Fraudulent EMGs

[Neurogeneral]

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I am an general neurologist who does EMGs at my community hospital. I have been working for 3 years now post fellowship. I am employed directly by the hospital. However, there is another private neurologist who does EMGs as well at this same hospital.

This private neurologist has a long standing history at the hospital (+30 years). I have ended up seeing quite a few of his previous patients or ones who have had EMGs performed by him.

His EMG reports often don’t make any sense. The listed raw data often doesn’t jive at all with his electrodiagnosis. He routinely erroneously diagnoses patients with carpal tunnel syndrome, ulnar neuropathies, peripheral neuropathies, etc. He never checks for any insertional activity either (according to our tech). What is most worrisome is that many of these patients go on to see hand surgeons who operate on them to decompress their misdiagnosed entrapment neuropathies.

I know there are varying degrees of quality in terms of EMGers but this goes way beyond that IMO. I feel that he should not be doing EMGs at all. Just wondering whether I should complain to someone or not and to whom? Some advice would be appreciated.

 

[Thama]

I don't know the right way to go about this either, but you're not alone here. There are a couple of community neurologists whose patients I regularly end up seeing where I've learned never to trust their EMG reports. Really obvious ALS being read as a totally normal exam, etc. The shame is that they are just as able to bill for those worthless EMGs as the expert electrodiagnosticians that have to repeat their exams (and probably bill more as they appear more interested in increasing the billable complexity of the exam than arriving at a diagnosis).

 

[Neurogeneral]

Agreed. I try to be very pragmatic about things. I know that crappy EMG quality is not that uncommon. It’s just jarring to see it occur for likely decades with no one saying anything. Will likely just keep pushing the hospital to refer all the EMGS in house (for financial reasons of course) and not to private docs like him.

 

[neglect]

Intent matters. You might be picking up an impaired physician (in practice 30 years, so totally in dementia territory), so who knows what sorts of errors he's making. If he or she has partners, would have a word in private. Obviously you're upset enough to post here, so I'd strongly consider a direct call to the doctor to ask if everything is OK.

You can (and have a duty to) report to the state boards.

 

[nvrsumr]

Chiropractors do EMGs in neurosurgeons offices in Colorado.

 

[xenotype]

Intent matters. You might be picking up an impaired physician (in practice 30 years, so totally in dementia territory), so who knows what sorts of errors he's making. If he or she has partners, would have a word in private. Obviously you're upset enough to post here, so I'd strongly consider a direct call to the doctor to ask if everything is OK.

You can (and have a duty to) report to the state boards.

If this guy has been at this hospital for decades, is friends with the hospital administration and brings money into the hospital, a board compliant and a direct phone call criticizing them would be a terrible idea. The guy could complain, have the hospital label OP a disruptive physician, etc. The bar for disruptive physician is extremely low, and a very established longtime guy like this probably knows everyone. In an ideal world one can change poor care like this, but in reality you are sticking your neck out into hospital politics and might get severely burned. What if the surgeons like him too, and decide they don't like OP? I could be very wrong, but hospital politics can be a no win game and being on the radar screen anywhere in medicine is often a bad place to be.

 

[neglect]

If this guy has been at this hospital for decades, is friends with the hospital administration and brings money into the hospital, a board compliant and a direct phone call criticizing them would be a terrible idea. The guy could complain, have the hospital label OP a disruptive physician, etc. The bar for disruptive physician is extremely low, and a very established longtime guy like this probably knows everyone. In an ideal world one can change poor care like this, but in reality you are sticking your neck out into hospital politics and might get severely burned. What if the surgeons like him too, and decide they don't like OP? I could be very wrong, but hospital politics can be a no win game and being on the radar screen anywhere in medicine is often a bad place to be.

Patients come first. You will not be faulted for good faith reporting. Early in a career, you can pull out of any situation. Later in a career, you can pull out of any situation.

Obviously this is difficult. No doubt. But never abandon your moral compass because it is easier. Screw that.

The Taliban, all 70k of them, just took over an entire country because of the same attitude. You gotta live with consequences of your cowardice.

 

[xenotype]

Patients come first. You will not be faulted for good faith reporting. Early in a career, you can pull out of any situation. Later in a career, you can pull out of any situation.

Obviously this is difficult. No doubt. But never abandon your moral compass because it is easier. Screw that.

The Taliban, all 70k of them, just took over an entire country because of the same attitude. You gotta live with consequences of your cowardice.

You can't 'pull out' of a disruptive physician NPDB black mark, and dipping into politics (as your comment has a direct, completely irrelevant political analogy doing so) can get you burned. Obviously my example is extreme, but reporting colleagues outside of circumstances you are absolutely legally required to report is full of risk(which this situation is unclear- why? the OP has not asked their lawyer that question). I'm all for great patient care but going after a senior, very established physician in a good ole boys network hospital absolutely could trigger negative consequences unless it is done very tactfully, very politely, and very carefully. My local academic NM department would NEVER file a board complaint just because they get 10 referrals a month from one of the local guys that obviously can't do a good EMG- and that isn't even in the same hospital system. There would never be a community referral to the department again amongst the mildest of consequences- more severe would be a lawsuit for defamation. Are you protected from that in a board complaint? Are you sure you are protected?

