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When doctors betray their patients and science-based medicine for money

We spend a lot of time on this blog discussing failures of the medical system. Usually, we such discussions occur in the context of how unscientific practices and even outright quackery have managed to infiltrate what should be science-based medicine (SBM) in the form of so-called “complementary and alternative medicine” (CAM) or “integrative medicine,” in which the quackery of alternative medicine is “integrated” with SBM. Our attitude towards this practice is, of course, completely in tune with that of fellow SBM blogger Mark Crislip when he so famously wrote, “If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.” However, as grave a threat to SBM as CAM and integrative medicine are, there is a threat at least as grave here in the U.S. (and, I presume, in many places in the world). It has little or nothing to do directly with CAM, but often CAM practitioners benefit from it. What I am referring to is the utter ineffectiveness of most state medical boards in reining in quackery and bad physician behavior that endangers patients. A recent story about a prominent Detroit area oncologist named Farid Fata, MD, who has been arrested and charged with administering unnecessary chemotherapy and of diagnosing patients with cancer who turned out not to have cancer in order to defraud Medicare, has led me to think that now might be a good time to revisit this issue. Then I heard about an Ohio spine surgeon indicted for performing unnecessary surgeries to defraud insurance companies, and I knew that now is a good time to revisit the issue.

I’ve discussed this issue before with respect to various practitioners over the years. One that comes to mind immediately is Dr. Rolando Arafiles at the Winkler County Memorial Hospital in Kermit, TX. Basically, a CAM-friendly physician was practicing substandard medicine, and two nurses reported him anonymously to the Texas Medical Board. Dr. Arafiles was a business partner with Winkler County Sheriff Robert Roberts, who left no stone unturned to discover who had complained about his good buddy, leading to the prosecution of the two whistleblowing nurses for violation of patient privacy, even though Texas law explicitly said that using patient information to report substandard care is not a violation of patient privacy. The entire medical establishment seemed to be trying to come down on the two brave nurses like the proverbial ton of bricks. Ultimately, the Texas Medical Board did the right thing, but it took a long time, and two responsible nurses who couldn’t bear seeing Dr. Arafiles continue to betray patient trust. There are many other examples, such as that of Dr. Rashid Buttar, a North Carolina doctor known for using “alternative” treatments for autism and cancer who got off with a slap on the wrist for some truly horrendous violations of the standard of care.

And don’t even get me started on the utter failure of the Texas Medical Board to put a stop to Dr. Stanislaw Burzynski’s unethical abuse of clinical trials and use of an unproven cancer drug for over 36 years or on how it took decades to finally put a stop to Dr. Mark Geier’s autism quackery in the United States. So what about these recent cases have in common? It’s that they were both busted by the feds. The relevant state medical boards in Michigan and Ohio (both states in which I hold a medical license) did not detect the medical misadventures and did, as far as I can tell, basically nothing to stop it.

Farid Fata, MD

To all appearances, prior to his arrest and indictment last week, Dr. Farid Fata was a hugely successful oncologist and businessman with impeccable medical credentials. According to his practice’s website, after graduating from Lebanese University in 1992, he went to medical school at Cornell Medical College, did an internal medicine residency at Maimonides Medical Center in Brooklyn, NY, and then completed a medical oncology fellowship at one of the premier cancer centers in the world, Memorial Sloan-Kettering Cancer Center. In 2005, Dr. Fata founded Michigan Hematology Oncology (MHO), which rapidly grew to seven locations with 60 employees throughout some of the more affluent northern suburbs of Detroit; his hospital affiliations grew to include Crittenton Hospital, Rochester (his main affiliation); St. Joseph Mercy Oakland Hospital, Pontiac; Lapeer Regional Medical Center, Lapeer; Pontiac Osteopathic Hospital, Pontiac; and Doctor’s Hospital, Pontiac. In addition, Dr. Fata has published 20 articles indexed on PubMed for which he is primary or co-author and has widely lectured at local hospitals. He’s a member of the usual list of medical organizations, including the American College of Physicians, American Medical Association, American Society of Clinical Oncology (ASCO), and American Society of Hematology (ASH), plus the Memorial Sloan-Kettering Alumni Association, and Hour Detroit Magazine named him one of the “Top Docs” in oncology in 2006, 2007, 2008, 2009, 2011, and 2012.

Not only all of that, but Dr. Fata founded a charity, Swan for Life, a nonprofit organization whose purpose is to provide “support, education and resources to cancer patients and their families” and whose mission is described thusly:

Swan for Life Cancer Foundation exists so no person affected by cancer will feel alone in their journey.

Swan for Life serves cancer patients and those who love them. Swan for Life nurtures, supports and encourages healing of the whole person; mind, body and spirit.

Swan for Life runs programs that range from support groups and educational workshops for patients and their families, to various medical services. Unfortunately, as is so often the case for “supportive service” groups, Swan for Life appears to “integrate” acupuncture into its evidence-based medical services, but such is medical life in these days of “integrating” cow pie with apple pie. In any case, Swan for Life generally raises money through fashion shows, a gala ball, a 5K run, and, of course, direct donations.

So how did it all go so very wrong? What is Dr. Fata accused of doing? For that, I have to reference some local news stories, such as this one from WXYZ-TV:

And this story from WDIV-TV:

In this story, arguably the most shocking example of patient mistreatment is the man who had head and neck cancer and was treated inappropriately with chemotherapy while receiving radiation, leaving him disfigured. Perhaps the most useful way for me (and perhaps for you) to understand the full scope of the charges is to peruse a summary published on Medscape on Friday, the actual criminal complaint against Dr. Fata, and the memorandum in support of detention that characterizes Dr. Fata as a flight risk and asks the court to keep him in custody until trial. There are dozens of examples of wrongdoing described, and the activities of which Dr. Fata is accused fall into these general categories:

  1. Administration of unnecessary chemotherapy to patients in remission
  2. Deliberate misdiagnosis of patients as having cancer to justify unnecessary cancer treatment
  3. Administration of chemotherapy to end-of-life patients who will not benefit from the treatment
  4. Deliberate misdiagnosis of patients without cancer to justify expensive testing
  5. Fabrication of other diagnoses such as anemia and fatigue to justify unnecessary hematology treatments
  6. Distribution of controlled substances to patient without medical necessity

The details of the allegations, obtained from various employee whistleblowers, range from the mundane to the truly horrific, and the amount of money involved is truly staggering, $35 million. Some of the mundane examples include charges such as this:

68. The unlicensed doctors are generally assigned to examine Dr. Fata’s patients and complete write-ups of their exam. Dr. Fata typically sees his patients for only a few minutes at the end of their typical 2-4 hour visit to the clinic. The rest of the patients’ time is spent with the unlicensed doctors and other MHO staff. This arrangement allows Fata to routinely see between 50-70 patients per day while other doctors in his practice see between 5 and 10.

Not to mention upcoding the billing to collect as much money as possible from Medicare. The general pattern in the complaints is that Dr. Fata would see large numbers of patients per day but bill every patient at the highest possible billing code, even though he spent only 3-5 minutes with each patient. For those of you not in the medical field, there are generally five levels of patient visits for billing purposes, from quick visits designed to look at one problem to highly complex visits that take over an hour. Upcoding visits (billing for a higher level visit than is justified by what was actually done at the visit) is common, and not all of it is with nefarious intent, mainly because the billing guidelines are confusing and complex. However, when a physician consistently bills at the highest levels for every patient, there’s no way that’s anything but intentional:

79. Dr. Fata typically sees 30-60 patients in a single day. Because of the volume, unlicensed doctors and nurse practitioners divide up his load, examine the patients, and create courses of treatment. Dr. Fata sees the patients for a cursory exam and often changes the course of treatment. EE-6 [one of the whistleblower employees] believes he bills the two highest level office visit codes under his own number.

