Subject: the ongoing slaughter in the offices, clinics, gurneys, and beds of Managed Care. This is not the gun-to-the-head assassination of the uncooperative, it is the slow vitamin-deficiency-like-poisoning caused by acts of omission perpetrated on the cooperative. This new killing is being wrought on those very patients who suspended their general disbelief of advertising and got hooked for one more year by slogans like "in the hands of doctors" -- the Kaiser system.
But before giving you the new details I have come across today, let me ask for you to pause and judge the relative depravity of two assassins. One is guilty of a rapid commission of death sentence comprising a millisecond of pain perhaps not even perceived by the victim but rather beaten by the bullet to the centers of recognition. The other is guilty of ignoring long suffering until its own terminus extinguishes the contract of care, thus also pulling down generations of love ones who can't get past the anger of grieving the unnecessary pain. I would imagine that society has always assigned the degree of murder based on the length and complexity of premeditation as well as the unnecessary pain produced.
Yesterday, I shared with you my impression that two stress tests considered negative performed two months apart at a Kaiser "hospital" on a man just below 50 would soon be read by an impartial, private cardiologist as being positive. This was on the man who suddenly died at home still dutifully taking his stomach acid pill as a non-cardiac patient.
I called the cardiologist about 2 p.m. today, thinking that I had blown my chance for a sudden reading on a Friday afternoon -- as he is one of the busiest cardiologists in Fresno. My office staff was prepared to take the copies of past tests wherever he was to be found. But he called back personally and said he would come to my office to solve my question. Yes, it was to be a free gift -- half of what medicine is all about according to the Mayo Clinic.
He had no problem as I blinded out the past Kaiser readings. Rather he turned his rapid review of the 58 pages into a teaching session. In turns out that stress test interpretation is a common topic he likes to teach. He told me to pay special attention to poor circulation persisting into the Recovery Phase when the patient is lying down again -- no other muscles interfering.
To the first stress test he said that he would have been highly suspicious of coronary artery disease. He would at least of started an enteric coated aspirin once a day as well as a beta blocker. He would have told the patient that the answer was not yet conclusive even though the test was basically positive by the math of the Bruce protocol.
At the first symptom of more chest pain, the standard of care, he continued, (and I am only paraphrasing) would be to advance to a stress ECHO or stress thallium test to gain sensitivity and precision. The fact that the institution merely repeated another stress test two months later was of itself not up to the standard of care; it fell to malpractice.
The second test was definitely positive by symptoms, by the math, and by an extension to another area of the heart -- although not interpreted that way by the Kaiser cardiologist. The private cardiologist would have recommended an angiogram at that point in time, willing only to delay if the patient required a middle ground.
He would have told the patient clearly that he had angina until proven otherwise. Strong medication protection would have been started; activity would have been limited until solutions were found. Maintaining the patient only on stomach acid medication after both stress tests was an unbelievable outcome. (This confirmed what I had read of the same tests in my own amateur style last night wandering through the Internet for backup calculations and diagrams.)
I told him that my 18 months in the emergency room at Kaiser lead me to believe that this was the global standard -- medical marginalization. And that any sequential private reading of tests from stress tests to x-rays to lab tests would demonstrate the calculated errors of omission practiced by most. (Such practice, I believe, falls to Kaiser management more than the medical professionals, the former for setting impossible time/volume interactions; it is the reason I propose that health care administrators need now to be licensed -- accountable for the time/volume decisions that maim and kill.)
The cardiologist was not surprised. He also understood the concept of the obvious anchor effect noted when managed care comes to town -- the competitive draw down spilling over into the private community. If Kaiser can pass off a hospital that isn't, I added, every hospital in town is at risk. (If you can pass off sandstone for granite, you can destroy the granite industry in less than a generation.)
I asked if he could take on the role and pressure of looking at 100 sequential stress tests within the crucible of the legal industry. He explained that he has already had to testify within the Fen-Phen legal arena and realizes that it now comes with the territory.
He could be contacted if needed. Cardiology, which is not used to the benefit of the patient, is not real cardiology.
Soon after I was distracted by a pleasant conversation with one of the founders of NeedyMeds.com as well as possible chance to network on medication costs with a local senior advocacy group. Next I saw my last patient, adjusted his cholesterol medicine, and turned off the lights.
But it was clear to me as I pulled into my garage that Kaiser had stumbled -- no fallen flat. In their race for "productivity" they had gone beyond just missing cancers -- and other subtle areas of judgment -- into a mathematical zone with a reproducible record. And massive shredding would get them nowhere. The absence of hundreds of stress tests would be as much fraud as the misreading of those found.
I had the confidence of going to the medium mountain and returning not with a set of tablets but a new Rosetta stone. The key to breaking the code of the Pharaohs was at hand. And the firewall of "that's just an isolated Permanente physician problem" would not work. The dangers of having chest pain -- or any illness with a document track -- would someday fall out of the Kaiser fortresses.
The New Killing Fields responsibility reaches up to the top floor of the Kaiser high rise overlooking Lake Merritt in Oakland, California. You will know you are at the top floor when the usual potluck chicken lunches further down turn to catered roast tenderloin.
And Kaiser is only a single estate in a land of mismanaged killing fields. I'd suggest to all top managed care executives -- MDs and/or MBAs -- that the writing in blood is already on the wall and it is time to call U-Haul for boxes, packing your family pictures first. But if any of you turned whistle blower on the way out, you might still avoid the curse of Hippocrates.