Jun 05, 2004 - 23:25:15 CDT
ELGIN -- An Elgin doctor with a large patient base in the Elgin and Glen Ullin region faces a hearing with the Board of Medical Examiners that could end his 17-year medical practice.Dr. George Hsu, 61, claims his license was suspended in March partly because he respects his patients' right to die without last-ditch, expensive medical intervention.
Hsu was suspended when the board, which was already preparing to take action on seven of his cases, was presented with three more cases that it saw as a pattern of inappropriate care and poor to nonexistent chart keeping.
The June 15 hearing, which is open to anyone interested, will be Hsu's chance to defend the three latest cases. Sometime soon after, the board will determine the fate of his medical career.
Hsu said in an interview he is guilty of nothing except failing to live up to a standard of documentation rarely achieved by any busy physician.
State law requires documenting a patient's history and physical exam within 24 hours and summary discharge notes within 30 days.
He said the suspension is costing him money, putting at risk his position as a Reserve U.S. Army hospital commander and inconveniencing his patients.
An administrative law judge, a lawyer used by the board to hear the facts of the case and make a recommendation for action, had already reviewed seven of the 10 cases. The administrative law judge, Allen Hoberg, recommended the board monitor Hsu's record keeping and restore his standing if he complied after a pre-determined amount of time.
However, the emergence of three more cases prompted the board to issue a summary suspension, pending another hearing.
Hoberg's comments lend some substance to Hsu's claim that his primary fault is in not documenting the steps he takes in treating his patients, or not treating them in cases where he says they want to die.
The comments also detail instances of inappropriate and substandard care found by other doctors reviewing the cases.
The board said Hsu's continued practice presents a significant risk of serious and ongoing harm to the public while the disciplinary proceeding is pending.
Rolf Sletten, the board's executive secretary, said such suspensions are issued only in the most serious cases, once or twice a year, on average.
Sletten said "most of the time" a summary suspension such as the one issued to Hsu results in the revocation of the medical license, often permanently.
Between clinics at Elgin and Glen Ullin, Hsu says he has an estimated 8,000 charts, each related to a patient he's either seeing or has seen since coming there in 1987.
Hoberg found in most of the cases that weeks, if not months, elapsed between patient care and documentation. In some instances, he found no documentation at all.
In his analysis of the original seven cases, Hoberg writes, "He (Hsu) tends to believe that the end result justifies the procedures used. To a large extent, it appears, Hsu has been lucky. Either that or he is extremely talented and wise. The evidence at this hearing does not show that he is a great physician, however."
Hoberg continues, "Perhaps for the most part, Hsu has provided adequate medical care, the care required under the circumstances, or at least the care his patients want." He notes that two other physicians found he has provided inappropriate care in several cases, though it is not certain whether anyone has really suffered as a result.
"Yet, even if he is right as to the substance of the care he has given his patients ... he presents a disservice to his patients and to others in the medical profession by not providing timely and adequate documentation. About his documentation there is no doubt."
Hsu says he is guilty of nothing but poor charting habits, a trait that landed him in some disciplinary trouble with the Board of Medical Examiners back in 1996.
"There's a difference between poor care and poor charts," Hsu says. "It's their position that if it's not documented, it's not done. There's no truth to that."
He also says he is being targeted by competing medical interests in Elgin.
The community's hospital -- Jacobson Memorial Hospital -- took over operation of the town's second clinic last year, when Bismarck's Medcenter One pulled out of clinic operations in several rural communities.
Hsu said the acquisition of the clinic by the Elgin hospital put him in financial competition with the hospital "and I was not about to close up my shop so that their clinic could succeed."
He said no patient or patient's relative has complained about him to the board and the investigation was instigated by local competition.
Sletten said the identity of complainants is not part of the public record while cases are still being investigated.
Elgin hospital and clinic administrator Kurt Waldbillig said Hsu might believe the hospital or its physicians are the source of complaints against him, but that's not the case.
Waldbillig said two of the 10 cases were raised through a peer review, required because the hospital doesn't have enough staff for doctors to review each other's cases, and another six were raised because the Board of Medical Examiners conducted its own review of Hsu's cases.
Waldbillig said he doesn't know the source of the two other complaints.
Physician's Review Network of Phoenix, at Waldbillig's request, initially reviewed one case involving the death of an 82-year-old woman, brought to the Elgin hospital with chest pains, in February.
That reviewer gave a positive review, finding the patient was given the proper standard of care and every chance for a good outcome.
The reviewer did say he would have interpreted the initial electrocardiogram slightly differently, but that three follow-up EKGs were interpreted correctly.
Despite that, Hsu said Waldbillig then sent the case off to a different reviewer and it was eventually included in cases brought up to the Board of Medical Examiners.
Waldbillig said his hospital board directed the case to be reviewed by three reviewers and both others were "negative" about Hsu's care.
One of the issues with delayed charting is that it delays billing the federal government for reimbursement on Medicare-covered patients, something that affects a hospital's cash flow.
Hoberg noted Hsu was suspended from the Elgin hospital medical staff for 10 days in 2001 and told to bring 35 history and physicals and 23 discharge summaries up to date.
The three most compelling cases in the dispute involve what Hsu calls "right to die" cases.
In each, he is criticized for improper medical procedure and documentation.
Hsu says all three cases are instances of the patient and in one case both the patient and her daughters resisting either more tests, treatments or transfers to a Bismarck hospital.