 

[neglect]

You can't 'pull out' of a disruptive physician NPDB black mark, and dipping into politics (as your comment has a direct, completely irrelevant political analogy doing so) can get you burned. Obviously my example is extreme, but reporting colleagues outside of circumstances you are absolutely legally required to report is full of risk(which this situation is unclear- why? the OP has not asked their lawyer that question). I'm all for great patient care but going after a senior, very established physician in a good ole boys network hospital absolutely could trigger negative consequences unless it is done very tactfully, very politely, and very carefully. My local academic NM department would NEVER file a board complaint just because they get 10 referrals a month from one of the local guys that obviously can't do a good EMG- and that isn't even in the same hospital system. There would never be a community referral to the department again amongst the mildest of consequences- more severe would be a lawsuit for defamation. Are you protected from that in a board complaint? Are you sure you are protected?

The only thing necessary for the triumph of evil is for good men to do nothing.

Your call, you get to choose who you want to be. Physicians have an amazing skill set, thus a ton of privilege. We can afford to be right.

The fact you can’t see how this is exactly like the cowardice of the Afghanistan military speaks to your blind spot. Everyone likes to imagine they are good, until the moment they have to do something hard.

 

[xenotype]

The only thing necessary for the triumph of evil is for good men to do nothing.

Your call, you get to choose who you want to be. Physicians have an amazing skill set, thus a ton of privilege. We can afford to be right.

The fact you can’t see how this is exactly like the cowardice of the Afghanistan military speaks to your blind spot. Everyone likes to imagine they are good, until the moment they have to do something hard.

You can be who you want to be until a bunch of other people decide you are a jerk they cannot work with. If medical staff at a hospital decides this, your career and 'privilege' as a physician is in grave danger and you need a lawyer. Your cause is noble, but getting in colleague's faces even when you are right can have major downstream consequences that also could be bad for patients- ie the loss of both neurologists here from bad blood.

 

[sharkbaitwhohaha]

Patients come first. You will not be faulted for good faith reporting. Early in a career, you can pull out of any situation. Later in a career, you can pull out of any situation.

Obviously this is difficult. No doubt. But never abandon your moral compass because it is easier. Screw that.

The Taliban, all 70k of them, just took over an entire country because of the same attitude. You gotta live with consequences of your cowardice.

I get your point. But also, it's likely that you have this view point if you have no more student debt and have built a solid retirement.

Those of us in the trenches with 300-400k in debt are not risking our careers to be the "good guy".

 

[neglect]

You can be who you want to be until a bunch of other people decide you are a jerk they cannot work with. If medical staff at a hospital decides this, your career and 'privilege' as a physician is in grave danger and you need a lawyer. Your cause is noble, but getting in colleague's faces even when you are right can have major downstream consequences that also could be bad for patients- ie the loss of both neurologists here from bad blood.

We're talking about patients being put at extreme risk due to mistakes with an EMG. When surgery depends on the results of the EMG, get it right. This is a matter of patient's lives and deaths and disability.

I get your point. But also, it's likely that you have this view point if you have no more student debt and have built a solid retirement.

Those of us in the trenches with 300-400k in debt are not risking our careers to be the "good guy".

I have been in your situation as a new attending. Try to imagine yourself starving. Given the need for neurologists, it’ll never happen. At most you won’t go on a vacation. And that’s what is preventing you from having a shred of moral courage. By shred, I mean microscopic, the minimum. The situation is that patients may suffer needless surgeries, increased risk, increased harm. And you're afraid of literally nothing.

Fine. Create a throw-a-way email, send the concerns to the chief of staff. Total cowardice, but at least you can go to sleep at night.

@xenotype and @sharkbaitwhohaha - may you and your family receive exactly the same care you'd offer others.

 

[robellis]

I am an general neurologist who does EMGs at my community hospital. I have been working for 3 years now post fellowship. I am employed directly by the hospital. However, there is another private neurologist who does EMGs as well at this same hospital.

This private neurologist has a long standing history at the hospital (+30 years). I have ended up seeing quite a few of his previous patients or ones who have had EMGs performed by him.

His EMG reports often don’t make any sense. The listed raw data often doesn’t jive at all with his electrodiagnosis. He routinely erroneously diagnoses patients with carpal tunnel syndrome, ulnar neuropathies, peripheral neuropathies, etc. He never checks for any insertional activity either (according to our tech). What is most worrisome is that many of these patients go on to see hand surgeons who operate on them to decompress their misdiagnosed entrapment neuropathies.

I know there are varying degrees of quality in terms of EMGers but this goes way beyond that IMO. I feel that he should not be doing EMGs at all. Just wondering whether I should complain to someone or not and to whom? Some advice would be appreciated.

