(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.
- 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."
- 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.
- 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.
- 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.
- 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.
- 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."