Both the wife of a 78-year-old man, who died of heart failure, and a daughter of a 94-year-old woman, say Hsu followed his patients' wishes.
Neither would be identified for this story and adamantly insisted their names not be used. In both instances, they say the patient made the decision to refuse treatment and testing.
In the case of the 78-year-old, Hsu said the man refused treatment and a transfer to Bismarck.
The chief complaint in the case by the reviewing physician, Dr. Craig Lambrecht of Medcenter One, was that "care went half way and not all that could have been done was done," Hoberg said.
He also wrote, "There was no indication in the medical records other than a nurse's note that the risks of refusing treatment were explained ... and that he voluntarily refused treatment."
However, the man's wife, who insisted on privacy for herself and her husband, said her husband was clear about not wanting treatment or life support.
"According to what he (my husband) wanted, yes, I'm satisfied," she said.
Hsu said in the case of the 94-year-old woman, she told him, "Please don't do anything. Let me die. I'm miserable and I'm glad to die."
That patient's daughter confirms that communication occurred between Hsu and her mother.
"She stated she did not want those tests. Otherwise, he did everything he could for her," she said. "It wouldn't have mattered what the doctor said, her mind was made up."
In that case, Lambrecht, who again provided the medical review of the case, said the patient had complicated symptoms and that Hsu's treatment and diagnosis did not reflect that she was "being managed in any coherent way."
In the third case, the Board of Medical Examiners said Hsu didn't see the 80-year-old patient until after she'd been in the hospital for 10 hours, nor immediately prior to her being transported from the Elgin nursing home to the hospital.
Hsu said in fact he saw her twice and because of her condition -- blood loss from the rectum and dehydration -- offered her blood transfusions, and other treatment.
"She said, 'No,' she was ready to go. It was her choice. She was competent and her children were dead," Hsu said.
Lambrecht -- again the reviewing physician -- said the patient could have received more therapy.
Hsu said he believes patients have the right to refuse treatment and he has the right to be "passive" in those instances.
He said he is not "like a Kevorkian kind of guy. I try to find out what the patient wants and to honor that."
He refers to Dr. Jack Kevorkian, a physician who has been prosecuted for actively assisting the deaths of terminally ill people at their request.
About half of Hsu's patients are of Medicare age and nearly 100 of them are in either the Elgin or Glen Ullin nursing homes.
Hsu said he always talks to nursing home patients, or their families, about end-of-life issues. He said patients should have the right to decide whether to die in the relative comfort of the nursing home, or be transferred to Bismarck, where sometimes all that results is three to six days of tests and procedures at enormous expense and then death anyway.
"I go to great lengths so that people don't have to be jerked around, or manipulated," he said. "I can tell their children, 'Your mother already made the decision, you don't have to do this, I'll take the hit for it,' " Hsu said.
He said he feels so strongly about the rights of the elderly in that regard, that if their children insist otherwise, he'd make them get a court order before complying.
In another case, Hsu is faulted for not following standard medical procedure, such as administering the drug heparin to a 73-year-old stroke patient without first calling for a CAT scan.
Hsu says there is no published medical authority that requires the scan prior to administering heparin. Besides his experience with such cases, the medical likelihood that the patient had an ischemic, not hemorrhagic stroke, for which heparin is appropriate, was already at 80 percent, he said.
Hoberg noted that there is no documentation that Hsu told the patient about the potential fatal risk of heparin without a CAT diagnosis. Hsu said he talked about it both with the patient and the patient's daughter, who decided to proceed.
Besides, he said, Elgin has no CAT scan and it didn't make sense to transfer the patient to Bismarck and risk a second, possibly fatal stroke in the meantime.
He said practice in a rural setting forces him to rely on his own competency and experience, where doctors like those who reviewed his cases have more sophisticated equipment at their disposal.
In another case, Hsu was criticized for not immediately transferring a 44-year-old patient, severely diabetic, whose body temperature at reaching the hospital was nearly 108 degrees. There was no air conditioning unit in the man's low-income housing unit and Hsu diagnosed heat stroke.
Criticism from two other physicians included Hsu's documentation as very tardy and nonexistent to some extent.
They also said that Hsu's treatment, which involved flushing his abdominal cavity with water to bring down the patient's internal temperature was "antiquated and may have hurt the patient more than helped him," Hoberg said.
Hsu, who spent three months in the Mideast during Desert Storm, said the army has given him special training in treatment of heat strokes.
Hoberg also found no record that the patient's family refused a transfer to Bismarck.
Hsu says the man was brain dead on arrival, though he immediately packed him in ice and flushed his abdominal cavity with water to bring down his temperature.
He said he saw the heart arrhythmia, normal after a heat stroke. Another Elgin physician ordered a transfer to Bismarck.
Hsu said the patient was found to be brain dead and died in Bismarck three days later.
"It added an enormous expense," Hsu said. "He should have been allowed to die at home (hospital) with his mom."
Hoberg noted that Hsu admits he is "out of step" with current medical requirements for appropriate care in North Dakota, operating on a basis of mutual trust with his patients.
From Hsu's perspective, it comes down to documentation.
"They say I don't document well enough, but I don't keep my records for them. Since this started, I'm spending a lot of time dictating to cover myself, but that's not what I wanted to do in my practice, protect myself from the Board of Medical Examiners," Hsu said.
(Reach reporter Lauren Donovan at 888-303-5511, or lauren@westriv.com.)
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