Sunday, February 26, 2006

Medical Algebra -- "New Math" for Physicians

Let's go through everybody's favorite high school exercise, the algebraic word problem:

Somewhere in the US is a busy, and by all accounts, good and caring cardiothoracic surgeon. Let's call him Surgeon A. He is a member of a group of well respected cardiac surgeons; let's call them Surgery Group X. Surgeon A and Surgery Group X receive patients in consultation from a variety of sources, but many come from a particular group of cardiologists --- Cardiology Group Y.

Believing they can increase their revenue, the cardiologists in Cardiology Group Y approach Surgery Group X with an offer: join us as our employees, and you will get a good salary and see all of our patients! They are mathematically stating:

(Cardiology Group Y) + (Surgery Group X) = good things for all

As it turns out, the dollars and cents part of that equation was somewhat lacking for Surgery Group X, so that they felt:

(Cardiology Group Y) + (Surgery Group X) = good things for all ....of Cardiology Group Y

Since no mutually agreeable method of joining could be found, Y + X never occurred. But, as spurned physicians are wont to do, Cardiology Group Y found and brought in Hired Gun Cardiac Surgeon Z, so:

(Cardiology Group Y) + (Hired Gun Z) = a change in referral patterns!

Let your imagination run wild, and I think you will agree that things might have been just a little testy in this alphabet soup. However, there's nothing inherently illegal in this arrangement, and such situations are present all over the country; any multispecialty group is based upon this type of setup. It can, however, appear somewhat undignified to one day stop referring patients to a specialist, who up until this time was perfectly capable of caring for your patients, all because of a financial arrangement.

Enter Patient C, who is in need of heart surgery as determined by a cardiologist in Cardiology Group Y....and who has been operated on by Surgeon A.....and who, upon being informed of the need for more surgery, specifically requests Surgeon A, whom he likes and trusts. His formula is therefore:
(Patient C) + (Surgeon A) = hopefully good results

But there is a problem -- Cardiology Group Y tells Patient C, "we're sorry but Surgeon A is not available, but we have Hired Gun Z right here and ready to take care of you this instant." Patient C acquiesces, Hired Gun Z operates, and.....there are complications requiring more procedures --- cardiac reoperations are nothing if not difficult, hazardous, and not a lot of fun for patient or surgeon.

(Patient C) + (Hired Gun Z) = oh, shit

Patient C subsequently finds out that Surgeon A was available all along, and that the financial arrangements of Cardiology Group Y, rather than his own requests for surgical care, were the sole reason he was sent into the operating room with Hired Gun Z. And, boy, was he pissed --- not about the complications, as he understood his risks, but about the fact that his physicians lied to him and camouflaged their financial shenanigans as appropriate delivery of care. The ultimate equation, in his estimation, is:

Cardiology Group Y's $$ >> Patient C's desires (which approach the value of "zero")

(cue the music) Enter Slick Attorney G, who sues Cardiology Group Y and Hired Gun Z for fraud and battery on behalf of Patient C. And who wins -- big. To the tune of $2.25 million in compensatory damages, and $2.75 million in punitive damages, finding the two physicians and their group guilty of fraud, and Hired Gun Z guilty of battery -- for having operated on Patient C without having valid consent to do so.

And that, my friends, is a far more harsh way to learn "New Math" than the way I was instructed in school. There is no insurance coverage for that sort of verdict, and no amount of "spin" can make this most unseemly deal look even remotely redeeming. You can read a less mathematic account of this very real case in Surgery News (bottom of page 4). Having experienced this type of behavior first hand on more than a few occasions, I wonder what the effect of this ruling will have on physicians who have more than a medical relationship with other specialists, or with labs/x-ray facilities/outpatient surgery units etc, for that matter. News of this case has hardly had a wide audience, and I suspect many who currently practice in this manner have yet to hear about it. They would do well to heed the warning given by the attorney involved:
William F. Gately, attorney for the Bargars, said that the verdict was "thoroughly and entirely appropriate. For any physicians to do to a patient what this jury found that these two physicians did to Harry Bargar is obscene."
I'm sure he's available to sue those who refuse to let their patients choose their own specialists -- and that will give you a headache that is worse than anything a Diff. Equations professor could ever dream up. And, no, wearing the dunce cap will not suffice as punishment (although it might be a a worthwhile addition!).