The only thing that puzzles me here is how Dr. Fata could possibly have gotten away with this over so many years, if he is in fact found guilty. Medicare pays very close attention to the percentage of patients billed at each level. If a physician bills for every patient at level 4 or 5, that’s a huge red flag.

Another mundane charge against Dr. Fata is that he ran a self-referral setup with an imaging company that he owned, much the same way that Stanislaw Burzynski required his patients to get their chemotherapy from a pharmacy that he owned:

81. According to EE-7, Dr. Fata opened a company known as United Diagnostics to perform medical testing. Since he opened United Diagnostics, the percentage of patients in his practice receiving PET scans she estimates has increased from 30% to 70%.

Another whistleblower reported:

64. EE-1 advised that all patients referred to MHO, even those referred only for hematology issues, are prescribed PET scans and blood tests. EE-1 advised that two MHO medical assistants questioned him about the practice of giving all patients PET scans, even those referred only for anemia or other hematology issues.

One notes that Dr. Fata also had a relationship with a pharmacy that he always liked to use for his patients when he prescribed oral chemotherapy agents. Indeed, in the criminal complaint up until now the charges are basically for running your standard Medicare scam in which inflated bills are submitted for services rendered and there are incestuous relationships between imaging centers, pharmacies and the physician’s practice. This sort of thing is sadly all too common. However, such shenanigans, although they are designed to enrich the doctors who run them and frequently lead to overuse of services, don’t necessarily grossly endanger patients (at least not all the time), as it’s quite possible that the pharmacies involved can be qualified and that the imaging center provides quality imaging. If this were all that Dr. Fata was charged with and ultimately convicted of, he’d be a greedy bastard but not the monster he is accused of being. The charges go far beyond his being just a greedy bastard, though.

If the federal charges are correct, where Dr. Fata took it to the “next level” was in the brazenness and callousness of it all. His practices, the feds charge, grossly endangered and injured patients. For instance, in the complaint we learn that he appears to have been the living embodiment of an old (and rather offensive) joke about oncologists that goes something like this: Why do they nail the coffins of cancer patients shut? So that the oncologist stop trying to give them chemotherapy. Sadly, with Dr. Fata, that old joke appears not to have been (much of) an exaggeration:

46. In two instances, Dr. Fata directed that chemotherapy be administered to patients who had other serious medical conditions that required immediate treatment before he would permit them to go to the hospital.

47. In one instance, a male patient fell down and hit his head when he came to MHO. Dr. Fata directed EE-4 that he must receive his chemotherapy before he could be taken to the emergency room. MHO administered the chemotherapy, after which the patient was taken to the emergency room. The patient later died from his head injury.

48. In the second instance, a patient came to MHO with extremely low sodium levels, which can be fatal. Dr. Fata again directed that the patient must first receive chemotherapy before being taken to the emergency room. MHO administered the chemotherapy and the patient was taken to the emergency room and hospitalized.

Consistent with the case above and that horrible old joke, Dr. Fata is accused of administering chemotherapy to patients with late stage and terminal cancer who could not conceivably have benefited from the treatment. For such patients and, of course, for patients who don’t have cancer in the first place, chemotherapy can only cause harm because, depending on the specific regimen, it’s very toxic.

Other charges against Dr. Fata’s include ordering chemotherapy inappropriately for patients in remission and falsifying cancer diagnoses:

42. In addition, Dr. Fata falsifies cancer diagnoses to justify cancer treatments. Where a test falls in a “grey” area, he will diagnose cancer in order to start cancer treatment. EE-4 explains that it is easier for the doctor to do this for blood cancers, where the doctor has more discretion to interpret blood test results vs. tumors, for which it is harder to falsify diagnoses.

One of the whistleblowers quit because Dr. Fata had instructed her to falsify cancer diagnoses in order to justify ordering PET scans. While he was in the process of opening his imaging center, Dr. Fata also allegedly delayed PET scans that were actually medically indicated so that he could have them done at his new facility. He was also reported to become quite angry when his staff failed to follow through on these instructions.

As for chemotherapy, Dr. Fata is accused of not just of ordering it inappropriately for patients who had urgent medical conditions requiring attention before any conceivable need to give chemotherapy or for patients at the ends of their lives, but he is accused of ordering it inappropriately for many other reasons and, even when the chemotherapy was indicated, prescribing too much of it. For example, he is accused of routinely ordering “maintenance” chemotherapy for patients who did not need it. Indeed, one medical assistant quoted Dr. Fata as telling patients that once they had chemotherapy, “they had to have it for the rest of their lives,” which is utterly unnecessary for nearly all cancers. That’s how he is thought to have racked up nearly $25 million worth of chemotherapy charges over the last couple of years. Finally, one offense that I hadn’t thought of before but that I came across in an article yesterday is that Dr. Fata wasted chemotherapy drugs on people who didn’t need them, harming those people, but also potentially denying those drugs to people who could benefit from them. There have been shortages of certain drugs, and one wonders how much of these drugs could have helped other people. Causing harm both to the patient through unnecessary treatment and to others through potentially making it harder for them to get the drugs they need is a double whammy on Michigan cancer patients.

Again, if these charges hold up, not only did Dr. Fata commit Medicare fraud (which is the least of the charges against him, as far as I’m concerned), he betrayed, endangered, and injured his patients. He betrayed the trust and enormous privilege given to him as a physician by society, all for money, all at enormous cost to his patients and society. Already, stories are coming out of patients who died under Dr. Fata’s care whose families are now not sure whether they actually had cancer and died of chemotherapy complications or whether they died of their cancers. Hundreds of patients currently under treatment now don’t know where to go.

Abubakar Atiq Durrani, MD

Abubakar Atiq Durrani, MD is a spine surgeon in the Cincinnati area who, if federal authorities are correct, suffers a similar lack of ethics as Dr. Fata. Instead of administering unnecessary chemotherapy to patients, Dr. Durrani is accused of doing unnecessary surgeries on patients through his private practice, Center for Advanced Spine Technologies (CAST), all to bill insurance companies and Medicare:

A federal grand jury indicted Abubakar Atiq Durrani on Wednesday on five counts of health care fraud and five counts of making false statements in health care matters, according to prosecutors.

Durrani’s fraud scheme resulted in serious injuries in some cases, with many patients treated by Durrani for back and neck pain left in worse pain because of unnecessary surgery, the indictment states. Durrani also would tell some patients the medical situation was urgent and that back surgery was needed immediately, according to the indictment.

“For cervical spine patients, Durrani would often tell a patient that there was a risk of paralysis or the head would fall off if the patient was in a car accident because there was almost nothing attaching the head to the patient’s body,” the indictment states.

Dr. Durrani collected over $10 million from Medicare and private insurers for services rendered. Earlier this year, 88 of Dr. Durrani’s former patients sued him for doing “criminal … medically unnecessary, experimental spine surgeries” without informed consent in order to sell Infuse Bone Graft for Medtronic, for which Dr. Duranni is accused of taking kickbacks from Medtronic. Some of the civil complaints can be found at this link, as well as the response by Dr. Durrani’s lawyer. There are also several patients of his defending him in the comments. Since February, the number of patients suing has ballooned to 150.