If this guy has been at this hospital for decades, is friends with the hospital administration and brings money into the hospital, a board compliant and a direct phone call criticizing them would be a terrible idea. The guy could complain, have the hospital label OP a disruptive physician, etc. The bar for disruptive physician is extremely low, and a very established longtime guy like this probably knows everyone. In an ideal world one can change poor care like this, but in reality you are sticking your neck out into hospital politics and might get severely burned. What if the surgeons like him too, and decide they don't like OP? I could be very wrong, but hospital politics can be a no win game and being on the radar screen anywhere in medicine is often a bad place to be.

You can be who you want to be until a bunch of other people decide you are a jerk they cannot work with. If medical staff at a hospital decides this, your career and 'privilege' as a physician is in grave danger and you need a lawyer. Your cause is noble, but getting in colleague's faces even when you are right can have major downstream consequences that also could be bad for patients- ie the loss of both neurologists here from bad blood.

I get your point. But also, it's likely that you have this view point if you have no more student debt and have built a solid retirement.

Those of us in the trenches with 300-400k in debt are not risking our careers to be the "good guy".

OP you absolutely have an obligation to report this guy. Always put your patients first you know what the right thing to do is don’t make it more complicated than it needs to be. Obviously don’t go “getting in his face” but asking him about it politely then escalating it up the chain of command/to the medical board is extremely appropriate if needed

 

[xenotype]

We're talking about patients being put at extreme risk due to mistakes with an EMG. When surgery depends on the results of the EMG, get it right. This is a matter of patient's lives and deaths and disability.



I have been in your situation as a new attending. Try to imagine yourself starving. Given the need for neurologists, it’ll never happen. At most you won’t go on a vacation. And that’s what is preventing you from having a shred of moral courage. By shred, I mean microscopic, the minimum. The situation is that patients may suffer needless surgeries, increased risk, increased harm. And you're afraid of literally nothing.

Fine. Create a throw-a-way email, send the concerns to the chief of staff. Total cowardice, but at least you can go to sleep at night.

@xenotype and @sharkbaitwhohaha - may you and your family receive exactly the same care you'd offer others.

OP you absolutely have an obligation to report this guy. Always put your patients first you know what the right thing to do is don’t make it more complicated than it needs to be. These two spineless cowards above are the reason doctors get a bad reputation. Obviously don’t go “getting in his face” but asking him about it politely then escalating it up the chain of command/to the medical board is extremely appropriate if needed

You guys are incredible. Do you report all the NPs in town to anyone who will listen too? The majority of EMGs performed in the US are poor quality and inaccurate. You cannot control or change this, just like you cannot control NP encroachment. I did report your posts for insulting me, the quality of care I deliver, and calling me a spineless coward when you know nothing about me other than a few forum posts. This is completely inappropriate in my opinion, and seems to be against SDN forum rules.

 

[robellis]

You guys are incredible. Do you report all the NPs in town to anyone who will listen too? The majority of EMGs performed in the US are poor quality and inaccurate. You cannot control or change this, just like you cannot control NP encroachment. I did report your posts for insulting me, the quality of care I deliver, and calling me a spineless coward when you know nothing about me other than a few forum posts. This is completely inappropriate in my opinion, and seems to be against SDN forum rules.

I apologize for the disrespectful comments as things can get out of hand on the internet but my post was assuming that the EMG result (as OP is stating) was clearly a fraud and that any neurologist could see it to be true and surgeries were being unnecessarily performed on patients akin to what doctor death used to do..we are often times the only thing that can protect our patients so I don’t think when there’s such a clear and serious crossing of lines that reporting the person responsible is inappropriate. No I don’t report NPs even though half of them are clueless because their behavior is not an imminent and serious risk to the patients life/limb/etc and when it is I definitely do talk and educate them about their actions

 

[xenotype]

I apologize for the disrespectful comments as things can get out of hand on the internet but my post was assuming that the EMG result (as OP is stating) was clearly a fraud and that any neurologist could see it to be true and surgeries were being unnecessarily performed on patients akin to what doctor death used to do..we are often times the only thing that can protect our patients so I don’t think when there’s such a clear and serious crossing of lines that reporting the person responsible is inappropriate. No I don’t report NPs even though half of them are clueless because their behavior is not an imminent and serious risk to the patients life/limb/etc and when it is I definitely do talk and educate them about their actions

A board complaint is a big deal. Yes, ethically we must try to help incompetent colleagues and protect their patients. The reality in many states is a board complaint is not at all anonymous and may immediately expose you to significant civil legal liability. A big enough ego and bank account of whoever you are going after may mean the legal harrassment never ends. I am not saying OP should ignore this situation but you have to be very careful and very polite. Medical staff is a much better route particularly if there is anyone you can trust. If OP does not know anyone- anonymity at least initially is the safest play, along with gathering documentation and involving medical staff. But of course I am a spineless coward for not wanting to expose myself to legal liability. This senior physician might be incompetent at EMG but an otherwise OK neurologist- someone in medical staff privately convincing him to stop doing the procedure or recertify his EMG boards would be much more ideal than immediately involving a bunch of lawyers with a board complaint. This is different than you seeing an obviously drunk/high physician taking care of patients- that you must report. Incompetent is more subjective, less legally protected in terms of whistleblowers, and needs more tact, documentation, and time. Some medical boards won't even be able to access patient records even if they get a board complaint for incompetence. Medical staff has many more tools to address the situation.

