picture for anticoagulant use is somewhat hazy. As it turns out, there is a significant portion of the population that has single nucleotide polymorphisms that alter the way many anticoagulant treatments are metabolized in certain individuals. This can result in drastic consequences. The point is that a one-size-fits all approach to anything in medicine, especially anticoagulant use, is short-sighted. Again, I am very sorry that you lost a friend who likely would have benefited from anticoagulant prophylaxis (but I can’t comment further because I am not familiar with the case). However, slapping on an anticoagulant-for-all requirement will lead to more problems than existed in the first place.

      • http://twitter.com/DavidGelberMD David Gelber MD

        The guidelines were not ignored in any of the cases. The patients were treated appropriately in each case. There has to be room for judgment or medicine will descend to a level of universal mediocrity.

        • morebuzzkills

          WELL SAID! KEEP FIGHTING THE GOOD FIGHT!

          • meyati

            My poor PCP has been called in by the HMO pharmacy board, because I’m allergic to cough OTC syrup and acetaphetamine I use Armour thyroid-which makes OTC respiratory meds dangerous because of their pseudoephedrine and sudafed. The jerks even wrote me letters saying that I have to stop using Armour-they seem to think that my PCP and I are stuck in a 1940 time warp, and they warned my doctor about it. I wrote them back- They finally decided that I can pay for it myself-and they’ll leave us alone. The pharmacy was complaining to the HMO that I should use OTC instead of antihistamines. The difference is that I spend about $6 for 90 days-compared to the pharmacy getting $45 a month for OTC. The HMO reached out to pharmacies to save a few bucks. Well, the HMO changed its mind after I had a few ER visits because of my reactions to the meds. I went in to my pharmacy and asked them if they liked money upfront or preferred waiting for the HMO to pay them? and as long as my PCP wasn’t doing anything illegal-they didn’t have any business interfering. It was between me and my doctor.
            Considering what my PCP has gone through, I can only imagine what a surgeon goes through-sometimes-it’s not about the laws- but mindless bureaucrats that have deals with big pharma and even pharmacy outlets. It sounds like the surgeon practiced medicine at the best. My brother is a bleeder that needed dental work and surgery. He was turned down until he ran into an old DO that recommended this type of surgery procedure. My brother has safely gotten through everything.

      • azmd

        With all due respect, and with condolences for the untimely loss of your friend, I must say that your comment brilliantly illustrates how we got to where we are in medicine.

        “I don’t know the details of anticoagulant use” (but I am very, very sure that there should be guidelines and that this doctor is rightfully in hot water for doing whatever he did).

      • http://www.doctordinusha.info/ Dinusha Sirisena

        Yes, the guidelines are established by consultants using the “available” evidence at the time. And those evidence need to be metanalysed and also those evidences would not be considering all the variables. I trust in your point that “in my experience” kind of statement is out dated. And “guidelines” are not set in stone. The attending has the right to decide on the the risk vs benefit, regarding the use of pharmacological anticoags. A guideline would a be a shot gun approach, one must contemplate on following to avoid falling to to legal troubles. But the attending would be using a sniper, that is tailor made to the patient. This is because the patient in front of you needs specific care. Not that algorithm in the board. When thinking about all the variables, you might be pushed to do an action which may be forbidden in the guidelines.(Again due to the lack of variables in the study that we would quote)

      • PoliticallyIncorrectMD

        Some doctors (groups of doctors) have their own agenda. Unfortunately the reason for many guidelines (which are frequently “expert consensus” and are not based on any hard evidence) is to create an illusion of safety in the public’s eye. In addition they create a comfort zone for those of us who wold like to practice medicine while avoiding making any decisions.

      • Sam Moskowitz

        Thou shalt respect guidelines.
        Thou shalt not be subservient to guidelines.

    • Lori

      Think Kaiser, Recipe (algorithm) for every care. You don’t have to think

  • Guest

    SCARY. I will do anything I can to avoid being a patient.

  • Seiha Kim

    What the inquisitors fail to understand is that you do not have to give every patient lovenox. If you document something to the extent of “no pharmacologic VTE prophylaxis due to bleed risk” in the progress notes, cases will not fall out. Hope this helps.

    • http://twitter.com/DavidGelberMD David Gelber MD

      Actually,it was documented, but not in the computer on their “VTE Analyzer”.. Even if it was a documentation issue, the cases should never had merited level 3 or 4 variances.

      • Guest

        So, the next question is did you piss someone off in administration or not play nicely? At my hospital physicians that are too “troublesome” get targeted like this and hauled in front of committees, usually with benign indications.

      • E Summers

        How much of an issue is the computer programming – database setup forcing documentation into black and white data accessible answers rather than the true multitude of “shades of grey and colors” representing the diverse presentations of patients and their complex situations?

  • John Henry

    you do realize none of this would have occurred had you written in the record ” Use of Lovenox preoperatively as a DVT prophylaxis was considered but determined under the circumstances and for this patient to present an unacceptable risk of intraoperative and post-operative hemorrhage and sequelae. Alternative anti-thrombotic therapies will be deployed.”

