Whistleblower
Doctor
The Politics and Economics
Of Pain and Dying
Copyright 2010 by David K. Cundiff, MD
Smashwords Edition
Also by David K. Cundiff, MD
Euthanasia is Not the Answer—A Hospice Physician’s View
The Right Medicine—How Make Health Care Reform Work Today
Money Driven Medicine—Tests and Treatments That Don’t Work
The Health Economy
All available at: http://TheHealthEconomy.com/
Disclaimer
This book is for general informational purposes only and is not a substitute for professional medical advice.
You are encouraged to confirm information with other sources and confer with your doctor with regard to information contained in this book.
© Copyright 2011, David K. Cundiff, MD
All rights reserved.
Photocopy and Electronic Reproduction Policy: Authorization to print or otherwise reproduce items for internal or personal use, the internal or personal use of specific clients, or for reviews is granted by David K. Cundiff, MD, provided that the source is cited.
Library of Congress Cataloging in Publication Data
Cundiff, David K.
Whistleblower Doctor—The Politics and Economics of Pain and Dying
David K. Cundiff
ISBN 0-9761571-3-6
1. Medical care—United States.
2. Hospice—United States.
3. Health Care Reform—United States.
4. Health care economics—United States.
5. Medical malpractice reform—United States
6. Cancer and AIDS pain management
7. Anticoagulation prophylaxis and treatment
DEDICATED
with much respect
to
To the patients and staff of the LA County + USC Medical Center, who deserve to receive and deliver the best possible medical care.
Contents*
page
Executive Summary vii
Chapter 1 Need for Pain Control and Hospice Services 1
Chapter 2 The Cancer and AIDS Pain Service 1987-1992 7
Chapter 3 Conflicts over Resources for Palliative Care 15
Chapter 4 LAC-DHS Financial Crisis 33
Chapter 5 Letters of Concern and Poor Performance Evaluations 37
Chapter 6 Whistle-blowing Activities 43
Chapter 7 Getting Fired 51
Chapter 8 Awaiting Civil Service Hearing Appealing Termination 65
Chapter 9 The Civil Service Hearing 73
Chapter 10 Medical Board Hearing 87
Chapter 11 Petitioning for Reinstatement of Medical License 121
Chapter 12 Medical License Reinstatement Hearing 127
Chapter 13 Researching Anticoagulation Clinical Science 133
Chapter 14 Superior Court Appeal For License Reinstatement 159
Appendices 1—422 and Exhibits 1—44* 181
References 205
Acknowledgments 215
* This book is documented with 422 appendices and 44 exhibits totaling over 2,000 pages. To access any appendix or exhibit online, go to http://TheHealthEconomy.com/WD/Appendices.htm and click on the appropriate appendix or exhibit.
Executive Summary
A one-month experience of working in three hospices in England convinced me to focus my medical career on alleviating pain and suffering of terminally ill cancer patients. After finishing my fellowship training in hematology and medical oncology (cancer) at the University of California San Diego Medical Center, I resolved to find a way of integrating hospice principles and philosophy with my practice of cancer medicine.
I worked at the Los Angeles County Department of Health Services (LAC-DHS) from 1979–1998, including nine years of directing the Pain and Palliative Care Service at the Los Angeles County+University of Southern California Medical Center (LAC+USC Medical Center). By the early 1990s, the Pain and Palliative Care Service (the Service) had become very popular with the patients, housestaff, nurses, social workers, and other caregivers. Overworked residents and nurses saw that we alleviated pain of their patients while reducing work for the hospital caregivers. We provided their patients with outpatient hospice follow-up and 24-hour/seven-day phone availability that prevented many readmissions for uncontrolled symptoms. In addition, we educated the doctors and nurses in pain management and palliative care techniques.
Unfortunately, for the financial bottom line of the hospital, the better the Service controlled pain and distressing symptoms the more money the hospital lost. Our success in controlling pain and providing comfort to over 400 terminally ill patients led to an estimated 4,000 fewer reimbursable inpatient days in 1994, saving the taxpayer over $9 million in Medi-Cal spending. (California’s Medicaid program) However, LAC-DHS management did not appreciate the savings to taxpayers by the Service, since our efficient and effective outpatient care reduced the Medical Center’s revenue by the same $9 million.
By the time cancer and AIDS patients reached the end stages of their diseases, they almost all had Medi-Cal insurance. Consequently, prolonged hospitalizations for terminally ill cancer and AIDS patients served as a “cash cow” for the LAC+USC Medical Center. This population comprised less than 1% of patients treated, but yielded as much as 15% of the $700 million Medi-Cal yearly revenue for the Medical Center. Since Medi-Cal paid a high all-inclusive daily fee for acute hospital care and little for outpatient treatment, the LAC+USC Medical Center needed a high inpatient census to maximize government reimbursement for services. This discouraged appropriate outpatient pain management and palliative care for terminally ill cancer and AIDS patients.
As the Service had an increasingly adverse effect on inpatient census, management became more and more hostile to me. They reassigned me to additional duties, took away two federal grants for improving the evaluation and treatment of pain, did not permit me to apply for other outside funds to improve pain management, and failed to allocate resources to keep up with the volume of work.
Financial Crisis Hits LAC-DHS
In the summer of 1995, the LAC-DHS faced the largest budget shortfall in its history—$655 million deficit out of an operating budget of $2.3 billion. To resolve the budget crisis, the Los Angeles County Chief Administrative Officer’s proposed budget to the Board of Supervisors for 1995–96 included the closure of the LAC+USC Medical Center. After all of the politicians and County Administrators completed their negotiations over the crisis, the LAC+USC Medical Center was saved, but employees and services of the LAC-DHS were downsized by nearly 15%. Under the cover of this crisis, the LAC-USC Medical Center management closed the Pain and Palliative Care Service and transferred me to attending in internal medicine inpatient wards and outpatient clinics.
In conjunction with the LAC-DHS downsizing of personnel and services in September 1995, management negotiated a $1.2 billion five-year Health Department bailout from President Clinton to save the LA County Government from threatened bankruptcy. The strings attached to the bailout included reengineering the LAC-DHS to shift considerable resources from inpatient care to out-of-hospital services. I rejoiced that, finally, financial sanity would come to the LAC-DHS and that pain management and palliative care would have to be recognized as a necessary component to comprehensive care, requiring significant resources.
