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Is there a "Medical Mafia"?
(06-23-2013, 05:21 PM)DocWils Wrote: Archangel, that is simply not my experience. It may be so in your town, but certainly not in the bulk of the US and not over here at all.

Yes, collegiality is very important in our field (in what field isn't it?) but there is a medical board in every state, and sooner or later bad doctors are carpeted by it. I have seen it myself several times both during my time in the US and here.

Considering how Americans are willing to sue at the drop of a hat (and is one thing that pushes medical costs through the roof, BTW, due to the massive malpractice insurances medical professionals in the US must carry), I doubt that dangerous doctors can stay in practice for very long unless there is an "old boy's network" in the justice system that helps them out. My experience is that for the most part, the bad ones don't manage to stay on for long.

Laser eye surgery is licensed differently the US than over here - you don't have to be a board certified ophthalmic surgeon to perform it in the US and that will lead to all sorts of abuses. Personally, I wouldn't have it done anyway, since there is a growing body of evidence of negative side effects as one ages, but that is another debate for another time. I assume no one ever filed an official complaint with the state licensing board against said eye-cutter?

I think the problem is that what the medical community considers a "bad" doctor is entirely different from what the general public calls a "bad" doctor.

I don't think the medical community considers the following hypothetical cases to be a "bad" doctor.

  1. The chop happy ENT who thinks every apneac needs a UPPP. He doesn't seriously discuss UPPP vs. CPAP with his patients. When they check into the hospital for the procedure, the patient is given 10 pages of paperwork, one which is a 3 page legalese generic legal disclaimer with a paragraph added at the end about the risks of UPPP.

    He counts any apneac who shows a 50% reduction in AHI as "success."

  2. The "sleep specialist" who sends patients to an overnight sleep study, allows the DME to dispense a brick CPAP machine, and even if the patient has a data capable machine, he never looks at the CPAP data.

    He depends on the DME to read the data if any. The DME reports anyone who gets 4 hours use a night as "everything looks fine."

    If there are any problems, instead of looking at the "free" data that tracks the actual data, he requires the patient to pay for a new expensive and profitable sleep study with a single night's data where the patient sleeps poorly, in an uncomfortable setting, with wires taped all over him, forced to sleep on his back instead of on his side the way he normally does. The patient gets a few hours of sleep with no REM, but it's still better than the "unreliable" data the CPAP has collected for free for the past seven days.

  3. The doctor who prescribes the expensive new drug that costs 10 times as much even though there is little evidence it's better than the old drug, and little evidence of the long term side effects.

  4. The doctor who habitually prescribes lots of expensive and profitable medical tests that only have a tenuous medical justification. You can't absolutely prove the test are unnecessary, but it's clear the benefits don't exceed the risks or costs for the average patient.

  5. The doctor who does expensive, thoughtless, uncaring, assembly line style office visits. Bring in the patient. Rush the patient through the discussion. Pick the easiest, textbook style diagnosis without doing much to figure out whether there's some other possible cause. Ring the register. If the patient doesn't get better right away, he has to suffer several weeks waiting for another appointment.

  6. The doctor who lets his patient suffer in pain because there's no clear objective measure of pain, and the doctor doesn't want to get a reputation as overprescribing narcotics. I will admit this is largely a fault of "the system" and our anti-drug Nazi government attitude.

Let's consider the hypothetical Dr. E, another bad laser eye doctor.

He runs an assembly line operation. He heavily promotes laser eye surgery. He downplays the risks. He's a very likable character with a good bedside manner. He's really good at talking people into the procedure.

When the patient checks in for the procedure, they get the standard 10 pages of forms and legalese with the checkin clerk impatiently waiting for the patient to sign. Buried deep in the legalese is a statement of risks, including anasthesia, drug reactions, infections, etc., along with an unhighlighted discussion of the risks of the particular surgery buried on page 7.

He uses older, but still FDA approved, laser equipment. Newer equipment has sensors that shut off the laser if the eye moves, but Dr. E hasn't bothered to upgrade. Dr E. gets a larger than normal number of bad results because of this.

Dr. E does a lot of operations per day. He doesn't do a lot of clear "errors," but he has a higher than average number of patients who develop problems.

There is some delicacy in the process of finding the right depth to cut into the cornea to find the right layer and peel back the flap before the laser process. Dr. E is in a hurry and has a larger than normal number of problems due to a bad cut. All eye surgeons have some degree of this problem, but Dr. E gets more problems. Nothing he does is clearly wrong, he's just not very good at it.

There's some delicacy in getting the flap to lay back down correctly after the eye surgery. Sometimes, it ends up wrinkled and gives poor vision. This happens to all eye surgeons, but the high volume Dr. E gets more than his share of problems.

Dr. E is a very glib talker who is well liked by his patients. He manages to convince a lot of his patients that they were just one of the small number of patients who experience problems, and that it won't be so bad as it heals up and they adjust to it. Very few of his patients end up filing formal complaints.

He's in his own private practice, so there's no higher level medical practice that evaluates his results. He keeps his own statistics in terms of "success" rates.

In theory, there is a state medical board, but they are "overworked" and mainly look for blatant, black and white violations of clearly defined practices. As long as Dr. E knows how to "CYA" in terms of procedures, nothing will happen to him.

