Category Archives: Physician Quality

Joan Rivers and Office Based Surgery

This weekend, we say goodbye to the great comedian — Joan Rivers.  She said so many things that made us laugh.  My most favorite was  — “Can we talk.”

Joan Rivers
Joan Rivers

She often used those three little words while interviewing someone whom she felt was less than frank.  I can still see her leaning forward, as if to whisper, and saying with a crafty smile, “Can we talk.”  Those words immediately shifted the conversation to what was really important.  It was as if she said, “Ok let’s stop beating around the bush;” or  “Let’s get down to the juicy stuff.”  The words disarmed people in a simple, yet funny, way that made us see the real story.

Though no one could use those words the way she could, I often pilfered her expression to get others to say what they really meant.  In my many years in university academics, medical forums, and governmental service, I’ve attended countless meetings.  It’s always impressed me what people say in public compared to what they say immediately after the meeting, perhaps in a rest room, snack bar, or quiet corner.  Generally in the latter locations, their true sentiments explode with slang, profanity or worse.

Joan Rivers could cut through this politically correct “public speak” and get people to say what they really meant, which sometimes wasn’t always nice.  Yet Joan had a way to use self-deprecating humor to put folks at ease.  Almost as if to say, “See look at me, I’m not embarrassed and neither should you be.”

In matters of healthcare, truth is vital.  However, in this era of political sensitivity, freedom of speech appears extinct.  Unless we couch every sentence in words that couldn’t possibly offend anyone, we risk unmasking an unintended offense.  Discussing important matters under this camouflage begs for Joan Rivers and her three little words — “Can we talk.”  To speak otherwise elicits Winston Churchill’s admonition, “If you can’t say what you mean, how can you possibly mean what you say.”

From what I have read surrounding Joan Rivers’ death, it’s reported that the family suspects complications due to surgery performed in a non-hospital environment.  In other words, surgery/procedure carried out in an office.  Since others have also suggested this cause, the family is considering malpractice litigation.

It’s ironic that she died in this manner, considering the extensive debates over office-based surgery in New York State.  I can’t help but wonder if a little more “Can we talk,” — I mean really talk, would have helped.

The year was 1997, and I was Chairman of the New York State Public Health Council.  As a practicing surgeon at the time, I disagreed with the market driven recommendations to dismantle hospital based surgery and instead move so-called minor surgical procedures to a physician’s office.  I held that opinion for two reasons:

  1. There is absolutely no such thing as a minor surgery.
  2. And any surgery on me or you is never a minor procedure.

Whether it’s passing a tube down a person’s windpipe, or going up in the other direction, there are inherent risks dependent on many factors, age, co-existing medical illnesses, anxiety, and drug history to name a few.  I have seen complications from vocal cord spasms that stopped breathing, perforated livers and spleens from faulty colonoscopies, and collapsed lungs from a simple needle touching the lung.  Though these complications are admittedly few, their occurrence in those affected is 100%.

As Chairman of the Public Health Council, I had the privilege to recommend that the Council undertake a study to investigate the movement of surgical procedures to an office setting.  The Council supported this initiative and selected an all-star panel of medical experts from all sectors across New York.  That empowered committee then held public hearings in the major cities across the state to elicit comments from patients, business leaders and other interested stakeholders.

Over a several month intensive effort the committee forwarded to the Council its report, which was immediately endorsed and recommended to the New York State Commissioner of Health, Dr. Barbara DeBuono and the NYS Legislature for consideration of possible legislation.

Unfortunately we found that sometimes “Can we talk” just isn’t allowed.  The New York State Association of Nurse Anesthetists sued the Public Health Council and barred the report from becoming public.   Since the Council report was muffled by the lower court’s, New York State’s Health Department appealed the lower courts decision to the state’s highest court, the Court of Appeals.  Finally with the report requiring some “tweaking,” a decade later in 2007, the report was released.

I don’t believe Joan Rivers would have allowed ten years to pass, if only we could have talked.  And what exactly did we need to talk about, and why all the sensitivity about what and how to say it.

