“Let’s kill all the lawyers.” It’s every doctor’s favorite Shakespeare quote. And if you’re giving a talk to doctors there’s no better way to get the audience on your side than by starting with a lawyer joke.

But perhaps we shouldn’t be too hasty about killing all those lawyers. As recent commentary about the Mark Midei case makes clear, modern medicine doesn’t know how to police itself. And until medicine does learn to police itself and protect patients from incompetent or greedy or just plain self-deluded practitioners, we will still need the lawyers as a last safeguard, even acknowledging the many, many shortcomings of the current legal system regarding malpractice.

But of course there’s more involved here than just malpractice. At first glance it appears to be only a simple case of greed and arrogance, the story of an interventional cardiologist who made a lot of money by performing procedures on patients who didn’t need them. On further examination, however, the story runs much deeper, striking into the heart of the way medicine is practiced today. Before modern medicine learns to police itself, it will first need to change its culture.

When I first wrote about this case in January, and when I revisited the case last week by posting a guest comment on the case by Robert Wachter, I asked a number of acquaintances — interventional cardiologists, Baltimore-area cardiologists, and others — what they knew or thought about the case. Most of course did not want to speak on the record, but the responses were really quite interesting.

I don’t know whether I just got lucky or if Midei was a really sociable guy, but as it turned out just about everyone I asked knew Midei. Most even said they liked him, and they all expressed sorrow for Midei’s family. Several of my respondents also talked about the heated medical politics in Maryland, and the nasty feud that has embroiled St Joseph’s hospital and its relationship with Midei’s former group practice, MidAtlantic Cardiovascular Associates. (Even before Midei split from MidAtlantic, something was deeply amiss in the local medical culture. Back in 2005 Midei and a cardiac surgeon lost a $5 million lawsuit for fraud. You can read all the gory details in an article in the Baltimore Sun.)

But what I didn’t hear from any of my sources was serious doubts about the current accusations. All agreed that Midei had a right to tell his side of the story, but time and again I heard that they were aware that things were wrong. One interventional cardiologist told me about a colleague in that group who always felt befuddled at the cath conferences “because he said he could never see the lesions before a stent went down the coronary artery.” Another cardiologist, who had sent patients to Midei, told me he had reviewed angiograms that looked like a 50% narrowing but had been labelled 80-90% narrowing by Midei before performing the procedure.

So it appears that at the very least there was widespread suspicion that something was wrong. These days in New York City the motto is: “If you see something, say something.” But apparently for a long time a lot of people in Maryland saw something and didn’t say anything.

Here’s my question to the cardiologists and healthcare professionals who read this blog: what have you seen? Is there a physician out there who you would warn a family member against seeing? Have you reported this physician?

Here’s the problem: it’s not easy to rock the boat. In the case of a Midei, or the earlier, equally egregious case in Redding, California, there’s a powerful incentive for administrators to look the other way. No one wants to kill the cash cow. As one of my sources noted, “I suspect that many were aware but at all levels were too intimidated for fear of loss of job, professional rebuke, or some other form of ‘retaliation’ for questioning his practice.”

To help prevent a case like this, Wachter proposes “random over-reads of a sample of catheterization studies.” That strikes me as a good start. But it won’t be enough to prevent other types of abuse. There are innumerable roads to incompetence. Something needs to change so that a permanent, ongoing, peer review process becomes a standard part of the medical culture. Until then we need to keep the lawyers alive. Alas.

Larry Husten is a writer and editor of CardioBrief.org.

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