Tuesday, February 22, 2011

Doctors in Wisconsin Sign Fake Sick Notes for Protesters; Civilization to Collapse Shortly

Whenever I begin to think that I have Sold Out in life and have embraced respectable living and taken an establishment career track, something will happen to remind me that, whatever desires I might nurture in the bosom of my soul to be acceptable and thus accepted, I am in fact a person with a fringe philosophy that most in my profession would consider dangerously radical.

A long sentence, that, but a good summary of my reactions to recent blog posts by my medical blog siblings. Their scorn was directed at physicians (several, apparently, from the Department of Family Medicine at the University of Wisconsin School of Medicine) writing fake sick notes for the protesters hunkered down for the political fight in Madison, Wisconsin, in which Governor Scott Walker is attempting to rewrite, and effectively strip, the collective bargaining power of public-sector workers. Health Care Renewal led the charge, calling it "the face of postmodern medicine: lying," while Happy Hospitalist danced a little jig after having 10,000 hits after Instapundit's shout-out on his post calling these docs "an embarrassment to their profession." db's Medical Rants piled on, saying much of the same.

I'd be so much more impressed by these sermons if they weren't so over-the-top in both their collective tone and in their historical comparisons. Based on their posts, you'd think that because of this little stunt, which is equal parts civil disobedience and wink-wink chicanery, the world was coming to an end or thereabouts. Happy uses the event to scream with a certain incoherence at Democratic pols involved in the fight, and HCR compares the sick-note signing to doctors who enabled the legal claims of minor car accident victims by medically legitimizing their fake symptoms. (Is this really the same thing? If so, do tell me what is in it for the docs this time around; accident-injury fakery yields a financial benefit for the doc, which is, to my moral compass, considerably more troubling.) db uses lots of words heard at White Coat Ceremonies and the like, intoning about the "sacred trust [between physician and] society."

Curiously, back in 2003, db (of whom I am normally a fan) not only chose not to utter so much as a peep about the potential dissolution of that sacred trust when doctors in New Jersey refused to see patients as a protest about malpractice insurance rates, he wrote several entries that were sympathetic toward them (such as here and here--the latter entry explicitly entreating us to understand the motivations of the physicians, while never wondering if it's maybe unbecoming for a physician--as well as a violation of that supposedly precious "sacred trust"--to tell a patient to go Shove It). Last year, when urologist Jack Cassell thought it a good idea to notify patients that, had any of them voted for Obama, they should seek care elsewhere, db did not see fit to call this man to account for what I would define as deeply unethical behavior (from what I could find on db's archives, at any rate), though perhaps he was unaware.

To be clear: I'm not so sure I'm supportive of these docs, and I do think they've gotten themselves into swift waters without, it appears, thinking carefully about the consequences of their actions (at the very least, they didn't take into account the political consequences, if not the moral ones). But this isn't the beginning of some fake sick-note movement, and none of these people are doing it for personal gain. I don't have qualms with raising doubts about the ethical wisdom of their actions, but the smell of sulfur coming from these heavy-handed judgements is a bit much for me.

UPDATE: So far I appear to stand alone among doc blogs in not jumping up and down in blistering condemnation of the sick note scandal: GruntDoc's quick take is here and Retired Doc shakes his head here. RW Donnell, who against all expectations manages to once again defend the status quo, airs his thoughts here among various entries.


  1. I posted on HCR the idea that the "docs" could be plants to make the unions look bad. Maybe they are real docs.

    In that case it can be considered civil disobedience since, as you point out, they are not doing it for personal gain and are not harming the people they are writing the slips for.

  2. I just posted the following to the HCR post.

    "I do want to challenge your comparison between these docs and the ones doing fraudulent disability exams. The latter are doing it for personal gain, and may well be harming the patients, since I find that disability can easily be disabling.

    These doctors writing scripts for people protesting are engaging in civil disobedience. There is no personal gain, some personal risk, and no harm to the person receiving the script.

    I know of doctors who certified examinees as unfit for military service to keep them from having to go to Vietnam during the draft. I also read about doctors who "doctored" medical findings to try to make it easier for detainees imprisoned in concentration camps. I knew of such a one personally from the former Soviet Union.

    While those doctors were lying, I see their actions as respectable. I am wondering how you would see them.

    I'm not sure that I agree with the doctors writing absence from work scripts. However, they are clearly different from doctors who lie about disability exams."