By 1997, healthcare costs were sky-rocketing and the wisdom of that decade was to unleash market forces on healthcare.  Surely if American competition made us wealthy, easily it could make us healthy.  Performing surgery in a hospital was expensive.  Why do we need this costly infrastructure for a “minor” procedure?

Many physicians rallied to this cry.  Some doctors argued that most of their routine surgery could be carried out in an office, if only the insurance company would pay them an augmented fee.  To many this was a win-win situation.  Insurance companies got to pay less than the hospital charge, and physicians got a raise.  The only downside was that equipping an office just like a hospital was expensive, so medical supply companies filled the gap by providing equipment which was nearly like the hospital’s.

Another advantage to market based decisions was that now non-physicians could perform services in an office which they formerly were not allowed to do in a hospital.  That was the key element of the litigation against the Public Health Council cited above.

According to market driven theory, this competition would greatly improve public health at a lower cost.  As we have suggested in an earlier blog, apparently this hasn’t yet achieved the intended result.

Perhaps Joan Rivers’ spirit acting through her family may trigger some meaningful changes as this investigation progresses.  However, it may not happen unless we ask — “Can We talk.”

 

Physician Quality Scores

Physician Quality Scores:      What You Don’t Know — Can Hurt You.

Before choosing a doctor, we investigate.  And before investigating, we usually begin with a premise.  While the scientist may devise an elaborate experiment to test the premise, choosing a healthcare  provider may only involve a superficial analysis.  For example, one may simply ask their friends: “What do you know about this doctor?”  Or perhaps the analysis may go deeper and employ a search on Google or Angie’s list.

Insurance companies try to assist by giving doctors in their network titles like “Preferred Providers,” or “Gold Choice Doctors,” or “Approved Quality Physicians.”  But in the end those titles are generally garnered by any licensed physician in good standing willing to accept the insurance company’s fee schedule.

If the doctor has a web site, there may be pictures of the office and smiling staff, along with a list of degrees and awards.  Hopefully the entire page will confirm a wise choice.  But colorful web pages may be more of a testament to the web designer than the physician.

How then can we evaluate a service industry populated with so many different providers?   A problem made worse if one needs a specialist from a medical field unknown to us.   Are choices in healthcare dependent on personal taste only?  Is it like finding a good restaurant?  Unfortunately for a person struggling with a chronic illness, this choice is crucial.

Currently marketing companies, using metadata mining, can predict our buying habits even before we make a purchase.  Where then can people go to gather the necessary information they seek?  One likely source is government agencies created to protect the public health and identify problem doctors.  Let’s explore what we can learn from these state medical boards.

State Medical Boards

Physicians in the United States are regulated by individual state medical boards. These boards license and oversee medical practices.  Their authority evolves from either the state Department of Education or Department of Health.  The Office of Professional Medical Conduct (OPMC) is a sub-agency that investigates doctors accused of poor conduct. Their findings are significant.  Yet these agencies may be limited either by law or regulation as to what they share with the public.

It wasn’t until the late-1990’s that some states passed legislation that required state medical boards to use the world-wide web and share information about physician conduct.  In 1996, Massachusetts became the first state to provide information about doctors online.  By 2006, only twenty-two states had laws requiring state medical boards to provide basic physician profiles online.  Unfortunately that information is still limited.

One organization proactive in driving transparency is Public Citizen.  This nonprofit group with offices in Washington, D.C. and Austin, Texas monitors several public utilities, and also has a division focused on monitoring healthcare information available to the public.  In 2006, they released an extensive report on the state medical boards from all fifty states. The medical boards of thirty-five states oversee both medical doctors (MD’s) and doctors of osteopathic medicine (DO’s).   Fifteen states have separate boards for doctors of osteopathic medicine, bringing the total number of state boards in the U.S. to sixty-five.

The bare bones information about a doctor is called the physician profile.  It contains only each doctor’s name, license number, and license status (active, inactive, retired, or suspended).  In addition, there may be information on each doctor’s education, where the degree was obtained, and whether the doctor is board certified by the American Board of Medical Specialties.  Some states include additional facts like which hospitals the doctor is affiliated with, whether there has been any disciplinary action by any state or federal agency, or the existence of civil and criminal court actions.