Inexplicably, the federal Medicaid bureaucracy increased rather than decreased our inpatient reimbursement rate and did not increase funding for outpatient services. I had hoped for a comprehensive change in the system of funding the LAC-DHS to per patient (capitated) reimbursement or another system that encouraged outpatient care. Paradoxically, complying with the conditions of the federal bailout by shifting resources from inpatient to outpatient care would have severely reduced revenues to the LAC-DHS. Consequently, resources were never shifted.
Challenging the LA County+USC Medical Center $900 Million Replacement Project
After averting the Medical Center closure by receiving the federal bailout in 1995 and securing an outrageous daily fee rate for Medi-Cal inpatients ($3,800 per day), LAC-DHS management next set its sights on replacing the aging Medical Center with as large a hospital as possible. The more beds in the new hospital, the more of the 8,300 LAC+USC Medical Center employees would salvage their jobs. This increased ongoing census-raising strategies that precluded an effective pain and palliative care service designed to help terminally ill patients remain comfortably at home rather than in acute-care hospital beds.
Policies and procedures throughout the Medical Center encouraged unnecessary hospitalizations and encouraged more days in hospital than needed for those admitted appropriately. Major deficiencies in primary care services in affiliated clinics and comprehensive health care centers paid off financially with more emergency admissions to the hospital. As had long been the case at LAC-DHS hospitals, admitted patients could wait days or weeks for surgery, diagnostic studies, or specialty medical procedures. Nearly everyone believed that the long waits were due to underfunding of the LAC-DHS. In reality, the LAC-DHS depended on long waits of Medi-Cal patients to increase revenue. Inefficiency paid well while efficiency was financially punished.
In a highly contentious meeting in November 1997, the LA County Board of Supervisors approved a 600-bed replacement hospital instead of the management-supported proposal of 750 beds. This meant that up to 4,000 jobs would be lost at the Medical Center.
Later that month I published an editorial in the LA Times, advocating that the LAC-DHS lease acute-care hospital beds from private hospitals or buy existing hospitals instead of spending $900 million on a replacement hospital. Since LA County had about 20,000 acute-care licensed beds, of which only about 10,000 were filled in an average day, I argued that a replacement hospital of any size would waste taxpayers’ money. Instead, I recommended immediately switching to per patient (capitated) reimbursement from Medi-Cal, reorganizing the LAC-DHS as a health maintenance organization, and leasing or buying the necessary acute-care beds from the private sector. Then, we could effectively compete with the rest of the LA community health care providers by making efficient use of hospital beds and shifting more resources to out-of-hospital care, such as hospice. With capitated reimbursement, we would no longer be financially dependent on institutionalized inefficiency and waste driven by the dysfunctional funding system.
Management responded to my editorial with resounding silence. Despite the fact that I claimed that the Health Department fostered dysfunctional policies and procedures that purposefully raised the census solely to increase reimbursement, no one issued a verbal or written rebuttal.
In February 1998, I audited my inpatient medical service, carefully documenting the unnecessary patient days in hospital. Applying my findings to the census figures of the LAC+USC Medical Center, I calculated that the average inpatient census should have been about 480 patients rather than the actual 860 (44% of days unnecessary). In March 1998, I sent the results of this audit and my suggestions for re-engineering the LAC-DHS to the federal and California State Medicaid offices and to 11 legislators. Only the California State Medi-Cal office replied to the conclusion from my audit that the Medical Center was defrauding Medi-Cal out of over $200 million per year by institutionalized inefficiencies. They did nothing to investigate.
Chief among these strategies to raise the inpatient census was inadequate pain management and palliative care services, accounting for 28% of the unnecessary inpatient days in my audit.
Complaints about Poor Treatment of 83 Patients
After the Pain and Palliative Care Service closed in September 1995, I assumed full-time duties as an attending physician on the general medicine wards and in the outpatient clinics. In those roles I found numerous instances of poor pain and symptom management of cancer and AIDS patients. Over five years I submitted 83 incident reports to the LAC+USC Quality Assurance Committee, mostly about patients suffering poor pain management. I also formally submitted these cases as patient care complaints to the Medical Board of California. The Medical Center QA Committee did not acknowledge receipt of the complaints. The Medical Board responded that the patients and/or patients’ families would have to submit the complaints rather than a physician that was aware of the substandard care. Unfortunately, all the patients were dead and I had no access to the charts at that point to contact the families.
Fired and Medical License Revoked
Four days after I sent the results of my inpatient service audit to Medicaid administrators in Washington, DC and Sacramento and several legislators, my supervisor placed me on paid administrative leave. Seven months later management fired me supposedly for my clinical decision (a judgment call) to stop the drug Coumadin (generic name: warfarin, a blood thinner) in an alcoholic patient with a leg clot (deep venous thrombosis or DVT). He had a very high bleeding risk. The patient later died of a clot in his lung. I had no previous malpractice judgments or disciplinary actions in 25 years of practice.
In a Civil Service Hearing, I lost my case to be reinstated in my job. Subsequently, the California Superior Court denied my appeal. Finally, I faced a California State Medical Board hearing for my medical license.
I defended my judgment to stop the Coumadin in my patient by pointing out that Coumadin is contraindicated in alcoholic patients because of the bleeding risk. My medical resident on the case diagnosed alcoholism by documenting in the chart that the patient reported drinking a six-pack of beer per day for 20 years. Neither the Deputy Attorney General nor the judge disputed that alcoholism is a contraindication for using Coumadin for deep venous thrombosis. The decision in the case hung on whether the patient was an alcoholic.
The Deputy Attorney General responded by bringing the patient’s daughter to the stand in court as a surprise witness to testify not only about her account of the events of her father’s illness but also as a quasi expert witness. She worked as a substance abuse counselor. She said that her father did not drink “cans of beer” but “quart bottles of Colt 45 Malt Liquor”—not more than two quarts of malt liquor per day on weekends. She testified that she had never seen her father drunk and that he was not an alcoholic. The district attorney brought no other substance abuse expert witnesses to challenge the diagnosis of alcoholism documented in the chart by my medical resident who, under cross examination, stood firmly by the accuracy of her medical history.
Referring to the daughter’s testimony, Administrative Law Judge H. Stuart Waxman wrote in his decision to revoke my medical license, “. . . (The patient) drank less than two quarts of malt liquor per day on weekends. (The evidence did not disclose his drinking customs during his workweek.)” Rejecting my defense that it would have been malpractice for me to continue the Coumadin in an alcoholic, Judge Waxman ruled that I should have continued the Coumadin.
He would not allow into evidence the results of a survey of internists and anticoagulation experts done by my expert witness, Dr. Matthew Conolly, UCLA Professor of Medicine, and me that showed a remarkable variation of medical opinion about the best management of the case. After hearing my testimony on the lack of scientific evidence supporting anticoagulant treatment of deep venous thrombosis, Judge Waxman asked me that were I to treat another patient with identical circumstances, would I again stop the Coumadin. I said, “Yes.”
