Risk.

risk In some ways this one word defines what it is to be a doctor.  We practice applied science.  We look at a patient and take general scientific concepts and personal experience to decide what needs to be done.  We make the decision.  We take the risk.  We put ourselves on the line.

Sometimes it feels like I am tiptoeing past a sleeping tiger.  A misstep will change life, yet I have no choice but to take the risk.  It happens nearly every day.  I try not to think about it too much, but it sits there in the back of my mind.

Narcotics, disability forms, depression, pediatrics, test results, fraud - each one can be like defusing a bomb.  Be careful, think straight, second guess yourself frequently, and allow yourself to worry.  Do I lose sleep on these?  No, but I do get gray hairs and take antacids (and compulsively blog).

Let me explain:

Narcotics

Each day I get requests for pain medications and anti-anxiety medications.  I get many requests.  I do believe that these medications are appropriate if used for the proper situation, but also know they can be abused. 

While I think I am pretty good at spotting drug abuse, I also believe in making patients show me they are not trustworthy.  I don't want to be used by a drug-seekers, but I also don't want to be unsympathetic to pain, either physical or emotional.

I have my typical "shpiel" I give folks when I first prescribe them - how they should not be taken regularly - but I am pretty sure some abusers get by me.  Every time I give a refill on these medications I get that feeling in the pit of my stomach.  When I see stories of doctors prosecuted for over-prescribing these medications, I wonder how much it needs to cross the line.  I try not to cross it and document as well as I can, but I know some patients that put their toe on the line.

Disability Forms

These forms are no-win situations.  Some of the time I fill them out, I don't really think the patient is disabled; other times, I feel strongly that they are.  The questions on these forms are often difficult judgment calls - they ask me when the patient can return to work, whether the disability is partial or total, and what types of duties they can do if it is partial.

I often have no idea.  The person is sick and can't work.  They are not real functional.  Could they sit at a keyboard all day and type?  Maybe, but that is not what these forms are generally asking.

I try to fill them out as convincingly as I can, but am aware of the fact that if I don't have substantiating information, I can be seen as defrauding the government.  So I am caught between the desire to help my patient, and the fear of prosecution.

I hate disability forms.

Depression

Depression scares me.  I am trained to handle diabetes, heart problems, infectious disease, etc.  I expect to deal with these problems, and generally know what to do with them.  Either I diagnose and treat them myself, or I send the patients to a specialist.  If they are really sick, I call the consultant and can generally get patients in the same day.

But people walk in with the main problem of depression, and I am stuck.  I can't call a psychiatrist and get the patient seen immediately.  I Can't even get one on the phone.  Plus, I don't really know if the patient is suicidal or is at risk of harming others.  I do my best to triage this, but I have only 10-15 minutes to come to this decision.

Even after making the decision, I have to choose a plan of action and send the patient out the door.  I can't expect the patient to necessarily be reasonable and know when to call me.  They are depressed. 

But I can't keep them from coming into my office.  They know me and trust me.  Who else can they go to when they are depressed?  Once they are there, I have no choice but to treat as best as I can and cross my fingers as they walk out my door.

Kids

Being a pediatrician, sick kids scare me less than they do other doctors.  Certain ED physicians are notorious to pediatricians as being uncomfortable with kids. 

But the reason I am not as scared taking care of them is because I know when to turn on the paranoia.  I have seen enough truly distressed kids to know them by looking at them.  There are certain things that make me anxious: kids with a limp, fever under 3 months, little girls with fever, peeling lips, and purple rash on the legs.

Still, it only takes one bad day to change your life forever.  It is one thing for an adult to suffer harm from a misdiagnosis, it is another for it to happen to a child.  Kids aren't sick a lot, but when they are truly sick, it is far more scary because of the number of years they could lose if you mess up.

Child abuse is even worse.  I wonder all the time at how many abused kids have come through my office without me catching it.  I don't want to falsely accuse someone of abusing a child, so I tend to suspend belief.  All people do that.  But the thought of a sexually abused child being missed by me gives me a sick feeling.

Test Results

If I order a test, I have to follow up on it.  If I don't then I can be sued.  Even if the patient does not get it done by their own choice, I must give reasonable effort to make sure they get it done.

Only with the best information system can give reasonable assurance that I am seeing all of the tests I order.  Very few of us have those systems.  I have been on an EHR for 12 years, and I don't. 

So I do my best.  I try to follow-up on all tests I order.  The problem is, I don't get paid a dime for being careful, and being careful takes a ton of time.  This means that nearly everyone cuts corners.  You just hope that those corners don't come back to haunt you.

Fraud

I do pretty good with my charting.  We have a good system that makes compliance with E/M coding a pretty good bet.  But I know that if an auditor combed over the records, they would find disparities in how I charted and how I billed.  If someone wanted to get any physician in the US, they could.  The documentation process is too difficult to get perfect.

Many physicians fight this by simply down-coding their notes so that they know they are compliant.  Others (like me) use EHR systems that do the charting in a way that complies with the gods of insurance.

The problem here is that my mistake is not simply a mistake, if it is in a Medicare or Medicaid chart.  My mistake is considered an attempt by me to defraud the government.  Does that worry me?  Yes.  I don't lose sleep over it, but I do wonder what will happen if/when I get audited.  I know I am not consciously trying to cheat anyone out of money, but an audit could get my name on the front page of the paper.

Conclusion

Those who think that doctors are overpaid need to consider these things.  It is my name on the prescription.  It is my name on the chart.  I sign the form.  I decide if the person can go home, or if the child is being abused.  Nobody is standing behind me to take the blame.  I will be blamed for errors.

I signed up for this job, and I continue to do it.  I still don't want to quit.  But that does not mean that the daily burden of risk does not take its toll.  That toll is fatigue and chronic anxiety for many.  That toll becomes bitterness when coupled with a system that keeps lowering what they pay us while raising our exposure to risk.

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