Preventive Medicine and the Seven Deadly Sins: Avoiding Discipline Against your
The final article for the "Seven Deadly Sins" series on avoiding
discipline against your medical license will address pride. Pride seemed
like such a proverbial "no-brainer" that I decided to save it for the last essay.
Little did I know that I would get stuck on pride (a note-to-self moment?). So I
conferred with my most trusted source of inspiration, who referred me to the well-known
adage of Proverbs 16:18 which reads, "Pride goeth before destruction, and a haughty
spirit before a fall." Then I went to my second most trusted source of inspiration,
Google, where I was delighted to learn how ecumenical the sin of pride is. That
pride is recognized and derided by most religions suggests that pride must be a
flaw with which most everyone struggles, but I have a question for you: do certain
professions exemplify this sin better than others?
What happens when highly-accomplished personalities find themselves in need of help?
Does that translate to a self-perception of failure? Being so unaccustomed to failing,
is it thus exponentially more difficult for a physician to ask for help? This is
when pride does, in fact, precede destruction.
I know this is neither glamorous, scandalous, nor particularly memorable, but the
first thing my colleagues and I thought of as examples of pride had to do with consultations
- or more precisely, the failure to obtain a consultation. I guess if you look at
it from pride's point of view, a consultation literally requires asking for help.
And wait! If you have to ask for help, you might have to admit you don't know it
all. Admitting you don't know it all requires ... swallowing ... your ... pride.
I can think of one physician where his pride actually rendered him dangerous. In
this particularly egregious case, the physician was not a trained surgeon; however,
he took a one-week class in performing liposuction. The training recommended 20
proctored sessions prior to independently performing the procedures, but this physician
was so arrogant he felt he did not need this level of oversight. Because the physician
was performing the surgery in an outpatient setting, he was able to forego the proctoring
requirements. The result: complication after complication. And, to compound this
scenario, the physician was too proud to seek help when the complications occurred.
One patient suffered from profuse post-operative bleeding. Rather than call an ambulance,
or drive the patient to an emergency room, this physician actually tried to check
her into a hotel! The hotel refused to accept her so the physician drove her to
his home where she bled to death. In cases where we can establish a physician poses
an imminent threat to public safety, we are able to seek an interim suspension order
(ISO). The ISO prohibits the physician from practicing medicine pending the outcome
of legal proceedings seeking to revoke his or her medical license. This physician's
license was revoked (after it was suspended), and this case contributed to substantial
legislative changes that now pertain to outpatient surgery. It is unfortunate that
laws have to be created to counteract such egregious levels of pride.
The standard of medical care is frequently breached when a physician fails to seek
a consultation, which is naive on several levels. Consults provide access to quality
care for the patient. Consults prevent errors. Averted errors prevent lawsuits.
If a lawsuit or complaint is filed, then consults often prevent them from turning
into formal action. (Of course, the consult is only really valuable when it is documented
The specialty we investigators observe as most susceptible to the consultation omission
is pain management. Many physicians dabble in pain management. Many internists,
psychiatrists, family physicians and even pediatricians will acquire a patient with
an intractable pain condition, and they will get into trouble when they either didn't
refer the patient to someone who is well-versed with this specialty, or confer with
a pain management physician only when the situation gets too complex. Remember,
physicians who practice any specialty are held to the standard of care for that
specialty they are practicing, whether they were formally trained or are board certified
in that specialty.
Another common challenge for pain management practices is the drug-seeking patient
who is quite cunning when it comes to compromising a physician's lack of knowledge.
What if the doctor faces the dilemma of the drug-addicted patient who is also suffering
from chronic pain? All it takes is a consultation with experts and documentation
Psychiatrists are sometimes conned into prescribing narcotics for pain management.
Internists often prescribe psychotropic medications without the appropriate knowledge
of their effects. And is it me, or has pharmacology itself become a Pandora's Box
of liability? I know many people who are prescribed so many pills, for so many varying
ailments, that it's a wonder most physicians know all of what the patient is receiving,
let alone how these various medications interact.
Here's another area where we often see problems because of pride. There are a lot
of doctors out there who are brilliant practitioners, but they have no business
acumen. Being too proud to admit it, they are lured into contracts and obligations
due to their business naiveté and end up being cited for all kinds of violations
(failing to have a fictitious name permit, aiding/abetting the unlicensed practice
of corporate medicine, advertising violations). I hate to be the bearer of bad news,
but ignorance is never a valid defense.
And finally, how about the most common demonstration of pride? How about being afraid
to ask for emotional help, when the stresses of a busy practice, society's extraordinary
expectations, extracting compensation from insurance companies or HMOs, malpractice
premiums, complaints, technology, traffic, not to mention the activities of just
a normal day, how do most physicians handle that cornucopia of stress? In my line
of work, we see the physicians who find it easier to succumb to a panacea of alcohol
or drugs than to ask for help. (See "Physician Wellness as Constrained by Burnout"
article, November 2007 MBC Newsletter, front page.)
Pride challenges us all to some degree. A healthy sense of self-pride isn't entirely
horrifying, and I know in my experience, whenever I exceed a healthy sense of esteem,
an omniscient pride-ometer is just waiting to slap me down to reality.
I am proud to have had the opportunity to write these words of caution to you. I
hope there is a parcel of information contained within this catalog of sins to help
you navigate the investigative process and have a better understanding of what we
investigators encounter in our job. Most important, I hope there was some advice
within these sins that helps keep someone out of this newsletter! But if I have
failed, and if you do end up here, we can consume our pride together and learn from
the experience. After all, as C.S. Lewis said, "A proud man is always looking down
on things and people; and, of course, as long as you're looking down, you can't
see something that's above you."