Laura Nathanson, MD
Laura Nathanson, MD
Check your own Medical RecordsKeep safe in under-staffed HospitalsOutwit Insurance Companies
Laura Nathanson, MD
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Note: These excerpts are taken from an uncorrected proof.

Physician Unresponsiveness

By this I mean that a crisis is occurring but the physician is, well, unresponsive. The reason doesn't matter, nor does the nature of the crisis itself. When this happens, you may need to go to the nurses and do whatever you need to have them get appropriate help. Fortunately, your very presence as sentinel has increased the chances of your success in this regard.

First, it is infinitely comforting for the patient just to know you are right there, an intimate connection to normal health and life. A patient who feels loved and watched is spared the kind of anxiety that can precipitate a crisis all by itself.

Second, you have very likely earned the good opinion of the staff on your ward, a reputation for being a good citizen who is there to help them, not harass them. So you, too, can be spared anxiety. You know that if you really need help, they'll be there for you.

Third, you are extra insurance that if a crisis occurs, it will be recognized and dealt with promptly. That's because you are yourself an exquisitely sensitive monitor of the patient's condition.

The Human Monitor

Sure, there are monitors attached to your patient. But each monitor is programmed with a preset "normal range." The monitor will not alarm until the out-of-range point is reached. However, it's rare for a disaster to occur from one heartbeat to the next; the human body is very sturdy, and fights off most disasters with vigor. So there's a period of time between when the first signs of trouble occur and when the monitor goes off.

If a nurse could watch each and every monitor and each and every patient all the time, chances are such trouble triggers would be picked up nearly immediately, because the nurse would see a trend in the tracking of at least one monitor -- would see the trend, that is, before it actually reached the out-of-range mark.

But that really defeats the whole labor-saving point of the monitors. Besides, there are three important "vital signs" the monitor can't measure: how the patient is feeling, how he is behaving, and what the trend is in vital signs on the monitors. It used to be that nurses tracked this, but these days you, and they, cannot count on the staffing to do so.

But you, the sentinel, can be crucial in this effort.

Peer Review

Another reason you need to monitor your care!

If you sat down and "thought with both hands for a fortnight," you couldn't come up with a worse concept than peer review as the sole method for preventing and disciplining physician errors in a hospital.

Peer review takes place when a complaint is made about a physician's character, behavior, or actions. The peer review committee then discusses the complaint. In many hospitals, the committee is hand-selected from the more senior physicians, those who feel a sense of "ownership" of the hospital and its workings. The defendant may be an insider with this group, an outsider, or an adversary. This is not supposed to have any effect on the outcome of the Review.

The committee can dismiss the complaint, or it can administer discipline ranging from a friendly rebuke to kicking the physician off the hospital staff, effectively demolishing his or her livelihood and reputation. Most of the criticism of the peer review concept has come from physicians who feel they have been wrongly punished. Many of these cases accuse the committee of using peer review as an instrument to get rid of a competitor, or a whistleblower, or someone they just don't like -- perhaps on the grounds of race, religion, ethnicity, or style of dress. Some of these physicians have sued successfully, winning millions of dollars in damages.

Patients who have been injured by the errors of a physician do not have access to the peer review discussions, documents, or findings. Physicians say that if this weren't the case, that "peer review would be the inexpensive gathering of evidence for a lawsuit . . . The plaintiffs would just sit back, let the peer reviewers do their thing, then discover what peer review has done and they'd have their case."

The American Medical Association has tried its best to clean up corrupt or sham peer review practices. At the same time, it has thrown itself into preventing states from passing laws that would open the peer review process to others -- patients, attorneys, the press.

No matter how all this sorts out, the underlying problems with peer review will remain:

1. It must be triggered by an error or complaint about something that already has happened.

2. It is adversarial in nature, with a defendant and a jury.

3. There is no mechanism for restitution -- no way that an injured patient can receive an apology, explanation, or reimbursement for loss.

4. It ads to the mystique of the "physician brotherhood," in which group loyalty supersedes the interests of the larger society.

Managed Care

The most important managed care concept to grasp is the concept of the network. A network is a web of physicians, hospitals, emergency rooms, and other services. Each network is contracted to refer patients only to other entities on the same network. The network you will be assigned to is the one to which your PCP belongs. This is true whether you have a PPO, POS, or HMO medical plan.

The second most important managed care concept to grasp is that the contract you signed with your insurance plan is not the contract you have with your network. That plan contract is overridden by the contract that your primary care physician has with your network.

Copyright 2007 Laura Nathanson


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Public Declaration regarding Scripps Clinic, Green Hospital

Laura Nathanson, MD
author of What You Don't Know Can Kill You

Copyright 2007-08 Laura Nathanson, MD
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