Taking Risk

Risk.

\"risk\" In some ways this one word defines what it is to be a doctor.  We practice applied science.  We look at a patient and take general scientific concepts and personal experience to decide what needs to be done.  We make the decision.  We take the risk.  We put ourselves on the line.

Sometimes it feels like I am tiptoeing past a sleeping tiger.  A misstep will change life, yet I have no choice but to take the risk.  It happens nearly every day.  I try not to think about it too much, but it sits there in the back of my mind.

Narcotics, disability forms, depression, pediatrics, test results, fraud – each one can be like defusing a bomb.  Be careful, think straight, second guess yourself frequently, and allow yourself to worry.  Do I lose sleep on these?  No, but I do get gray hairs and take antacids (and compulsively blog).

Let me explain:

Narcotics

Each day I get requests for pain medications and anti-anxiety medications.  I get many requests.  I do believe that these medications are appropriate if used for the proper situation, but also know they can be abused. 

While I think I am pretty good at spotting drug abuse, I also believe in making patients show me they are not trustworthy.  I don\’t want to be used by a drug-seekers, but I also don\’t want to be unsympathetic to pain, either physical or emotional.

I have my typical \”shpiel\” I give folks when I first prescribe them – how they should not be taken regularly – but I am pretty sure some abusers get by me.  Every time I give a refill on these medications I get that feeling in the pit of my stomach.  When I see stories of doctors prosecuted for over-prescribing these medications, I wonder how much it needs to cross the line.  I try not to cross it and document as well as I can, but I know some patients that put their toe on the line.

Disability Forms

These forms are no-win situations.  Some of the time I fill them out, I don\’t really think the patient is disabled; other times, I feel strongly that they are.  The questions on these forms are often difficult judgment calls – they ask me when the patient can return to work, whether the disability is partial or total, and what types of duties they can do if it is partial.

I often have no idea.  The person is sick and can\’t work.  They are not real functional.  Could they sit at a keyboard all day and type?  Maybe, but that is not what these forms are generally asking.

I try to fill them out as convincingly as I can, but am aware of the fact that if I don\’t have substantiating information, I can be seen as defrauding the government.  So I am caught between the desire to help my patient, and the fear of prosecution.

I hate disability forms.

Depression

Depression scares me.  I am trained to handle diabetes, heart problems, infectious disease, etc.  I expect to deal with these problems, and generally know what to do with them.  Either I diagnose and treat them myself, or I send the patients to a specialist.  If they are really sick, I call the consultant and can generally get patients in the same day.

But people walk in with the main problem of depression, and I am stuck.  I can\’t call a psychiatrist and get the patient seen immediately.  I Can\’t even get one on the phone.  Plus, I don\’t really know if the patient is suicidal or is at risk of harming others.  I do my best to triage this, but I have only 10-15 minutes to come to this decision.

Even after making the decision, I have to choose a plan of action and send the patient out the door.  I can\’t expect the patient to necessarily be reasonable and know when to call me.  They are depressed. 

But I can\’t keep them from coming into my office.  They know me and trust me.  Who else can they go to when they are depressed?  Once they are there, I have no choice but to treat as best as I can and cross my fingers as they walk out my door.

Kids

Being a pediatrician, sick kids scare me less than they do other doctors.  Certain ED physicians are notorious to pediatricians as being uncomfortable with kids. 

But the reason I am not as scared taking care of them is because I know when to turn on the paranoia.  I have seen enough truly distressed kids to know them by looking at them.  There are certain things that make me anxious: kids with a limp, fever under 3 months, little girls with fever, peeling lips, and purple rash on the legs.

Still, it only takes one bad day to change your life forever.  It is one thing for an adult to suffer harm from a misdiagnosis, it is another for it to happen to a child.  Kids aren\’t sick a lot, but when they are truly sick, it is far more scary because of the number of years they could lose if you mess up.

Child abuse is even worse.  I wonder all the time at how many abused kids have come through my office without me catching it.  I don\’t want to falsely accuse someone of abusing a child, so I tend to suspend belief.  All people do that.  But the thought of a sexually abused child being missed by me gives me a sick feeling.

Test Results

If I order a test, I have to follow up on it.  If I don\’t then I can be sued.  Even if the patient does not get it done by their own choice, I must give reasonable effort to make sure they get it done.

Only with the best information system can give reasonable assurance that I am seeing all of the tests I order.  Very few of us have those systems.  I have been on an EHR for 12 years, and I don\’t. 

So I do my best.  I try to follow-up on all tests I order.  The problem is, I don\’t get paid a dime for being careful, and being careful takes a ton of time.  This means that nearly everyone cuts corners.  You just hope that those corners don\’t come back to haunt you.

