As I sat in a cramped doctor's office the other day, listening to his story of why my client never received a life-saving colonoscopy, I realized my client had died because we lack a very simple health care reform, one that doesn't seem to be on the agenda of Congress, or even the town hall protesters. And it made me a little mad.
I call it "no patient left behind" -- a simple report card system to give patients a heads-up about their doctors' credentials and safety record, something almost impossible to get now.
My client was a working-class father of three who put his life in the hands of this general practice doctor for eight years. He had good insurance with modest co-pays, and he could park right at the door of the doctor's office in Lanham, Maryland, a few blocks outside Washington's beltway. He finally switched doctors at his wife's insistence. After only two appointments with the new doctor, a large cancer was found in his colon. Too late: it had already spread to his liver.
His new doctors attacked the cancer with everything they had, but after two years, he succumbed a few months ago at age 59 -- one of the 100,000 Americans who will die unnecessarily this year from medical mistakes.
Medicine knows how to prevent death from colon cancer. Soon after your 50th birthday, you should have a colonoscopy to inspect the lining of the colon for pre-cancerous growths or early cancers, which can be snipped off before they've spread. That's for everybody, with or without symptoms. Then if you get anything like blood in the stool, it's even more urgent to get the entire colon inspected with the same flexible telescope.
The statistics on colonoscopy are so impressive that, unlike mammograms, PSA testing and other cancer screening tools, no one debates that colonoscopy saves lives.
So I showed up at my client's doctor's office on a hot summer afternoon with a court reporter to take a deposition and ask why my client never got a colonoscopy in eight years of treatment for high cholesterol, kidney stones, muscle strains and other care. The doctor's handwritten records said nothing about colonoscopy. His office notes, scrawled on pre-printed forms that had a box for every appointment for "assessment" and "plan," did record one episode of "blood in stool." The "plan" section of the note for that visit was blank. The notes for two later visits for other problems didn't mention it at all.
I counted seven times at this doctor's office when my client would have qualified for a colonoscopy by being over age 50 or, more urgently, having unexplained bleeding once in his lower intestine. So why didn't it happen?
It was the patient's fault, the doctor told me. While the doctor admitted he couldn't remember any details of any of the visits not recorded in his notes, he must have told the patient to get a colonoscopy every time it was indicated. He always tells any patient over age 50. So he claimed. "I can't drive them to the colonoscopy office," he added.
I gestured at my client's widow sitting next to me. She too had been this doctor's patient at the right age for colonoscopy. Did he contend she also refused his advice? Her records were as silent as his about colonoscopy. But he insisted that she too must have turned it down. When I pushed him, he claimed that every time his records left out an important piece of advice for the patient, it must have been given, just not recorded.
Now, lots of people, with or without a medical degree, tell whoppers when backed into a corner. The issue here, which the health care reform debate mostly ignores, is how to protect patients from the mediocre practitioners who don't deliver the quality care that we deserve.
This doctor showed telltale signs that were obvious to me as a patient advocate attorney, but easy to overlook for the average, trusting patient. He had a medical degree but nothing more: no completed residency training programs, no certification by any specialty boards. His records were sketchy, and he kept track of pending test results on his 4,000 patients with a scratch pad and his memory. Still, he had built a busy practice for thirty years, because insurance companies don't care about qualifications and up-to-date office practices. They negotiate for price only. So many thousands of these borderline doctors do very nicely in our current system.
I wrote a book about how patients can find the best medical care in our current fragmented system. But it shouldn't be so hard that you have to read a book.
With a "no patient left behind" system of mandatory report cards, patients could comparison-shop for doctors based on what's important: not price but quality. Right now, sophisticated patients can look up on the Internet a doctor's basic credentials and lawsuit history but not much more. Researchers have published dozens of studies on how quality of care can be audited by looking at simple measures like what percentage of the doctor's patients get sent for screening tests like colonoscopy or get important but simple treatments like aspirin right after a heart attack.
Nobody runs these audits regularly now. With a modest chunk of money in the health care reform budget, we could have quality data on every doctor, or at least on the front-line primary care doctors that millions of Americans rely on.
Reforming access to health insurance is important. Yet universal care could help the marginal doctors thrive even more than they do today, unless we give patients the tools to make intelligent choices.
I think this is worth getting mad about.
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