This is a hard situation, and I honestly believe OP both needs to try to help the senior physician, their patients, and protect themself in the process. Talking to a lawyer knowledgeable in this area (medical staff bylaws, state medical board complaints) is very important before taking any big steps. This is a high risk situation for everyone, and handling it poorly will involve lawyers from multiple angles.

 

[neglect]

You guys are incredible. Do you report all the NPs in town to anyone who will listen too? The majority of EMGs performed in the US are poor quality and inaccurate. You cannot control or change this, just like you cannot control NP encroachment. I did report your posts for insulting me, the quality of care I deliver, and calling me a spineless coward when you know nothing about me other than a few forum posts. This is completely inappropriate in my opinion, and seems to be against SDN forum rules.

It is just so sad and hilarious that you reported a post on a meaningless board, but you wouldn't report the next Doctor Death. You are too cowardly to even look inward at yourself, instead just blaming the messanger. I have nothing to apologize for, so won't. Report all you want. Your opinion is meaningless. I know you better than you know yourself. You put your own well-being (with marginal delta) above the lives of patients, but you want to pretend to be a victim. It must be this delusion of virtue that permits your posts above.

Funny that you mention extenders. I live in a state where they cannot practice independently. When the system recently fell short and endangered patients, I did do my duty and raised concerns, which were non-acrimonious, focused on safety, and thus taken seriously. While things didn't turn on a dime, I'm happy to say the system changed and patient lives are no longer in as much danger (NPs without closest supervision are a threat to patients). I practice exactly as I do. And guess what, none of your imaginary fears came true.

It must be so terrible to live in fear like you do. Because there's fear on the other side of this coin. Don't report, one fear gone. But you face jaopardy because legally (and ethically) the AMA considers you to be an obligated reporter. Depending on the state, you could be legally liable for failure to report.

I apologize for the disrespectful comments as things can get out of hand on the internet but my post was assuming that the EMG result (as OP is stating) was clearly a fraud and that any neurologist could see it to be true and surgeries were being unnecessarily performed on patients akin to what doctor death used to do..we are often times the only thing that can protect our patients so I don’t think when there’s such a clear and serious crossing of lines that reporting the person responsible is inappropriate. No I don’t report NPs even though half of them are clueless because their behavior is not an imminent and serious risk to the patients life/limb/etc and when it is I definitely do talk and educate them about their actions

You have nothing to apologize for.

 

[xenotype]

It is just so sad and hilarious that you reported a post on a meaningless board, but you wouldn't report the next Doctor Death. You are too cowardly to even look inward at yourself, instead just blaming the messanger. I have nothing to apologize for, so won't. Report all you want. Your opinion is meaningless. I know you better than you know yourself. You put your own well-being (with marginal delta) above the lives of patients, but you want to pretend to be a victim. It must be this delusion of virtue that permits your posts above.

Funny that you mention extenders. I live in a state where they cannot practice independently. When the system recently fell short and endangered patients, I did do my duty and raised concerns, which were non-acrimonious, focused on safety, and thus taken seriously. While things didn't turn on a dime, I'm happy to say the system changed and patient lives are no longer in as much danger (NPs without closest supervision are a threat to patients). I practice exactly as I do. And guess what, none of your imaginary fears came true.

It must be so terrible to live in fear like you do. Because there's fear on the other side of this coin. Don't report, one fear gone. But you face jaopardy because legally (and ethically) the AMA considers you to be an obligated reporter. Depending on the state, you could be legally liable for failure to report.

Your point is to immediately report this guy to the medical board. My point is that is not strictly required in all states, may not help patients at all if the board has limited oversight abilities in this circumstance, and that talking to a lawyer for a few hundred bucks and hospital medical staff office is a more prudent strategy. Sure if the lawyer says you must report, then you report. Your response to that is call me a spineless coward and someone putting myself above patients. I guess there are no mods here that really care about the level of disrespect and personal attacks- sure this is just a meaningless board with you getting meaningless likes for virtue seeking emotional non-sense. I put you on ignore to filter out anything else from you.

 

[Phantom Spike]

OP, how are these questionable EMGs coming to your attention? You mentioned that you see some of these patients in your clinic; perhaps you could add a comment in your visit notes pointing out the discrepancy between the reported numbers in the raw data and the interpretations? "The EMG report written by Dr. Private Neurologist suggests ulnar neuropathy at the elbow, but my review of the nerve conduction studies and needle EMG is inconsistent with this conclusion", or some such. Bold, underline, italicize, highlight those lines as needed to make sure they are noted, and fax the note to the hand surgeons. Do you have a good relationship with these surgeons? Perhaps you could call them and unoffiically let them know you disagree with the official EMG report and suggest the EMG be repeated at another center? If you make enough of these calls and write enough of these notes the message will come through clear enough.