Fraud

I do pretty good with my charting.  We have a good system that makes compliance with E/M coding a pretty good bet.  But I know that if an auditor combed over the records, they would find disparities in how I charted and how I billed.  If someone wanted to get any physician in the US, they could.  The documentation process is too difficult to get perfect.

Many physicians fight this by simply down-coding their notes so that they know they are compliant.  Others (like me) use EHR systems that do the charting in a way that complies with the gods of insurance.

The problem here is that my mistake is not simply a mistake, if it is in a Medicare or Medicaid chart.  My mistake is considered an attempt by me to defraud the government.  Does that worry me?  Yes.  I don\’t lose sleep over it, but I do wonder what will happen if/when I get audited.  I know I am not consciously trying to cheat anyone out of money, but an audit could get my name on the front page of the paper.

Conclusion

Those who think that doctors are overpaid need to consider these things.  It is my name on the prescription.  It is my name on the chart.  I sign the form.  I decide if the person can go home, or if the child is being abused.  Nobody is standing behind me to take the blame.  I will be blamed for errors.

I signed up for this job, and I continue to do it.  I still don\’t want to quit.  But that does not mean that the daily burden of risk does not take its toll.  That toll is fatigue and chronic anxiety for many.  That toll becomes bitterness when coupled with a system that keeps lowering what they pay us while raising our exposure to risk.

27 thoughts on “Taking Risk”

  1. When I was a resident Rob I had a guy in DT’s (alcohol withdrawal) all night after a neck dissection (oral cancer). He was restless but tolerable with a heart rate in the 120’s. I was green and scared and alone so I gave him 2mg of valium all night long (instead of the 30 or 40mg he likely deserved). On morning rounds, the sun came up, the guy went over the edge and the chief resident gave him a real dose of valium but it was too late and he’d already had an MI.
    Years later my friend (a former nurse) graduated from the RCMP (Mounties) training academy as valedictorian and came up with the best line I’ve ever heard on the subject; “Sometimes even the wrong decision is better than no decision at all”.

    It’s too bad that your concerns have had to shift from the drama of residency life to the humdrum of billing and narcotics control but the quote still applies.

    http://www.waittimes.blogspot.com

  2. When I was a resident Rob I had a guy in DT’s (alcohol withdrawal) all night after a neck dissection (oral cancer). He was restless but tolerable with a heart rate in the 120’s. I was green and scared and alone so I gave him 2mg of valium all night long (instead of the 30 or 40mg he likely deserved). On morning rounds, the sun came up, the guy went over the edge and the chief resident gave him a real dose of valium but it was too late and he’d already had an MI.
    Years later my friend (a former nurse) graduated from the RCMP (Mounties) training academy as valedictorian and came up with the best line I’ve ever heard on the subject; “Sometimes even the wrong decision is better than no decision at all”.

    It’s too bad that your concerns have had to shift from the drama of residency life to the humdrum of billing and narcotics control but the quote still applies.

    http://www.waittimes.blogspot.com

  3. I really enjoyed this post, thank you for the insight. When my son was 2 he had chicken pox. He had a 103 degree fever for four days. I kept calling the pediatrician, but he said that could be normal. By the fourth day my son couldn’t walk, something was apparently wrong with one of his legs. I called the doctor again, practically begging to be seen. They finally allowed me to bring in my son before regular office hours (along with my 9 month old daughter who also had chicken pox). When the doctor saw a purple rash on my son I noticed that he immediately became a different person. At first he was looking at a child with chicken pox, a minute later he was looking at a child with something much worse (I still don’t know what that might have been). So between the fever, the rash, and the leg problem he immediately sent my son to have a bone scan.
    Luckily he did not have a bone infection. He did have a skin infection which required antibiotics, and an emergeny visit to the orthopedist which resulted in a diagnosis of synovitis – the virus got into his hip and thus he couldn’t walk.

    He recovered from the chicken pox, from the side effects of the antibiotics (ugh), and from the synovitis. It was scary for me, and the only time that I ever saw a doctor visibly shaken. Perhaps because I had been asking to bring in my son for 4 days, and they just treated me like an overreacting mother. But I guess its such a judgment call, and sometimes you can get it wrong. Hopefully those times are very rare.

