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Recognizing your individual practice risk

Each of us is at risk for something unique when practicing medicine. Your individual practice risk is worth recognizing.

I look back at my career in medicine and just now I am realizing that I’ve been a bit of a rebel. I paved my own way in my work, I broke some molds, I ruffled some feathers, and in return I usually got my way – at a cost. 

Such was the career of Dr. Mo. Such were the risks that Dr. Mo took and, of course, he eventually had to deal with the consequences

I should have been able to recognise my individual practice risk. I don’t want to go as far as to say that I could have guessed that I was going to be investigated by a medical board, or terminated by multiple employers… but, I could have guessed that I was at a high risk for it. 

Taking an even bigger leap, I may have been able to recognize that a doctor like myself would have burnt out eventually from the practice of medicine. 

In this post I want to touch on some of these points and by the end of it, some of you might recognize that you too are at risk of being a white coat criminal

Join the movement. 

Grab some popcorn. 

 

Rebel physician

I don’t even consider myself a rebel physician but I would be labeled as such by colleagues. And this mismatch is probably one of the biggest reasons I’ve dealt with my fare share of troubles. 

  • I don’t get CT’s for acute abdominal pains without just cause
  • I don’t refer for knee replacement for osteoarthritis
  • I don’t order LDL’s on everyone
  • no xrays for an uncomplicated cough
  • no tamiflu for every flu patient

MRI’s, CT’s, routine lab tests, these are things done in most urgent cares, reflexively for particular chief complaints. 

We order them to be thorough and to not miss something. It has become more acceptable to have ordered 100 unnecessary CTA’s and picked up one PE than having ordered few/none and having missed a single insignificant PE (most PE’s). 

I was that physician who was bucking the trend, being the rebel, going against the grain, being cavalier. 

I’ve missed my fair share of diagnosis and I’ve picked up my fair share of zebras. I don’t feel that I fall far outside the average for competent physicians. 

 

Patient volumes

You’re also at risk if you’re a high volume clinician. If you see a lot more patients compared to your colleagues, it means that you are spending less time per patient and your test ordering habits are likely different from your colleagues.

As a fast clinician, you’re either a high-volume or low-volume tester.

I’m a very low-volume tester. I’ve felt that being a high-volume tester is more risky, more resource intensive, and rarely beneficial to patients. 

The only other physician I’ve known in my career who was faster than me was an ER doctor in San Diego and he was a high volume-tester. Even though some people talked shit about him, his outcomes were good – I know because I paid attention to that, I’m weird like that. 

 

Getting labeled

When you don’t order a lot of tests, when you see a ton of patients, when you’re jovial with colleagues – even if serious as fuck with patients – colleagues and staff tend to label you as potentially careless or reckless.

Many clinicians have a linear thinking model when it comes to patient assessment. They have rigidly designed flowchart diagrams for medical decision making and can’t be convinced otherwise. 

You may not be labeled out loud, but you’ll be labeled. 

 

Patient outcomes

The first 3 years when I started as an urgent care doctor at Kaiser Permanente, I followed the majority of my patients to completion after I saw them. 

I would call 10 random patients from my schedule, including some of the more complicated cases, in order to follow up with them and see how they did. 

I learned where I went wrong, what I missed, and this process helped me improve. 

But sometimes others don’t see that. They see you work fast and they see you dismissively address an abdominal pain patient, not understanding that you have a system in place. That you have multiple other patients waiting and that your exam of this abdominal pain patient was benign enough that you have no need for further testing. 

Should there be a bad outcome, you will be thrown under the bus. And I have. I’ve had colleagues report me to QA for a couple of cases – around 5 in total over a 10-year career. I came out unscathed for each case review, except for 1. 

The dumbass doctors who reported me to QA were judging my management against their own standards. There was a cancer patient, a flu patient, a migraine patient.

The only case which I fucked up on was a new onset diabetic woman who wanted nothing done. Didn’t want to go to the ER (it was late and the urgent care was closing), didn’t want to do her labs that night, and didn’t want to start her medications until the next morning.

I had a thorough and in-depth conversation with this patient and thought, mistakenly, that I had documented everything. I have no fucking idea how but I completely forgot to document on this woman. Nothing. Not a word in the chart except for the orders I placed. And I always close my charts the same day. 

