Play By The Rules, If You Can Figure Them Out

As some readers of my recent columns figured out, I’ve been channeling some of my meager “free” time into preparation for an exam on jurisprudence, in order to obtain another state licensure (happily, an exam now passed). I’m guessing my mention in that column of a 500+ page source-material text that had been sent to me was the major clue for them in identifying which state.

While I think it’s safe to say that was the most in-depth treatment of such material I’ve yet been presented, it was far from the first. Mandated conferences, online CME, lunchtime lectures, etc. for nonclinical matters have dotted the landscape of my medical career dating back to before I even had my MD degree.

If you’ve been in the health care field for more than a few days, you probably know the sort of stuff I’m talking about: Rules for reporting various types of abuse and communicable diseases; rules for advance directives, health care proxies, and organ donation; anti-kickback and Stark laws.

All of which, at least initially, seems very reasonable for folks in our field to know about: fairly common, sensible, and straightforward. After the outermost layer of the onion is peeled, however, this changes. I’ve come to recognize some common phases by which these educational (and often admonishing, as in “follow these rules or else”) affairs seem to transition from simple/sensible to byzantine/boggling:

First, a reasonable, makes-sense-to-everyone presentation of the rule (or set of rules). For instance, a doc diagnosing a highly contagious, communicable, and reportable disease needs to notify the proper authorities for tracking and containment purposes. Members of the audience may feel good about themselves for knowing that they would do these things on their own, anyway, even if no relevant rules existed.

Second, a bit of historical background as to how the rule(s) came into being. For instance, showcasing how, prior to Stark and anti-kickback laws, physicians could (via unsavory intent or otherwise) come to benefit from business arrangements at the expense of fair competition or even the best interests of patients. During this phase, some of the audience (especially younger docs) may find themselves daydreaming about how their elder colleagues might have “made a mint” in the less regulated good ol’ days.[[{"type":"media","view_mode":"media_crop","fid":"44515","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6712576551990","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4990","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 193px; width: 200px; margin: 1px; float: right;","title":"©Modella/Shutterstock.com","typeof":"foaf:Image"}}]]

Third, a presentation of the rules that have thus been enacted. Especially with such subject matter as Stark laws, these rules are sometimes presented in an iterative fashion, such that the initial version of the rules (say, in 1989) is gone over, then subsequent additions, alterations, and deletions (say, in 1994, 1997, 2000, 2003, 2005, and 2008). During this phase, some of the audience may feel their eyes glazing over and find themselves daydreaming about matters completely foreign to the subject. Others will already be asleep. None whatsoever will be able to keep track of precisely what the current rules actually are, which is understandable since few, if any, of the regulators and policymakers probably do.

Fourth, a discussion of the rules’ provisions for enforcement, including penalties or other punishments for transgressors. It is often emphasized that ignorance of the rules is not a defense for breaking them (with a tone implying that anyone claiming ignorance is therefore probably a career criminal). During this phase, audience members who remain asleep, unconsciously hearing the subject matter, may have their dreams turn into nightmares. Those remaining awake may find themselves having daymares as they mentally tabulate the huge sums of penalty money and potential jail time for being proclaimed guilty of offenses during good faith efforts at having a career in health care. Or simply the torture of standing accused of wrongdoing and having to defend oneself over a duration of months, if not years.

Thus, an individual properly trained will emerge with complete bewilderment and an inability to conceive of actually comprehending what the rules are without looking them up on a case-by-case basis. He will have a nigh visceral fear of not even knowing when he needs to conduct such research, and a certain resignation that he’s probably breaking the rules on a regular basis, and thus in constant jeopardy of his livelihood, possessions, and freedom being snatched away. That is, unless he’s a crook and actually plans to subvert the rules, in which case he might just have figured out a loophole through which he can still “make a mint” and inspire the next round of rule revision.