As was the case for Dr. Fata, I think a local news report gives the flavor of what’s going on:

The federal grand jury indictment can be found attached to this news story. The indictment lumps the charges into these categories:

  1. DURRANI would persuade the patient that surgery was the only option, when in fact the patient did not need surgery
  2. DURRANI would tell the patient the medical situation was urgent and that surgery was needed right away. He would also falsely tell the patient that he/she was at risk of grave injuries without the surgery
  3. For cervical spine patients, DURRANI would often tell a patient that there was a risk of paralysis or the head would fall off if the patient was in a car accident because there was almost nothing attaching the head to the patient’s body
  4. DURRANI often did not read or ignored the radiology reports written by the radiologists for imaging studies that DURRANI ordered (e.g., xrays, CT scans, and MRIs)
  5. DURRANI would provide his own exaggerated and dire reading of the patient’s imaging that was inconsistent with or plainly contradicted by the report from the radiologist; at times, DURRANI provided a false reading of the imaging
  6. DURRANI would dictate that he had performed certain physical examinations and procedures on patients that he did not actually perform
  7. DURRANI would order a pain injection for a level of the spine that was inconsistent with the pain stated by the patient or the imaging
  8. DURRANI scheduled patients for surgeries without learning or waiting for the results of certain pain injections or related therapies
  9. DURRANI often dictated his operative reports or other patient records months after the actual treatment
  10. DURRANI’s operative reports and treatment records contained false statements about the diagnosis for the patient, the procedure performed, and the instrument used in the procedure
  11. When a patient experienced complications resulting from the surgery, DURRANI at times failed to inform the patient of or misrepresented the nature of the complications

There’s also a rather strange, but interesting, twist in this story, namely that the five patients whose medical records were reviewed might all have Ehlers-Danlos syndrome, a connective tissue disorder in which the collagen that makes up certain connective tissue is too elastic and easily deformed. Most forms of Ehlers-Danlos syndrome are inherited in an autosomal dominant fashion. Dr. Durrani’s attorney is arguing that the standard of care is different for these rare patients and that they did need surgery. Even if that’s true, I don’t see how it would absolve Dr. Durrani of charges that he documented diagnoses patients didn’t have, procedures never done, and dictating procedures and charts months later. In any case, I will concede that, to me at least as a surgeon, Dr. Durrani’s case strikes me as less clear-cut than that of Dr. Fata, but quite troubling nonetheless.

The problem

In the wake of these cases, I have heard many observations, some reasonable, some not, regarding what the problem is. As an example of the unreasonable, take a look at Debbie Schlussel’s profoundly racist and offensive take on Dr. Fata’s case, where she accuses that “a significant percentage of doctors and other healthcare professionals who commit healthcare fraud are Muslims, Arabs, or both.” One notes that she provides zero evidence to support her assertion that a disproportionate amount of Medicare and health insurance fraud is committed by “Muslims, Arabs, or both.” Can anyone say, “confirmation bias”? Sure, I knew you could. I’ve also heard it also said that the problem is foreign medical graduates (FMGs). Never mind that Dr. Fata received all of his medical training and Dr. Durrani did his orthopedic surgery residency and multiple advanced fellowships at top-notch institutions right here in the good ol’ U.S. of A. While it’s true that we need good mechanisms to make sure that physicians who receive their medical training outside of the U.S. are trained up to the standards expected in the U.S., if there’s any evidence that FMGs are more prone to fraud than U.S.-trained physicians, I am unaware of it. Certainly Schlussel hasn’t provided any such evidence.

One reasonable observation that is unavoidable from all this is that an impressive pedigree and having trained at top-flight medical schools, residencies, and fellowships are no guarantee against what Dr. Fata and Dr. Durrani are accused of having done. Dr. Fata, for instance, routinely won local “top doc” honors from the local magazine that publishes the annual list (every major city has one). Dr. Durrani was on the clinical faculty at the University of Cincinnati and had a reputation as an expert in complex spine surgery.

The real question that cases like this bring up is about state medical boards. Fraud almost never gets to the level of what Dr. Fata, for example, is accused of without a long prior history. Indeed, Dr. Fata apparently had that history, as is coming out now in local news reports, for example, this report from WXYZ-TV, which describes allegations of patient mistreatment going back years. Also revealed is that there is currently an open complaint against Dr. Fata with the Michigan Board of Medicine:

Interestingly, a search of the Michigan website for Dr. Fata’s medical license reveals no open complaints against him. Similarly, neither the State Medical Board of Ohio nor the Kentucky Board of Medical Licensure websites have any notice of action against Dr. Durrani. The question is: Why not? Why is it that it took the feds investigating Medicare and health insurance fraud to discover—virtually stumble upon, actually—evidence of Dr. Fata’s wrongdoing? Why is it, for example, that the North Carolina Medical Board has been unable to do much against Dr. Rashid Buttar and, even more egregiously, the Texas Medical Board hasn’t been able to stop Stanislaw Burzynski? It matters not to me whether the offense is practicing pseudoscientific “alternative medicine” (as Dr. Buttar does, in my opinion), using unapproved and unproven cancer drugs (as Dr. Burzynski undoubtedly does), administering unnecessary chemotherapy (as Dr. Fata is accused of doing), or doing unnecessary surgery (as Dr. Durrani is accused of doing). What matters is that these physicians either administer treatments far outside of the science-based standard of care or are accused of doing so.

As I’ve pointed out before, one of the most contentious and difficult aspects of trying to improve medical care is enforcing a minimal, science-based “standard of care.” Optimally, this standard of care should be rooted in science- and evidence-based medicine and act swiftly when a practitioner practices medicine that doesn’t meet even a minimal requirement for scientific studies and clinical trials to support it. At the same time, going too far in the other direction risks stifling innovation and the ability to individualize treatments to a patient’s unique situation–or even to use treatments that have only scientific plausibility going for them as a last-ditch effort to help a patient. Also, areas of medicine that are still unsettled and controversial could be especially difficult to adjudicate. The cases I’ve described above, with the possible exception of that of Dr. Durrani (and even then I’m not convinced yet) do not fall into these gray areas. So why can’t medical boards protect patients against such doctors? Why did it take allegations of insurance fraud to bring in the feds, who acted rapidly to shut them down? Indeed, in the case of Dr. Fata, U.S. District Attorney Barbara McQuade explicitly said, “Our first priority is patient care. The agents and attorneys acted with a great attention to detail to stop these allegedly dangerous practices as quickly as possible.”

Why couldn’t the Michigan Board of Medicine have done the same? Why couldn’t the other relevant state medical boards do the same about the other doctors? Unfortunately, our current system doesn’t do a very good job of protecting the public from physicians who practice obvious quackery or who commit fraud, for many reasons. Most medical boards are overburdened and underfunded. Consequently, until patient or fellow practitioner complaints are made and there is actual evidence of patient harm, there is all too often literally nothing they can do. Also, in my experience, state medical boards tend to prefer to go after physicians who misbehave in undeniably bad ways: alcoholic physicians or physicians suffering from other forms of substance abuse; physicians who sexually abuse patients; or physicians who are “prescription mills” for narcotics. As our very own Kimball Atwood put it:

When a physician is accused of DUI, “substance abuse,” being too loose with narcotic prescriptions, throwing scalpels in the OR, or diddling patients, the response of a state medical board tends to be swift and definitive. Shoot first, ask questions later. After all, the first responsibility of the board is to the public’s safety, not to preserving the physician’s livelihood.

As well the boards’ responses should be in these cases. Still, these sorts of cases are easier to adjudicate. They tend to be more clear-cut (you don’t have to be a doctor to understand why these sorts of behaviors endanger patients), but most importantly they don’t force boards to make value judgments on the competence and practice of physicians, such as determining whether Dr. Fata’s use of chemotherapy or Dr. Durrani’s surgical practice are outside the standard of care. Unless a patient is hurt and complains, state medical boards often can’t even investigate.