  4. I really enjoyed this post, thank you for the insight. When my son was 2 he had chicken pox. He had a 103 degree fever for four days. I kept calling the pediatrician, but he said that could be normal. By the fourth day my son couldn’t walk, something was apparently wrong with one of his legs. I called the doctor again, practically begging to be seen. They finally allowed me to bring in my son before regular office hours (along with my 9 month old daughter who also had chicken pox). When the doctor saw a purple rash on my son I noticed that he immediately became a different person. At first he was looking at a child with chicken pox, a minute later he was looking at a child with something much worse (I still don’t know what that might have been). So between the fever, the rash, and the leg problem he immediately sent my son to have a bone scan.
    Luckily he did not have a bone infection. He did have a skin infection which required antibiotics, and an emergeny visit to the orthopedist which resulted in a diagnosis of synovitis – the virus got into his hip and thus he couldn’t walk.

    He recovered from the chicken pox, from the side effects of the antibiotics (ugh), and from the synovitis. It was scary for me, and the only time that I ever saw a doctor visibly shaken. Perhaps because I had been asking to bring in my son for 4 days, and they just treated me like an overreacting mother. But I guess its such a judgment call, and sometimes you can get it wrong. Hopefully those times are very rare.

  5. You all have so much responsibility on your shoulders. I am thankful for good docs like you and thank God for you.
    You’ve paid your dues in pursuing your education and continue to do so with the the increased wokload and all that entails.

    Physicians deserve to be well compensated.

  6. You all have so much responsibility on your shoulders. I am thankful for good docs like you and thank God for you.
    You’ve paid your dues in pursuing your education and continue to do so with the the increased wokload and all that entails.

    Physicians deserve to be well compensated.

  7. I agree when you say that it is your name, your signature. In my classroom my personal philosophy is that it is my name on the door, so all decisions I make are reflective of that. What I hate most are the abuse calls – I don’t want to accuse if it is not warranted, but I also don’t want a child to suffer because I am afraid to make the call.

  8. I agree when you say that it is your name, your signature. In my classroom my personal philosophy is that it is my name on the door, so all decisions I make are reflective of that. What I hate most are the abuse calls – I don’t want to accuse if it is not warranted, but I also don’t want a child to suffer because I am afraid to make the call.

  9. For what it’s worth: for every person who wants the disability forms filled out, there is one getting it who would just as soon not get it filled out, but the system is so screwed up they don’t have a choice.The ability to work part time, and still get partial disability, or help with medical coverage … isn’t possible. So it’s either totally disabled or not at all. At least as far as the government is concerned, which is absolutely absurd! as you well know. (punctuation rather purposeful)
    There is a far cry from being able to do some things as long as you get appropriate rest, and self care, joint protection, etc. and not being able to do anything.

  10. For what it’s worth: for every person who wants the disability forms filled out, there is one getting it who would just as soon not get it filled out, but the system is so screwed up they don’t have a choice.The ability to work part time, and still get partial disability, or help with medical coverage … isn’t possible. So it’s either totally disabled or not at all. At least as far as the government is concerned, which is absolutely absurd! as you well know. (punctuation rather purposeful)
    There is a far cry from being able to do some things as long as you get appropriate rest, and self care, joint protection, etc. and not being able to do anything.

  11. Great post and it really spells out the sense of responsibility and “weight” doctors feel in the every day caring for patients. I hate disability forms so much for all the reasons you said and also that they take so much (free) time to fill out. I need to have the chart in front of me and do a complete chart review for each one.
    The most stressful thing, however, is the chance that I will miss a diagnosis or abnormal test result. That fear makes me more diligent (which is good) but also keeps me awake at night. I missed a ruptured spleen in a child who fell off a bike when I was in training and I will never forget it. Fortunately his dad brought him back and it was caught and he did well, but knowing how easy it is to miss something serious has stayed with me my entire life.

  12. Great post and it really spells out the sense of responsibility and “weight” doctors feel in the every day caring for patients. I hate disability forms so much for all the reasons you said and also that they take so much (free) time to fill out. I need to have the chart in front of me and do a complete chart review for each one.
    The most stressful thing, however, is the chance that I will miss a diagnosis or abnormal test result. That fear makes me more diligent (which is good) but also keeps me awake at night. I missed a ruptured spleen in a child who fell off a bike when I was in training and I will never forget it. Fortunately his dad brought him back and it was caught and he did well, but knowing how easy it is to miss something serious has stayed with me my entire life.

  13. You said it all! This is a fantastic post about what we physicians face day in and day out in a profession that never sleeps and rarely gives back what is due. The rewards (to me) come irregularly and inconsistently as a sense that I’ve made a difference in someone’s life. Some days I get that; many days I do not.
    Thank you for articulating the issues; you are right on and I will reference this post often as a piece that makes the points loud and clear. The dilemmas are real, the risks great, and those that don’t feel this as they move through each day as medical care-givers are either in a coma or just don’t care (I suspect the former).