The Public Citizen report only gave one state, Maryland, an A grade for the information presented on its site and for its ease of use.  Ten other states were rated as “best,” which were in ranking order the states of: New Jersey, Virginia, Massachusetts, New York, Vermont (medical only), Georgia, California (medical only), and Idaho, Florida (both medical and osteopathic medicine).  Ten states were ranked as being the “worst” a title earned by only reporting the basic physician profile and board disciplinary action.

According to the Public Citizen report, there are six categories of information that should be available for public disclosure. Those categories and their explanations are as follows:

  1. Physician Identifying information – This would include the physician’s name, year of birth, address where the physician practices or resides, license number and license status as well as verification of specialty with board certification.
  2. State Board Disciplinary Action – This would include information that defined the offense committed, the action taken, the date of the action, the full board order, and a summary narrative of the offense.
  3. Hospital Disciplinary Action – This disciplinary action should include the committed offense, the date of the action, a summary of the hospital order, and the hospital order itself.
  4. Federal Government Disciplinary Action – This would include information on a physician disciplined by Medicare, FDA (U.S. Food and Drug Administration) or the DEA (Drug Enforcement Administration).  Medicare actions are generally on fraudulent billing or overcharges, the FDA would be misuse of medical instruments, devices, and medications in non-approved manners, and the DEA would be unlawful prescribing of narcotic substances.
  5. Malpractice Information – This would include judgments and settlements against each physician, including the dollar amount within the past ten years.
  6. Conviction Information – This would include information on all felony and misdemeanor convictions or nolo contendere pleas in the past ten years.

I abbreviated the following tables published in the Public Citizen report.  Although their report is over seven years old, I suspect, given current budget downturns in most states, the report’s information is still substantially the same.  Their report underscores the variable range of information found on state web sites.  Some state boards received a low score due to difficulty in use.  They required viewers to log onto a different web site to retrieve information, or request a written mailed report.

The table displays what information is available for each state:

Disciplinary actions against medical doctors or osteopathic physicians.

State Report Offense Action Date of Action Summary Board Order
Alaska YES
Ala. YES YES YES YES YES
Ark. YES YES
Ariz. Osteo YES YES YES YES
Ariz Medical YES YES YES YES YES
Calif Osteo YES YES YES YES
Calif Medical YES YES YES YES
Colo. YES YES YES YES
Conn. YES YES YES YES
D.C. YES YES YES YES
Del. YES YES YES YES
Fla. Osteo YES YES
Fla. Medical YES YES
Ga. YES YES YES YES
Hawaii YES YES YES YES
Iowa YES YES YES YES
Idaho YES YES YES YES
Ill. YES YES YES YES YES
Ind.
Kan. YES YES YES YES
Ky. YES YES YES YES
La.
Mass. YES YES YES
Md. YES YES YES YES YES
Maine Osteo YES YES YES YES
Maine Medical YES YES YES YES
Mich. Osteo YES YES YES
Mich. Medical YES YES YES
Minn. YES YES YES YES
Mo. YES YES YES YES
Miss. YES YES YES YES
Mont.
N.C. YES YES YES YES YES
N.D.
Neb. YES YES
N.H. YES YES YES YES
N.J. YES YES YES YES
N.M. Osteo
N.M. Medical YES YES YES YES
Nev. Osteo YES
Nev. Medical YES YES YES
N.Y. YES YES YES YES YES
Ohio YES YES YES YES YES
Okla. Osteo YES YES
Okla. Medical YES YES YES YES
Ore. YES YES YES YES YES
Pa. Osteo YES YES YES YES
Pa. Medical YES YES YES YES
R.I. YES YES YES
S.C. YES YES YES YES
S.D. YES YES YES YES
Tenn. Osteo YES YES YES YES YES
Tenn. Medical YES YES YES YES YES
Texas YES YES YES YES YES
Utah Osteo YES YES YES
Utah Medical YES YES YES YES
Va. YES YES YES YES YES
Vt. Osteo YES YES YES YES
Vt. Medical YES YES YES YES YES
Wash. Osteo YES YES YES YES
Wash. Medical YES YES YES YES
Wis. YES YES YES YES
W. Va. Osteo
W. Va. Medical YES YES YES
Wyo. YES YES

For the total 65 boards:

  • 58 report disciplinary actions taken against physicians
  • 31 summarize the action taken
  • 30 display the actual disciplinary order itself.