In his decision on my case, Judge Waxman wrote:
“. . . Respondent is now even more convinced than he was in 1998 that he made the correct decision in discontinuing the anticoagulant medication he had been approving for (patient) BR, and he made it very clear at the administrative hearing that, if faced with the same situation today, he would make the exact same decision. Respondent is entitled to that opinion. However, he is not entitled to foist that opinion on an unsuspecting public, more than 2,000,000 of whom suffer DVT annually. Those popliteal DVT patients who may be treated by Respondent in the future are now at even greater risk of pulmonary embolism than before because of Respondent’s ongoing belief that the standard treatment for the condition, accepted by the vast majority of the medical profession, is nothing more than “dogma.” No probationary order can adequately address and prevent that risk to the public. That risk to the public is too great to permit Respondent’s continued practice of medicine.”
After I lost my medical license over this case, the patient’s daughter brought a wrongful death civil suit against me and LA County, which the County administration settled, over my objections, for $175,000. In a deposition of the patient’s daughter before the settlement, my attorney showed her a 40-ounce magnum of Colt 45 Malt Liquor, asking if this was her father’s preferred drink. After she said it was, she acknowledged her error in calling it a quart (32 ounces). Two magnums of malt liquor are equivalent in alcohol to eight 12-ounce cans of beer. Only an alcoholic with a high tolerance could consume this much in a day and not appear drunk.
Discovering that Anticoagulation Increases Deaths Overall
This DVT case led me to research the evidence-basis for warfarin (Coumadin) and other anticoagulants for treating clots in the leg and lung veins (DVTs and pulmonary emboli or PE, together called venous thromboembolism or VTE). To my great surprise, I found all the published studies supporting anticoagulants for DVT and PE to be flawed. In court, my expert witness, Dr. Conolly, and I testified about a particular randomized controlled clinical trial comparing standard anticoagulants (heparin and warfarin) to phenylbutazone (an anti-inflammatory drug). The prosecuting attorney objected to us entering the trial into evidence, and the judge sustained the objection. In malpractice proceedings, you cannot have expert witnesses debate the evidence-basis of a medical test or treatment. All that matters is the prevailing opinion of the medical establishment.
I have subsequently published a number of articles in peer-reviewed medical journals showing that anticoagulants increase rather than decrease mortality for deep venous thrombosis. I found that 28 other medical indications for anticoagulants to be likewise based on scientific errors and biases of drug company-funded investigators. None of these challenges to “standard” anticoagulant treatment has been rebutted by any anticoagulation expert in academia or government.
Worldwide, at least 100,000 people bleed to death from anticoagulants or die of rebound clotting after stopping anticoagulants each year. My quest is to stop this doctor-caused epidemic.
Stonewalling of U.S. Department of Health Services Health Regulators
In August 2010, my sixth major review article challenging the effectiveness and safety of anticoagulation was published by a BioMed Central Journal. (http://www.tbiomed.com/content/7/1/31) The article entitled, “Diet for prophylaxis and treatment of venous thromboembolism?”, reviewed the data on anticoagulation drugs for prophylaxis and treatment of VTE and found that they cause about 40,000 deaths per year worldwide of which about 20,000 occur in the U.S. The article went on to recommend either withdrawing the FDA approval of anticoagulants for VTE or funding randomized controlled clinical trials to compare a low VTE risk diet (mostly plant-based foods) with standard anticoagulation for VTE.
I immediately notified leaders at the Food and Drug Administration (FDA) and National Institutes of Health (NIH) by email of the publication of this article and requested their critique. Janet Woodcock, MD, Director of the Center for Drug Research and Evaluation of the FDA, delegated the job of replying to me to Ann Farrell, MD, Acting Director of the FDA Division of Hematology Products. Dr. Farrell was explicit about refusing to go on record with a critique of my paper: “We have reviewed your interesting paper but have no written critique.”
My email to Francis Collins, MD, Director of the NIH began
I am the lead author of an article published in a BioMed Central Journal that provided literature documentation that anticoagulant prophylaxis and treatment for venous thromboembolism (VTE, i.e., DVT and PE) unnecessarily causes about 40,000 bleeding and rebound clotting deaths per year worldwide, about 20,000 of which occur in the U.S. http://www.tbiomed.com/content/7/1/31 . . .
Dr. Collins delegated his reply to me to Susan Shurin, MD, Acting Director National Heart, Lung, and Blood Institute. Dr. Shurin completely avoided any direct response to my data and conclusions of the article and replied in boilerplate bureaucratese:
The risks and benefits of the prophylactic and therapeutic use of current anticoagulation therapies are well recognized. Therefore, the NHLBI actively supports basic, translational, and clinical research on safer and more effective therapeutic options for VTE. . . .
Despite multiple attempts by me and others to have FDA and NIH scientists and drug regulators critique the data and conclusions of this article of any of my other five published peer-reviewed medical journal articles showing that anticoagulants do catastrophic harm to people, they continue to stonewall with no public, transparent, detailed analysis of my data and conclusions.
Medical License Reinstatement Hearing in LA County Superior Court
On May 27, 2011, I will appear before Judge James Chalfant in Los Angeles County Superior Court to appeal for the reinstatement of my medical license. Deputy Attorney General Klint McKay’s brief in opposition to my license reinstatement maintains that I am a risk to patients because of my opinion that anticoagulant drugs do harm in patients with deep venous thrombosis.
My reply brief concludes:
Petitioner’s medical judgment that anticoagulants for VTE treatment increase the risk of death has not been rebutted in six peer-reviewed medical articles published from 2004–2010. That anticoagulants cause catastrophic harm to patients has not been rebutted by the FDA or NIH leaders in charge of regulating these drugs. The burden is on Respondent to produce declarations by authoritative physicians that are expert in anticoagulation medicine to address Petitioner’s medical judgment in 2011 that anticoagulant medication for treatment of VTE does harm to patients. Failing that, Respondent should reinstate Petitioner’s medical license.
Conclusion
By relating my 19-year saga in the LAC-DHS, I hope to focus attention on issues that are much more important than my case for medical license reinstatement:
My hostile work environment and job termination resulted from perverse financial incentives in the Medicaid program that rewarded hospitalization and discouraged outpatient hospice care. This increased pain and suffering and impaired training of health care providers, compounding the other barriers to effective and compassionate palliative care of the dying.