  3. I saw it! I had hoped against hope that you were right and this was an Andrew Beitbart-style operation, but alas, further investigation appears to confirm that at least several of these docs were, in fact, docs.

    They were too cute by half, I'll grant, but so far I've yet to be persuaded by the yawping that calls for their heads. Best, Billy

  4. Wow!
    Godwin's Law in 2 posts.
    " I also read about doctors who "doctored" medical findings to try to make it easier for detainees imprisoned in concentration camps."
    The docs who wrote fake notes in Madison were heroes like the ones who opposed Nazism. Hitler liked dogs. I like my dog. Therefore I'm a Nazi.

    Every time a physician places his or her signature on a document, he or she is placing his or her professional reputation on the line. Honest mistakes can and must be tolerated, but deliberately signing a document that the doc knows is false will call every document the doc has signed, or will sign in the future, in question. If the profession tolerates this, we all will suffer, and so will our patients, who will not have the benefit of society's trust in physicians that allowed this to occur in the first place.

    Sorry Billy, but this is not a prank. The "sacred trust" that you flippantly discuss is the one constant in our relationship with our patients. Standards of care change, outcomes change, resources and tools of the trade change, but when patients lose their trust in us, and society stops believing in that trust, it's game over. These docs must be dealt with- a 90 day suspension of their licenses and permanent notation on their online profiles. That way, patients who want to choose their physicians by their political leanings can do so, while the patients who want their doctors to deal with them honestly will be able to tell who they are.
    I occasionally am asked to sign a fraudulent document- off work for an extra week, or a permanent handicap sticker when a temporary one will suffice. I tell the patient, "Sorry. I won't lie to you and I won't lie for you."

  5. jb--

    Thanks for your thoughts, and the introduction to Godwin's Law. Point well taken! I will let you and Dr. Arpaia duel over that one, 'cz I didn't make the Nazi comparison.

    A couple of thoughts in reply:
    a. Your explanation of the meaning of a physician's signature is eloquent and I take no issue with it. As I wrote in the post, and repeated in my response to Dr. Arpaia, I am not condoning their behavior; it's clearly a violation of the standards of medical practice. That's an act of civil disobedience for which they should expect some sort of sanction. But as the violation is largely a symbolic one--good grief, they were doing it right out in the open, and deriving no financial benefit from it--the punishment, to my mind, should match and be equally symbolic...say, an official reprimand or something like that. Other than this "sacred trust" nonsense that keeps getting bandied about (see below), no real harm came to anybody, and if anything these physicians may have succeeded in gaining people's trust, so I'm unable to understand the venom directed at them. Yet all the other medbloggers seem to think that their right hands should be cut off, or in your case, both hands for a three-month period. Tell me, who's being political now?

    b. You talk about people losing their trust in doctors. Do you think that, as a consequence of this stunt, that patients with a Republican bent would feel intimidated by going to these doctors? I'm thinking not. Yet how would a patient who had voted for Obama have felt in Jack Cassell's office? Yet the med blogosphere from what I've been able to discern remained silent on the matter. I didn't see a lot of indignation on the blogs about Bush 43's "Provider Conscience Rule," which allowed docs to deny treatments to patients simply based on the fact that it didn't wash with the doctor's moral system. Yet everyone's jumped on the bandwagon here.

    c. I would submit that you mistook righteous fury for flippancy when you dinged me for my point about "sacred trust." I do believe in a sacred trust between physician and patient and I take it quite seriously. That said, when I read sentences such as those of the redoubtable db (see his link and my comment) in which "sacred trust" is invoked, I feel the words tumble out a bit too easily. Back in 2003 db didn't seem to think that doctors refusing to see patients was a violation of this "sacred trust." Indeed, he openly sympathized with the physicians, who were protesting malpractice rates. To me, a sacred trust is above monetary concerns, and you don't ever not see a patient because of something like that. To me, what those doctors did was disgusting. Yet our brothers and sisters mostly circled the wagons at the time. I find this unconscionable, so please forgive my skepticism when I hear the sermons this time around.

    I look forward to any further thoughts you have, and thanks again for your post. Best, Billy

  6. JB,

    Where did you get the idea that I was referring to Nazis. I specifically mentioned the former Soviet Union as one example. There have been plenty of concentration camps in other countries as well to which I referring.

    Perhaps we could consider you to have applied Godwins' Godwin's law. That is, accusing someone of using Nazi analogies when they were not.