That doesn’t leave physicians off the hook. Having spoken to oncologists I know last week, I know that some of them who saw patients of Dr. Fata’s as second opinions had serious misgivings about some of the courses of treatment they encountered. I know that some physicians in the area of Dr. Fata’s home base (Crittenton Hospital Medical Center) did not think very highly of him. Although I’ve never had any personal interaction with him and don’t recall seeing any of his patients for surgery, from what I can tell there were many indications and red flags, but for some reason Dr. Fata practiced for eight years untroubled by the state medical board or the law except for the occasional malpractice suit. Did any of these doctors seeing Dr. Fata’s patients for second opinions think to report him to the medical board? What about those doctors who saw some of Dr. Durrani’s patients and told them they had had unnecessary surgery? While it’s true that sometimes doctors have differences of opinion, if what the feds say is true these go far beyond reasonable medical differences of opinion between health care professionals. Of course, it doesn’t help that in some states health care professionals can suffer serious consequences for filing reports, as two nurses in Winkler, TX discovered when they tried to report a bad doctor. Also making it difficult to discipline physicians is the problem that in many states physicians who are on these medical boards are unpaid and reluctant (as they see it) to strip a fellow doctor of the means of his or her livelihood. There’s also a cultural tendency among physicians to stick together. We understand the difficulty of making decisions that can have profound consequences in our patients’ lives, and we tend to want to bend over backwards to give fellow doctors the benefit of the doubt.

Advocates for science-based medicine cannot help but be appalled at how easily physicians can get away with practicing far outside the standard of care, even to the point that patients are harmed, with little or no interference by state medical boards. Boards are outgunned and underfunded to the point where they can barely deal with the sorts of cases Dr. Atwood described. Also, truth be told, part of the problem is that the attitude among doctors seems to be that a medical license is a right, not an incredible privilege, bestowed upon us by society that takes an equally incredible commitment and skill to be allowed to keep. That being said, I will take this opportunity to emphasize again that doctors who consistently do not practice science- and evidence-based medicine to the minimal standard of care, be it because they are incompetent, dishonest, impaired by substance abuse, or because they have come to believe in quackery, do not deserve to be physicians. If we as a profession do not find a way to do better, legislators will do it for us, but that shouldn’t be our primary motivation. Our primary motivation should be that quality patient care should rule supreme because our patients deserve no less.

Posted in: Health Fraud, Politics and Regulation

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61 thoughts on “When doctors betray their patients and science-based medicine for money

  1. Thanks for these shocking facts. There is an easy solution. In the UK we have a wonderful system in which doctors don’t profit personally from treatments they recommend. Good idea uh?

    1. elburto says:

      Exactly. There have been recent cases over here where doctors have been investigated for one SAE, and suspended or struck off for recurrences.

      After Shipman** the establishment are determined to never have such a disgraceful situation happen ever again. I just cannot imagine doctors here falsely diagnosing cancer, it’s horrifying. There’s more risk involved of course, as medical care is more collaborative here, not named doctors practicing solo and referring to private clinics.

      *Serious Adverse Events

      **Harold Shipman, worst serial killer in British history.

      1. windriven says:

        “There’s more risk involved of course, as medical care is more collaborative here, not named doctors practicing solo and referring to private clinics.”

        I’m not sure I follow your thought here. A more collaborative practice model would seem to leave less room for incompetence and/or greed to govern the treatment plan. Of course in a collaborative system when things go wrong it is sometimes hard indeed to pinpoint just who effed up.

        1. elburto says:

          Actually there’s pretty good accountability in most hospitals.

          During my last inpatient stay (ten days) every interaction with medical personnel left a ‘footprint’, as did each piece of equipment used.

          The patient ID bands have barcodes, the staff ID tags have barcodes, and every piece of machinery has a barcode. As an example – the individual bedside medicine lockers cannot be opened if the nurse has not scanned the patient ID band. Only medication prescribed to a patient is kept in their locker, so incorrect medication cannot be given.

          When healthcare assistants do basic observations (temperature, blood pressure, blood oxygen, heart rate) they ‘log in’ to the trolley they’re using. The patient barcode is scanned, and the patient record will show which assistant did the obs, which equipment was used, the time, and the results.

          I had to get my record for an insurance claim and the detail was extraordinary. Which doctor I saw when, their recommendations and dispositions, all obs taken, medications taken, the time/dose/nurse administering it, and locker number.

          When I worked within the NHS the computer, phone, and textphone (for deaf service users) was the same. The phones had to be logged into, then there was the individual PC login, two system logins, and a separate login for the textphone.

          Every action within the system, on the phone, internet, email system or literature lookup programs was automatically logged. Even accidentally clicking onto a patient record in the queue would be recorded. Each patient file had a footprint/activity section that looked like:

          elburto – phone #43/0141 – file created at 01:04

          elburto – phone #43/0141 – file sent to queue at 01:27

          Karen A – phone #12/1131 – file accessed at 02:07

          etc.

          Like I said, post-Shipman they are sh¡t-hot on this. One health trust has been threatened with closure and has had highly publicised sackings and even legal action against negligent staff.

          Nurses like Beverley Allitt led to drugs access being behind several layers of security, so much so that any suspicious activity can be checked out fairly easily. It’s not perfect, but it helps. Also there’s no gain to be had at all. You go to work, do your shift, come home – your pay rate is not dependent on anything but your pay scale band and the hours that you put in, that’s true pretty much across the system.

    2. Pedro says:

      Hear, hear!

  2. Nice article. There are several pill mill doctors in the Ypsi / Ann Arbor area that have been reported to the State Board several times in the last year. One of the MD’s in our group even called the AG for Michigan and nothing has been done.

  3. Michael Finfer, MD says:

    I don’t think that we are doing a good job of teaching medical students and residents ethics. There’s vast room for improvement there, and I think states should move to require that everyone who currently holds a medical license take an ethics course. I realize that that has no teeth, but it might make some people think twice about their practices.

    Here in NJ, the medical board is so underfunded that they do not answer the telephone. They tell us that if we need to reach them, we must e-mail them. Also, they make it very difficult to pay their fees by check. They basically want everyone to pay by credit card on the web site, again because of a lack of warm bodies.

    Sorry if this is a duplicate post. I was bounced off the wi fi, and I had to restart by browser.

  4. Michael Finfer, MD says:

    One more comment. We are making no effort at all to teach newly minted doctors about medical billing. I think that is a major oversight.

    1. David Gorski says:

      So true. It’s easy to fall afoul of Medicare billing rules completely innocently through simple error. These errors can lead to actual prosecutions for Medicare fraud. That’s obviously not what’s going on in these two cases, but it’s a peril and pitfall of billing Medicare.

  5. angorarabbit says:

    Dr. Finfar makes an excellent point and I am disappointed to learn that ethics training is not standard practice. Our grad students and postdocs who receive federal funding, for example NIH fellowships, are required to take a course in ethics. This runs a full semester and consists of weekly readings, discussions, and viewings of video material. It seems reasonable that physicians / practices obtaining federal funding (Medicare, Medicaid) should be subjected to similar training. In reality, the training is taken by all students / postdocs simply because of the possibility of receiving federal support. The programs are partly plug-and-play and would not be so challenging to implement if there is the will.

    1. Kathy says:

      @angorarabbit – is there any way of detecting and excluding/failing a medical student that shows signs of having ethical problems? Does it happen in practice? In other words, do these courses have teeth?

      1. Andrey Pavlov says:

        Yes, there are ways to fail students (at least in my program and I believe in most others) who fail at ethics. The way our program is set up each “discipline” has a different grade and if you outright fail any one of them you cannot progress. Depending on your track record and how badly you failed it (just barely or absolutely bombed it) you may or may not be given an opportunity to make up the grade and continue on. This is different to just a few years ago where everything was lumped into 1 single grade for the year and you could fail ethics but if you did well enough in the other disciplines it would let you pass overall with no issues. IMHO, I think the new model is an improvement (and more common with most programs, to the best of my knowledge).

