WhiteCoat

Why I’m A Bad Doctor – Part 2

Better Be Prompt!It isn’t just the patients who think I’m a bad doctor.

Based on the information from all the pinheads at Medicare’s “HospitalCompare” web site, I’m downright dangerous.

For those who don’t know about Hospital Compare, it is a site where the general public can compare the “quality indicators” for hospitals on measures deemed important by the AHRQ.

I failed to meet a couple of indicators recently, so I received notices from our hospital administration that I am now considered out of compliance with the HospitalCompare guidelines and am bringing down our numbers on the HospitalCompare.gov web site.

In other words, Medicare thinks I’m a bad doctor.

Let me tell you about the patients I screwed up on.

The first patient was a gentleman in his 70’s who started having chest pain at home. He got sweaty, passed out, and hit his head on the concrete floor in his house, causing a nice goose egg on the back of his noggin. When he arrived in the emergency department, he was still having chest pain, so we hooked him up to an EKG and … lo and behold … he was having a myocardial infarction.

According to the quality indicators at “HospitalCompare”, if a patient with a heart attack is going to receive thrombolytics (“clot busters”), the thrombolytics must be given within 30 minutes of the patient’s arrival at the hospital. If a health care provider takes longer than 30 minutes to administer thrombolytics to someone with a heart attack, the government considers that provider to be practicing bad medicine.

Now I’m faced with a choice:
A. Do I give clot busters to someone who sustained a significant head injury (and may be bleeding internally) so that I can look like a “good doctor” to Medicare and HospitalCompare.hhs.gov? If there is bleeding inside his brain, clot buster medications will make the bleeding worse and could kill him.
-OR-
B. Do I perform a CT scan on the patient to make sure that there is no bleeding inside his brain before I give the clot-buster medications? If I do the CT scan, there is no way that we’ll get the results and be able to give the patient thrombolytics within the 30 minute window.

If I choose “A,” the hospital stays in the upper echelon of facilities that meet HospitalCompare.hhs.gov‘s guidelines. Doesn’t matter if the patient dies – according to Medicare, “We’re Number ONE!”
If I choose “B” I’m doing what is right for the patient, but our hospital will look bad and HospitalCompare.hhs.gov will plaster it all over the internet that our hospital doesn’t follow Medicare’s rigid and sometimes life-threatening guidelines.
I chose “B.”
According to HospitalCompare.hhs.gov, my decision made me a bad doctor.

The second patient was an elderly lady who came to the hospital with leg pain and weakness. She was in a lot of pain. We did some testing and she ended up having a blown disc in her back that was pressing on a nerve root. She was admitted and had surgery. Five days after she was admitted, she ended up having a heart attack while she was recuperating on the medical floor.

According to the quality indicators at “HospitalCompare”, if a patient has a heart attack and does not have contraindications to receiving aspirin or beta blockers, the patient must receive aspirin and beta blockers within 24 hours of their arrival in the hospital.

The brainiacs at Medicare who run this HospitalCompare site expect that I put on my Amazing Kreskin glasses, bust out the crystal ball, and predict with 100% certainty which patients I admit will later have a heart attack while in the hospital. A patient might get admitted for an infected hangnail. If the patient later has a heart attack and I didn’t give aspirin and beta blockers or document a contraindication to those medications, CMS considers me a bad doctor.

(Note: The “beta blocker on arrival” metric has since been dropped from the list of current measures – the first of several indicators that CMS apparently is admitting it was wrong about. However, the aspirin on arrival metric still exists and is calculated in the same retrospective fashion)

By looking out for my patients and by failing to be a prophet, I’m a bad doctor.

So be it.

Add these to the reasons why so many doctors and nurses are getting fed up and leaving medicine … at a time when more doctors and nurses are needed to care for sick Americans.

If you believe all of the information on the HospitalCompare.hhs.gov web site, you deserve what happens to you.

Maybe you’ll get lucky and have a “good” doctor who treats your heart attack and head injury the “right way”.