Anticoagulation drugs for VTE prophylaxis and treatment doesn’t work and causes about 40,000 deaths per year worldwide. Drug company financial clout has exerted its influence on academic researchers, medical journal editors, government regulators, and the medical media to foster this ineffective, dangerous, and expensive practice.
For many other medical indications where anticoagulation is used according to clinical practice guidelines as the standard of care, it is not evidence-based to work and, in fact, may be evidence-based to increase complications and death.
“Sham peer-review,” as in my case, has become an increasing problem that stifles health care innovation, efficiency, and quality of care improvement. Whistleblowing physicians who point out deficiencies in health care and expert physicians who pose competitive threats to local medical establishments may be targeted for retaliation like I was. Resolving the current medico-legal mess regarding physician malpractice requires a comprehensive overall of the tort system in health care.
More broadly, health care in the U.S. is in crisis with decreasing access and quality while costs escalate. We will never be able to control medical costs and provide universal access to quality medical care until we stop paying for tests and treatments that don’t work such as anticoagulation drugs for prophylaxis and treatment of VTE. My saga relates to the need for a wide-based restructuring of health care to get the financial incentives right. If we properly reward good, efficient, compassionate care rather than ineffective medical interventions, quality will go up and costs will come down.
Chapter 1
Need for Pain Control
and Hospice Services
President Richard Nixon signed the National Cancer Act of 1971, providing generous funding to greatly expand the National Cancer Institute in order to cure cancer. Nixon wanted to outdo President John F. Kennedy who signed the legislation to put a man on the moon. As a third year medical student at the University of California, San Diego (UCSD) in 1971, I saw how dying cancer patients were neglected and decided to specialize in cancer treatment—medical oncology. After medical internship and residency at the University of Pittsburgh Hospitals, I took a fellowship in medical oncology at the Cancer Control Agency of British Columbia.
Many of my patients died horrible painful deaths despite my best efforts to cure them or alleviate their pain and suffering. No expert in pain management or hospice was available to call on for help. In my subsequent hematology (blood)-oncology fellowship at UCSD, my teachers, colleagues, and I focused on attempts to cure people or prolong life more than to relieve pain and distressing symptoms in people with advanced cancer. Again, no consultation service in cancer pain management was available for us to call for help.
To learn more about pain control and symptom management for cancer patients, I took my last clinical elective of my hematology-oncology fellowship in hospices in the United Kingdom. In 1979, over the course of one month, I served as assistant physician on hospice teams in London, Oxford, and Worthing. During that time, I participated in the care of over 100 cancer patients. Only one had poor pain control, and the morphine dose for that patient was still in the process of being adjusted. The superior quality of symptomatic care that these cancer patients received astounded me.
I was also amazed at my lack of knowledge of how to effectively prescribe medication to control the symptoms of the terminally ill. Previous to my experience in England, I literally did not know that I did not know how to effectively treat pain and distressing symptoms of advanced cancer. In some cases, a junior doctor only one year out of medical school taught me techniques of adjusting doses of morphine and related medicines—things I had not learned in six years of post graduate training in internal medicine and medical oncology. The English hospice consultants, nurses, and social workers showed me a manner of caring for patients that I could not have learned by reading books or attending lectures. They masterfully translated hospice philosophy and treatment knowledge into practical techniques to address the complex physical, psychological, social, and spiritual issues in order to help patients live fully and comfortably for whatever time their diseases allotted.
At the end of the experience, I resolved to bring this quality holistic care for the terminally ill—palliating the physical, psychological, social, and spiritual suffering—to whatever type of oncology practice I would subsequently undertake. My perspective on medicine and on life was forever changed.
LA County+USC Medical Center Hospice Care/Pain Management Subcommittee
Before disbanding in 1984, the Los Angeles County-Department of Health Services (LAC-DHS) Ad Hoc Committee on Hospice recommended to the LA County Board of Supervisors that the County should start a hospice program and appoint a full-time hospice and pain control physician for the Department of Health Services. Consequently, in 1985, the Hospice Care/Pain Management Subcommittee of the Quality Assurance Committee was formed at the LAC+USC Medical Center in response to the request of the LAC-DHS that each County hospital review care of the dying and the facility’s approach to pain control in cancer patients. Because of my interest and work in this area, the hospital medical director appointed me to this subcommittee.
On May 24, 1985, Peter Heseltine, MD, Chairman, of the Quality Assurance (QA) Committee, and Kathy Lohr, RN, Coordinator of the QA Committee, reported that, “Considering our findings, as well as those of the LAC-DHS Ad Hoc Committee on Hospice, we feel that the lack of medical training in pain control and palliative care is an epidemic problem.” (Appendix #3) On August 23, 1985, the Committee minutes stated the following: (Appendix #4)
The committee indicated that the first goal should be to make people realize that there is a problem with pain management. Although the committee’s original recommendation for a pain consultation service was rejected, it was felt that there would be an advantage to having such a resource. The ideal, of course, would be to have a Hospice Unit within the hospital to show the staff “how to.”
Dr. Heseltine presented the recommendations for management of chronic/terminal pain to the medical director, Dr. Sol Bernstein: (Appendix #5)
It has been established through evaluation of patient discharge plans and interviews with staff that the prescribing of narcotics for outpatients is significantly underused. We have found that very few medical residents or staff possess DEA (Drug Enforcement Administration) issued “triplicate” prescriptions. (Ed., California and nine other states require physicians to purchase special prescription forms for scheduled drugs such as opioids. One copy goes to the DEA; one to the pharmacy, and one remains with the physician.) The result is that patients with chronic pain that are maintained well on narcotics (in hospital) are often sent home on inadequate analgesia because no one is available to prescribe triplicate-required medication. As the problem is so widespread, and the need much greater than previously thought, the committee after considerable deliberation recommends that the Executive require all licensed physicians to possess DEA-issued triplicate prescriptions. By definition this would exclude interns but include faculty. The Committee believes that obtaining a license to practice medicine carries an ethical obligation that the physician be able to provide his/her patients with optimum pain management. A physician without “triplicates” is not in a position to do so. Physicians that have no patient care responsibilities and insist on being exempt from this policy should be reviewed by an appropriate group.
The second recommendation by the committee is that a multi-disciplinary “pain management team” composed of interested physicians and other healthcare professionals be available for consultation by the medical and nursing staff. This team, in addition to ensuring appropriate management of difficult cases, would augment the teaching of pain management to the staff and improve the quality of patient care. Some of the members of the ad hoc committee would be willing to play a role in such a team.
