Jeffrey Segal, MD, JD

Here’s one doctor not afraid of the future of healthcare in the U.S.

Meet rheumatologist Dr. Ephraim Engleman who will turn 102 in March.

He said he has no plans on retiring. He drives from San Mateo to the campus of UCSF three days a week. He treats eight long term patients (one wonders just how long term). He spends the rest of his time directing the Rosalind Russell Medical Research Center for Arthritis. He has held that position since 1979.

Dr. Engleman also plays the violin once a week with a chamber music group.

His only ailment: spinal stenosis which forces him to walk stooped over with a cane.

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A good question was posed on physician forum. Why do doctors treat medical malpractice differently than being in an auto accident? Shouldn’t we just turn it over to our carriers and be done with it?

The reason: The two systems have little in common. First, a med-mal lawsuit is packaged as an assault on your reputation. If you doubt that statement, just read the typical cut and paste summons. It often includes language such as “with willful and wanton neglect” and so on. It’s never couched in language such as “you are a talented doctor who made a mistake. We understand you are human and care deeply about your patients. But, with Mr. Smith, the injury has cost him lost wages and future medical costs.”

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Finally…a non-controversial blog post.

My mother taught me not say anything if I could not say something nice. Suffice it to say, many times I have fallen short of that aspirational goal. And, diving deep into the Affordable Care Act, I could not find much positive to say.

In particular, there was almost nothing written about reigning in the dysfunctional medico-legal tort system. To the extent anything about med mal is buried in the ACA, it is limited to a “sense of the Senate” – a nonbinding statement used to express the position of the Senate on a particular issue. Through this language, the ACA suggests states should be prodded to “develop and test” alternatives to the existing medico-legal tort system. And Congress should “consider establishing a State demonstration” to run pilot projects on such solutions.” The ACA, however, includes no funding or binding provisions to those ends.

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In 1997, Dr. Robert Smith, a Scottish surgeon saw a patient with an atypical request. He wanted the surgeon to amputate his perfectly healthy left leg. Why the request? The patient argued his left foot wasn’t part of him. “It felt alien.” Dr. Smith had the patient see a psychiatrist. The patient was diagnosed with Body Integrity Identity Disorder (BIID). Smith performed the operation. At follow-up a couple of years later, the patient reported his life was positively transformed by the operation. Word got out. Smith saw another such patient and performed a similar amputation. And the second patient also reported a positive result.

Then, the story hit the media. The public reacted. Smith was ordered by his hospital to cease and desist.

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Surgeons are typically afforded great latitude in choosing whether or not to operate on a patient. For example, Jehovah’s Witnesses generally eschew transfusion of blood products. If a Jehovah’s Witness needs a coronary artery bypass, you are not obligated to operate on this patient. You can, of course, send the patient to another surgeon who will accede to the restrictions. If you make the decision to cut, you must honor the patient’s religious request to avoid using blood products. But, if you’re not comfortable with the demand, you can Just Say No.

Further, you can generally refuse to operate on an elective patient because you don’t like him. If that is the real reason, and it’s not based on the fact the patient belongs to a particular protected class, such as race or religion, you’re typically on safe ground.

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The FDA has been in the news lately. For those returning from two month news-free National Geographic vacation in Antarctica, a compounding pharmacy in Massachusetts was supplying vials of preservative free methyl-prednisolone for epidural injections and much more. Some of these vials were tainted with fungus. Many people got sick. Some died. The FDA does not typically have any statutory authority over such compounding pharmacies. But, anything related to pharmaceuticals gone bad gets the attention of the FDA. So, it took us a while to get an answer from the FDA about a completely unrelated item – also in the news, but less so.

The cycling world went public with evidence about performance enhancing ‘doping.” Doping is defined broadly, and includes anabolic steroids, EPO, human growth hormone, and more. Whether doping was or is ubiquitous in the cycling world is not the subject of this blog. It’s the question of whether doctors can prescribe various pharmaceuticals and stay on the right side of the law.

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