You have titled this thread "Fraudulent EMGs" but do you actually believe there is fraud or incompetence/lack of skill? Do you get the impression the private neurologist is cutting corners, coming up with inaccurate diagnoses to please the hand surgeons, or simply clueless? You mention that he "never checks for insertional activity"; do you mean he does not do the needle EMG at all? If he doesn't, does he report falsely that he did (which of course would be undeniable fraudulent activity but difficult to prove if all you have is the word of the techs). If he doesn't report needle EMG at all, that might be a reason to have all his EMGs repeated by more competent EMGers.

 

[xenotype]

OP, how are these questionable EMGs coming to your attention? You mentioned that you see some of these patients in your clinic; perhaps you could add a comment in your visit notes pointing out the discrepancy between the reported numbers in the raw data and the interpretations? "The EMG report written by Dr. Private Neurologist suggests ulnar neuropathy at the elbow, but my review of the nerve conduction studies and needle EMG is inconsistent with this conclusion", or some such. Bold, underline, italicize, highlight those lines as needed to make sure they are noted, and fax the note to the hand surgeons. Do you have a good relationship with these surgeons? Perhaps you could call them and unoffiically let them know you disagree with the official EMG report and suggest the EMG be repeated at another center? If you make enough of these calls and write enough of these notes the message will come through clear enough.

You have titled this thread "Fraudulent EMGs" but do you actually believe there is fraud or incompetence/lack of skill? Do you get the impression the private neurologist is cutting corners, coming up with inaccurate diagnoses to please the hand surgeons, or simply clueless? You mention that he "never checks for insertional activity"; do you mean he does not do the needle EMG at all? If he doesn't, does he report falsely that he did (which of course would be undeniable fraudulent activity but difficult to prove if all you have is the word of the techs). If he doesn't report needle EMG at all, that might be a reason to have all his EMGs repeated by more competent EMGers.

Great post on all of the different possible variables in this complex situation and agree with everything especially with how to deal with the surgeons. Outright fraud/abuse like making up data, billing for needle when it wasn't done would be a much a bigger problem- potentially federal investigation if systemic and would need to be reported to hospital compliance for medicare. Incompetence is harder to prove, harder to investigate, and more subjective.

 

[Neurogeneral]

OP, how are these questionable EMGs coming to your attention? You mentioned that you see some of these patients in your clinic; perhaps you could add a comment in your visit notes pointing out the discrepancy between the reported numbers in the raw data and the interpretations? "The EMG report written by Dr. Private Neurologist suggests ulnar neuropathy at the elbow, but my review of the nerve conduction studies and needle EMG is inconsistent with this conclusion", or some such. Bold, underline, italicize, highlight those lines as needed to make sure they are noted, and fax the note to the hand surgeons. Do you have a good relationship with these surgeons? Perhaps you could call them and unoffiically let them know you disagree with the official EMG report and suggest the EMG be repeated at another center? If you make enough of these calls and write enough of these notes the message will come through clear enough.

You have titled this thread "Fraudulent EMGs" but do you actually believe there is fraud or incompetence/lack of skill? Do you get the impression the private neurologist is cutting corners, coming up with inaccurate diagnoses to please the hand surgeons, or simply clueless? You mention that he "never checks for insertional activity"; do you mean he does not do the needle EMG at all? If he doesn't, does he report falsely that he did (which of course would be undeniable fraudulent activity but difficult to prove if all you have is the word of the techs). If he doesn't report needle EMG at all, that might be a reason to have all his EMGs repeated by more competent EMGers.

His EMGs have to come my attention because some of his patients end up seeing me for a second opinion. There are times when the EMG is reordered and I end up redoing it and there are other times his patients end up seeing me in clinic. I am often left trying to make sense of his awful EMG reports. He is a private doc but uses the same EMG lab at my hospital. Our tech is present during his EMGs (even though he does his own nerve conductions) and she has given me more insights into his practice habits.

I truly believe this is a combination of cutting corners, dishonesty, and lack of competence. The raw data is often outright contradictory to the electro-diagnosis. He will say there is CTS, ulnar neuropathy, peripheral neuropathy, etc but the conductions are completely normal. He will say mild CTS but the data is saying “severe” (and vice versa). He will diagnose ulnar neuropathy at the elbow but no 3 point ulnar motor conductions have been done. He will analyze voluntary motor activity but will skip checking insertional/spontaneous activity and then call the insertional/spontaneous activity completely normal on the report. If a referring provider orders an EMG to evaluate for CTS, peripheral neuropathy, radiculopathy, etc his EMG report will give the patient that diagnosis no matter what. None of his EMGs (that I have come across) are reported as normal.

