Medical Ethics

Medical Ethics: Is the Price Right?

 

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Over the years as a practicing primary care physician, I have witnessed ethical dilemmas that remind me of the long-running, popular TV show, THE PRICE IS RIGHT. But unlike the show, the price one pays for medical care encompasses not only money, but issues of quality of life, unintended consequences, and possibly life itself. Options and decisions are not always black or white and the person or group tasked to render best practices advice does so from a complex of diverse educational and cultural backgrounds.
The following are real cases that highlight questionable medical practices with respect to ethics, proper oversight, credentialing and licensing. Even though the majority of clinicians deliver health care ethically, deeply caring for their patients, there are some who do not. In these cases, the lay public too has responsibilities. As Jay Leno once said, “If you trust Google more than your doctor, it’s time to get a new doctor.”

CASE ONE:
An 83-year old married, Caucasian male with no children has noticed problems with intellectual processes (thinking, reasoning, remembering). He and his slightly younger wife of over fifty years attribute the changes to “getting older.” He still drives short distances, eats without help, and takes care of his personal hygiene and grooming. He usually takes a morning walk around his neighborhood retirement community, with or without his wife. One morning he was walking alone, passed out, and hit the side of his face and head. Golfers in the area called 911 and an ambulance arrived within minutes to transport him to the emergency room of the nearest hospital. Luckily, he had his wallet with identification. His wife was notified and she immediately went to the hospital ER.
The emergency room evaluation revealed an elderly man with a badly bruised face, no recollection of his name, date, transport or location. He recognized his wife when she arrived. His injury was diagnosed as a concussion and he was admitted to the hospital. Because the couple did not have a family physician, the hospital assigned several physicians: an internist, a general surgeon, a neurosurgeon, and a cardiologist. They ordered multiple laboratory tests, a total body CT looking for trauma, and two MRI’s. The cardiologist ordered daily EKGs. He submitted bills to Medicare and their secondary insurance but never talked to the wife. The internist told the wife that he placed her husband on an ACE inhibitor and diuretic for blood pressure control. He also left an order for sleep medication if needed. The general surgeon exited from the case after concluding that his services were no longer needed.
The wife called me, as a family friend, on the third hospital day. She told me what had happened to her husband and was particularly upset about two things: 1) Her husband was still confused about his surroundings and had no recollection of his fall or the transport to the hospital; and 2) The neurosurgeon had made a diagnosis of “normal pressure hydrocephalus” and recommended an immediate shunt operation. I told the wife that a diagnosis of “normal pressure hydrocephalus” was, to me, an oxymoronic conclusion; i.e. if the pressure is normal, why put a tube in to relieve excess pressure that doesn’t exist? I also checked with various specialty colleagues and came away with the same conclusion; a shunt was not needed. The most likely diagnosis was a concussion that would most likely improve over time. Once the wife refused permission for neurosurgery, the social worker suggested that her husband be transferred to the “acute rehabilitation service.” She was told that Medicare covered him for two weeks, after which he would be eligible for possibly 180 days of “chronic rehabilitation care,” depending on his progress. After further discussion with the social workers, the wife found out that she could sign her husband out of the hospital and have Medicare cover home rehabilitation and nursing care for several weeks. Even though I advised that her husband extend his stay in the hospital for a few days, she opted to take him home right away. She was very disappointed with her assigned physicians’ lack of attention to her husband and communications with her.

After the third day at home, the therapist arrived for the usual morning workout. She took the patient’s pulse and told the wife she would have to skip that morning’s therapy because his pulse was down to 40 beats per minute. The wife called me and I made an immediate appointment for him with a cardiologist friend of mine. He needed a pacemaker. The cardiologist explained to the wife that an irregular heart rate probably caused him to blackout during his walk. His blood medication was discontinued because of unpleasant side effects.

It has been three years and he is doing well; not perfect, but well. He needs assistance with bathing and help in getting his clothes on. He feeds himself. He discarded his walker after the first 4 months post pacemaker and he accompanies his wife on errands about town.

What is your evaluation of this scenario?

  1. Did the medical attention given to this patient and communication with the wife meet acceptable standards?

Yes        No

  1. What about the neurosurgeon’s diagnosis and recommendation for a shunt?
  • An error in judgment?    Yes        No
  • Outright medical malpractice?    Yes        No
  • Too busy, tired, or preoccupied?     Yes        No
    Should the wife have asked about the average number of shunts he had implanted compared to local and/or national data bases?    Yes        No

3. Why didn’t the hospital cardiologist or the internist diagnose the need for a pacemaker?

  • An honest medical error?    Yes        No
  • Inadequate attention to test results?    Yes        No

4. As this woman’s primary care physician, would you have reported this incident to the hospital’s ethics board?

Yes        No

Please explain your answers.

