Random Thoughts from a Restless Mind

…well, you know.

It finally happened; I have finally made decisions that were based primarily on covering my own  ass.  One of these decisions was strategic, and the other one was directly related to the care of one particular patient. Let me explain.

The first decision, the strategic decision, had to do with performing consultations in the hospital setting. These have never been a whole lot of fun, and they have never been a terribly profitable venture from a business standpoint. But for many years I, and most other off ophthalmologists in my community, have performed hospital consultations at the request of both community primary care physicians and hospitalists, pretty much whenever we were asked. Almost none of these consultations was mandatory, an examination that absolutely had to occur during the time of hospitalization. Oddly enough, or perhaps not so oddly, a significant percentage of the patients for whom these consultations were performed were uninsured, way more than the likelihood of this occurring due to chance.

That was okay, though, for the longest of times. Everybody was doing it, performing these consultations, and those of us who did so received a kind of “good Samaritan” benefit of the doubt. You see, we do such extraordinarily good work as a specialty, and that work is so terribly dependent on very advanced technology including large, expensive, and mobile equipment, that every consultation that we performed in the hospital setting was a pale, inferior product in comparison to a consultation performed in our offices. As time has gone on my sense that I would continue to receive this “good Samaritan” dispensation has disappeared. I have  come to feel more and more vulnerable, more and more concerned that the inherent deficiencies of the hospital consultation in  ophthalmology make it more likely that I will miss something important despite my best efforts.

And so I am now declining to  accept hospital consultations except when I am obligated to do so as part of my turn covering the emergency room.

Now, you could accuse me of being selfish, of using everything above as a simple rationalization to stop doing something that is inconvenient and unprofitable. It’s ALWAYS been inconvenient and unprofitable! What has changed is that it now feels more dangerous to ME.

I’ve struggled with this decision, frankly. In the end, though, the decision to stop doing consultations in the hospital was actually rather easy because the quality of care that I was able to provide in that setting was so dramatically inferior to the quality of care that I have been able to provide in my offices. It was a different event, a different decision made in the context of caring for one, individual patient that has brought home just how pervasive this climate of fear in which all physicians live has become. Faced with the decision that hinged on my safety versus the convenience and care experience of one of my patients, THIS time I chose my own safety, and I made the decision in a nanosecond.

My patient was scheduled for cataract surgery on her left eye. During her prep in the pre-op holding area it became clear right away that she had prepared at home for surgery on her right eye, putting her preoperative eyedrops in the wrong eye despite our verbal and written instructions to the contrary. What  should we do, the nurses asked? Easy answer: cancel the case. But her son had to take off work, and another family member took off work to stay home with her this afternoon. Easy answer: cancel the case.

It wasn’t always this way. Years ago, in the early 90s, a patient prepped the wrong eye for glaucoma surgery. Knowing that I was planning on doing both eyes eventually I simply changed course, changed all the paperwork, and went ahead and did the eye that she had prepped. Things are different now, though. There is a paper thin line between “other eye” surgery and “wrong eye surgery”. Wrong eye surgery is a “never event”, one of those things that is simply inexcusable, and one of those things that various and sundry watchdogs are looking to find. Take a chance on some overzealous, faceless, nameless functionary, perhaps someone who has never been involved in the surgical process confusing “other eye” surgery with “wrong eye. surgery? Not a chance…cancel the case.

And that was that. For the first time in my career I had put my own ass ahead of the convenience and experience of my patient. I willingly and knowingly inconvenienced by patient and her family, even though the eventual plan was to remove both of her cataracts, because I was afraid to change the surgical plan at the last minute. Afraid that some red flag would be raised because I had changed the surgical site. Afraid to expose myself to those overzealous, nameless, faceless functionaries.

I covered my own ass!

Again, one could accuse me of being self-serving, self-righteous even. This was the first time that I had ever knowingly made this kind of decision, and frankly I can’t even remember a time when I made a similar decision for a similar reason. What was so extraordinary was how instantly I came to this conclusion, how quickly the words “cancel the case” came out of my mouth, and how completely comfortable I am with the decision. Me, the champion of patient-centered medicine, borderline obsessed with the crusade to bring the best customer – centered practices from the best consumer service industries to medical care. I instantly and knowingly put my own self protection ahead of the convenience and experience of my patient and her family.

To be honest, both the patient and her son were very understanding, and she has gone on to have very successful cataract surgery on the correct eye. No harm no foul, as the basketball great Bill Russell would put it. But that’s not really true, is it? An entire system is set up in such a way that my decision has become the  ONLY viable decision. Only the foolhardy, the reckless, or the naïve would do anything else. It’s a non-choice anymore. We physicians, descendents of those who willingly and knowingly walked among lepers and ENTERED plague-infested cities, fearless in our professional service, we have finally met our match. Terrified by those nameless, faceless, functionaries, cowed by those most definitely named, whose pictures grace the covers of our phone books, we are now left with but one  course of action.

Physician, cover thine own ass.

This entry was posted on Thursday, May 27th, 2010 at 8:49 am and is filed under Eye Care, Health Care. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.