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      so the grand tribunal was convened because of failure to make explicit notes, not failure to provide proper treatment. Shouldn’t they just sent a secretary over with a note to that effect, or something like that?

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Our hospital VTE protocal on the CPOE system gives us the choice of opting out of using an injectable or oral anticoagulant if there is a risk of bleeding or ongoing bleeding. I suspect the author had a similar choice and executed it as well as noting the reason for opting out in the chart. The ” Frank Burns MD” of the world are running the show today and are coming down hard on independent patient advocates and excellent docs like the author.

    • http://twitter.com/DavidGelberMD David Gelber MD

      The problem with the computer VTE protocol is that it only allows opting out for documented chronic coagulopathies or active bleeding. No surgeon is going to finish an operation while there is active bleeding. The cases in question all had more than the usual risk for post operative bleeding. There is no spot in the computerized protocol for this particular risk.

      • azmd

        The problem with these computerized guideline protocols is that for complex clinical decision-making, like VTE prophylaxis, the order set is rarely precise enough for someone who is doing any sort of critical thinking about their patients. Also, communication about the protocols tends to be sloppy. At our hospital, the VTE order set was recently revised to force either mechanical prophylaxis, or pharmacological, unless there is a bleeding diathesis of some sort. But it includes no pathways to provide prophylaxis to the occasional behavioral health patient, some of whom do need prophylaxis, or to avoid prophylaxis for the rest. Instead, we are told by the CMIO that “the protocol does not apply to behavioral health providers,” which would be somewhat OK, except that we still get the annoying q 3 second prompt for VTE orders when admitting a patient. So the whole protocol is useless for my patients but still included in our order sets but we are apparently just supposed to ignore it, which is super-annoying since I am a big proponent of VTE prophylaxis for our population. It also puts us at risk for liability in the case of a VTE in one of our patients since I’m pretty sure ignoring all those prompts would be hard to explain during a lawsuit. However, I know at this stage of the game that saying something to the CMIO would only get me in hot water.

  • Marc Friedman

    These patients are so jacked up on anticoagulants that is is nearly impossible to perform any kind of regional anesthetic block despite the clear benefits of regional. The industrial approach to medical decisions are just perfect for the nodoc approach to medical care and decision making. The most effort is applied to the least rewarding quality improvement. When I hear “evidence based medicine” …I run for cover. Warning warning…incompetence at 12:00.

  • buzzkillerjsmith

    Fair enough.

  • Jack Robertson

    I have run into the same experiences as the author. I believe that he is correct in his assesment of the situation , i.e. that it is purely based on money. I also believe that any physician who is willing to treat each patient individually and tailor their care to their specific problems will not fit in what has become “the system” I advocate that those of us who wish to practice medicine capture that name and split off from the bean counters and bureaucrats. We allow them to in the future not use the word, medicine, but let them proceed with the practice of “Dollarcine”. Their signs on their facilities would have to be changed from ( as example) Northcrest Medical Center , to Northcrest Dollar Center. The insurance companies will gladly follow the path of “dollarcine” but maybe a few patients will opt for medicine as it was meant to be practiced.

  • retired RN

    Please don’t give up the good fight. Each patient should be treated as the individuals they are. We can have a similar diagnosis but varying histories. Come on doctors, administrators and others, stand up for your patients and the AMA should fight for us too. I know it is all about money but we are losing our way….

  • http://twitter.com/TPane1 Thomas Pane

    Consider the potential complications and the odds of what could happen in either scenario: No Lovenox -> small chance for DVT, smaller chance for massive PE. Lovenox -> small chance for modest bleeding complication, smaller (probably much smaller) chance of massive bleeding complication. The protocol authors likely base this on the massive PE risk being higher than the massive bleeding risk. My estimation is that is correct.

    A fatal outcome is low risk in either situation, but probably more likely in the event of a massive PE than it would be with a bleeding complication. However, there should be an allowance for clinical judgment to be implemented and alter the protocol, because the patient populations may not be the same in practice as those which were used to generate the recommendations.

    • http://twitter.com/DavidGelberMD David Gelber MD

      In this case an intrabdominal bleeding complication almost certainly would have led to an intrabdominal abscess with the potential for serious, life threatening sepsis. Patients with severe intraabdominal sepsis like the patient cited often have a low grade DIC. My choice to use only mechanical prophylaxis with sequential compression devices was, in my opinion the proper one; still providing VTE prophylaxis, while minimizing the potential for a bleeding complication.

  • drjoekosterich

    Yes we all must bow before the gods pf protocols. Who cares whether an individual patient has individual needs? Not governments.

  • http://twitter.com/JJenningsRN Jackie Jennings

    That’s ridiculous. As a nurse I’ve been increasingly discouraged by these types of things…the politics of health care. However, I am extremely encouraged by your persistence in speaking out about it! Thank you for sharing this.