        You can also be called up and ethics/professionalism “charges” and if you have mild repeated mild infractions or a single large one will end up sitting in front of a PPD (person and professional development) committee lead by the head of the the ethics department. It is possible to have an unequivocal fail and be asked to leave the school at that time, though usually remediation and probation is offered (on the discretion of the committee based on the severity of your infraction and your ability to explain and discuss).

        That said, it is still obviously reasonably easy to memorize enough test answers to eek by on ethics exams and actually documenting, picking up on, and enforcing the PPD process is a little difficult and not all that common. So it certainly is not 100% effective. However, it does seem reasonably good and it does make sense to have the system stacked in the students’ favor (innocent till proven guilty style). There has been at least one case that I am aware of where the student was flagrantly unethical and the school was ready to remove him post-haste but he quit before they could. So they revoked his Visa and made him leave the country post haste.

        1. jade07030 says:

          What about using retired doctors/retired hospital administrators on the boards? Would that break the culture of “medical brotherhood”. Or perhaps routine audits authorized by the state medical boards (that are funded by licensing fees) to deter “cow pie/apple pie” treatments. I’m appalled that it took financial fraud for this medical quackery to be stopped instead of the medical community.

          I don’t put too much stock in an ethics course because it can be faked. Also – it’s only for the student doctor. These doctors listed in the article had been practicing for years. Where was their ethics board to review their medical/operational treatment?

  6. WilliamLawrenceUtridge says:

    Do people think that teaching these doctors about ethics would help? Do you think they started on a slippery slope and eventually slid to the bottom, or are their behaviours so egregious that it’s simply a matter of fundamental dishonesty? These don’t seem to be well-meaning quacks, they seem to be doctors treating their patients as cash cows.

    I’m not a doctor though, I don’t understand how difficutl it is to commit this degree of fraud.

    1. windriven says:

      As Drs. Gorski and Finfer suggested above, it is very easy to run afoul of the law through coding issues. Coding is often a judgment between several possible choices.

      Physicians want to be sure that they are compensated the maximum amount that they are entitled to (forgive the dangling participle) just as you and I want to take every legitimate tax deduction to which we are entitled. But the line isn’t always clear. There are courses for physicians and for billing clerks to learn to code for maximum compensation. There are billing services whose claim to physicians is that they will deliver maximum payments.

      If you speak with American physicians in private practice, billing problems are a huge headache. Worse, the physicians who get creamed the worst are primary care physicians, some of whom earn on a net basis less than the plumbing contractor down the street. This is one of the factors that leads some physicians to abandon private practice in favor of working for a hospital or hospital chain, an eventuality that leads to higher costs, not lower.

      1. Is there any reason the plumbing contractor should not be as well-compensated at the physician? Just asking :-)

        1. windriven says:

          I knew that was going to raise eyebrows! I’m hoping this doesn’t go off into the weeds of Austrian v Keynesian v Randian v MMT economic theory. Pretty please.

          Physicians make a huge investment of time and money in their professional preparation. Plumbers less so. A functioning toilet is really, really important. A functioning liver, more so. If your plumber really screws up you get new carpeting ;-)
          If your physician really screws up you wake up on the wrong side of the dirt.

          1. A master plumber does five years of coursework and apprenticeship, minimum as well as continuing education to keep abreast of technology and changing codes. A non-functioning toilet can land you at Dr. Crislip’s door. Still, point taken and, of course, I agree with your well put defense and am not seeking “weeds”–hence the :-)

            Disclosure: My eldest son is a master steamfitter (a lot like plumbing) and makes about as much as an average (perhaps non-specialist) MD. He has excellent medical benefits too! He did math through calculus, physics, and works with a lot of specialized hi-tech equipment. Your computer and other stuff gets built in places he “pipes”. He’s union, of course.

          2. windriven says:

            @irene

            “My eldest son is a master steamfitter”

            I have a stepson who is a master plumber. I certainly didn’t mean my comment to disparage plumbers. But they haven’t paid the same dues as physicians. I have one of those too.

        2. weing says:

          My brother-in-law is a plumber and makes a lot more than me. But I am just a general internist. He works long hours like I do, too.

      2. WilliamLawrenceUtridge says:

        That’s not really ethics though, and billing irregularities are very far from the only things these two were charged with. I can’t think of any course that would make a doctor realize that it’s wrong to perform an operation that the patient absolutely doesn’t need, or to give chemo to a dying patient.

    2. Sciencebasevet says:

      Unlikely to stop the person but educating people about ethics but education about ethics might make people report unethical behavio because they clearer about what is ethical.

  7. Sean Duggan says:

    Looks like Cracked.com has room to add two new cases to their list of terrifying medical malpractice cases

    It is tremendously scary, though, in part because doctors are so high up on the list of people you have to trust, often without any ability to independently verify their results (even second opinions don’t necessarily bear much weight since, as you indicated above, there’s a bit of a “good ole boy” situation where doctors are reluctant to criticize the decisions of their colleague. And that’s not even getting into the risk that you were right the first time and the second guy is the quack. Sure, you could go for the best 2 out of 3, but when a medical appointment with a specialist can take months to schedule and each appointment requires taking a half to a full day off from work, how feasible is that?). Cases like this strike deep into people’s fears, much like when you find that the local school teacher, or minister, has been up to no good. Sadly, I expect to see a few of my more kooky friends post this story as one more example of why they can only trust their chiropractor/naturopath/witch doctor/whatever…

    1. windriven says:

      I hope NOTHING in that Cracked piece was true. But I’m not betting that way :-(

      1. duggansc says:

        Cracked occasionally runs bad research, especially if it’s sensationalistic, but they’re generally pretty reliable for actually citing their sources, better than Huffington Post, which means you can check for yourself.

        Personally, when they started getting into the penile mishaps, I suspected they’d namecheck that case of the boy who suffered a bad circumcision and whose doctor convinced the family to raise him as a girl as an experiment on gender identity. That one combined a botched procedure, some pretty skeevy manipulation of patients for the benefit of a doctor’s pet theory, and lastly some very clumsy manipulation of data when the doctor learned that the boy in question indeed was not adjusting well (and, sadly, ultimately committed suicide years after he learned of the hoax played on him and how it wrecked his life).

        Hmm… I wonder if one could convince one of columnists to do something on the fun things that can happen to you during SCAM procedures. Cracked.com seems like the kind of place that’d jump on the fun of untrained acupuncturists piercing lungs and chiropractors blithely waving off stroke symptoms after neck cracking.

        1. Check out Edzard Ernst’s blog entries for Aug 8 and 10!

          http://edzardernst.com

        2. zoebrain says:

          The botched circumcision case was that of David Reimer, and the doctor was John Money.

          Money’s theory was that gender identity was a tabula rasa at birth. By appropriate upbringing, any child could develop whatever gender identity was desired. This was more than a hypothesis, there was some evidence in support.

          The Reimer case falsified it completely, though it was reported in the literature as confirming it. A real tragedy, Money did a lot of good work, and for him to abandon ethics and honesty at the height of his career is the stuff of Greek Tragedy.

          There are indications – hints, signs and portents – that in about 1/3 of neonates, the neuro-anatomy dictating which direction gender will develop is ambiguous enough so the child could function adequately as either sex. This may only apply to Intersex children though, the only ones likely to be arbitrarily assigned a sex that is deemed convenient. So such assignment is “successful” to varying degrees about 2 times in 3 rather than the 1 in 2 that would be expected if gender identity was 100% binary and unambiguous in every case.

          “Primum non nocere” as a principle used to deny treatment to fully informed consenting patients kills. So does intervention on non-consenting patients, some of the time.

          This blog is about science-based medicine. When it comes to Intersex and Transsexuality, there’s nowhere near as much evidence as there should be. One thing we do know : get it wrong, and the consequences can be fatal. In what proportion? Not enough evidence, the best figures we have put it at nearly 100% in severe cases, about 30% overall, but “best” doesn’t mean “good” or even “fair”.