 

[robellis]

His EMGs have to come my attention because some of his patients end up seeing me for a second opinion. There are times when the EMG is reordered and I end up redoing it and there are other times his patients end up seeing me in clinic. I am often left trying to make sense of his awful EMG reports. He is a private doc but uses the same EMG lab at my hospital. Our tech is present during his EMGs (even though he does his own nerve conductions) and she has given me more insights into his practice habits.

I truly believe this is a combination of cutting corners, dishonesty, and lack of competence. The raw data is often outright contradictory to the electro-diagnosis. He will say there is CTS, ulnar neuropathy, peripheral neuropathy, etc but the conductions are completely normal. He will say mild CTS but the data is saying “severe” (and vice versa). He will diagnose ulnar neuropathy at the elbow but no 3 point ulnar motor conductions have been done. He will analyze voluntary motor activity but will skip checking insertional/spontaneous activity and then call the insertional/spontaneous activity completely normal on the report. If a referring provider orders an EMG to evaluate for CTS, peripheral neuropathy, radiculopathy, etc his EMG report will give the patient that diagnosis no matter what. None of his EMGs (that I have come across) are reported as normal.

REPORT or you are complicit and any horrible patient outcomes are also your responsibility

 

[Thama]

His EMGs have to come my attention because some of his patients end up seeing me for a second opinion. There are times when the EMG is reordered and I end up redoing it and there are other times his patients end up seeing me in clinic. I am often left trying to make sense of his awful EMG reports. He is a private doc but uses the same EMG lab at my hospital. Our tech is present during his EMGs (even though he does his own nerve conductions) and she has given me more insights into his practice habits.

I truly believe this is a combination of cutting corners, dishonesty, and lack of competence. The raw data is often outright contradictory to the electro-diagnosis. He will say there is CTS, ulnar neuropathy, peripheral neuropathy, etc but the conductions are completely normal. He will say mild CTS but the data is saying “severe” (and vice versa). He will diagnose ulnar neuropathy at the elbow but no 3 point ulnar motor conductions have been done. He will analyze voluntary motor activity but will skip checking insertional/spontaneous activity and then call the insertional/spontaneous activity completely normal on the report. If a referring provider orders an EMG to evaluate for CTS, peripheral neuropathy, radiculopathy, etc his EMG report will give the patient that diagnosis no matter what. None of his EMGs (that I have come across) are reported as normal.

This is definitely more than the typical inadequately trained person that is probably fine diagnosing CTS, etc but gets it wrong on complex cases more often than they should. This someone who is obviously incompetent to perform EMGs in any capacity who wants to keep billing for them.

 

[Phantom Spike]

His EMGs have to come my attention because some of his patients end up seeing me for a second opinion. There are times when the EMG is reordered and I end up redoing it and there are other times his patients end up seeing me in clinic. I am often left trying to make sense of his awful EMG reports. He is a private doc but uses the same EMG lab at my hospital. Our tech is present during his EMGs (even though he does his own nerve conductions) and she has given me more insights into his practice habits.

If his EMG patients are being sent to you for second opinions, or the EMGs are being re-ordered, then clearly other people share your concerns, which is a good thing for the patients.

 

[esob]

Please allow this post to serve as a friendly reminder that SDN's TOS includes the following basic rules:

1. Treat others with kindness and respect
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3. Have fun and support each other

We encourage healthy discussions but please refrain from personal attacks and name-calling.

 

[Telamir]

I've run into a similar situation in the hospital. I am an epileptologist myself but I am not typically reading cEEGs. Our epileptologists are overcallers to the extreme, which puts me often in a precarious situation. Fortunately, in this case they don't really get a production kickback from reading cEEGs so I think it's mostly not the greatest skill rather than being sloppy/financial incentive.

For instance, I have them call FIRDA an epileptiform finding (it's not), and on some status cases I believe they have done harm by overcalling and causing the patient to go back on anesthetics for prolonged periods of time eventually resulting in harm/demise. Fortunately for me I can read the studies myself and write on my note why I disagree and why I'm going against it, but it obviously doesn't look good. In my case unfortunately not much I cando other than what I'm doing and making myself available for my other colleagues to interpret the studies for them although unfortunately off the record.

 

[NotAProgDirector]

This is an interesting discussion and a difficult issue.

Part of the problem is that most physicians can't interpret EMG's at all. I am fully dependent on someone else telling me what they mean -- unlike EKG's, imaging studies, etc where I might rely on someone else's interpretation but at least can look at the thing myself and have some sense of what it means. So it's quite possible that this person has been "misreading" them for some time and there was no way anyone would notice.

The second issue is in regards to style and accuracy. It's possible that two different, well trained neurologists would see the same EMG and come to different opinions. The details you report suggest these issues are far beyond this, but I think it's healthy to consider that some variablility is to be expected.

With all of that, you are raising concerns that this person is grossly misinterpreting these studies. Perhaps they are interpreting them based upon "the science" 30 years ago. Perhaps they just don't know what they are doing. Perhaps they never really learned how to do so in residency and just picked up pointers from someone. We (and you) have no idea. Nor do we know if this is driven by incompetence, fraud, or just carelessness. And we don't know if the person involved even knows that they don't know what they are doing.

