Tuesday, March 22, 2005

More on Dr. Hsu

For a follow up to the story about family physician Dr. George Hsu, I found another news article from June 2004 which gives more insight into his conflict with the North Dakota Board of Medical Examiners:
In another case, Hsu is faulted for not following standard medical procedure, such as administering the drug heparin to a 73-year-old stroke patient without first calling for a CAT scan.

Hsu says there is no published medical authority that requires the scan prior to administering heparin. Besides his experience with such cases, the medical likelihood that the patient had an ischemic, not hemorrhagic stroke, for which heparin is appropriate, was already at 80 percent, he said.

Hoberg noted that there is no documentation that Hsu told the patient about the potential fatal risk of heparin without a CAT diagnosis. Hsu said he talked about it both with the patient and the patient's daughter, who decided to proceed.

Besides, he said, Elgin has no CAT scan and it didn't make sense to transfer the patient to Bismarck and risk a second, possibly fatal stroke in the meantime.

He said practice in a rural setting forces him to rely on his own competency and experience, where doctors like those who reviewed his cases have more sophisticated equipment at their disposal.

This would be a tough decision for me to make. Either call for an ambulance to transport a possible stroke victim 87 miles to Bismarck, knowing that there is only a 3 hour window of opportunity for thrombolytic therapy. Or start heparin in hopes of preventing a progression or recurrence. I wonder if there is only one correct answer? Is the answer different depending if you are the treating physician with a ticking clock, or a reviewing physician with hours to peruse the chart and a CT scanner down the hall? And what is it that they say about hindsight?
The three most compelling cases in the dispute involve what Hsu calls "right to die" cases.

In each, he is criticized for improper medical procedure and documentation.

Hsu says all three cases are instances of the patient and in one case both the patient and her daughters resisting either more tests, treatments or transfers to a Bismarck hospital.

Both the wife of a 78-year-old man, who died of heart failure, and a daughter of a 94-year-old woman, say Hsu followed his patients' wishes.

Neither would be identified for this story and adamantly insisted their names not be used. In both instances, they say the patient made the decision to refuse treatment and testing.

In the case of the 78-year-old, Hsu said the man refused treatment and a transfer to Bismarck.

The chief complaint in the case by the reviewing physician, Dr. Craig Lambrecht of Medcenter One, was that "care went half way and not all that could have been done was done," Hoberg said.

He also wrote, "There was no indication in the medical records other than a nurse's note that the risks of refusing treatment were explained ... and that he voluntarily refused treatment."

However, the man's wife, who insisted on privacy for herself and her husband, said her husband was clear about not wanting treatment or life support.

"According to what he (my husband) wanted, yes, I'm satisfied," she said.

Hsu said in the case of the 94-year-old woman, she told him, "Please don't do anything. Let me die. I'm miserable and I'm glad to die."

That patient's daughter confirms that communication occurred between Hsu and her mother.

"She stated she did not want those tests. Otherwise, he did everything he could for her," she said. "It wouldn't have mattered what the doctor said, her mind was made up."

So according to the family members, Dr. Hsu carried out their relative's wishes. According to the medical board, he didn't document that this was the case. What is the purpose of documentation? To demonstrate that he obtained informed consent from the patient and/or family. It would be a different matter if the family members didn't back up Dr. Hsu's story. This way it's like being arrested for shoplifting because you forgot to keep the receipt when you walked out of the store carrying the groceries you bought, even though you paid your money and the shopkeeper even vouches for you.
"They say I don't document well enough, but I don't keep my records for them. Since this started, I'm spending a lot of time dictating to cover myself, but that's not what I wanted to do in my practice, protect myself from the Board of Medical Examiners," Hsu said.

If all doctors were judged on the quality of their documentation, there'd be a LOT of suspended doctors. Notes that are illegible, incomplete, inadequate are rampant. Even with the coming of the electronic medical record, bad handwritten progress notes are being replaced by bad templated progress notes, which are often applied indiscriminantly, regardless of their correlation to actual physical findings or history.

For clarification, I do not know Dr. Hsu, and have never met him. But I could see myself in a similar situation someday, through no fault of my own, but because people don't realize how difficult it is to be a family doctor.

Lastly, I wanted to post Dr. Hsu's comments that he left in response to my entry about him (since I figure most people don't read the comments).
I appreciate your comments and insight; I also applaud your efforts to move from the "norm" of what I call "institutional medicine". I graduated from medical school at age 41 and from a FP residency at 44. After one year as an employee of a tertiary care hospital I took the chart of an uninsured rural patient who needed a cholecystectomy, but got in addition every conceivable consult (including a pyschiatric consult because he had expressed concern about the cost of his hospitilization) to the CEO with my resignation and the comment "this is not medicine, this is rape."

I started an independent rural clinic fifteen years ago and have had the kind of rewarding practice I believe most of us aspire for-- one based on trust and compassion rather than compensation.

I do not resist change nor distrust technology. But I feel strongly that investigative procedures are no substitue for clinical judgment, and when a choice has to be made, I have trusted my clinical judgment. And although I was correct in every case before the board of medical examiners, their comment was that I was "lucky". I was criticized for not ordering an EKG on a patient who "might have" had an MI, and for not ordering a CXR on another patient who "might have" been in heart failure, though neither patient in fact had either entity and both DX's had been ruled out on clinical exam.

Well, good luck to both of us.


Maybe Dr. Hsu should give these guys a call.