who can you trust

Monday, June 24, 2013

Dr. David Chao’s recent fall from grace is a reminder that it is hard to decide who might be trusted to provide medical care and who should be avoided. Dr. Chao had been team physician and orthopedic surgeon for the San Diego Chargers, until he resigned this week, ostensibly because of a back injury and to spend more time with his family. Then the news broke that his privileges had been suspended and he was no longer allowed to operate at two hospitals. This came after the National Football League Players Association had questioned his competence because of two malpractice lawsuits and a letter of reprimand from the California Medical Licensing Board. However, the NFL had three independent physicians review his medical care and found it to be satisfactory. Plus, there were the testimonials of the Charger players, including Philip Rivers and Nick Harwick, supporting Dr. Chao.

There is a difference between the ability for a doctor to practice medicine and the ability to practice well. The presumption is that there safeguards on place to keep the public safe and informed about physicians who hand out their shingle. But that information is not readily available; the journey from medical school to looking after patients is not necessarily a line easily followed.

The first step is the easiest. Go to medical school (also appreciate that this timeline may also apply to doctors of osteopathy or DOs) and get an MD. Then it’s time for postgraduate training. Complete an internship year and pass the national medical board exam and you can apply for a license to practice in most states in the US. Each state has its own rules and regulations and medical licenses don’t cross borders. Some states require two years of extra training while Maine requires three. Some states have no limits as to how often the new MD can fail the board exam, just as long as there is an eventual passing grade. Other states may allow only two failed attempts. There are different requirements for graduates of foreign medical schools that are somewhat more stringent.

This first step allows the doctor to open a practice and see patients. The state medical licensing board has little continuing oversight, except for the yearly medical license renewal, where the physician attests that they have completed continuing medical education, have not been convicted of a crime and have not been sued for malpractice. While most doctors practice in their field of training, there is little to stop a doctor from opening a weight loss or cosmetic surgery clinic or any other area of practice.

Most doctors take step two and continue residency training to become a specialist. Primary care takes three to four years, while surgeons and subspecialists may spend the better part of a decade developing their skills. To qualify as a specialist, the doctor is required to pass an exam given by their specialty board; some are written, some are oral and many have both. The certificate is often time limited and the specialist has to pass exams every 7-10 years.

Finally, there is step three. Many physicians care for patients in a hospital and need privileges to do so. These are granted by the hospital medical staff through the credentialing committee and allow the doctor to work in the areas where they are qualified. An internal medicine specialist would not be given obstetric privileges to deliver a baby and a pediatrician would not likely practice in an adult ICU. Hospital credentials are a big deal because each doctor is his or her brother’s keeper. The background of each doctor is scrutinized including medical school, residency training, licensing, disciplinary actions and malpractice lawsuits. An information clearing house allows information to be shared nationwide, and most hospitals require privileges to be renewed every couple of years. It is a big deal for a hospital to limit or remove privileges. Most doctors are held to minimal standards of performance and skill and it takes great effort to fall below that low bar. Insurance companies may also screen doctors and HMOs, PPOs and the other alphabets of managed care may also set practice standards.

How to choose a doctor remains a difficult problem. Some pro sports teams have made that decision based on money; what doctor or hospital will pay the most to advertise themselves as doctors to the stars. The rest of the world often relies on word of mouth and referral from family or friend. This may be problematic because most patients love their doctor but are less than aware of training, credentials or practice issues. This is where the internet comes in handy and here are a couple of places to check:

The saga of Dr. Chao seems more than a little contentious and his story will fade. The San Diego Chargers and Scripps Hospital will continue on. The NFL Players Association will fight to provide their members with the best doctors available. And fans will appreciate that it’s hard to decide whether a doctor is a star, a benchwarmer or shouldn’t even be in the league.

