Monday, June 30, 2008

The 7 Deadly Sins

The Medical Board of California lists the seven deadly sins that can cost a doctor his license.
Often its possible to committ more than 1 sin at a time:
Each Medical Board investigator probably can recount three or four outrageous cases of sexual misconduct that they have investigated. For me, one was a renowned psychiatrist who had a seven-year affair with a schizophrenic patient. Their sexual relationship began in the library of a university medical school. Their relationship culminated with the psychiatrist using the patient to procure prostitutes with whom he, and the patient, would have group sex. Instead of paying money for the prostitutes' services, he bartered by providing them with prescriptions for Klonopin or other controlled substances. Not to be limited to a mere one or two violations of law, he would then bill Medi-Cal for group therapy (definitely one of the more creative liberties I've seen taken with a CPT code). This physician's license was revoked and he was also criminally convicted of fraud. Lust and Greed.
Not everyone agrees that Greed is bad:
"The point is, ladies and gentlemen," Gordon Gekko pontificated in the movie "Wall Street," "that greed - for lack of a better word - is good. Greed is right. Greed works. Greed clarifies, cuts through, and captures the essence of the evolutionary spirit. Greed, in all of its forms - greed for life, for money, for love, knowledge - has marked the upward surge of mankind."

In my opinion, Pride is probably the most common deadly sin among physicians:
There are a lot of doctors out there who are brilliant practitioners, but they have no business acumen. Being too proud to admit it, they are lured into contracts and obligations due to their business naiveté and end up being cited for all kinds of violations (failing to have a fictitious name permit, aiding/abetting the unlicensed practice of corporate medicine, advertising violations). I hate to be the bearer of bad news, but ignorance is never a valid defense.

Pride is also known as Vanity:
Vanity, definitely my favorite sin.

For those of you who don't watch movies much, that last quote is from The Devil's Advocate- A great performance by Al Pacino.

Saturday, June 28, 2008

Vitamin D

Vitamin D has recently become a hot area of research.

Low vitamin D- 25(OH)D- has been linked to depression.

Low Vitamin D levels have also been linked with a poorer prognosis in women with breast cancer.

Friday, June 27, 2008

Are Psychiatrists Real Doctors?

Dr. Moffic attempts to answer this question in Clinical Psychiatry News:
A flight attendant came down the aisle asking whether there was a doctor on the plane. My wife must have thought I was one, and told the flight attendant so. She then woke me and told me of the concern.
Was I a “real” doctor? After all, hadn't I been writing about how psychiatrists' medical backgrounds should distinguish them from psychologists, even to the extent that I suggested that our next diagnostic manual should only be for us? But being a “real” doctor in real life is far different from just writing about it. Was this some sort of cosmic test for me?
My wife, who is a psychiatrist, has volunteered my medical services on a flight before.

There are some inaccuracies in Dr. Moffic's article:
These days, a medical internship is the first of the 4 years of psychiatric residency training, and consists exclusively of medical rotations, including neurology.
A psychiatric internship is not the same as a medical internship. A typical psychiatry internship consists of 4 month of medicine, 1-2 months neurology, and 6-7 months of psychiatry. Most psychiatrists are ill-prepared to treat medical illness.

Sunday, June 15, 2008

ER call ethics

I was recently asked to comment on this article written for the blog Brain Blogger (shortened version below, I encourage you to read the full article):

In a fit of rage, a thirty year old otherwise healthy man punches a hole through his window.

Unfortunately, there is no hand surgeon in the community that takes on-call service for the ER. Thus, the ER doctor calls various community hand surgeons to see if they will take care of the patient.
Finally, the ER is able to get a hand surgeon who will answer his pager. The hand surgeon agrees to get involved with the care of the patient. He listens to the story over the telephone and feels in his best judgment that the patient will need an exploration of his hand in the operating room. Studies show that there is no difference whether this happens sooner or later as long as it is done within 24 hours. Thus he explains to the ER doctor that he is out to dinner with his family and won’t be able to see the patient until the morning. He tells the ER physician to either discharge the patient and have him come to his office in the morning, or to admit the patient and that he will see the patient in the morning.

Several ethical issues are raised later in the article and by commenters to the article, and I will only address a few of them, but I encourage comments.

1. I do not think that physicians have an ethical obligation to provide hospital/ER call. I think this is a matter of negotiation between hospitals and the doctors who apply for medical staff privileges. Hospitals have the right to refuse medical staff privileges to doctors who don't want to meet the hospitals' call requirements. Doctors have the right not to apply for privileges at hospitals that have onerous call requirements. To attract physicians of certain specialties, some hospitals may need to pay the doctors for taking call, though this is a legally tricky area.

2. Regarding the specific case, once the surgeon "agrees to get involved with the care of the patient", I think he is obligated, at least from a medicolegal perspective, to go in and see the patient that night. If he wasn't prepared to go in that night, he should have told the ER doctor that in general that type of injury requires surgery within 24 hours, but that he couldn't comment on the specific patient. If I was in that surgeon's place, I would have offered to see the patient in the morning, but made clear that the ER doc was responsible for the patient until then and that no doctor patient relationship would exist until and unless the patient arrived at my office. I would tell the ER doctor that if he was uncomfortable with that disposition, he could always send the patient to a university hospital/tertiary care center (if the ER doc thought the patient was stable for transfer).

Iowa floods

Fifteen years ago I arrived in Iowa City, Iowa to begin medical school, just as the great flood of 1993 was ending. It looks like this year's medical students will have a similar experience.

Here's a link to more information about the situation in Iowa City.