40 Responses to “Why I’m A Bad Doctor – Part 2”

  1. What if we just ignore this bureaucratic stuff and take good care of patients?

  2. ERP says:

    I got dinged once back when Beta blockers where required for all STEMI’s because I did not give it when the patient had heart rate of 55. Turns out to avoid being a “bad” doctor, I had to document the obvious. “No Betablocker given due to bradycardia”. Duh.

  3. igloodoc says:

    And this is how the hhs cocktail came to be. For any symptom between the nose and the belly button you get nurse K to administer asprin, nitro, beta blocker, morphine, zofran to counter the nausea of the morphine, iv fluids to counter the beta blocker and nitro, and zithromycin (you can’t miss the 4 hr door to antibiotic pneumonia metric) and if Nurse K is feeling spunky, a GI cocktail just to cover the bases… in triage. Then you do an ecg and chest xray.
    You may miss a lot, especially in the pediatric crowd and 9 year old children really hate the nitro, though. And Nurse K is probably gonna write you up in her blog. , but you will hit almost every hhs metric in the hhs universe.

  4. hashmd says:

    I am the Utilization Management Chairperson at our little hospital. Our Quality Management Dept., who collects the data on these types of metrics, actually looks at these cases that “fell out” of the initial screen.

    The review nurse forwards the case to a Peer Review MD. If the MD sees what you describe, or you clearly document (for a non-MD reviewer) the reasons why you didn’t give TNK or the beta blocker, we DON’T count the case as being out of compliance!

    Only then do we submit the numbers to CMS which then goes on the web. CMS allows this.

    Even with our “scrubbing” of the data, we still have an elevated mortality rate for death after MI or pneumonia so we obviously are honest enough when we report our data.

    Our hospital is small enough that just 1 extra death per month in those catagories changes our percentage death rate by 5-10%!!!

    You need to argue with the people who review for these “guidelines” in your hospital that you should be notified when such a case appears so you can review it, point out exactly what you pointed out, and then get it removed from the data for your hospital BEFORE it goes out, not after.

    Yes, more hassle for you. But you’ll then remember to document for the lowest common denominator reviewer next time.

    • WhiteCoat says:

      I’ve tried to argue with the case reviewers, but they don’t have the medical background to debate the issue. The guidelines are black and white and not subject to interpretation in their books.
      If we’re allowed to make “exceptions” for medical judgment, then the whole system is useless. GIGO as Scalpel says.

  5. Nurse K says:

    Then you do an ecg and chest xray.

    Um….DUHHHR, Nurse K does the EKG first and only if your story sounds good. I want you to go buh-bye cath lab asap. That’s the only way to dispo someone in under 7 hours in my ER. That, I guess, or have the patient see Dr. Bloody Gloves where they’re celestially discharged in all likelihood.

    PS If I ACCIDENTALLY give the antibiotic AFTER the unnecessary blood cultures x 2 for pneumonia without charting the phrase “antibiotics given after blood cultures drawn” and the times on the blood cultures and antibiotics are close, then I get nasty-grams in the mail. FU chart revieweurs.

  6. cynic says:

    WC, even with a negative CT would you have given the TNK ? I would be reluctant in a 70 y/o.

    hashmd, why is it that WC or ERP should have to jump through hoops to demonstrate the obvious? I could have our ED Unit Secretary do a better audit than these “UR boards”. What is wrong with this picture?

    • WhiteCoat says:

      Would have and did.
      Trauma is a relative contraindication for thrombolytics and to me, the risk of him dying from a bleed with a normal head CT is a lot less than him dying from the tombstones on his EKG.
      Fortunately for me, he did fine.

  7. I work on a floor with primarily the elderly in a hospital setting and post cardiac events, a lot of medication decisions are based on their hx of falling (asa instead of coumadin for chronic rate controlled afib) do these docs get dinged too?