  8. Marc Schwartz says:

    I will preface this comment by saying that I have known people at Duke University for many years and have the utmost personal and professional respect for them.

    That being said, one of the larger incidents of deception in the recent past was at Duke University in the realm of genomics and proteomics research. This was covered last year on 60 Minutes (http://www.cbsnews.com/video/watch/?id=7398476n), in the Journal of the NCI (http://jnci.oxfordjournals.org/content/103/12/916.full) and in statistical journals such as Significance (http://biostat.mc.vanderbilt.edu/wiki/pub/Main/MSJournalClub/DukeScandal.pdf) among others.

    This particular situation and the background was presented by Kevin Coombes at a statistics conference that I attended last year at Vanderbilt University. It was frankly frightening.

  9. windriven says:

    “Unfortunately, our current system doesn’t do a very good job of protecting the public from physicians who practice obvious quackery or who commit fraud, for many reasons. ”

    This is a difficult but nonetheless essential nut to crack. Back in the day when I was involved with health care at the hospital level everyone in the facility knew who the gifted physicians were and the execrable too. But one needs to be tied into that community to have ready access to that information. The average consumer doesn’t have that connection.

    Many proposals have been floated to ‘rate’ physicians but none that I have seen could credibly be expected to deliver reasonably objective results. Moreover, once a grading scale is put in place physicians will, to one degree or another, practice to that scale. I would happily debate anyone who thinks that to be an unalloyed good idea.

    But the reality is that one or another of these grading systems will ultimately gain favor unless the profession gets more proactive. In my years in the medical industry I have only come to be aware of a large handful of really bad physicians. They’re out there but it isn’t as if one stumbles over them at every turn. To me this makes inaction of state boards doubly unconscionable. They know – or can easily learn – who the bad apples are and they are few enough that disciplining them wouldn’t be burdensome.

    Further, a better mechanism at the state board level would serve physicians on the left side of the practice curve by bringing deficiencies and the threat of future sanctions to their attention before they become career crippling. Only a vanishingly small fraction of MDs are crooks or flatly incompetent.

    “Most medical boards are overburdened and underfunded.”

    That may or may not be true. But physician compensation consumes roughly 10% of America’s bloated health care spending. This is not an insurmountable problem.

  10. Alia says:

    Over here we have another billing problem, which probably is not so dangerous to the patient, but really annoying. And that is – in case of some medical procedures, patients need to stay in the hospital for a prescribed number of days (prescribed by the state insurer). Otherwise the hospital won’t get reimbursed. And so in the hospital they stay, even though they do not really need it, feel well, want to go home and their doctors agree. It’s a waste of time and resources, really.

    1. windriven says:

      Years ago that was common in the US. At that time hospitals were paid on a fee-for-service basis. It behooved them to keep patients as long as possible so as to rack up room, medication and services fees. Now hospitals are generally paid by Diagnosis Related Group so it behooves them to excrete patients as quickly as possible to avoid racking up room, medication and services costs.

      1. duggansc says:

        Which, of course, dovetails into your comment above that whatever metric we grade physicians / hospitals by, they’ll adjust to maximize their score in many cases, sometimes to detriment of what we’re actually aiming for, namely the health of our populace at a reasonable cost.

  11. nybgrus says:

    I won’t have time to participate in this conversation nor write a particularly luminous post at this time as I have a friend coming into town to visit tonight and will be devoting my non-service time to spending time with him and his wife.

    However, I think this is a very important topic. SBM tends to go after the low hanging fruit of CAM but there is bad practice at all levels within medicine. Much of it attributable to the old “that’s how I was taught” or simply fear-based responses (the patient has a hemoglobin of 8! Two units pRBC’s stat!) without thinking just a little more deeply.

    But cases of egregious misconduct do occur and I agree with the commenter above that in cases like this, I doubt additional billing courses or ethics training would have mattered. I can’t imagine you go that far off – intentionally misdiagnosing a patient to subject them to highly morbidy and potentially lethal interventions for money – simply because your med school and residency was a little light (or hell, even completely absent) of ethics courses. These cases are the outliers that, I would argue, cannot reasonably be caught and prevented a priori.

    That said, we should have a much better way of stopping such things once before they can do more harm. And the reality is that medical boards are sorely lacking in their ability and temperment to do so. And I agree with all the reasons Dr. Gorski stated above. I believe it can all pretty well be summed up by the concept of bureaucratic inertia (with many other factors, as well, of course). But this is much like Al Capone getting busted for tax evasion by the Feds.

    In any event, I believe that it is important to always hold ourselves, our colleagues, and our superiors accountable for their actions. This is not always easy to do. And we will often fail, but we should strive for it. I’ve found the easiest thing to do is simply ask “Why are we doing that? How will it change our management?” Anecdotally I’d say the answer is lacking between 10-40% of the time, depending on the service and how high up the chain of command you are asking.

    CAM is the low hanging fruit, but the principle is the same. We are a profession and we need to be policing ourselves. And because we are granted the awesome privilege and responsibility of doing so, we must be particularly discriminating in our charge. I think that this is happening – my experiences so far at my institution have been largely very positive. In fact, I can say that in reading and hearing from others at other medical schools, my institution does a very good job of espousing and engendering exactly this ethos.

    Also, I’ll add that all medical schools have ethics courses and exams. The USMLE has ethics questions. They are just, sadly and somewhat understandably, a relatively small portion of our education and most of my colleagues take a very flippant attitude towards it, usually brushing it off. I’ll be the first to admit that I do not aspire to be an ethicist, but I do take it seriously.

    Billing, however, is indeed something we know nothing about and learning more about that could actually be quite helpful in making sure we actually get paid what we deserve and saving some money for the taxpayer. But I do not think that is particularly relevant to the grist of this article.

    I’ll close my somewhat rambling comment by saying that this is all compounded by what I see as the hardcore capitalist bent American medicine has. I do not believe that direct-to-consumer advertising for prescription medications makes any sense (I mean really – can a person figure out anything about a TNF-alpha inhibiting monoclonal antibody from a 30 second spot??), I do think that a single payer system is better (maybe not the best and certainly not perfect, but better) than this frankenstein of a system we have in the US, and I think that physicians who own resources for medical testing/pharmacy/sell stuff should be under much more scrutiny due to the inevitable conflict of interest. I’ve had classmates tell me that they love Dr. Oz. Not because they believe in the quackery he sells – but because they want to be able to sell whatever they can to make money hand over fist, ethics be damned (it was a more nuanced discussion, but not much more). I’ve overheard some classmates during Year 1 lectures talk about what specialty they want to do based on what cars they’d be able to afford by doing it, and viewing their MD as a means to get money. I hope to be successful, get paid well, invest well, and be quite comfortable. But that is ancillary to medicine – not the goal of it.

    I’ll stop rambling now.

    1. windriven says:

      ” I hope to be successful, get paid well, invest well, and be quite comfortable. But that is ancillary to medicine – not the goal of it.”

      You will doubtless be a credit to medicine.

      1. Much too kind, windriven. I only hope to do the best I can and take no shame in living well for it, but eschew any avarice along the way. If I can do legitimate medicine and science and find a way to get paid well and fairly for it, mores the better.

        1. windriven says:

          I share your ethic in this regard. For what it is worth, windriven was the name of my last sailboat, not an admission of out-of-control competitiveness (but I enjoy the uncertainty associated with the avatar!). It is quite possible to live a most comfortable and enjoyable life while making a positive contribution and without being an a-hole.

