The Haunted Waters of our Healthcare: Our System's Flying Dutchman--a Captainless Ship

    

    The legend of the Flying Dutchman, a captainless & spectral ship doomed to endlessly sail the seas, has haunted maritime folklore for centuries. But this ghostly tale finds an eerie echo in a far more tangible realm: our healthcare system. Like the Dutchman, our healthcare system often feels like a fragmented, perilous voyage, fraught with hidden dangers and elusive destinations.

A Ship Without a Port

    The Flying Dutchman is cursed to never find port, forever adrift. Similarly, many patients find themselves lost in the labyrinth of healthcare, unable to find a clear path to effective, affordable care. They are tossed about by a sea of specialists, referrals, and insurance complexities, never reaching the safe harbor of true well-being.

Hidden Reefs and Treacherous Currents

    The Dutchman's journey is fraught with peril, sudden storms, and unseen obstacles. Our healthcare system, too, is full of hidden reefs: unexpected costs, bureaucratic hurdles, and gaps in coverage. Patients must navigate treacherous currents of confusing policies and procedures, often facing financial ruin or inadequate care.

A Desperate Crew

    The crew of the Flying Dutchman is often depicted as ghostly figures, trapped in their endless voyage. In our healthcare system, patients can feel equally isolated and desperate. They may face chronic illness, debilitating conditions, or the crushing weight of medical debt, feeling abandoned and adrift in a system that should be their lifeline.  

The Illusion of Control

    The Dutchman's captain, according to some legends, is driven by a desperate desire to overcome the odds, even at the cost of his soul. Our healthcare system often presents a similar illusion of control. We are told that with the right insurance and the right doctors, we can conquer any health challenge. But the reality is often far different, with patients feeling powerless against the vast and complex machinery of the system.

A Call for Change

    The tale of the Flying Dutchman serves as a warning, a reminder of the dangers of hubris and the power of fate. Our healthcare system, too, needs a course correction. We must strive to create a system that is not a source of fear and frustration, but a true beacon of hope and healing. Like a ship in need of a safe harbor, our healthcare system requires reform, compassion, and a commitment to serving the needs of all those who navigate its waters. Only then can we avoid the fate of the Dutchman and create a healthcare system that truly delivers on its promise of health and well-being.

Know Thyself--Your Market Value's Worth

    Early in my career, fresh from escaping an unsupportive toxic work environment, I had a memorable phone interview with a solo surgeon. He was looking for a PA to join his practice, which had been running for over 37 years. I’d almost forgotten about the written ad I’d responded to weeks prior, assuming he’d moved on or my qualifications weren’t a match. Then, out of the blue, I received a message on my answering machine. He wanted me to call him back—on a Saturday—for a preliminary chat before potentially flying me out to an onsite face-to-face interview.

    I scheduled the call, running through countless possible scenarios in my head. When the day arrived, the first few minutes were standard interview fare. But the surgeon quickly shifted gears, adopting a blunt, “cut to the chase” approach—not entirely unexpected given the nature of the profession.

    As I began explaining how I could assist with his OR cases, he interrupted me with a single, direct question: “So, what’s the hourly rate you are looking for?”

    Internally, I froze. I didn’t want to undersell myself, but I also didn’t want to price myself out of the running. My research suggested aiming for 20% above my current hourly salary, but I worried that number would seem exorbitant to him, especially given the pay scale he was likely accustomed to. Taking a deep breath, I composed myself and stated my desired salary and benefits package.

    I braced for a reaction – a pause, perhaps, or a counteroffer. Instead, he simply said, “Oh, you’re asking too much.” While I was open to negotiation, his tone and inflexibility made it clear he wasn’t.

    That phone call was a turning point. It drove home the importance of not undervaluing my skills. It also reinforced the fact that medicine, like any business, has a power dynamic. The buyer often seeks to leverage their position, especially with newcomers or those lacking experience.

    Many new PAs struggle with determining their worth and often accept lower pay when starting out. I’ve seen firsthand how this can lead to regret, as it’s often difficult to correct the pay disparity later on. I didn’t get the job, but I later learned this surgeon had a high turnover rate among his PAs, so it was a bullet dodged.

    My advice to all my fellow colleagues is this: Don’t undervalue yourself or your profession by accepting lowball offers. Know your market value. Do your research.

    Consider this: If you needed an expert service and received three estimates at a fair market price, but someone offered to do it for significantly less, you’d likely question their competence, right? Undervaluing your services can diminish your perceived value and impact your future earning potential. Don’t fall prey to those looking to take advantage.

    In short, know your realistic worth and, more importantly, don't undersell yourself.

Law #71 of Puerto Rico-- PA Engaged Advocacy Matters

   

    Seven years after its enactment, Puerto Rico's Ley #71 remains a deeply divisive and restrictive obstacle to the optimal practice of medicine within the Commonwealth. This legislation continues to hinder our ability to provide care in a manner we believe best serves our patients. Despite the efforts of organizations such as AAMPR, AAPA, and PAHL to enhance our professional standing, this detrimental legislation has yet to be repealed or amended.