A questionnaire survey of senior residents in Women’s Hospital, regarding their ability to manage pain, revealed that 80% felt the need for more resident training in chronic pain management. A Women’s Hospital nursing survey showed that 60% felt they needed additional information/education regarding pain management. (Appendix #6)
A patient audit by the Hospice Care/Pain Management Subcommittee reported the following major findings: (Appendix #7)
Pain control was ineffective as only 23% of narcotic orders were for round- the-clock administration. Effectiveness was, for the most part, not charted.
Psychosocial care mostly focused on placement though 73% of patients in the sample lived with primary care persons. Only four of 30 patients were referred for home care.
Length of hospital stay averaged one month per patient.
Reimbursement: 50% of the sample had no source of reimbursement.
A comparison of home-care costs versus conventional hospital-care costs revealed that hospital-care costs were approximately $12 million per year for 500 terminally ill cancer patients. Home care would cost less than $1 million.
A repeat audit of general medicine and oncology wards reported by the Hospice Care/Pain Management Subcommittee in November 1986 included the following statement: (Appendix #8)
In general, the audit demonstrated inappropriate ordering practices for pain control as well as lack of documentation regarding effectiveness or non-effectiveness of the pain medication. Out of the 16 patients sampled only one from a General Ward had a VNA (Visiting Nurse Association) referral. There were no VNA referrals from the Oncology/Hematology wards.
Follow the Money
The LAC-DHS Ad Hoc Committee on Hospice analyzed the financial feasibility of instituting a hospice program. (Appendix #1, page 14)
Attempts by the Ad Hoc Committee to determine the financial feasibility of a County-operated hospice has brought mixed results. On the one hand, it is clear that the County could save money in the care of an individual dying patient by moving that patient to a less costly level of care. However, the Department of Health Services as a system would save money only if that now-empty acute care bed were not immediately refilled with other patients and if the necessary personnel and other supports were reduced accordingly.
Since this is not likely to be the case, the only factor that would make it financially feasible to transfer the terminally ill patient to a hospice would be the existence of adequate reimbursement to meet the cost of hospice care. Unfortunately, at the present time, the information with regards to the reimbursement for hospice care is too uncertain and too untested to allow for reliable financial predictions to be made with any degree of certainty.
In 1984, the LAC-DHS Ad Hoc Committee on Hospice did not even consider the additional Medi-Cal revenue loss from shifting substantial numbers of AIDS patients from hospitals to hospice programs. However, by the peak of the AIDS epidemic in 1994, LAC+USC Medical Center alone had an inpatient census of AIDS patients ranging from 80–100 per day, according to Fred Sattler, MD, chief of the AIDS Clinic. The census of LAC+USC Medical Center HIV/AIDS patients subsequently fell precipitously because of the advent of Medi-Cal and other funding for HIV/AIDS patients in the private sector. However, state-of-the-art palliative care and hospice for AIDS patients still would have further decreased LAC-DHS Medi-Cal reimbursement by tens of millions of dollars per year.
Launching of LAC+USC Medical Center Cancer and AIDS Pain Consultation Service
In a report to upper management regarding the findings of the Hospice Care/Pain Management Subcommittee, Dr. Sol Bernstein, LAC+USC Medical Director, wrote the understatement, “In summary, we have confirmed that pain management may in fact be less than optimal in many patients treated as inpatients.” (Appendix #2) Dr. Bernstein relayed the results of the LAC+USC Medical Center Hospice Subcommittee audit and re-audit of pain management to LAC-DHS administration and mentioned that a Cancer Pain Consultation Service was beginning under my direction. (Appendix #9)
Chapter 2
The Cancer and AIDS Pain Service
1987–1992
In February 1987, my seven-year campaign to begin a Cancer and AIDS Pain Service in the Los Angeles County-Department of Health (LAC-DHS) was finally realized. Based on the recommendation of the Hospice Care/Pain Management Subcommittee, the Cancer and AIDS Pain Service began with a research/clinical nurse and one physician—me. (Appendix #10) The only cost to the hospital of this new consultation service was the loss of my time in general internal medicine. From the pharmaceutical company, Purdue Frederick, I negotiated funding for a research study of long-acting morphine. This money paid for the pain management nurse on the Service.
The volume of consults quickly grew to make it one of the ten busiest palliative care services in the United States. In 1991 and 1992, I sought to significantly increase the resources allocated to palliative care by campaigning for an inpatient palliative care unit. (Appendices #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26) Jonathan Weisbuch, MD, medical director of the LAC-DHS, actively helped in this effort in many ways, including arranging for me to meet with T. George Wilson, MD, Chief, Medi-Cal Policy Section in Sacramento, and his staff.
I explained to the Medi-Cal Policy personnel that I was a consultant to other physicians at the hospital in the management of their patients’ pain from cancer and AIDS. A nurse worked with me to help control that pain. Our care for terminally ill patients was rooted in the hospice philosophy and employed hospice techniques. When no cure of these patients is possible, the hospice approach emphasizes the management of pain and the provision of psychological, social, and spiritual support for both patients and family members. Using a team approach, we often called in physical therapists, psychiatrists, anesthesiologists, and other specialists.
To describe the situation in terms of human suffering and wasted resources, I related the state of palliative care at the LAC+USC Medical Center to Dr. Wilson and his staff with the following example of a patient referred to the Cancer and AIDS Pain Service:
Mr. Lee (not his real name) was a 52-year-old Korean man who had undergone surgery for stomach cancer 13 months earlier in Seoul, Korea. Since the cancer had already spread to the liver and elsewhere, he had received intra-operative chemotherapy followed by conventional outpatient chemotherapy. When this failed, he immigrated to Los Angeles hoping for a cure.
At my hospital, he received an experimental chemotherapy drug for six months. This also failed to control his disease. It lowered his blood platelet count, thus increasing his chances of bleeding from the remaining abdominal tumors. As an outpatient, multiple transfusions of blood were given because of hemorrhage through the gastrointestinal tract.
One bleeding episode required hospitalization to achieve control. During that time, after discussing it with his doctor, Mr. Lee agreed to a “do-not-resuscitate” order that was then recorded in his chart. Unfortunately, on discharge from hospital he was not referred to our visiting nurse association hospice program or to my Cancer and AIDS Pain Service.
He had been out of the hospital only three weeks when he began to vomit blood and was again rushed to our emergency room. He was immediately transfused with blood and quickly moved to our new, ultramodern intensive care unit. When bleeding persisted, he underwent angiography (i.e., an X-ray dye study) of his abdominal blood vessels and the bleeding artery was blocked off by an injection of a special material. Soon the specialists in interventional radiology repeated this procedure because of recurrent bleeding. Because the cancer was so advanced and the patient’s inability to take food while the acute bleeding problem persisted, the intensive care unit physicians ordered total parenteral (intravenous) nutrition to prevent malnourishment. This provided about 3,000 calories per day, along with plenty of intravenous fluid.