  8. […] complexity associated with doing the right thing for patients. Here is an excerpt from the WhiteCoat’s Call Room blog that perfectly illustrates why practicing good medicine often requires a break from […]

  9. hashmd says:

    Cynic,

    If you jump through the hoops enough times, maybe you figure out that adding the statement in your documentation “Beta blocker contraindicated in a patient with a heart rate of 50″ or “the risks of TNK are high in an elderly with direct head trauma and therefore relatively contraindicated”.

    Yes, it is stupid. But the simple addition of those lines in your documentation saves you all the hassle and justifies your decision to the Joint or any other reviewer. You have to assume they are 8th grade intelligence. (That’s the level of reading skill they take when they read a chart!) That way, even a non-medical or unrelated specialty reviewer can clearly see your thought process. They don’t have to assume it.

    • WhiteCoat says:

      I’m not willing to write “beta blockers and aspirin not indicated because no evidence of acute MI in the ED” on every patient I admit that doesn’t have an acute MI just because that is the only way for some AHRQ and CMS pinheads to figure out what medical care is and is not appropriate.
      If I had to document why I didn’t provide unrelated care, I’d only see one patient a day.
      No splint placed because no evidence of broken bones
      No needle stuck in throat because no sign of peritonsillar abscess
      No chest tube inserted because no hemothorax present
      Et cetera
      Et cetera
      And so on

  10. Interesting stories on quality improvement guidelines and their implementation. Patients and decisions don’t always fit neatly into databases.

    As hashmd suggests, you could add notes to your documentation. Hopefully, that would be read by humans at your institution, but it probably won’t help your standing with those big databases in the sky.

    Pamela Powers
    Managing Editor

  11. hashmd is an intriquing name…do you practice in california? as for the additional documentation, I’m sure white coat is pleased to hear such a simple solution…let’s just surgically attach the keyboard to his hands or the dictation phone to his ears…that way he can do his justification addendums and CPR at the same time.

  12. hashmd says:

    WC has to document sometime after seeing his patients. I have to as well. He doesn’t document while he is coding someone.

    Years ago doctors could write 3 line office notes and get paid. Now I have to generate 2 page documents just to justify a “simple” office visit. The same for WC and every other doctor. Thats why we grumble about “just adding another line”. Absolutely no improvement in the QUALITY of the care delivered, just a huge pile more documentation of such care just when we have less time to deliver that care.

    Yes, I do happen to practice in CA. The pen name is shortened; it is not short for hashish either (although college friends called me that for no reason whatsoever).

  13. it was a joke hashmd (do love that monikor)..I’m just a lowly floor nurse but I do get “it”…everybody is going deaf from the more documentation mantra. cookie cutter one size fits all medicine…too bad the patients won’t cooperate. :)

  14. hashmd says:

    Can’t always tell. Non-medical people write to this blog as well.

    Floor nurses are not lowly in my eyes. They are the last bastion of defense between the chaos and the patient in a hospital. Who spends more time with a hospitalized patient, me or you? You do. By far.

    As a PCP, all I do is make your life hell and you have to bail my rear end out when the patient gets sicker. As the UM Chair, all I do is make you document more so the hospital justifies the care delivered OR I just make you “do it faster” so we can get the patient out sooner.

    No win, heh?

  15. k says:

    So how much are we paying in taxes for HHS’s version of Angie’s List (Hospital Edition)? Jeez.

      • k says:

        (To the tune of the Dragnet TV show theme): Dumb da dumb dumb!

        Throw out Hospital Compare and give Medicare recipients subscriptions to Angie’s List – they’d probably negotiate a bulk discount. Cut costs and eliminate BS rules in one swoop.

        @defendUSA – This is the thing that will be happening with UHC. You’ll have people with no real background deciding who will be treated for what disease.

        Happens already – who do you think is sitting in all of those insurance company call centers telling patients ‘you can’t have that’ and physicians ‘we don’t pay for that’? Nothing to do with UHC, everything to do with bottom line.