    As we approach 2025, it is evident that sustained advocacy by Physician Assistants (PAs) is crucial to overcome the entrenched political obstacles and outdated, misinformed perceptions surrounding our role within the team-based medical model. Now, more than ever, unwavering commitment and active engagement in this challenging struggle are essential, particularly given the substantial financial resources invested by hospitals, insurance companies, and local nursing and physician groups in lobbying against our interests. We must, however, maintain a steadfast resolve in our ability to influence the narrow legislative agenda of their elected officials, a force that should not be underestimated by any member of our community involved in this process.

    To effectively address this issue and move forward, we must consolidate our efforts and amplify our voices alongside those who understand and support our profession. It is important to remember our history of successful lobbying efforts both within the United States and internationally. This advocacy demands not only patience but also unwavering determination, embracing even the smallest gains within the political arena as we advance our cause and interests among all stakeholders.

    Furthermore, current industry trends, including the expansion of scopes of practice, affirm the influence of our voices and the progress we have made. Our five-decade history of providing high-quality medical services and improving access to care underscores our contributions to the healthcare landscape. However, passivity and a spectator stance in this debate would allow other stakeholders to dictate our professional destinies.

    PAs are uniquely positioned to lead and influence critical decisions by actively participating in these discussions rather than relinquishing these opportunities. By acting decisively and with a clear understanding of our professional calling, we must seize these pivotal moments to continuously and positively shape the delivery of healthcare within Puerto Rico's severely strained healthcare system.

METADATA: A New Legal Foe to contend with.

Designer Microsoft.com 

      One of the greatest changes in the practice of medicine in recent years has been the introduction of the electronic medical record (EMR). A change heralded by many with significant promises, and welcoming enthusiasm at the time. However, this was not the case, especially when we started seeing “The Law of Unintended Consequences” play itself out in many allegations of medical malpractice across the country.  

      Thus, for many the good old days of the paper chart comfort and safety vanished rapidly from the charting landscape shortly thereafter. As we knew it, our former world of paper charting practices was turned inside out, and all because of a new unanticipated legal risk exposure introduced by this new technology—metadata. Plaintiff attorneys began and are still using EMR audited metadata to bolster their electronic discovery, much like they used to when subpoenaing paper charts to determine a case's merits; or to see if it was or is worthwhile to pursue. 

        Metadata is commonly defined as “data about data” by techno-savvy folks, that is, non-med-malpractice attorneys. Conversely, to med-mal attorneys is the data encrypted (attached) to an EMR that describes the file in its totality.  Basically, meaning the extra “hidden” (encoded) information that is created and embedded every time a chart is opened, amended, revised, or edited.  Essentially, this is tracking the author’s usage or “footprints” in a timeline fashion of a patient’s electronic medical record. Metadata is particularly important in healthcare litigation because it firmly establishes the “who,” “what,” “where,” “why,” “when,” and in many cases the “how,” basically analogous to someone’s fingerprints (1).  In other words, metadata shows the author’s log-on/log-off times, the dates & times of what was reviewed, revised, amended, added, or deleted, and for how long the chart was “open”.  This makes all electronic interactions not only documented and time-tracked, but ultimately discoverable too; therefore, potentially increasing the legal vulnerability of an EMR user.  

      Plus, this raises the risk/possibility of fraud allegations against the provider if the services rendered vs. billed are questionable by the EMR audit trail. These time stamps of clinical activity under Federal law are discoverable and admissible in most jurisdictions in civil trials (Williams vs. Sprint— United Management Co. 2005, WL2401626, D. Khan, Sep 29th, 2005). Legal experts believe the increased usage and spread of EMRs have reshaped the medical liability landscape by altering the way American courts will determine the Standard of Care.  

      Moreover, patient treatment errors may be unproven or unclear, yet the collective weight of time-care stamps discrepancies in alleged med-mal cases could be so heavy that in itself could render the case difficult to defend as many legal scholars as possible and theorists observe.  While discrepancies in general do not necessarily mean negligence, they certainly can call into question the provider's credibility rather easily.

 It is imperative for medical professionals to carefully and timely chart patient records because metadata is making note of their every move.  

      Often times that’s all it takes in some juror’s mind…which story is the most credible one, the plaintiff’s or the defenses?  

Resources Researched: 

1. Blake, Carter, Note- EMRs: A Prescription for Medical Malpractice Liability? Vaid, J. Enterprises & Technology, L 385 (2011), Vol. XVII, Number 4. 

