Friday, July 6, 2012

The slippery slope of "Providers."

I'm a physician. I'm not a "health care provider."  I hate that term. The insurance companies call me a "provider."  In a sense, it's true.  I provide health care services.  However, over the past few years I've noticed that the lines between different types of "providers" are getting more and more blurred.  Sometimes they're blurred to the point that patients don't even know what kind of "provider" they are seeing.  I often have patients tell me about their previous doctors, only to review old records and find that their "doctor" was a nurse practitioner or a PA.  I'll be reviewing lab tests that look kind of unusual, only to find that they were ordered by a naturopath.  And so on.  I'm not saying that there's not a place for everyone in health care.  I'm not saying that physicians are at the top of the hierarchy (trust me, most days I feel like I'm in the basement).  I'm just saying that patients deserve to know who is providing their health care and what their training is.

Here's an example- something that I've been reading about as a result of my interest in running.

On February 5, 2011, the annual Kaiser Permanente Half Marathon took place.  As is typical of large races, Kaiser was the main sponsor but outsourced the race management to a company called RhodyCo Productions.  It was an unusually hot day for February.  About 2 hours into the race, a 36 year old man named Peter Hass neared the finish line.  As he approached it, he collapsed.  Apparently, it took more than 20 minutes for an ambulence to arrive.  Other racers performed CPR.  Sadly, Mr. Hass died, apparently of a cardiac event. 

The City of San Francisco has now released a report regarding the events of the day.  You can link to the full document and read it.  There were obvious problems in communication and there did not appear to be enough ambulances present.  However- this stood out to me:


"There were several items listed in the EMS Plan for this event that were not adhered to by the permit holder for the event, RhodyCo Productions. For example, the number of EMTs at the starting and finish lines was insufficient, pursuant to EMSA Policy 7010. Additionally, chiropractic students were used as medical staff rather than EMTs or emergency medical personnel. The EMS Plan also stated that one MD would be stationed at the Medical Tent or at the event, which did not occur. Rather, a chiropractor from PCCW was provided. "

Whoa.  Double take.  Triple take.  There were no MDs present.  The production company was using students from a chiropractic college as "medical personnel."  What?  This can't be true, can it?  So, using the powers of Google, I investigated futher.  I found this.  For those of you who don't want to click, it's the RhodyCo Productions Emergency Procedures for the 2011 San Francisco/Kaiser Permanent Half Marathon. It states:

 "There will be Medical Personnel onsite at the START line till the last runner/walker passes.  There will be medical personnel at the Finish Line for both the 5K and Half Marathon till last walker/runner crosses the finish line.  There will be a minimum of 3 Medical Personnel mobile on the course during the race."

Sounds good, right?  Sounds like "medical personnel" will be ready and available.  Until you read a bit further, that is.

"Medical Personnel:  Palmer College of Chiropractic West Sports Council will provide event trained medical teams for the event (students are all CPR certified and have taken emergency response class).  The head clinician event day, Dr. Hal Rosenberg, (phone number redacted) will be onsite at the post-race Medical Tent."

Yup.  It's true.  They had "health care providers" present.  Except they were chiropractic students.  Even if they were real, live, actual chiropractors, they STILL wouldn't have been qualified to provide emergency medical services at a half marathon, unless they were also EMTs or paramedics.  But wait, what about Dr. Hal Rosenberg?  He's a doctor, right?  At least he would be overseeing the medical response team.  Right?  Right?  Except...not.  Yeah.  He's a chiropractor, too. 

It's true that running a half marathon is an inherently dangerous activity.  A distance runner is pushing his or her body to its limits.  Even elite athletes die during endurance events.  That's why all these events make you sign a liability waiver prior to participating.  However, this is what the half marathon website says about available medical support (from the 2012 race page- I'm not sure what the 2011 page said, but this is fairly typical):


Medical Support

  • Medical Support will be overseen by a Medical Director experienced in event medical response.
  • There will be a Medical Tent staffed with trained emergency personnel at the start line, at the finish line and in the expo area of the event.
  • Ambulances will be located at the start line, on the course, at the finish line and in the expo area.
  • There will be mobile Medical Teams at each of the 5 water stations and roaming the course throughout the race.
  • Medical personnel will be clearly visible, wearing a medical response uniform.
  • Race monitors on the course will be in constant communication with the Event's Medical Director. If there is a medical need on the course, please let one of the course monitors know as soon as possible and they will call for medical assistance.