It’s noteworthy to consider that when state medical boards take an action against a doctor, it’s the result of an extensive investigation that may have taken several years.  It’s not based on a single patient complaint.  Usually it’s more than several cases which are then evaluated and distilled down to the most egregious cases.  The voluminous data is collected and verified and the doctor is given an opportunity to refute the evidence.

By the time a board action leads to license revocation, the potential for ongoing risks to patients is real.  As shown above, the lack of a summary report, or viewing the board order itself, forces people to speculate on what triggered the disciplinary action in the first place.  At the time of this report, four states did not have a web based mechanism to report state disciplinary board actions to the public.  Of interest are the fourteen states that distinguish between the types of material disclosed for medical doctors versus osteopathic physicians.  Of those fourteen states, two states report disciplinary actions taken against medical doctors, but report nothing for osteopathic physicians.

The practice of medicine frequently involves care rendered in hospitals.  If patients need hospital care, choosing quality providers is even more important.  The table below, summarized from the 2006 Public Citizen report, illustrates the available information concerning hospital disciplinary actions found on state medical boards.

Hospital disciplinary actions against physicians:

State Medical Boards reporting restricted physician privileges
State Medical Boards reporting restricted physician privileges

A cursory view of this table illustrates the paucity of such data with only eleven states displaying any information of this type, and only four boards displaying a summary of the disciplinary action taken by the hospital.

Since there are more hospitals than states, and each hospital is governed by quality assurance boards, there is a wealth of information on physician quality and treatment outcomes.  In addition, a hospital may decide to restrict a surgeon’s operating privileges due to many complications.  Such factors place the hospital at risk as a co-defendant in malpractice.  Even more alarming, in many states, when hospitals reduce a doctor’s privileges, they must notify the state medical board.  Yet that same information may not appear on the public web site.

Reporting Medical Malpractice:

How frequently malpractice embroils a physician is something most people would like to know.  The table below, also summarized from the Public Citizen report, reveals available information on malpractice made available on state medical board web sites.

State Medical Boards reporting medical malpractice
State Medical Boards reporting medical malpractice

Only eighteen states provide some information on their web sites.  Of those states, only 5 report the dollar amounts of the settlement.  Such information is also valuable because it speaks to the gravity of each specific case, and may distinguish between so-called nuisance suits.  Interestingly, at the time of this report, only four states displayed all information regarding malpractice litigation.

An AMA Forum presented an interesting solution to enhancing transparency in this area.

Finally let’s explore how criminal activity by physicians is reported by state medical boards.  In choosing any provider, be it doctor or baby-sitter, most people shun providers with a felony conviction.  Yet it’s surprising how this is handled among various state medical boards.

Reporting Criminal Convictions in Physicians:

Criminal Activity reported by state medical boards
State medical boards reporting criminal activity

In this report, only 13 states report criminal convictions on their web sites.  Eight of those states give details about the conviction and only four of those states report all of the conviction information.

Although personal privacy, forgiveness and compassion are important after someone commits a serious mistake, there is still a debate on how much information should be in the public domain.   After “paying back their obligation to society” and amending their ways, many feel that doctors should be granted a new start.  Yet  the nature of the conviction alters how far the public forgiveness can be stretched.  For example, people may be willing to forgive a DUI in a dermatologist nine years ago, but not a sexual offense in an obstetrician committed a year ago.

As we have seen thus far, it appears that healthcare prices are quite variable and unrelated to treatment outcome.  In addition, it appears that selecting a medical provider based on a background check is dependent on where one lives.  And most importantly, current information systems reveal nothing about the doctor’s skill for treatment results in patients with similar levels of illness.  It remains one of the greatest challenges facing good public health at reasonable costs.  It’s also what we will continue to explore in ongoing blogs.  As a matter of fact, healthcare is one of the few service industries where payment is primarily based on delivery of service, not outcome.