  16. cynic says:

    “You have to assume they are 8th grade intelligence. ”

    Therefore, they should assume being 8th graders, that the doctor had his reason for not beta blocking the patient. This is where the problem lies, you are not evaluated by peers..

    I could go on for days about this, but we all know the lowest denominator is the dumbing down of this country and the way medicine is practiced.

    • k says:

      And if my recent experience on jury duty is an indication of the overall process, it will never be possible for a physician to have a jury of his peers in a malpractice trial.

  17. Rogue Medic says:

    If we’re allowed to make “exceptions” for medical judgment, then the whole system is useless.

    And

    If you jump through the hoops enough times, maybe you figure out that adding the statement in your documentation “Beta blocker contraindicated in a patient with a heart rate of 50″ or “the risks of TNK are high in an elderly with direct head trauma and therefore relatively contraindicated”.

    Yes, it is stupid. But the simple addition of those lines in your documentation saves you all the hassle and justifies your decision to the Joint or any other reviewer. You have to assume they are 8th grade intelligence. (That’s the level of reading skill they take when they read a chart!) That way, even a non-medical or unrelated specialty reviewer can clearly see your thought process. They don’t have to assume it.

    HashMD,

    Doesn’t the statement, Yes, it is stupid, make the point of this post?

    We have doctors making patient care decisions. The people reviewing these decisions are not remotely qualified to review these decisions. This quality-oriented decision, to use morons to review medical decisions, comes from the people deciding what quality is.

    Isn’t it clear that the bigger quality problem is in the organizations reviewing quality?

    Why should an emergency physician document the reasons for not giving inappropriate care? So some medically naive pencil pusher can decide when the doctor is bad? That is irresponsible.

    Any emergency physician, looking at these charts, would recognize the obvious contraindications to standard treatment. Maybe one of the reasons there are no qualified physicians to review charts is that they are too busy documenting why they did not kill their patients, just to satisfy JCAHO/TJC.

    Then there is Press Ganey. Hospitals are so enamored of their ratings that they want the doctors to cater to the whim of any crackpot, who comes in with an old wives tale treatment recommendation. Don’t treat what the patient has. Treat what the witch doctor just knows the patient has. We should just put antibiotics in the water supply to satisfy the customers.

    Quality is a problem in medicine, but going behind a screen to pull levers to make fire and smoke and noise, will not improve patient safety. This will only distract from real quality improvement.

    Yes, it is stupid.

    Banks do not take risks with their money, because they have risk analysts. These are people, who just put a bunch of numbers into computers, but do not understand the derivatives being traded by their traders. That worked very well for them. Maybe medicine will follow the housing, insurance, banking, . . . disasters.

    Yes, it is stupid.

    Exactly the reason to change it.

    Even better – eliminate it.

  18. cynic says:

    Well said Rogue.

  19. defendUSA says:

    I published a comment here. It seems to be missing…Do you need to be a member or something?
    I can try again.
    I have issues with the protocols and the so-called governing bodies of care. The limitations on the physician to treat the immediate problems of the patient become restricted if some rules exist that override each other. These are not medically trained people. It frosts me, frankly. Like WC points out- you cannot discuss anything of merit, they don’t get it. Yet the doc takes the licks for “bad medicine?”

    This is the thing that will be happening if we end up with UHC. You’ll have people with no real background deciding who will get treated for what disease. Subjective at best. I don’t agree with that. It becomes not about the patient, but what is cost effective. Like is a 3 time cancer patient worthy of more treatment? Or should they tell her nope and send her to the hospital version of a concentration camp to die?

  20. Mottsapplesauce says:

    Whitecoat, this sort of thinking is what’s happening to many funding sources. One in particular that I have to contend with doesn’t even use licensed professionals (i.e. clinicians) to oversee their ‘authorization department’. I can’t believe these people are involved in making decisions about a policyholder’s plan of care. I think it’s a lawsuit in the making…..