After more time in the intensive care unit, Mr. Lee developed a fever; his doctors promptly ordered antibiotics. Later, when the fever persisted and blood cultures showed infection with resistant bacteria, he was switched to more powerful antibiotics.
On the tenth hospital day, a new intensive care unit doctor discussed with Mr. Lee and his family the seriousness of his condition. Mr. Lee again requested not to be resuscitated if his heart stopped beating. The doctor dutifully noted this in the chart. However, Mr. Lee remained in the ICU.
Abdominal pain had been a big problem even before this hospitalization. At least six months before hospitalization, Mr. Lee’s oncologist had prescribed prolonged-release morphine. While in intensive care, the pain increased despite institution of intravenous morphine infusion and titrating the dose to 20 milligrams per hour (a high dose).
Mr. Lee’s doctor asked the anesthesiology pain service to administer a nerve block to better control his severe pain. After deliberation for several days, the anesthesiologists declined to carry out the nerve block procedure for fear of causing internal bleeding, and possibly shortening his life.
At his wit’s end, on the 21st day in the intensive care unit, Mr. Lee’s intern called on me to offer new suggestions for the management of Mr. Lee’s pain. He had observed that a marked accumulation of fluid in Mr. Lee’s abdomen was now also contributing to the pain.
The intern told me that because of Mr. Lee’s pain and the overall poor prognosis, Mr. Lee had been begging for a lethal overdose of medication—in essence, begging for euthanasia. The young doctor was obviously in an uncomfortable position, as any doctor would be.
This case offered me an excellent opportunity to teach the intern some of the basics of palliative care. I explained that with a terminally ill patient in this situation, although we cannot honor a request for euthanasia, physicians are under no legal, moral, or other obligation to continue therapies designed to prolong life, such as blood product transfusions, total parenteral nutrition, and antibiotics.
I suggested that a paracentesis (removal of abdominal fluid) be done to decrease the pressure in Mr. Lee’s abdomen. I also requested that the intravenous fluids, including the total parenteral nutrition, be stopped in order to prevent further misery from the IV fluid accumulating in the abdominal cavity. Finally, I recommended an increase in the morphine infusion dose to 30 milligrams per hour.
The next day when I saw Mr. Lee, he had been transferred to a “closely monitored area” on a regular medical ward. He was in coma and the morphine infusion had been stopped. Very distraught relatives filed in and out of his room for short visits, making their way between the hospital staff and the life-support technology.
Skimming the chart (three thick volumes had accumulated during the 22-day ICU stay), I noted that the paracentesis had not been done, again for fear of causing bleeding and the shortening of Mr. Lee’s life. Two expensive intravenous antibiotics, total parenteral nutrition feedings, and frequent insulin injections had continued. Blood cultures drawn two or three days earlier showed that two types of bacteria were growing despite the antibiotics. Other laboratory tests continued to be ordered.
I spoke at length with the new intern and resident about what to do if abdominal or other pain reemerged and, in general, concerning palliative care in this type of situation. During the following night, Mr. Lee woke up enough to express pain. More morphine was given intravenously, but initially did not work. Instead of giving Mr. Lee higher doses of morphine, the doctors had injected Valium, which only quieted him down.
In the morning, the staff had suddenly become concerned with inappropriate utilization of the hospital’s resources (the closely monitored unit) and ordered Mr. Lee’s transfer to the regular ward. The total parenteral nutrition, antibiotics, and insulin could all be continued on the regular ward, but the morphine infusion pump could not.
The new intern wrote an order for prolonged release morphine sulfate to be crushed and given through the gastric feeding tube. I pointed out to the staff the problems with this strategy. Crushing prolonged-release morphine converts it into immediate-release morphine, which lasts only about four hours. In an acutely ill person with sepsis, widespread cancer, tense fluid throughout his abdomen, and low blood pressure, oral analgesics or other medications would not be reliably absorbed from the gastrointestinal tract. The nursing administration made an exception and allowed the morphine pump for his final hours. The pump was not turned on since he never came out of coma.
I wish there were a happy ending to this story, but there is not. When Mr. Lee died, the doctors told the family that they had done all that could be done medically to save him. No one could be charged with malpractice for undertreating pain, since this is not unusual care of the dying in America. However, a lack of training in palliative care and the obstacles built into our medical care system had prevented even rudimentary pain and symptom control measures for Mr. Lee, let alone help with the psychological and emotional process of preparing for his death.
In a time of dire shortages of health care funding for the poor, this hospitalization cost the taxpayer over $50,000 (1991 dollars). This hospitalization served only to magnify pain and suffering enough for him to beg for euthanasia. For Mr. Lee, euthanasia was not the answer. Physician training in palliative care offers the prospect of a far better solution.1
This story led to more recognition of the cost of futile care in the state Medi-Cal administration and an assurance of reimbursement policies that would not penalize the County for establishing an acute-level palliative care unit. In a letter to Dr. Weisbuch dated December 10, 1992, Sally Lee, Chief of Medi-Cal Operations Division, said: (Appendix #27)
While the Medi-Cal Program can only reimburse for medically necessary services, specific approval by the Medi-Cal Program is not required in order to establish these services at LAC-USC Medical Center or other Los Angeles County Hospitals. Determination of specific wards, staffing ratios, and professional services are matters of County administration under hospital licensure and certification requirements. Medi-Cal’s primary concern is that Medi-Cal beneficiaries treated in such a unit require and receive only medically necessary, acute level services under any acute inpatient settings.
The subject proactive approach in identifying areas where significant cost saving can be achieved by both the County and the Medi-Cal Program is commended. However, the overall success of this proposal, in terms of cost savings and quality of care, will largely depend on the County’s ability to establish the services that will be required beyond acute hospitalization. These would include the transition to traditional hospice as well as the availability of home health services. The County may want to consider the feasibility of becoming a separate provider for these services. This would allow the County greater flexibility in managing these cases without having to depend on other providers.
Unfortunately, the LAC-DHS did not act on Dr. Weisbuch’s recommendation and the encouragement by the Medi-Cal Program administrators to initiate an acute level palliative care unit. Not long after these events, LAC-DHS Director Robert Gates fired Dr. Weisbuch as LAC-DHS Medical Director, possibly, in part, because of his advocacy of more LAC-DHS resources devoted to the care of the dying.