Reading that, wouldn't a reasonable person assume that there will be physicians present?

Would having physicians present at this race have changed the outcome for Peter Hass?  I have no idea.  There's no way to know.  However, don't you think racers deserved to know that the "health care providers" at their endurance sporting event weren't physicians, but chiropractors and chiropractic students?  All health care providers are not created equally.

6 comments:

  1. As a parent of a child with hypertrophic cardiomyopathy, this shocks me to no end. This is a condition that is the most common reason for sudden cardiac death in young athletes. Having an incompetent "health care provider" would be even more disastrous.

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  2. Came over from your comment at RI

    Thanks for writing this. Palmer College West's campus is about an hour south of the race site, inSan Jose; there's a competing "school" in Hayward, Life Chiropractic West, about 40 minutes east of the race site. I wonder what motivated RhodyCo to not hire EMTs? I wonder if it was a cost issue (the chiro students working for free) or if the race organizers are true chiro believers, as many endurance athletes are. But to have no EMS personnel on duty, nor MDs? That's criminally irresponsible.

    A 2008 flyer describes the Sports club as

    Palmer College of Chiropractic West’s Sports Council is a student-operated, non-profit club that provides enrichment to the education of chiropractic students. This enrichment is achieved through outreach in the community providing complimentary, quality chiropractic care at local sporting events in the Bay Area under the supervision of sports trained Chiropractors.


    And the SF report also read (emphasis added):

    There were insufficient communication resources at the event, which resulted in poor information sharing among event and medical staff. In addition, Palmer College of Chiropractic West (PCCW) staff utilizing radios had not received proper radio training, which hampered effective communications.

    Interestingly, there was a petition to boycott RhodyCo productions, but it didn't mention the chiropractor angle.

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    Replies
    1. Thanks for your comment, Liz. I've been enjoying your comments on RI for years.

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  3. Sounds like a win-win to me. The company gets cheaper events and their health insurance saved money if the guy dies. If they had saved him, he'd cost them a long hospital stay plus long-term treatment afterwards. This is truly the wonders of our Capitalistic system working perfectly to reduce costs. If only the government could be run along these lines.

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  4. This is why I think that chiropractors, homeopaths, naturopaths, etc, should not be using the term doctor in their title, or practice name. It confuses people. They can call themselves a chiropractor, but not a doctor of chiropractic. I know many people who have Ph. D's in various non-medical fields and could use the title Dr. but avoid it, so that there is no confusion and people don't think they are an MD. I don't know how that would be done… Allow only people with MD, DDS, ?... to be able to refer to themselves with the term doctor, or not allow certain people to use it.

    I know many people who think that their chiropractor is giving them medical advice, because they are a doctor…if you ask the chiropractor if they are giving medical advice they would deny it, because they know they can't practice medicine without a license.

    As long as I can keep referring to myself as a DD…Disco Doctor…

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  5. Interesting article. I think the point you make is a good one, there is a need to distinguish between those who are qualified and those who are not. I think this is a growing problem in other industries as we are a society that can lose itself in titles...why else would someone call themselves a Doctor when they did not successfully complete medical school? Why are customer service folks calling themselves specialists? Did they really go through extensive training to earn that title? IF I call my bank and they put me in touch with a specialist, am I really getting the most qualified person to handle my situation? But the medical profession is more worrisome because unfortunately like the Mr. Hass situation illustrates, we are dealing with life and death situations.

    I think medical industry needs to set some boundaries relating to titles and have a clear definition of what that individual can and cannot treat---better yet, the title needs to set expectations as to what that individual is "qualified" to treat.

    I think the medical industry needs to look at how PA/NP are used ---many MD Specialists are using these folks to offer primary care services, thus keeping their referrals from trusting PCPs. If a patient thinks he/she is visiting her cardiologist, and ends up seeing a PA instead, I would think that's defeating the purpose of going to a cardiologist. I realize the MD has the final say on treatment, but something about that set up doesn't seem right.

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