    Gratefully, kate

  14. You said it all! This is a fantastic post about what we physicians face day in and day out in a profession that never sleeps and rarely gives back what is due. The rewards (to me) come irregularly and inconsistently as a sense that I’ve made a difference in someone’s life. Some days I get that; many days I do not.
    Thank you for articulating the issues; you are right on and I will reference this post often as a piece that makes the points loud and clear. The dilemmas are real, the risks great, and those that don’t feel this as they move through each day as medical care-givers are either in a coma or just don’t care (I suspect the former).

    Gratefully, kate

  15. I agree with one of the commenters: if you could work a few hours a day typing away on a computer and that’s it–you wouldn’t be allowed disability at all. It is a very tricky business. There should be more options and more questions on the forms, like there are for the NHS: you can work part time and get disability as well.

  16. I agree with one of the commenters: if you could work a few hours a day typing away on a computer and that’s it–you wouldn’t be allowed disability at all. It is a very tricky business. There should be more options and more questions on the forms, like there are for the NHS: you can work part time and get disability as well.

  17. I truly feel for my disabled patients. I wish I could give them partial disability, but they can’t work or they lose a lot of their benefits. The whole system is messed up. I also hate the fact that you ALWAYS have to be rejected for disability before you are accepted. I have never seen someone go through on the first try. It seems like a racket to me. Just a means of generating revenue for certain people.

  18. I truly feel for my disabled patients. I wish I could give them partial disability, but they can’t work or they lose a lot of their benefits. The whole system is messed up. I also hate the fact that you ALWAYS have to be rejected for disability before you are accepted. I have never seen someone go through on the first try. It seems like a racket to me. Just a means of generating revenue for certain people.

  19. As you can imagine, it’s a hot topic for me. When they talk about saving medicare or social security it is always about cutting benifits or reducing payments to doctors. It is never about cutting the redtape and chaos at the government side of the issue. THAT alone would save the system.There are a few simple things that could save the system, but, it is too simple for it to be even looked at.
    Reduce the red tape.
    Allow people who are disabled to work part time and pay into the social security system while still getting help with their medical coverage. (many jobs don’t offer medical insurance these days, but without it, they are severely disabled and can’t work, with it, they are able to work part time … the trap)
    Reduce the chaos at the government level and the automatic 90% plus refusal … as well as the other types of stupidity that takes place at the governmental level … would alone reduce the cost of the system.

    When I applied for disability .. I applied for Myasthenia Gravis. Turned down the first time, doc said “reapply, everyone is turned down” Turned down again. He said “everyone has to go before a judge, keep going.”
    So I did … I went before a judge (this process took 2 years)
    Myasthenia Gravis disability and social security requires that you be disabled under either symptomolgy A …or B.
    Under A … you have to have 8 of 12 symptoms.
    Under B …you have to have 9 of 13 symptoms.

    When I was seen by the judge, he found that under A I had 12 of 12 and under B I had 12 of 13.
    And he dated it back to 2 years before the application date. (as well as a scathing letter to the person who’d turned me down at the social security administration)

    My original denial letter from SSA said (I’ve never forgotten it because it was so absurd):
    “Even though the medical evidence shows that you have weakness in your arms and legs, double vision, blurry vision, difficulty swallowing, slurred speech, shortness of breath and generalized fatigue, we show that you can do the job of a waitress as it is generally performed.”

    All I wanted was for them to come let me pour them a cup of coffee after 2 hours on the job. Oh please!!!! (a waitress with double vision pouring coffee ..that’d be fun!)

    The wasted time, paperwork, manpower was absurd.

    For people who are disabled for issues like autoimmune diseases … you get treatment, you start to feel better,
    you feel like you can do something
    you go back to work,
    loose your medical coverage
    then you loose the very expensive treatments that were making you feel better
    then you are back to square one.

    Hopefully going back to school getting a degree will get me out of this trap. Unfortunately, when I got sick, I hadnt’ finished my degree. I was a waitress, in school and a new mom. Waitressing didn’t provide any coverage.
    ‘Unskilled’ left me with no choices. Granted, for many years I was too sick that even had I had a degree it wouldn’t have mattered. But … when the treatments started to go into effect …

  20. As you can imagine, it’s a hot topic for me. When they talk about saving medicare or social security it is always about cutting benifits or reducing payments to doctors. It is never about cutting the redtape and chaos at the government side of the issue. THAT alone would save the system.There are a few simple things that could save the system, but, it is too simple for it to be even looked at.
    Reduce the red tape.
    Allow people who are disabled to work part time and pay into the social security system while still getting help with their medical coverage. (many jobs don’t offer medical insurance these days, but without it, they are severely disabled and can’t work, with it, they are able to work part time … the trap)
    Reduce the chaos at the government level and the automatic 90% plus refusal … as well as the other types of stupidity that takes place at the governmental level … would alone reduce the cost of the system.