Chapter 3
Conflicts over Resources for Palliative Care
In September 1992, Dr. David Goldstein, my supervisor, gave me two new assignments. I was to supervise two physician assistants on an inpatient ward service (Appendix #28) and also to lead an admitting internal medicine ward team for the month of November 1992. My previously assigned other duty was to supervise about 10 residents one-half day per week in a general internal medicine clinic. I protested verbally and in writing with a formal grievance (Appendix #29), but I could not convince my supervisor that doing these two new jobs along with the Cancer and AIDS Pain Service was physically impossible. I couldn’t physically comply with Dr. Goldstein’s order to supervise the physician assistants from 8 AM to 4 PM Monday through Friday while also consulting on the Cancer and AIDS Pain Service. Nurses who worked with hospice patients wrote letters on my behalf. (Appendix #30, #31, #32)
David Hancock, a non-physician LAC+USC Medical Center administrator, served as arbitrator for the third and final level grievance hearing of my work assignment change. He filed a detailed report to Jerry Buckingham, LAC+USC Medical Center Executive Director. The report was favorable to me but deferred to LAC+USC Medical Director Dr. Sol Bernstein. (Appendices #33, #34) Dr. Bernstein agreed with me that the assignment was impossible. He deleted Dr. Goldstein’s harassing letters charging insubordination from my personnel file. (Appendices #35, #36, #37, #38) Although I filed an official grievance, Dr. Bernstein treated the matter informally and refused to document the resolution of the conflict in writing despite my written requests that he fulfill his obligation and do so. In a memo to Dr. Bernstein dated December 29, 1992, I finally documented the resolution of the grievance. (Appendix #39)
Losing this dispute made Dr. Goldstein even angrier. In a memo dated January 12, 1993, he continued my assignment on the Cancer and AIDS Pain Service 12 months per year but added four months of supervising internal medicine ward admitting teams. I still supervised a one-half day per week outpatient internal medicine clinic. Out of spite, he again gave me an impossible work situation stating: (Appendix #40)
Your work hours per week are 40, starting at 8:00 AM to 4:30 PM which includes a half hour lunch but does not include two fifteen minute breaks in the eight-hour day. . . . Any overtime request must have my prior approval.
He anticipated that newly instituted rules from Dr. Bernstein regarding overtime (Appendix #41), apparently with me in mind, would cover this new strategy. As the only physician on the Cancer and AIDS Pain Service that now had about 20 new consults per month and over 100 home patients being monitored at any given time, I could not limit my hours to 8 AM to 4:30 PM, Monday to Friday. Besides attempting to put me in my place after his loss of face due to the previous grievance outcome, this appeared to be an attempt to confiscate my overtime hours, which until then averaged 15–20 per week.
This policy discriminated against me as a County-employed physician versus the USC-employed physicians that Dr. Goldstein also supervised without imposing this kind of rigid schedule. Another new rule regarding overtime that greatly affected my situation was that “overtime may be accrued only for work performed on Medical Center grounds and for County-related duties.” (Appendix #41) Since I was on call 24 hours per day, seven days per week, I spent many hours per week away from the hospital speaking on the phone with interns, residents, nurses, and patients, phoning in orders, and otherwise dealing with the problems of my patients.
I asked for a clarification of this new directive and requested to average 40 hours per week on a flexible schedule. (Appendix #42) Dr. Goldstein denied my request with memos that hardened his position. (Appendices #43, #44) For instance, I had a speaking engagement on a weekday morning and asked for prior authorization to work 12 PM to 8 PM. Dr. Goldstein approved my absence from 8 AM to 12 PM but disallowed my “overtime” from 4:30 PM to 8 PM on the same day. (Appendix #45) He refused to answer another letter requesting clarification of the overtime rules. (Appendices #46, #47)
After I filed another grievance, Dr. Bernstein again called an “informal meeting” to resolve this matter and other conflicts. He used the word “chickenshit” to describe the aspect of Dr. Goldstein’s directive that I work only 8 AM to 4:30 PM Monday through Friday. However, we could not resolve the other scheduling issues, and Dr. Bernstein again refused to document in writing the results of the meeting.
I summarized the meeting content in a memo to Dr. Bernstein dated February 26, 1993 (Appendix #48), and followed up with related correspondence. (Appendices #49, #50)
In the hearing on this matter, I argued, “Dr. David Goldstein ordered unfair and prejudiced limitations on my work schedule (memo January 12, 1993). This denies reimbursement for some of my County time performing the duties in my job description. Other physicians in the General Internal Medicine (GIM) section do not have these scheduling restrictions.” An excerpt of this grievance follows:
This grievance derives from a fundamental conflict of interest which exists with Dr. Goldstein’s role as supervisor of GIM physicians, some engaged solely in LAC-USC duties and others dividing their time between USC private practice and research. Since Dr. Goldstein’s supervisors direct him to build the private practice and research components of the section, he is under pressure to sacrifice LAC-USC teaching and clinical care. In effect, the above mentioned work schedule memo requires me to choose between drastically reducing clinical services to LAC-USC patients and working many unreimbursed overtime hours. (Appendix #51)
In that year I gave 30–40 lectures to physicians in other hospitals, many out of town, so the lack of a flexible schedule, including recognition of out-of-hospital work on my timecard, meant an incredible number of uncompensated hours worked. (Appendix #52) On April 19, 1993, Dr. Bernstein finally denied my grievance without addressing my charge of conflict of interest. (Appendix #53)
My unsuccessful letter of appeal to Robert Gates, Director of the LAC-DHS, contained the following paragraph:
I complain about this situation because it is part of a pattern of using LA County resources (in this case my professional services) for the financial benefit of USC University Hospital. I work under administrators whose top priorities are the success of the USC hospital, the USC private practice program, and fundable research studies. Dr. Goldstein’s transparent scheme to confiscate a portion of my livelihood is supported by upper level USC administrators all of whom have a conflict of interest in dealing with LAC physician employees. (Appendix #54)
Mr. Gates sided with the hospital’s management. (Appendix #55)
As an unintended benefit to me arising out of this battle, Dr. Goldstein assigned me to supervise medical residents in evaluating and treating patients referred to the Cancer and AIDS Pain Service. (Appendix #56) Perhaps he hoped to make me redundant by having the medical residents do my work. I proposed some variations on Dr. Goldstein’s protocol to prevent delays in treating pain due to the busy schedules of the residents. (Appendix #57) He insisted that consults be called to the internal medicine office, rather than directly to me, but allowed for me to be paged if the delay would be more than two hours. (Appendix #58) Dr. Goldstein also forbade the residents to manage outpatients. (Appendix #59) Handling outpatient problems is an essential component to teaching doctors about palliative care.