CASE TWO:
An 80-year-old Caucasian lady living alone with a black German Shepherd in a small retirement community developed generalized abdominal discomfort with mild nausea on a Monday. Her personal and family history contained no significant disease condition. She belonged to a medical plan that required that she see a physician in their directory.
When this woman called the physician ‘s office on that Monday, the office staff listened to her complaint and advised her over the phone about drinking fluids, using Tylenol for pain, and resting. She called every day saying it was getting worse. She never spoke with the physician. By Friday she was throwing up, had severe diffuse abdominal pain, a temperature of 102, and could barely get out of bed. The staff advised to come in for an appointment that afternoon. The physician (according to the patient) did a very cursory examination and told her that she had diverticulitis. He prescribed an antibiotic and sent her home. She passed out at home. When she regained consciousness, she called 911. The ambulance took her to the nearest hospital where she was diagnosed as having diverticulitis with a perforated bowel. The surgeon did an emergency laparotomy with bowel resection, temporary colostomy, drainage, antibiotics and intravenous fluids. She did survive. After approximately six months, her surgeon admitted her to the hospital to reconnect the remaining bowel and do away with the colostomy. She developed a staphylococcus methicillin resistant infection, which led to increased morbidity, need for mesh reinforcement of the abdominal wall, and expenses not covered for outpatient perfusionists and very expensive antibiotics.
This patient had been an executive secretary in earlier life. She was computer savvy and very meticulous with keeping records. She had hospital records, ambulance records, doctor’s office records, prescription records and outpatient consult records. I looked at her copies of office records from her visits to an infectious disease expert. His records clearly stated, in his words, “hospital acquired staph resistant infection.” The preponderance of evidence leaves no other choice as to the origin of the infection; you go into the hospital fine and come out with an infection. The hospital, of course came up with other scenarios.
I became aware of this case through a series of award winning articles about hospital mishaps and I offered to look into the details to see if I could help this woman get monetary justice. The damage had already been done. She had written to the State Board of Medical Examiners. Their decision was, ”there was no evidence of malpractice.” She tried to find an attorney with no success. By the time I got  involved, the statute of limitations had expired. Of eight attorneys I called, one advised, “If the patient has sufficient money and longevity, she could find an attorney to take her case. Her chances of setting a precedent relative to the statute of limitations, based on mitigating circumstances, were next to none, but she could try.”
What do you think of this case?

  1. Why didn’t the primary care physician diagnose the perforated bowel?
    • An honest medical error?    Yes        No
    • Inadequate attention to the physical exam?    Yes        No
    • Failure to order lab or other tests?    Yes        No
  2. Should the surgeon or the hospital we held accountable for the infection and subsequent complications?
    • Surgeon
    • Hospital
    • Neither
  3. If she were your patient, would you advise her to report this problem to her medical insurance company?    Yes        No
  4. The infection that this woman developed following the surgery, was this due to:
    • An error in judgment?    Yes        No
    • Medical malpractice?     Yes        No
    • Being too busy, tired, preoccupied?    Yes        No
    • Lack of sterile technique in the surgical room?    Yes         No
  5. As this woman’s primary care physician, would you have reported this incident to the hospital’s ethics board?

Yes        No

Please explain your answers.

CASE THREE:

Recommended guidelines for colonoscopy are relatively clear with respect to when and how often the procedure should be done:

  1. There are high risk patients and low risk patients
  2. There are abnormal intestinal discharges or other chief complaints involving the large bowel

Yet unfortunately monetary incentives drive a minority of physicians to order certain tests. Some of the tests carry the risk of serious mishaps and the patient needs to know the risks. One such physician arrived in my hometown with very little material possessions but huge expectations coupled with an obsession to succeed in terms of money and power. Over the years, he became a leader in gastroenterology.
In 2007, the County Health Department was notified and investigated three closely-timed cases of Hepatitis C each following a colonoscopy at the hospital where the unnamed doctor was the chair of the GI department. The City Mayor first stepped in to curtail activities by revoking the business license of the Endoscopy Center. No health regulatory body came forward in an appropriate and timely manner.
In 2008, the Board of Medical Examiners restricted the doctor’s license and allowed it to expire in 2010. If he were to make application for licensing in another state, he could truthfully say that his medical license was never revoked. Although the unnamed doctor is up for trial, the date has been repeatedly rescheduled. The charges are serious. He and his two nurse anesthetists were charged with 28 felonies for allegedly exposing patients to hepatitis C. He was also charged with racketeering, patient neglect, and insurance fraud. One of the hepatitis C patients died in April, 2012. The doctor and company are now charged with second-degree murder. Not only are these undesirable events preventable, they should never have happened. But just as important, appropriate penalties and accountability should have been applied so as to minimize a recurrence. Effective oversight was glaringly lacking.

What do you think of this case?

  1. In your opinion, is there effective oversight in the hospital where you practice?    Yes        No
  2. Should the nurse anesthetists have reported the physician to the hospital ethics board?    Yes        No
  3. If one of the three individuals who contracted Hepatitis C after a colonoscopy was you patient, what would you have advised?
  • I will report the incident to the hospital ethics board
  • Contact your insurance company
  • Focus on managing the disease

4.  Would you refer a patient for a colonoscopy to the Endoscopy Center after its business license was reinstated?

Yes         No

For your patients’ Bill of Rights, go to Families USA. The Affordable Care Act: Patients’ Bill of Rights and Other Protections. April 2011.

http://familiesusa2.org/assets/pdfs/health-reform/Patients-Bill-of-Rights.pdf

Leonard Kreisler, MD

Published on April 2, 2013

Biosketch

Dr. Leonard Kreisler, MD received his Board Certification in Occupational and Environmental Medicine as well as Family Practice. He has fifty years in health care delivery (forty in Las Vegas). Dr. Kreisler’s medical practice started in 1960 with 13 years as an old-fashioned Marcus Welby-type family doctor in Peekskill, NY. He currently enjoys writing and lecturing on healthcare issues.