    When I applied for disability .. I applied for Myasthenia Gravis. Turned down the first time, doc said “reapply, everyone is turned down” Turned down again. He said “everyone has to go before a judge, keep going.”
    So I did … I went before a judge (this process took 2 years)
    Myasthenia Gravis disability and social security requires that you be disabled under either symptomolgy A …or B.
    Under A … you have to have 8 of 12 symptoms.
    Under B …you have to have 9 of 13 symptoms.

    When I was seen by the judge, he found that under A I had 12 of 12 and under B I had 12 of 13.
    And he dated it back to 2 years before the application date. (as well as a scathing letter to the person who’d turned me down at the social security administration)

    My original denial letter from SSA said (I’ve never forgotten it because it was so absurd):
    “Even though the medical evidence shows that you have weakness in your arms and legs, double vision, blurry vision, difficulty swallowing, slurred speech, shortness of breath and generalized fatigue, we show that you can do the job of a waitress as it is generally performed.”

    All I wanted was for them to come let me pour them a cup of coffee after 2 hours on the job. Oh please!!!! (a waitress with double vision pouring coffee ..that’d be fun!)

    The wasted time, paperwork, manpower was absurd.

    For people who are disabled for issues like autoimmune diseases … you get treatment, you start to feel better,
    you feel like you can do something
    you go back to work,
    loose your medical coverage
    then you loose the very expensive treatments that were making you feel better
    then you are back to square one.

    Hopefully going back to school getting a degree will get me out of this trap. Unfortunately, when I got sick, I hadnt’ finished my degree. I was a waitress, in school and a new mom. Waitressing didn’t provide any coverage.
    ‘Unskilled’ left me with no choices. Granted, for many years I was too sick that even had I had a degree it wouldn’t have mattered. But … when the treatments started to go into effect …

  21. The only way to break out from this constant nagging feeling of taking everyday risk is to become financially independent, that is, do not depend on your paycheck for living. Then the work will become fun, because if you feel like quitting, you can do it any time, and you can really start doing the right thing without of fear of litigation/repercussions from insurance companies etc.I know, it’s hard, but doable.

  22. The only way to break out from this constant nagging feeling of taking everyday risk is to become financially independent, that is, do not depend on your paycheck for living. Then the work will become fun, because if you feel like quitting, you can do it any time, and you can really start doing the right thing without of fear of litigation/repercussions from insurance companies etc.I know, it’s hard, but doable.

  23. Our Own System » Blog Archive » The voices are getting louder

    […] It’s a combination of many issues.  Reimbursement rates are constantly pushed downward.  Risk of malpractice lawsuits is rising.  Scopes of practice are under fire.  The days are long.  The list could go on. […]

  24. Great post, Rob! You’re so right… there’s no one standing beside you sharing the risk or the blame. And the stakes are so high.
    Oh… and I hate disability forms, too. Hell… how do you define disability in a 4 year old? How about a 19 year old who had an AKA for his osteosarcoma? Ugghhh.

  25. Great post, Rob! You’re so right… there’s no one standing beside you sharing the risk or the blame. And the stakes are so high.
    Oh… and I hate disability forms, too. Hell… how do you define disability in a 4 year old? How about a 19 year old who had an AKA for his osteosarcoma? Ugghhh.

  26. I’ll repeat what was said above: thank you and all the good docs for all you do despite the idiocy of medicare and drug seekers and pouncing lawyers. It would be no travesty of justice if you were indeed extremely rich from your work. I also agree with another commenter that if the bureaucrats were cut to a quarter of their present numbers the medicare system would be in good shape. Not only that, but they wouldn’t have time to harrass good doctors. I just need to remember that when I go into the voting booth because it is our Congress that has created the mess.

  27. I’ll repeat what was said above: thank you and all the good docs for all you do despite the idiocy of medicare and drug seekers and pouncing lawyers. It would be no travesty of justice if you were indeed extremely rich from your work. I also agree with another commenter that if the bureaucrats were cut to a quarter of their present numbers the medicare system would be in good shape. Not only that, but they wouldn’t have time to harrass good doctors. I just need to remember that when I go into the voting booth because it is our Congress that has created the mess.

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