2. Kern, Steven, Hidden Malpractice Dangers in EMRs, Med Scape Business of Medicine, Dec 3, 2010 (589724), www.medscape.com assessed October 30th, 2015. The 2015 MAPA

Straight Talk About High-Risk Patients from a Medical Heuristic Lens

    Reflecting back as an orthopedic hospital-based and former Emergency Medicine Physician Assistant (EMPA) at an urban inner city Level I trauma center, one of my biggest challenges was not only to spot the drug-seeking patients or rule out subtle life-threatening presentations but also to juggle and manage flawlessly two other high-risk types of patients: the “bounced-back” and the unimproved “signed-out” ones. Two potential medical malpractice time bombs waiting to happen most likely if not afforded the right clinical follow-through diligence or taken seriously on your watch, particularly when the liability factor was transferred to you by a recently graduated colleague or an intern completing their shift. 

    Why is that you ask? Well, possibly because these two types of patients in some instances are usually either insufficiently or possibly improperly worked up as I came to find out many times to my dissatisfaction. Thus, easily leading you astray (if not cautious enough) in these supposedly ready-to-go  “signed off” patient-shared presentations by the initial clinician.  Especially when the clinical management or your partner’s clinical decision-making process was determined pending the patient sobering up or diagnostics results returning normal or  “within normal limits ” before you decide on the final disposition. This means you having the final say before you discharge that patient. However, you must ask yourself these questions beforehand: Do I have all the pieces of the puzzle fitting properly before discharging the patient? Does the presentation, history, and findings fit the signed-out report given to me? 

    Typically these patients can present already diagnosed or labeled by another facility healthcare provider or simply yet by one of your very own colleagues from a different shift. This pre-packaging can easily lull you into a false sense of security. And, therein lies the legal risks & challenge(s). Given these situations unconsciously you are more apt to engage in potentially perilous clinical activities or behaviors unlike your usual methodical approach when working up your own patients. These faulty cognitive derailers like the following examples listed next can set you up for significant medical mishaps. Let’s dissect them and expose their perilous outcomes, to both, you the provider, and the patient, the recipient of your faulty or flawed narrow-framed medical decision-making shortcuts known as heuristics. Here they are: 

1. Overconfidence Bias. Beware and be careful of either you considering yourself or the other party as competently flawless as you think you are. Always be cognizant of this dangerous mindset because you or your partner may have acted on incomplete information, hunches, or very limited obtained data for that matter. This type of delusion of grandeur may result in catastrophic outcomes if we tend to believe we know more than we do, especially if we never had the “right” information or re-analyzed/re-assessed the presentation and/or signed off the patient altogether. Remember, even the best of us can have “off days” no one is perfect, especially at the end of their shifts–when they are most tired, fatigued, and very likely disengaged. 

2. Diagnosis Momentum Bias. This mindset has fooled many clinicians and accounts for many “missed diagnoses” simply because you have accepted what someone else or a few others have diagnosed the patient with. However, you may not realize or be aware that provider A, provider B, or provider C never objectively proved the patient’s recurring or for instance their unimproved symptomatology. For all practical purposes, you engaged in becoming a “clinical copycat” since the “dx” had already been made incorrectly and you went all along with it. So why reinvent the wheel? Again, clinical syndromes are not static, they evolve possibly leading to clinical instability in which you could miss a window of opportunity if fixated with the “signed-out” presented to you. 

3. Search Satisfied Bias: Here the element of premature closure surfaces because either you found or didn’t find what you were looking for in the history or physical exam. Or better yet, your cursory workup was acceptable at face value. Again, be aware not everything presents classically or the overlapping symptoms may be pointing to more than one condition. This phenomenon is very well-known and documented in many trauma-related presentations. Patients can present with different ailments/conditions that can be masked because they have a “distracting injury” or presentation for that matter. Therefore, it's best to do a secondary survey after the first one if no relevant or critical information was obtained initially. The bottom line is that you must remain vigilant and suspicious if the patient’s condition is unimproved or worsening or if alcohol is involved too. 

4. Anchoring Bias. In this situation, your colleague may have simply latched onto thinking his/her “first impression” was right or the only plausible one, therefore holding firmly onto that specific diagnosis. A very detrimental perspective or path to take when a patient’s course begins to prove inconsistent with the first diagnostic impression. This undue exerted influence or progressive development if it were to remain uncorrected, can certainly lead to possible allegations of a) failure to dx, b) failure to treat; c) failure to refer, or even d) wrongful death in some cases. This clinical inflexibility is very significant in the eyes of a judge and/or jury when the outcome of care is disastrous in terms of the outcome if there was a foreseeable medical intervention.  

5. Availability Bias. In this situation the clinician simply latches onto thinking his/her “first impression” is right thus holding firmly onto a specific diagnosis. A very detrimental stance to take when a patient’s course begins to prove inconsistent with the first diagnostic impression expected. Again this undue exerted influence or progressive development if it were to remain uncorrected, can certainly lead to possible allegations of a) failure to dx, b) failure to treat; c) failure to refer, or even d) wrongful death in some cases. This clinical inflexibility is very significant in the eyes of a jury.