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the “official” doctor

Monday, February 18, 2013

The same day that Rajon Rondo of the Boston Celtics underwent successful knee surgery in Birmingham Alabama, the NFL Players Association was demanding reform in how doctors are chosen to look care for their members.  The link between the two stories is one that affects most people in the US, not just elite athletes, and has to do with trust and the patient-physician relationship. How do you decide what doctor will be the right one for you, whether it is a family physician, obstetrician or surgeon? Even the most restrictive insurance plans offer opportunities to choose but how?

Back to the NBA and the NFL.  Rajon Rondo went doctor shopping to find the surgeon he trusted to repair the torn ACL in his knee and decided upon Dr. James Andrews of Birmingham, Alabama one of the most renowned orthopods in the country. He has operated on some of the most accomplished athletes in the world and is team doctor for the Washington Redskins, but not the Boston Celtics. Their team physician is Dr. Brian McKeon of the New England Baptist Hospital but that relationship was not enough for Rondo to pick the doctor and hospital preferred by his team. It seems that many pro teams view the official hospital and doctor designation no differently than any other sponsorship deal. For millions of dollars, New England Baptist has the right to advertise itself as the “official and exclusive Celtics hospital” just like the Celtic deals made with Dunkin’ Donuts and Reebok. There are many quality hospitals in the Boston area, home to Harvard, Boston University and Tufts to name a few, but for marketing hops, only Baptist can claim to be the chose one for Celtic green. And yet, the hospital that was good enough for Larry Bird was bypassed by Mr. Rondo.

The NFLPA has been working hard to promote safe medical care for its players, especially on the concussion front, pushing to get an independent neurologist on the field to assess any player with a potential head injury. Never mind that neurologists tend not to deal with concussions routinely; it is the purview of sports medicine specialists, emergency physicians and neurosurgeons. The idea, however, was to have a doctor who has no affiliation with the team provide care, presuming that the team physician might have mixed allegiances, to both player and team, and the advice given may not always be in the player’s best interest. There has been precedent for conflict of interest and perhaps the most flagrant case occurred with Marty Barrett who played for the Boston Red Sox in the 1980s. His ACL injuries were misdiagnosed by team physician Arthur Pappas, who also happened to be a minority team owner. Mr. Barrett was awarded a $1.7 million judgment. The latest concern of trust with an NFL team doctor rests in San Diego, where team physician, Dr. David Chao, has been sued numerous times for medical negligence. By itself, this is not an issue since many well qualified physicians are sued, but much more worrisome is that the California State Medical Licensing Board has publicly reprimanded him and is in the process of seeking to suspend his license to practice medicine in the state.

When choosing a doctor, most people give it little thought and usually spend more time and energy researching mechanics, painters and tennis instructors.  Finding the right fit with a family doctor is a tough job.  The ideal candidate will become a life-long advocate for your care with disease prevention and routine screenings, as well as caring for the acute illnesses and injuries that can happen. In today’s mobile society, people often move to places where they to start a new physician-patient relationship and the process is like getting divorced and starting to date again. The first place to start is with family, friends and coworkers for their recommendations but then the hard work begins. A computer search of the American Medical Association doctor finder website can tell you about training and qualifications. After that, a search for the State Medical Association or the State Licensing Board may be appropriate to look for licensing issues, reprimands or practice limitations. But the big test happens when you make an appointment and decide whether you like that particular doctor. There is no shame in looking for a personality or practice style that satisfies your need. Most often, you want to develop a relationship that lasts years and not just a one night stand.

Years ago, the AMA stated that it was unethical for doctors to advertise. Unfortunately, that ethics were trumped by legal rights and there are plenty of radio, TV, newspaper and billboard ads to go around.  While it may be fine to choose your next donut or running shoe based upon your favorite player’s testimony, finding your doctor soul mate should take more time an effort than knowing about the official doctor and hospital status of New England Baptist and Drs. Andrews, McKeon and Chao. It’s a title likely bought and paid for, just like a Yellow Pages ad.

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