Monday, December 10, 2012

Day 177 - Ana and Accountability

The original plan for today was a visit to Ana with Maggie so we could all go on a walk and then the humans could go to lunch. When I woke up this morning and saw the rain, I immediately began backpedalling. We decided to still have lunch which was delicious at Golden Bowl, a Vietnamese restaurant that Ana had been introduced to by a Vietnamese doc at Dartmouth. I had vegetarian pho which I thought was delicious. Ana had these crispy noodles with chicken and vegetables in a light sauce that somehow had been infused with just a slight hint of a smokey flavor. I enjoyed mine, but maybe wish I had gotten the noodles. Next time.

After grocery shopping, there was not a whole lot of time left for interesting activities besides a little more weaving and some reading, still Marty Makary's "Unaccountable." I was thinking about what I read yesterday in the setting of the hypothetical procedure of toe reversal. My patients don't need this done very often; I have sent one patient to get a toe reversed, to Dr. A and have had patients get toes reversed with Dr. B, C and D before I met them. None of these patients have had problems with their toes since I've known them so I conclude that probably Dr B, C and D all do a good job.

I have had a couple of patients who have had their toes reversed by Dr. F in the past or who have had the related procedure of toe inversion by Dr. F. Dr. F works in a hospital a few towns over from me. I have never actually even seen the hospital he works in. I have seen maybe three instances of his work. In one instance, the reversed toe, spontaneously re-reversed itself; in another the inverted toe, partially de-inverted and was left as a huge mess and in the third, the toe became infected and had scarred in a not very pretty fashion. Toe inversion is a tough operation, however, with a high fail rate for anyone, although I have not seen any complications with Drs B through D. Remember, however, that my sample size is very small. I have seen probably less than 1% of Dr. F's work and maybe I just got a skewed sample. Dr. F is in a different hospital than me, perhaps the patients who have bad experiences with him get so frustrated they leave that hospital and come to me whereas the happy ones stay there. Maybe it's just random chance and the next patient of his I see will have a perfectly reversed toe or maybe a whole foot of them. Alternatively, maybe Dr F really is not a good toe reverser.

What should I do in this situation? If a patient were to tell me they wanted Dr. F to do their toe reversal, what should I do? Dr F certainly has a right to be free from being slandered by me and with so little evidence. I could not tell a patient to avoid Dr F and to potentially harm Dr F's reputation. I would be speaking based on three bad toes. And yet, I don't really want my patient to go to Dr F. People don't get their toes reversed unless their feet are in desperate straights and no one who is considering toe reversal would be able to use the foot afterwards if it goes wrong. There is not room for a "margin of error" and I want to spare my patients the possibility of a nonusable foot after surgery if I can. How can I balance my need to help keep my patients safe with my need not to libel Dr F? If my husband told me he was considering Dr F for toe reversal, I would say, "please don't." My patients deserve this same level of information from me, don't they? If a patient thought that I let them go to someone I felt was a substandard specialist, they would not be happy with me. I wouldn't be happy with myself under that circumstance.

OTOH, maybe it's not my job to keep patients away from Dr F. He has privileges at a hospital that is supposed to be monitoring his skill level, that has access to all his outcomes, not just three. Maybe I should just relax and trust that the system is working.

If I were at a conference, would I raise my hand saying that Dr F was a "menace"? Certainly, his results are much worse than anyone else I've seen, but I have seen such a small set of his results, maybe what I've seen is not representative. I don't think it's fair to say "menace," but exactly where would one draw the line? What if I had seen six of his toe jobs and they all had complications? What if I had seen one with a really really bad complication--a "never" event, like reversing the wrong toe? Or what if I thought he reversed toes that didn't really need reversing, that he did procedures that didn't need to be done?

Fortunately, it is hypothetical, as I hope was emphasized by the crazy procedure I made up. The next few chapters of the book describe what happened in New York after they made hospital's mortality rates for CABG public as well as some horror stories from Dr. Makary's own training years. It is good reading, thought provoking and I'd encourage you to pick it up. When I'm done, I'll lend it to you if you'd like.

For tonight, for me, I'm going to wish for continued good fortune in excellent colleagues. For you, I'll wish that you are able to get high quality medical care when you need it.

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