Emory: A Follow-Up

First, during the debate that that followed my article when it was posted at Redstate, there was a few skeptics. They raised concerns that Kevin's story far fetched and hard to believe.

these comments seem fishy. Grady may have its problems, but the nurses and
administrative folks working the night shifts wouldn't have allowed the residents to leave a med student in charge. And even if a med student is placed in one of these situations, the proper course is to first do no harm. Which in the case of a med student, who by definition knows nothing and is not medically licensed to do anything, the proper course is to do nothing. If he stuck in a chest tube without supervision, not only should he be expelled, but he should be in jail.

Here is Kevin's response.

the chest tube was placed back in the incision - it was not surgically placed. Secondly, this incident took place at the VA, not Grady. Thirdly, this happened and was documented. Names were named, patients were named, etc. IT is not exactly like there are administrative folks at either hospital at night who have informed knowledge about what is going on on each medical team. Nursing shifts change, and communication is often improper as well. Bad communication happens daily at both places.

The questioner continued...

it's not a matter of "adhering to protocol". Placing a chest tube is a serious procedure which involves using a scalpel to cut through someone's chest wall. No, no, no - you do not do this as a med student. The likelihood of doing more harm is much greater than doing any good. And to believe the other stories requires that everyone in the hospital is in on this stunt. The primary care physicians for the patients coming into the hospital aren't complaining that their patients didn't get cardiac enzymes until 17 hours after going to the ED? This isn't showing up in the joint commission accredidation of the hospital? The emergency room physicians are leaving med students in charge too? There are no radiologists to read the chest x-rays because they are in on the scheme as well?

Here is Kevin's response.

I DIDN'T SURGICALLY PLACE THE CHEST TUBE. It had originally been done by the surgical team. What happened is that the chest tube came out of his chest. The incision was still there. There was no one there to take care of this situation, and I did it alone by taking the old tube and shoving it back in as best as I could since no one was there and his lungs were collapsing. In terms of the cardiac enzyes - the patients going into the hospital don't have primary care physicians. At Grady, you are dealing with the most indigent of indigent people. They havenowhere to go. They don't know what the delay was or means. I documented it and gave it to those in charge. Furthermore, in terms of JCAHO, it went even further - the federal Centers for Medicare and Medicaid services investigated, validated what I said, and stated to the hospital that "all patients are in immediate and serious jeopardy." They gave the hospital 30 days to fix these problems. This was released in a report in August 2005.

This isn't about some scheme that all doctors are "in." I never mentioned the Emergency Room, nor the radiology dept. I simply stated that when I was dealing with the man's chest tube, there was no radiologist in the hospital to read his chest x-ray. There was one on call at home and it would take him 30 mins to get to the facility. I documented this as well.

First, here is further information on the report Kevin mentioned. I should make myself clear. There was a lot of the same type of things going on at the VA hospital that also went on at Grady since the VA was also one with limited income potential.

I would also like to direct everyone to two articles that corraborate Kevin's assertions. Here is the first article. What follows is a detailed account from a doctor that worked at Grady though they wouldn't use their name on the record.

“Grady is a teaching hospital. In such a hospital, doctors in training, interns and residents, as well as medical students, are the first doctors to see and evaluate patients. Attending physicians, doctors who have completed all their training and have a license to practice medicine, oversee their work. For Emory, the attending physicians may be based at Grady, or may be based at Crawford W. Long or Emory, but they are medical school faculty and as such also have other responsibilities—teaching elsewhere, research or seeing private patients. In a healthy teaching environment, the attending physicians strike a balance between oversight and direct intervention. To make this happen, and to comply with state and federal law, the attending physicians must see and examine the patient themselves, and document this oversight in the medical record. Grady pays Emory and Morehouse for these attending physician services.

“Both the quality and quantity of these services was surely an area of concern in the audit. Each medical school, and each department (e.g., internal medicine, orthopedics, radiology) within each school, has discretion regarding how this oversight is achieved.

“One of the areas of serious concern has been the amount of oversight on the Internal Medicine inpatient service. Interns and residents will admit patients to the hospital during a 24 hour period, and then the attending physician is responsible for seeing those patients within 24 hours, and at least every 2-3 days thereafter (if not more frequently), and documenting their exam in the medical record.

“However, most physicians trained at Grady (and that probably means 85% of
the MDs in Atlanta!) will tell you that they “never saw” their attending physician. In other words, the interns and residents took care of their patients without appropriate supervision, meaning Grady paid Emory and Morehouse for “ghost” attendings.

“How much? However many physician salaries plus fringe should staff an 800 bed hospital—millions, if not tens of millions, of dollars a year. What were those attendings doing if they weren’t at Grady? See the paragraph above—“they are medical school faculty and as such also have other responsibilities—teaching elsewhere, research or seeing private patients.

“I was ... appalled by the lack of oversight.

“The dean will undoubtedly say: ‘Oh, it is just that our hardworking attendings don’t document their oversight’ but what the question really should be is, “Were those doctors that Grady paid for actually at Grady seeing and examining patients?’ Or were they elsewhere?”

The part that is of course most interestin to me at least is this "However, most physicians trained at Grady (and that probably means 85% of the MDs in Atlanta!) will tell you that they “never saw” their attending physician. In other words, the interns and residents took care of their patients without appropriate supervision, meaning Grady paid Emory and Morehouse for “ghost” attendings. This frankly is the same story Kevin tells only without the dramatics of a soffocating patient and a dirty chest tube. The second article deals with the convoluted way in which supervision was documented.

At least as recently as two years ago, Grady Hospital wasn’t able to accurately determine how much supervision doctors-in-training at Grady were getting from Emory faculty as they handled their caseloads at the trauma center because the reporting mechanism in place didn’t give them enough detail, a newly-released audit shows.

The audit shows that the information supplied by Emory, indeed, fulfilled the terms of its contract, as Emory has said, but the data still was “too general to allow the hospital to adequately monitor faculty supervision,” the report shows. The audit is dated Feb. 16, 2005 and covers the years 2002 and 2003. It was released Thursday under an Open Records Act request by Sen. David Shafer, R-Duluth.

It continues...

The audit was further complicated by data dumping, the audit said, explaining that “the majority of the medical schools’ information was provided as hardcopy reports. This made trending analysis very cumbersome, and searching for particular items in the historical data was extremely time consuming and susceptible to error,” the report said.

As for monitoring the time (and, thus, the reimbursement to Emory and Morehouse) of supervisory faculty, the report said Emory should check the time records of its doctors at least once per month instead of once per quarter. Morehouse collects time data two weeks each month, the report said.

“An accurate physician faculty time monitoring system is critical for both medical schools’ management and third parties (health system) to effectively measure faculty supervision. We determined that the medical schools perform the contractual minimum compliance requirements (one week per quarter) but it is inadequate for a third party to accurately monitor the actual level of faculty supervision...”

It is important to note that while the audit found that the record keeping vis a vis the amount of supervision provided at Grady was sorely lacking (as shown again here, "the report said Emory should check the time records of its doctors at least once per month instead of once per quarter") it also showed that this same system fulfilled the terms of its contract. Well, it is this diarists belief that the cozy relationship between Emory and Grady lead to this dichotomy, but that is for future diaries.