      2. Since there’s no “recommend” button, I’ll just say “ditto”.

        Good to hear from you Nybgrus. I’ve been wondering how you were getting on. :-)

        1. nybgrus says:

          I apologize that I have no extra time to respond to some of the other comments (and kind words) since I do have friends in town and have to rush off to a conference and see some patients today.

          However, I did want to take a moment to thank you very much for the kind words and to also clarify that I am Andrey Pavlov. I was fiddling around with wordpress yesterday trying to see if I could get it to work better and it must have somehow signed me in as NYBGRUS in my RSS reader but not in Chrome.

          In any event, I figured I may as well post under my real name now, but I figured I would clear up some confusion.

          Once again, thank you very much for the kind words!

          (Oh and I’ll probably have more time to post in a few months time as I will be holding my shiny new medical degree and have a few months before starting my graduate training)

          1. Kathy says:

            Looking forward to it, nyb/Andrey. And I like your attitude re money. You want to own it, not have it own you.

            Rather depressing reading, this article, but important.

            Still, while there are a few doctors that occupy the low end of the normal curve, we all know a few that are on the high end too. Like a Canadian I once knew who was one of the top 10 students in Canada and was offered a very well-paid job straight after qualifying, but chose to come work in a black township hospital in South Africa (the SA of the apartheid era too – not nice) at a tenth of the salary. And who stayed (on and off) for thirty years, working both as a clinician and a teacher. He’s gone back to Canada now, and is the only doctor in a hospital that should have four of them … on call every night and weekend … at the age of sixty … until the hospital admin gets its act together.

            1. Andrey Pavlov says:

              Thank you for the kind words Kathy.

              I have found that in all endeavors if you are passionate about it, do it well, and work hard you will be noticed and rewarded for that. Whether professionally, personally, or financially. Granted you almost certainly won’t be Forbes 500 rich without directed avarice but I have no distinct desire to be that rich. However it is quite easy to be in the top 1% and beyond by excelling and working hard. The only corollary is that you must be able to recognize and willing to take advantage of opportunities that come your way.

              I’ve always thought that succesful people don’t have more opportunities, they just take advantage of more of them. That said, putting out good work does seem to garner more opportunities and the effect snowballs over time.

  12. ravingdesi says:

    While I firmly believe in SBM, I have also grown depressed about the behavior of doctors. Finding a good one appears to be pretty hard here. It’s not as bad as the guys in the post, but I fear many physicians do take money into account for their decisions.

    It’s anecdotal, indeed, but here my two last experiences with doctors. As a note, in Germany, there are so called “private patients” who are billed directly instead of over their insurance company. They are easier to milk money from – and I’m one of those private patients.

    1) I had neck pain when tiling my head, possibly caused by exercising with too heavy weights. Arriving there, an assistant tried to talk me into doing some x-rays, I insisted on seeing the doctor first. Then a female doctor (although only males were supposed to be working there) took only 2 or max 3 minutes to solely put her hands on my shoulders and ask me to tilt my head until it would hurt. And then prescribed me 15 sessions of physiotherapy. As it got worse on physiotherapy I stopped it – in the end it got better on its own after a few weeks.
    I was charged over 40€ for her diagnoses. Looking it up, she billed something that may only be billed if “brain nerves, reflexes, sensibility, sensibility, coordination and the automomic nervous system” were tested, which was not performed.

    2) I went to a dentist (note: in Germany, some dentists are also licensed for extracting teeth). I had pain at a wisdom tooth. Again, for I was asked by one of the assistants to get and x-ray done, which I found reasonable and thus complied. Afterwards, I was sent in a room to wait. When an assistant set up some instruments and expressed her empathy for my situation, I knew what would come next. Yup, the dentist proclaimed I needed them extracted. Surprisingly, all at once, right now, despite having taking aspirin and stuff. I was against it because I wanted to think it over, but he kept insisting telling me that it would be fatal not to extract them right now, and even if the pain would go away this time, the teeth were “ticking time bombs” that would cause severe consequences very soon. Despite him trying everything to talk me into it, I stayed strong because I had two dentists as relatives (who work a couple of hours away) who would check me up from time to and they never saw any problems.
    I consulted my relatives along with the x-ray image, and they said it would have been an unnecessary operation and condemned his fear inducing behavior.
    Since then I have never had any problems despiting not having gotten an extraction.

    While it may be equally foolish of me to do so, due to lack of doctors to be trusted (except my relatives), I nowadays deal with my medical problems using “google university” and some critical thinking…albeit I wish I wouldn’t have to. And I fear the moment I’ll need a lab test or something, I’ll have to go visit one again.

    1. I am sorry to hear your story. And I know of many more like it, sadly. In my own particular chosen field that I would like to pursue – critical care – it is even easier to pull such shenanigans. When someone is going to die regardless of what you do, prolonging their misery by a few days is all upside and no downside (for you as the physician). You get to look like a hero to the family, you get paid even more money with little chance of any liability, you don’t risk a lawsuit or low patient satisfaction scores because you invoked the premise of futile care and did nothing further. But it is, IMHO, unethical and costly to our medical system.

      1. ravingdesi says:

        Thank you, it was interesting to hear that first hand!
        I was thinking that critical care was less susceptible for money induced “special” treatment. Here, it appears as if most critical care is done in hospitals, where (at least I thought) the doctors are paid based on their role and working time and do not directly get more money for more expensive treatments. Maybe it’s a regional difference since I don’t quite see the incentive for overtreatment, or maybe I’m misinformed (possible).
        However, that they are overly cautious to avoid lawsuits on the other hand, is a legitimate reason in my humble opinion. However, I find it unfortunate that the “more treatment is always better” mentality seems to be so strong when it comes to the law side of things.

      2. I’m very interested in your view on this as I have experienced a situation where a family, after intense searching, found doctors to do exactly as you describe for (sadly) two (relatively young) family members who died of dreadful cancers in the same year. Both were put back on chemo after having had it withdrawn and being sent to hospice. The family are extremely woo-ish and created a nightmare for the hospice by carrying on with aromatherapy, crystals, and all sorts of things at the hospice right up to the relatives’ last breaths.

        I have wondered ever since about the ethics of this situation and why the family were even able to locate such doctors. The patients in question were both on Medicaid by the time of their demises.

        How does one know if the doctor’s ethics are in line with nybgrus and Andrey Pavlov or more along the admirers of Dr. Oz?

    2. Harriet Hall says:

      “Then a female doctor (although only males were supposed to be working there)”

      I don’t see the point of this observation. How is the doctor’s sex relevant?

      1. ravingdesi says:

        My apologies. The sex does not matter! It was just to say that I am SURE that I was treated by a doctor who I did not expect.

        When it says on the sign outside that it’s the clinic of MD X (male name) and MD Y (male name) then I know that Z (woman) is neither of those. I am slightly annoyed by that. E.g. (not that it would matter that much), I have no idea if she was an MD as well. In Germany, they are not required to do an MD anymore to treat patients but only a “state exam”.

        1. windriven says:

          “In Germany, they are not required to do an MD anymore to treat patients but only a “state exam”.”

          Scary.

          I have both a female internist and a female proctologist (she was amazed that I chose her because of the sex difference but she came highly recommended by two (female) friends). My presumption is that she’s seen all the relevant parts before so neither of us should be shocked. But I draw the line at urology. I want my urologist to have the same plumbing as me. That way I get either empathy or schadenfreude but never outright guffaws ;-)

          1. windriven says:

            One of my favorite movie lines came from, I think, “Wagging the Dog”. Kathy Bates’ character says to (I’ve forgotten the actor playing) the James Carvillesque character: “Looks just like a penis. Only smaller.”