The next day when she came in for her follow-up appointment, the treating physician reported me to QA because it seemed as though I had done nothing for her even though the labs and medications were ordered. 

With another physician colleague she may have had the common courtesy and collegiality to discuss the case with them first. With me, she likely assumed that I’m a rebel and that this among many terrible cases I must have had. 

 

Benefit of doubt

From the above example it should be obvious that you won’t get the benefit of doubt from your colleague if you’re an outlier. 

She knew me as the doctor who always saw 2-3x as many patients as my colleagues. Who didn’t order a lot of tests, who didn’t refer a lot of patients, who didn’t phone-consult a ton of specialists, and who didn’t order a bunch of meds for the urgent care patients. 

In her eyes I must have been a reckless physician. 

It’s not that she is evil. It’s that I stand out as the rebel physician and she considers me, and others like me, as a threat to patient safety. 

I got publicly sentenced by her. No benefit of doubt. No phone call to let me know that: “hey, dude, what happened to this lady you saw, there was nothing on her in the chart and she’s sick as fuck?” 

 

Recognize individual practice risk

If you have a unique stance on treatment, medications, management, etc., recognize that you are standing out from your colleagues. This will rarely be a good thing. 

You’re carrying extra practice risk. And not that you shouldn’t continue doing what you’re doing, but recognize that one little mistake on your part will have far bigger consequences than a similar mistake by your nose-picking dumbass clinician colleague who missed a massive foreign body in a diabetic foot infection, who missed a retained tampon, performed a primary closure of a cat bite, and who took 1:45 hrs to close a wound on a finger. 

 

Protecting against the risk

I’m sad to say that the only real way to protect yourself is to develop the same stance towards your patients as the majority of your colleagues. 

If nobody removes IUD’s in your urgent care, don’t be the cowboy or cowgirl who does it. The same goes for complicated lacerations or corneal foreign bodies. 

If your colleagues take 30 minutes per cold and flu patient, try to spend more time with those patients, too. If they order tamiflu for every patient with influenza, consider upping your prescribing rate.

Understand that most of your colleagues are there to clock in a time and collect a paycheck. You will not be having an intelligent conversation about how useless it is for them to test everyone for epiglottitis with an xray, to get a DVT US for every calf pain, or to get a CTA for every SOB. 

I can’t speak about other specialties, I’m mostly referring to the IM/FM/EM physicians who practice in the urgent care and primary care settings. 

For many of your colleagues, finding a diagnosis is the definition of a good clinician. And they will shit their pants if you don’t drain an abscess which isn’t fluctuant and has already spontaneously drained. And they will have a rectal prolapse if you don’t give a patient antibiotics after draining an abscess. 

Get those phone consults. Call the on-call specialist and document the discussion. Even if you find it unnecessary, it will decrease your risk because you’re documenting that digital second opinion. 

I had a QA of a STEMI case which I immediately recognized (thanks to my astute nurse who ordered the EKG on the patient) and called 911. My spidey senses told me to call the cardiologist on call while waiting on transport. Sure enough, the QA committee commented how thorough I was for calling the on-call cardiologist which was end-stage unnecessary. 

CC the PCP and refer the patient to cardiology for stress testing. It will make you appear thorough, it will put the patient’s mind at ease, and it will decrease your practice risk because you’re involving more professionals in the care of this patient. 

 

Burnout

Each of us gets something specific out of practicing medicine. Some of us get off on the intellectual aspect. Others on the power trip. Some love the human interaction and helping others. 

If you are motivated by happy patients then you’ll do very well in western medicine where a surgery, a pill, a referral, or an injection is a high satisfier. This leads to high patient satisfaction scores which imprints even more satisfaction into your practice of medicine. 

If you’re driven by how fast you can complete a TKA or how fast you can see patients, how to minimize unnecessary prescribing, or having the fewest poor patient outcomes, you might be at risk of burnout

Burnout happens when you no longer can squeeze out any more satisfaction from your career and instead you start harping on the negative aspects which every job has. This tilt fucks with your mojo until all you can think about is the drama. 

So, you might achieve your work metrics quickly and then you are left with coming up with another esoteric metric or else you’ll be on your path to burnout. 

 

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