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On being a doctor and an advocate

I opened my internal medicine practice almost four decades ago to serve a growing urban community. I gravitated toward the underserved geriatric population as they were vulnerable patients and eventually moved into the bygone realm of house calls for home-bound seniors.

This enhanced my learning curve, as house calls are not taught in medical school or residency yet bridge the continuity gap between hospitalization and patients returning home after an acute illness. I spent many hours at our local hospital admitting older patients and managing their care once they were discharged home.

From this perspective, I saw the growing takeover of medical decision-making by doctors, which was then relinquished to hospital administrators.

As an outspoken medical staff member, I was urged to participate in the physician medical executive committee. My peers elected me for five years, and I served as chairman of the department of medicine for three years. I also chaired many hospital committees.

I clung to the hope of working within the hospital system to improve care. This did not happen. Several of my doctor colleagues were continually under siege from the hospital administration for speaking out against aberrant care. Immediately after my election, I became a target with false allegations of “corrective action” and code of conduct violations.

Questionable policies and procedures developed by the hospital administration raised concern. I reported them multiple times to oversight agencies, resulting in financial and operational sanctions.

Consequently, I was forced to jump through many hoops to remain on staff. For instance, most doctors know one must re-apply for staff privileges, usually every two years. The hospital administration made me re-apply every four months.

The hospital had a financial stranglehold on many doctor groups, with administrative tactics dangling contracts swaying them to vote to enrich profits augmenting administrative salaries, bonuses, and retirement packages.

In line with this, the hospital board of director members were awarded construction work, bank deposits, hospital building real estate leases, and medical office space for doctors appointed to the board. In exchange, the hospital administration also obtained their vote.

Quality health care was only a public relations illusion and was compromised at the hospital.

Functioning under duress made it challenging to work within the system, not only with aggressive and derisive tactics against doctors but with legal issues as well.

A prime example of this came when I was chairperson of the ethics committee.

The hospital administration notified me that the committee would convene for an emergency meeting concerning a critically ill ICU patient.

This 50-year-old gentleman had arrived unconscious, did not have an advance directive for health care, and was intubated.

His family, including his wife and three adult children, was present, as were two lawyers, one from the hospital and the other from the patient’s HMO. Three physicians and two community members whom I had appointed were also included on the committee. One was a member of the city planning commission, and the other was a local attorney.

Since the patient did not have an advance directive and could not verbally state his wishes, the lawyers contended that by law, the HMO and hospital administration could assume responsibility for making medical decisions.

The family passionately objected, requesting that care be continued, as they were told the hospital intended to “pull the plug” after a two-week stay as medical care was “futile.”

The local attorney quickly looked up California law and found that the hospital and HMO attorney were correct. We informed the family that the hospital and HMO could make medical decisions. Their frustrated statement, “There oughta be a law!” flowed tears.

Other ethics committee members were also disheartened, but before adjournment as chair, I warned the hospital legal team that if the community somehow finds out about this outrageous takeover of medical decision-making, it could negatively reflect on the hospital’s health care.

More appalling was the realization the hospital and HMO found a loophole in state law and wanted to use it against their patients and the community.

My wife and I have been senior advocates for decades and even organized a picket of the hospital when they decided to close the transitional care unit, which served as a stepping stone for older adults from acute care to home.

Subsequently, we were elected to a governmental group known as the California Senior Legislature, which helped us submit a proposal to the legislature.

In our research, 46 out of 50 states had hierarchy laws allowing family members to be placed at the top of the list should a patient be admitted to a hospital without an advance directive and could not consciously make medical decisions. California was one of those states that had a loophole.

We worked with state assembly member Mike Gibson from Los Angeles and his staff, presenting live testimony online and in Sacramento to the legislative assembly and senate committees to support our proposal, AB 2338 2022.

It passed unanimously and was signed into law by the governor of California.

It is common to hear about the grief family members experience at the hands of hospital administrators, insurance companies, and other health care roadblocks they face. Removing medical decision-making from doctors and placing it into the hands of profiteering hospital administrators is detrimental to our nation’s health care.

One hopeful reward doctors can receive serving the public is a monumental effort to take back medical decision-making from hospital administrators. As well, sometimes doctors can be better advocates for their patients and even make a law to close a legal loophole.

Yet, the greatest reward came when the hospital decided to heed the warning and not “pull the plug” on the 50-year-old unconscious ICU patient.

Eventually, he walked out of the hospital and returned home to his family.

Gene Uzawa Dorio is an internal medicine physician who blogs at SCV Physician Report.

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