The question is: what to do? Doing nothing is an option but seems wrong on many levels. You're probably one of the only people in a position to do something -- since no one else likely knows how to read an EMG. So if you do nothing, it's unlikely anyone else will do anything.

You could:

1. Talk to this person directly. Overall this is probably a bad idea, but if done carefully might help you understand what's going on. If you're new, a good way to address this is to ask to meet with this person to review some EMG's. You'll probably have to be deceptive, stating that you want to work with them to learn from their experience. But it might help you understand where the problem is.

2. If you both work at the same place, speak to whomever runs the group. Bring up your concerns, show them some examples, ask them what to do.

3. Reporting to the board seems overkill given what you've described here. There's no evidence that there's a kickback scheme at play, and I wouldn't create the mess of a board investigation without trying to fix the problem locally first. But this would be a reasonable option if #1 and #2 don't result in some sort of intervention.

Pitfalls to avoid:

A. Financial conflict of interest. If this person is stopped from doing EMG's, is that going to increase your business and paycheck? If so, there's the appearance of a COI. One could accuse you of purposefully sabotaging the senior physician's career to enhance your own. Even if that's not what you're actually doing, it's hard to defend against because it's "true".

B. Making your employer look bad. All of these incorrect EMG's may have led to inappropriate surgeries. The financial impact of that might be astronomical. Should your plan of action result in a public display of these issues, you may find that your employer spins this back upon you to protect themselves. You really don't want to get into this situation.

C. Local politics. As mentioned already on the thread, these folks have been here for decades and you're new. Even if you're right, you need to be smart about it. Trying to make a big splash about it may blow back badly.

Start with local leadership. If someone runs your Neuro group, that's where to start. Have them get someone external to confirm your concerns. Then, if confirmed, they can quietly remove this person's privileges to do EMG's. If you take it to local leadership and they just bury it and don't want to deal with it, then you're stuck with the more nuclear option of either a board complaint, or a whistleblower complaint. Both of these may result in making your workplace toxic enough that you'll need to leave, so you should be prepared.

 

[90sportsfan]

Yeah, it's also a tough situation because if you have seen the fraudulent EMGs and your name is now associated with the chart (not sure if this is the case), then the next Neurologist who sees it and does decide to say something may question how

If this guy has been at this hospital for decades, is friends with the hospital administration and brings money into the hospital, a board compliant and a direct phone call criticizing them would be a terrible idea. The guy could complain, have the hospital label OP a disruptive physician, etc. The bar for disruptive physician is extremely low, and a very established longtime guy like this probably knows everyone. In an ideal world one can change poor care like this, but in reality you are sticking your neck out into hospital politics and might get severely burned. What if the surgeons like him too, and decide they don't like OP? I could be very wrong, but hospital politics can be a no win game and being on the radar screen anywhere in medicine is often a bad place to be.

But on the flip-side, if the OP is seeing these patients for follow-up and sees that the EMGs are not accurate, wouldn't he/she be putting potential risk on themselves by not saying anything? If the patient ends up somewhere else, and a new Neurologist sees the chart (or even in a malpractice claim) and the OP is somehow attached to the chart and it is determined he/she was aware of the bad EMGs, that seems like a more dubious situation than hospital politics.

 

[nikolaite]

For whatever it's worth as anonymous web-advice...I'd say if you're having pts referred for second opinions or followups and you see what you judge as fraudulent in their chart, it might be better to decline to see the pt IF you are not going to put an effort into reporting what you judge as fraudulent. If a pt experiences a highly quantifiable damage, like say, complete loss of the use of a hand in the course of an unnecessary surgery after your visit, you open yourself to be named as a defendant in a medmal case. It doesn't mean you'll be unable to defend yourself successfully (as the odds favor medicoes), but being named is a HUGE disruption alone...as you have to be supplied or retain your own counsel, meet with insurance, perhaps go to hospital mandated education prior to pre-trial questioning, hours or days of deposition, etc. Then add in the second-guessing, sleep disruption and general misery of the process...

My thought is that if you can defend your position on the fraud, you ought to turn the doc in, if only to support the credibility of the medical profession. Forget fear of hospital politics.

 

[Vandalia]

The reality in many states is a board complaint is not at all anonymous and may immediately expose you to significant civil legal liability.

I would add that in every state of which I am aware a report to a professional licensing board carries with it privilege from civil suit. There is some division between the states as to whether this privilege is absolute or qualified. In those states with an absolute privilege, ANY complaint to a professional licensing board, even if specifically made in bad faith, cannot be the basis for a civil suit. If there is a qualified privilege, then the report is protected if made in "good faith."

So there would be no civil legal liability unless you wrote in a Facebook post "Dr. X is dating my ex, so I am going to make a phony complaint to the state medical board..." And in a number of states, even with that, the report would still preclude civil liability.

A lot of other stuff could happen to you, but the report itself cannot result in civil liability.