  21. anon says:

    for a bureaucrat process is eveything, outcome is nothing

    • FooFighter says:

      Bravo! Never a truer word spoken. Another variant is “In a bureaucracy, all work achieved is simply a by product of repeated delegation”

  22. anon says:

    “This is the thing that will be happening if we end up with UHC. You’ll have people with no real background deciding who will get treated for what disease.”

    Hell, we have that already! Insurance company paper-pushers decide what tests and treatments are permitted or not permitted, and the patient’s health needs be damned! Since when are unlicensed non-medical professionals allowed to effectively practice medicine???

    I went several rounds with an insurance company almost 20 years ago – had two different doctors saying yes, I needed surgery. The insurance buffoons said no, not necessary in their response letters. So I called the company and was told that my case didn’t fit the criteria, so no authorization and no pay-out if I went ahead and had the procedure. I asked what were the criteria? I don’t know. A committee makes those decisions; they know what they are. OK, can I talk to one of the committee members? NO. Nobody gets to talk to them!

    What they didn’t count on were my being blessed with two wonderful doctors who wouldn’t tolerate having their patients’ care dictated by desk jockeys, and weren’t afraid of a fight. Thanks to them, the company finally caved in.

  23. […] blog under the headline: “How following hospital quality measures can kill patients.” Whitecoat’s complaint is that HospitalCompare.hhs.gov has labeled him “downright dangerous”. Kevin sums up […]

  24. […] quality measures can make or break a hospital’s reputation, especially if they are being widely advertised. […]

  25. E Collemo says:

    It’s the first time I comment here and I should say that you provide us genuine, and quality information for bloggers! Great job.

  26. […] of misguided guidelines that were supposed to increase quality, but ended up hurting patients (a good example was given by ER physician White Coat).  So how can quality be encouraged without causing these […]

  27. […] However, the government does plan to establish a “quality reporting initiative” for end of life care that will essentially coerce physicians into doing what the government wants under the threat of being deemed a “low quality provider” if the physician does not comply. If the government states that “quality care” for end of life involves removing life support on patients that show no improvement after 72 hours, any physician that keeps comatose patients on life support longer than 72 hours will get quality “demerits” from the government. The government may then use those demerits to dock the physician’s pay or to post the physician’s name as providing “low quality” end of life care on some web site. Think about a tremendous database of physicians similar to the “HospitalCompare.gov” web site now. Because of Hospital Compare, hospital administrators strive to be at 100% “quality” even though “good” care may sometimes cause excessive costs without benefit, may be more likely to misdiagnoses and wrong treatments (I commented on this issue previously and the link to the actual article on a government website mysteriously went bad), or may even be more likely to contribute to patient deaths. […]

  28. teachme says:

    Hey, sounds like you medical professionals are getting the same deal teachers got years ago! The administration devises the standards and metrics, then you get to adjust your lesson plans to cover the metrics. Soon, you spend more time trying to please the metrics than teaching the kids. This started in schools 20 years ago – how’s those student test scores looking now? Expect your patients’ health to look just as dismal 20 years from now.
    As far as adding additional documentation, I assume you do your notes on a computer. Take the time to write all those standard phrases and keep it on your desktop. That way you just have to cut and paste the appropriate phrases. Yes, it still takes time, but not as much as typing it all out each time.

  29. Sue says:

    Bravo for speaking out and shedding some light on the fallacies of Medicare “law”.

    I wish I had a doctor that paid more attention to individual issues like you do. Instead, I am labelled as a hypochondriac with fibromyalgia. Trouble is, the symptoms aren’t specific to fibro and I feel as if they are tired of seeing me and are shoving me out the door with any diagnosis just so they can say they did something to help me. I could cry right now. I’ve had it with the doctors group in my area and can’t afford to travel to get a second opinion.

    Oh, and let’s not forget the six years I didn’t have health insurance, couldn’t afford private insurance, and my state no longer offers adult coverage due to budget cuts. Nothing says “shortcuts” and “speedy service” like knowing your patient can’t pay for scans and lab work.

    Forget it. Sadly, many doctors in my are are NOT like you. I’ve lost trust in them.

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