Despite these difficulties, supervising two medical residents per month and seeing the inpatient consults was a mutually satisfactory arrangement. Teaching these residents the art and practical details of caring for the dying gave me great satisfaction. It did not reduce my workload, however. The enhanced exposure and popularity of the Service, in part due to the rotating residents, caused the average number of monthly consults to rise from about 20 to 35. Almost all cases still required my direct and ongoing involvement, since I still had to write over 90% of the opioid medication prescriptions. Despite the hospital administration’s “carry your triplicates” mandate resulting from the Hospice Care/Pain Management Subcommittee, few residents or attendings had or carried the required triplicate prescription forms.
In June 1993, Dr. Goldstein assigned me to supervise an internal medicine admitting team ward in addition to my regular duties of supervising the one-half day per week internal medicine clinic, and also attending on the Cancer and AIDS Pain Service. Unlike the previous months in which I had additional attending duties (Appendix #60), Dr. Goldstein refused to approve the 15–20 overtime hours that it took me to accomplish all my tasks. (Appendix #61)
I filed a grievance (Appendix #62) that was granted by Dr. Bernstein but, pointedly, only for that particular month. (Appendix #63) For the next few months, Dr. Goldstein approved my overtime when I did the extra ward attending duties. (Appendices #64, #65)
A Vacation to Remember
I had been pre-approved to take my vacation in July 1993. However, Dr. Goldstein had forgotten that he signed my vacation authorization, and his office staff misplaced his copy of the form. On July 8, 1993, he sent the following memo to the LAC+USC Medical Center internal medicine personnel officer with a copy to me: (Appendix #66)
It is my understanding that Dr. Cundiff has taken a vacation. No request for this vacation was received in my office, and I am writing this letter to protest this unacceptable behavior.
After I produced my copy of the vacation request form signed by Dr. Goldstein, he still refused to apologize verbally or in writing. Consequently, I referred the matter to Dr. Goldstein’s boss, Richard Tannen, MD, Chief of Internal Medicine. The following was Dr. Tannen’s response to my letter: (Appendix #67)
Thank you for your memorandum of July 27, 1993 regarding your recent vacation. I did look into the matter and found that there was some confusion about your vacation approval.
Once Mr. Navarro reviewed the records and informed Dr. Goldstein that your time had been approved, the matter was closed. I have been informed that Dr. Goldstein’s memo to Mr. Navarro about your vacation has not been placed in your personnel file. All of us regret any inconvenience this may have caused you.
Overtime Denial Grievance
On January 6, 1994, Dr. Goldstein issued an order that required the LA County-paid physicians in General Internal Medicine—but not the USC-paid physicians—to sign-in and sign-out each day. (Appendix #68) I stated my objections to Dr. Goldstein, Dr. Bernstein, and to Robert Gates, claiming that this represented discrimination against LA County-paid physicians. (Appendices #69, #70, #71) Dr. Goldstein did not consider the directive discriminatory (Appendix #72). Ed Martinez, the new Executive Director of the LAC+USC Medical Center, and proxy for Mr. Gates, sided with Dr. Goldstein while steadfastly refusing to address the discrimination issue. (Appendices #73, #74, #75, #76)
Dr. Goldstein’s office staff analyzed the sign-in/sign-out sheets and reported that I averaged about 11 hours per day, whether I had additional ward attending duties or not. (Appendix #77) My weekends attending on the wards and hours of calls from home were not included in the analysis, however. Mysteriously, based on this audit of my work hours, he justified a policy of permitting only one extra hour per weekday worked when I was assigned to additional ward supervision duties.
I wrote Dr. Bernstein to update him on this issue on March 27, 1994 (Appendix #78) and met with him about this and other matters on May 5, 1994. (Appendix #79) However, management continued to stonewall. (Appendices #80, #81, #82) Dr. Goldstein proceeded to deny all my weekday overtime (Appendix #83) and alter the hours on my timecard. (Appendices #84, #85) Administration gave me an ultimatum to sign my timecard with the false low hours. (Appendix #86) My appeal to Dr. Bernstein, who was close to retirement, fell on deaf ears. (Appendix #87)
In September 1994, Dr. Goldstein again assigned me to attend on medical inpatient wards in addition to staffing the Cancer and AIDS Pain Service and a one-half day per week internal medicine clinic. I submitted pre-approval forms for 15–20 hours per week of overtime as this assignment had previously required. (Appendices #88, #89) Again, Dr. Goldstein would not approve the necessary overtime. (Appendix #90) I submit that no physician anywhere has managed this clinical load in 40 hours per week. The statement of my grievance on this matter went as follows: (Appendix #91)
This is a repeat of a grievance regarding denial of overtime for June 1993. That grievance was also heard by Ms. Hernandez and resolved in my favor August 20, 1993 by Dr. Sol Bernstein.
In the current grievance I specify September 1994 and all other months in which I am assigned medical ward attending duties in addition to my usual assignment of directing the Cancer and AIDS Pain Service, as well as supervising a medical clinic.
In September 1994, the Cancer and AIDS Pain Service had 55 new consults (an eight-year record) and followed over 200 active patients. In addition, I was responsible for over 120 hospitalized patients as medical ward attending.
Dr. Ronald Kaufman, the new LAC+USC Medical Center medical director, denied this grievance based on the time sheet data that I averaged about 55 hours at the hospital per week whether I attended on medical inpatient wards or not. (Appendix #92) This did not consider the many hours at home that I spent on the phone dealing with Cancer and AIDS Pain Service and inpatient medicine problems.
Medical Disability
While fighting these battles about overtime and having to clock in and out, I developed weight-bearing pain in my left hip. I consulted (John) Chang-Zern Hong, MD, an associate professor of physical medicine and rehabilitation from UC Irvine School of Medicine. On April 23, 1994, he wrote on my behalf to Dr. Richard Tannen, Chief of Internal Medicine, saying: (Appendix #93)
Dr. David Cundiff is under my care for the treatment of sprain of left hip with subtrochanteric bursitis and tendentious. He also has myofascial pain in the left gluteal muscles, pyriformis, and iliopsosas. Over the past six-months, he had three relapses of this condition which required him to walk with crutches. Most recently, he has been on crutches for the past two weeks. I injected the left hip bursa with Decadron LA today so, hopefully, this will speed his recovery. However, until the acute inflammation resolves, he must avoid weight bearing on the left leg.