    BTW I clearly stated "I'm not sure that I agree with the doctors writing absence from work scripts. However, they are clearly different from doctors who lie about disability exams." So where do you get the idea that I considered them "heroes".

    Your comments are clearly not based on what I really wrote. That puzzles me. Perhaps you could explain what you were actually commenting upon.

  7. Dr Arpaia-
    When I see "concentration camp," my first thought is that is that it refers to Nazi Germany. So are my 2nd and 3rd thoughts. If you Google or Bing the phrase, 90% of the first page of hits does the same. Quoting a resident of the former soviet Union does not change anything- they had some very unpleasant relationships with the Nazis also. Still, if your position is that you had no inkling that your reference to concentration camps would make readers think of Nazi Germany, I withdraw the Godwin reference.

    I was not clear about my concern of politics intruding on medical care. My greatest concern is that we not change the care we provide according to the political beliefs of our patients. Maybe I'm wrong about this, but I doubt that these physicians would provide me with a note to get me out of work to attend the NRA convention, or the YAF meeting. As part of my practice, I see patients from the local prison. Some of these are real bad people- rapists, murderers, child abusers. Swastika tattoos are not uncommon. Despite my distaste for these people, I make a conscious effort to treat them as normally as possible, given the restrictions of their shackles and other security requirements. You may think this is not comparable, but the principal stands.

  8. JB--I do think it's a comparable situation, and the more I chew on what happened in Wisconsin, the more it stinks to me. "Juvenile" is the word that pops into my head, mostly.

    I do wish, however, I could get someone to agree with me that if their selfless, though clearly misguided, actions are worthy of censure, then so too the "MD Strike" in 2003 is at least as bad. I've heard no explanation from db, who defended them in his blog entries at the time, despite leaving a comment in his blog and linking to my own. Perhaps I pushed the boundaries of collegiality with an overly nasty tone and he found me too rude to deserve a reply, perhaps he was just too busy with writing other entries and never had the chance to respond. I dunno, but on that point I will stick to my guns.

  9. I followed the link to the New York Times description of the doctors "strike." Some strike. The article states that emergency care continue to be provided, and introduced no evidence that any patient was harmed. While I do not have firsthand knowledge, I suspect that virtually all physicians at that time were careful to provide ongoing care to their patients. While the events in Wisconsin clearly demonstrate that physicians are capable of behaving foolishly, I doubt that any physician would risk his professional existence to make this point. Certainly, I do not believe that any surgeon would decline to see a postoperative patient. In practice, I suspect that this "strike" was restricted to new patient or new problem appointments. While this may lead to some decrease in patient welfare, it cannot be argued that prior to establishing a patient relationship, the physician owes any obligation to that patient.
    Incidentally, the New York Times online page had three advertisements for malpractice attorneys, and two for malpractice insurance providers.

    I see a curious alignment of your desire to criticize the striking physicians with the controversy surrounding Obamacare. In both settings, failure to act when there is no obligation to act is criticized/penalized. If a physician declines to take on a new patient, or an existing patient with a new problem, he is under no obligation to do so (absent a contractual agreement that requires this, of course, such as being on a call schedule or a member of an insurance company panel). If an American declines to purchase a product or service (whether a General Motors automobile or a government approved health insurance policy), that American is also subject to punitive action under the law as it stands. People do have a right to be left alone, with minimal interference in their daily lives by the heavy hand of government.

    I also do not agree that the fraudulent note writing physicians were being selfless. They were clearly enjoying themselves, basking in the glow of self-righteousness, providing a service to People Who Think the Right Way. While they were not being compensated financially, they were receiving psychic high-fives, and they were also marketing their practices to the best insured segment of the population.

    I believe that Dr Cassell, whom you describe as telling his Obama voting patients to seek care elsewhere, should be publicly sanctioned, possibly with a 30 day license suspension, more if he actually caused significant inconvenience or harm to an existing patient.

  10. ...which would make me 0-for-2 in the "winning over jb" category.

  11. Don't fret, Billy. You are in the same class politically with my mom, an otherwise very fine person who is a stereotypical lefty. She would give you the shirt off my back.

    Anyway, we can say that we agree about Dr Cassell, can't we?

  12. Indeed we can! That would make it 1-for-3. If we were playing baseball, I would say it wasn't too shabby.

    Best, your Otherwise Very Fine Person & correspondent, Billy

  13. People should not take advantage of accidents or sick notes. Thanks.