    3. Alia says:

      I had a similar experience, also as a private (paying) patient in a private clinic. I hurt my toe, and as I was planning to go on holiday a few days later, I went to a surgeon to have it checked. Arranging a free visit (that is, paid by state insurance) would take too much time, so I decided to pay. The visit cost me something like EUR20, the surgeon looked at my toe, moved it, said it was not broken, only strained – and then prescribed a course of laser therapy in the same private clinic. The whole visit lasted maybe 10 minutes.
      Anyway, when I learnt that the toe wasn’t broken, I skipped the laser therapy, used some cheap OTC remedy to reduce swelling and then went on holiday. But I did feel that I could use the money that I spent on the visit in a much better way. Like buying a few beers.

  13. mousethatroared says:

    I have wondered quite often if we would have fewer malpractice suits if there was better oversight of doctors and hospitals. At this point it seems like the primary oversight mechanisms are the fed looking for Medicare fraud and malpractice lawsuits. I don’t think that many patients believe that state medical boards have much impact on discouraging bad physicians from practicing.

    I know when my husband and I were undergoing fertility treatment I felt quite concerned with some of the things that went on. When asking for my chances of success with IVF, The doctor gave me IVF success rates for the clinic rather than for a person of my age and test results (50% success rate vs 30-25%) The way the doctor would recommend using their lab rather than the network lab that was covered by our insurance… a couple of short-cuts that they took that seemed to favor a choice of IVF rather than less expensive treatments…

    But not being a medical person, I couldn’t really tell if these things were inappropriate or I was just being paranoid. It would have been nice to have access to a neutral knowledgable party for advice.

    Luckily, the Pergonal made me feel unwell enough (possibly because of the thyroid condition I was diagnosed with a few months later or other health issues) that we just scrapped the whole fertility stuff and adopted, which was much easier physically and emotionally (and that’s saying something). But I never really did figure out what, if anything, was going on with that doctor.

    As an aside, while ethics classes may do nothing to prevent a sociopathic doctor from attempting harmful activities, they may prepare other doctors and medical staff who witness that doctor’s activities (or suspect a problem) by teaching a process for reporting unethical activities to the most effective authorities as well as following up with the same.

  14. Jim Smith says:

    But the bigger story would be: “When Pharmaceutical corporations betray doctors with money based science”

  15. pmoran2013 says:

    Good for you for you for airing these matters, David.

    This is what clear-cut health fraud looks like — of the worst possible kind, too. Hard to find any mitigating factors here.

  16. Andrey Pavlov says:

    I wish I had time to flesh out a better response, and I must caveat it by stating that my experience and knowledge is limited, not having yet earned my medical degree quite yet.

    However, I think a large part of the issue is motivated reasoning. I think the majority of physicians really are in it to help people and tend to have the right priorities in that regard. The problem comes about with death and what I find to be a peculiar view of the Hippocratic Oath.

    The Oath states to “first do no harm” which I think many in my field take very literally and very superficially. The reality is that everything we do does harm. And even in the cases where that harm can be quantified it still doesn’t give us a value judgement as to what that harm means to our patients. Me losing my fine motor skills is probably less of a “harm” to me than it would be to Dr. Gorski – I am not planning on being a surgeon, after all. And we also have to play the game of balance with the reality that people adapt to loss and harm much better than they think they will. Someone convinced that losing a leg is the most grievous of harms and life would not be worth living after tend to actually adapt and be happier than they would have imagined after the fact.

    But the biggest issue is death. I find, once again in my limited experience and knowledge, that a lot of physicians find death to be the “ultimate harm.” Nothing can be worse than death. And I find that to be trivially correct, but practically rather harmful attitude to have. And I think it is driven at least in part by our own discomfort with death and the view that the death of a patient is a failure on our part (no doubt, it often is, but certainly not always).

    So when the physician himself is uncomfortable with death how can the family become comfortable with it? If we view it as the ultimate failure, how can we possibly justify not doing something to avert it? And if it happens that these attitudes align with us making more money, it becomes rather easy to do a little motivated reasoning to justify continued care.

    I view things differently. Life does not exist without death (yet, at least). So I do not view my role as a physician as that of staving off death at all costs and with whatever means possible. I see it as being the expert who can provide the best evidence, the best counsel, and the best support for my patient to live the best life he or she can within the values and judgement framework of the patient. Which includes, at some point, their death. I also see myself as being in a unique role where I can actually make the death of a loved one “okay” for the family – helping them understand not necessarily that we’ve done “everything we can” (although many times that is the case) but that we have helped their loved one live the best life (s)he could as valued by the person whose life we are referring to. Death is always sad. But it needn’t always be rife with anguish.

    As for how to find such physicians… there I cannot help you. And sometimes you may be SOL. Asking the physician directly is probably the best way, but is understandably difficult if not impossible in many contexts.

    Well, time to get back to it!

    1. Kathy says:

      Well said Andrey. I hope when you come to practice, you can navigate safely between the Scylla of too little and the Charybdis of too much, care for a dying patient.

      Just b.t.w. it brings up a topic I’d really like to see covered by one of our writers here on SBM – the attitude of Cam practitioners to death. How do the explain it away?

      1. Andrey Pavlov says:

        Thank you once again Kathy.

        It is a difficult path to walk, but I have found repeatedly (including as recently as yesterday) that merely pulling up a chair and sitting down for 5 minutes to talk to a patient like a real person makes all the difference in the world.

        When I see my patient is very agitated (like yesterday) I consciously make the effort to find a chair and sit down. And I speak to them as I would any other normal person – I apologize for miscommunications and state plainly what we are thinking and explain what is going on. Something that many of my colleagues would consider “too much” information or at a level that is “too high” for them. Many of my patients are indeed very uneducated, but that doesn’t mean that they are stupid. So I find ways to explain complex ideas to them just so they can at least grasp a basic outline of what is actually going on with them and why the hell we are doing what we are doing. And even in the cases where it does go a little bit over their head, they are still appreciative that I didn’t talk down to them and included them in our thought process. I’ve even flat out stated that I believe doing so improves our outcomes because it engages them in the process of their care and motivates them to actually follow through with our recommendations. And I have gotten much good feedback on this style, so I intend to keep it up as much as I can.

        But of course, I am the pedantic scientist, the evil reductionist, the close-minded dogmatic fool who mocks “other ways of knowing” and happily tosses aside “centuries old healing” that “works and is much safer” than my “Western BioMedicine toxins and poisons” so what would I know about empathy and caring for the psychological well being of my patients? I only view them as livers and lungs and molecules, so thankfully we have those wonderful charismatic and caring CAM practitioners to fill the void left by my cold and heartless allopathy.

        //end snark

  17. “There’s also a cultural tendency among physicians to stick together. We understand the difficulty of making decisions that can have profound consequences in our patients’ lives, and we tend to want to bend over backwards to give fellow doctors the benefit of the doubt.”

    I think that is a problem in many places. We see the same thing in investigations of police officers, prosecutors, and judges. Only the most egregious cases seem to come to light, or if one person managed to make a lot of internal enemies…

  18. Have you seen this New Yorker article? It’s about why some regions have higher levels of medical costs than others with all else taken into account; it doesn’t mention outright fraud but it does blame local “entrepreneurial” cultures where it’s accepted among the medical community to overtreat. http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

    1. windriven says:

      The Atlas Project out of Dartmouth has been studying and reporting on this for years. This is an area where science based medicine and public policy intersect and is worthy of discussion in these pages. Unfortunately so far it has escaped the editors’ attention.

    2. windriven says:

      I should have followed your link before responding. I do believe that Gawande has been discussed here in the not too distant past.

      1. Argh, forgot the basic principle that just because an article is recently posted on Facebook does not mean it’s a recent article. Had I looked at the publication date, I would have searched the SBM archives.

  19. The website of Michigan Cancer Center was taken down, but its still available for viewing via the wayback machine: http://web.archive.org/web/20120508055156/http://www.michigancancercenter.com/our-physicians.aspx

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