All the other eye doctors in town see a lot of Dr. E's failure, but there's really no process in place for them to do anything about it. If they say anything, they'll be ostracized by the medical community.

As for the lawsuit risk, Dr. E is very well lawyered up. The form he sneaks into the checkin process is very well worded and gives him a lot of protection. He's well known for having high powered legal talent and vigorously fights every lawsuit. He's very careful to not do anything that's clearly and objectively wrong. He's very careful in his documentation to not document anything that can be used against him. He almost never settles. All the local attorneys know that he'll be a very tough fight in court, so most of them won't take the lawsuit on contingency. The high volume of his practice more than covers his legal expenses.

Yes, as I said, Dr. E is hypothetical. However, I don't think he's that atypical.

I don't think most doctors are that greedy or uncaring. However, the "bad" ones do happen. "The system," especially the corporate systems everyone is getting pushed into by insurance and regulation, pushes doctors into this kind of attitude and protects the bad apples.

Many of doctors I've talked to are very disgusted with the degree to which they're pushed into uncaring, CYA, profit centered, assembly line practice by "the system."
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Socialized Medicine ... The provision of medical and hospital care for all by means of public funds
The problem is that pure Communism is a fundamentally un-substainable system. Human nature being what it is, there will always be people who produce less than their ability due to laziness, and take more than their need due to greed.
Countries with so called "socialized medicine" are not run by some communist system
Just to name few ... United Kingdom, Australia, Sweden, Norway, etc ...
Can you spot what most top 10 world's happiest countries (according to "Organisation for Economic Co-operation and Development") have in common Rolling laugh

The World's Happiest Countries
United States
The Netherlands
United Kingdom

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(06-25-2013, 06:04 PM)zonk Wrote: Can you spot what most top 10 world's happiest countries (according to "Organisation for Economic Co-operation and Development") have in common

They all sell PRS xPAP machines?

Oh wait, that was the other thread!

(06-25-2013, 06:04 PM)zonk Wrote: Can you spot what most top 10 world's happiest countries (according to "Organisation for Economic Co-operation and Development") have in common Rolling laugh

Happiest? A drunk man is happier than a sober one.
(06-25-2013, 07:14 PM)jgjones1972 Wrote: Happiest? A drunk man is happier than a sober one.
Julius Caesar think so too Smile

Let me have men about me that are fat;
Sleek-headed men, and such as sleep o' nights.
Yond Cassius has a lean and hungry look;
He thinks too much: such men are dangerous.
Act 1 - scene ii

So, we've moved from the Medical Mafia to a discussion of economic politics (and yay! Isn't America great?)? Maybe THAT needs a new thread, too.

For the record, few of the countries listed are socialist or even neo socialist - Switzerland is so capitalistic that we make the Ferengi nervous and make the Amis look like communists. Canada is barely neo socialist, and only fits that in two regards - a public health care system and a government mandate to make sure that small businesses starting out can play on an "even" field with the big boys - but the mandate extends only to getting the business going - what the owner does with it after than is his own look-out. Britain gave up any pretence of socialism under Blair and his New Labour movement, better known as Cool Britannia. The Aussies sort of scratch neo-socialism and only Sweden and Norway have any real socialist credentials, and both are clawing those back to a more free-market economy than they previously had.

I hear constant griping here about the medical system in the US and when there is a suggestion of how to maybe make it better, the shrieks and cries of how Unamerican it is is deafening. So enjoy your very broken system (and it IS broken) and we'll work with our systems and our longer life expectancies, thank you.

And for the record, I get the impression that those of you who shrieked about lack of freedom when I suggested the US could easily adopt the Swiss system haven't a clue how the Swiss system works - it is still completely capitalistic and profit oriented at its core, but basic insurance for all (currently that is actually 95% of the populace) is guaranteed by all insurance companies being mandated to provide it more or less "at cost" and "no refusals". If your income falls below a certain level, the government will step in and make up the shortfall. For that we have not ever had to raise axes or any other form of fees from the public weal (although we DID have to raise taxes to pay for American fighter jets that we never needed or wanted or could ever be of real use to us, but that is a different story about government incompetence, and a lot of boys who wanted big toys for an air force that only works during office hours from Monday to Friday). You STILL pay for your basic costs yourself (called a franchise) which depending on how much your basic insurance is, can run from the first 500 SFR in medical bills in the year to the first 2700 SFR of costs in the year, and you still have to pay 10% of the fees after that, plus of course your basic insurance payments of anywhere from 3000 SFR in the year up to 5600 SFR per year. And that is only basic coverage - if you want supplemental insurance for half or fully private hospital rooms (and the added treatment options, including getting the top doc and not a resident, etc) you have to pay a lot extra, and NONE of it is covered by the government if there is a shortfall. So, I don't know - is that more expensive, the same or less expensive than most US plans? Dental isn't covered at all, btw - most of us go to Germany or Hungary because it is a LOT cheaper.

The difference is not that Americans would be forced to buy insurance, but that insurance companies would be mandated to provide it without refusal and for reasonable costs. To gripe about insurance companies on the one hand then rail against them being made to toe the line and do the right thing by law on the other hand, well, can you say cognitive dissonance?

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Zonk, methinks you did not understand what Ol' Bill was writing there - Julie was speaking against political ambition.

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