This is getting into employment law which is different in every state, and is most definitely something I am not an expert in, but firing a physician on the basis of a privileged report to a professional licensing board can create significant civil liability for the employer. Even though most physicians work under a contract, this is usually one of the practical exceptions to "at will" employment.

Very generally speaking, a report to a medical licensing board is about the safest thing you can do, it is far safer than talking with the hospital, peers, etc.

But consult an attorney licensed in your state.

 

[xenotype]

Yeah, it's also a tough situation because if you have seen the fraudulent EMGs and your name is now associated with the chart (not sure if this is the case), then the next Neurologist who sees it and does decide to say something may question how

But on the flip-side, if the OP is seeing these patients for follow-up and sees that the EMGs are not accurate, wouldn't he/she be putting potential risk on themselves by not saying anything? If the patient ends up somewhere else, and a new Neurologist sees the chart (or even in a malpractice claim) and the OP is somehow attached to the chart and it is determined he/she was aware of the bad EMGs, that seems like a more dubious situation than hospital politics.

Doing nothing is not an option for OP if it is this flagrant, but if I were OP I would talk to a lawyer to know what might happen going forward and how best to deal with it.

For whatever it's worth as anonymous web-advice...I'd say if you're having pts referred for second opinions or followups and you see what you judge as fraudulent in their chart, it might be better to decline to see the pt IF you are not going to put an effort into reporting what you judge as fraudulent. If a pt experiences a highly quantifiable damage, like say, complete loss of the use of a hand in the course of an unnecessary surgery after your visit, you open yourself to be named as a defendant in a medmal case. It doesn't mean you'll be unable to defend yourself successfully (as the odds favor medicoes), but being named is a HUGE disruption alone...as you have to be supplied or retain your own counsel, meet with insurance, perhaps go to hospital mandated education prior to pre-trial questioning, hours or days of deposition, etc. Then add in the second-guessing, sleep disruption and general misery of the process...

My thought is that if you can defend your position on the fraud, you ought to turn the doc in, if only to support the credibility of the medical profession. Forget fear of hospital politics.

You might get tossed into a case, and unfortunately serve as essentially a free expert witness. Certainly there are many that would refuse to see any of this other neurologist's patients. This will cause political friction in the hospital system anyways though- refusing to see a patient always gets attention. Would be interesting to know why they are being referred to OP as a second opinion, and by whom.

 

[xenotype]

I would add that in every state of which I am aware a report to a professional licensing board carries with it privilege from civil suit. There is some division between the states as to whether this privilege is absolute or qualified. In those states with an absolute privilege, ANY complaint to a professional licensing board, even if specifically made in bad faith, cannot be the basis for a civil suit. If there is a qualified privilege, then the report is protected if made in "good faith."

So there would be no civil legal liability unless you wrote in a Facebook post "Dr. X is dating my ex, so I am going to make a phony complaint to the state medical board..." And in a number of states, even with that, the report would still preclude civil liability.

A lot of other stuff could happen to you, but the report itself cannot result in civil liability.

This is getting into employment law which is different in every state, and is most definitely something I am not an expert in, but firing a physician on the basis of a privileged report to a professional licensing board can create significant civil liability for the employer. Even though most physicians work under a contract, this is usually one of the practical exceptions to "at will" employment.

Very generally speaking, a report to a medical licensing board is about the safest thing you can do, it is far safer than talking with the hospital, peers, etc.

But consult an attorney licensed in your state.

Could be really great, accurate advice, but you don't sound like an attorney qualified to give it in the state the OP is located. If OP wants to settle for 'in a number of states' for free, that's up to them.

 

[nikolaite]

Doing nothing is not an option for OP if it is this flagrant, but if I were OP I would talk to a lawyer to know what might happen going forward and how best to deal with it.



You might get tossed into a case, and unfortunately serve as essentially a free expert witness. Certainly there are many that would refuse to see any of this other neurologist's patients. This will cause political friction in the hospital system anyways though- refusing to see a patient always gets attention. Would be interesting to know why they are being referred to OP as a second opinion, and by whom.

Talking to an attorney is never a bad idea. As I always tell people, you can typically find a medico-legal counselor easily, but don't expect any attorney really to listen to you for under $1000 per hour.

I advise shirking patients for the simple fact that it makes waves. The patient wants to know why, and the admin wants to know why.

Generally: If admin is ruffled by your refusal to see a patient, it may get QC or risk management scrutinizing the patient record, if you pass on a patient after reviewing it. Even if they don't know what they're looking at, they may come ask, at which point you can say that the liability is too d*** high. If they want to know more, then they need to give you written assurances of no backlash. If they won't do it, then go on your jolly way without contracting the liability for potential patient injury due to unnecessary surgery.

If the patient is curious, they can get ahold of their own record and pay a record review service to tell them why they're being passed over by a second opinion doc. This can be a potential springboard for the patient to write the board of healing arts with a complaint on the fraudulent EMG if it's confirmed by the record review service.