How docs can be our own worst enemies

I have a relative who had an urgent gallbladder removal recently, and he’s doing well, thanks.

However, we’ve been having some email exchanges about his workup, and specifically a trip to the ED that didn’t diagnose GB dz.  (Patient presented with lower abd pain, N/V; presumably had labs done, though he doesn’t know the results, and had a CT to r/o appy.  No appy by CT).

So, he went home, felt better for a week, then worse again, and went to his PCP.  This is where it’s so easy to look smart by subtly (or non-subtly) saying ‘well, the answer is "x", and they missed the boat by not finding it’. For instance, from an email (excerpt):

…he said I was showing classic symptoms of a bad gall bladder. When he pulled up the results of my CT scan on his computer, he said the results clearly backed that up. He even questioned why the ER doc would not have ordered an ultrasound after seeing the same results. At any rate, he sent me to a surgeon right away. The surgeon agreed with the diagnosis and ordered an ultrasound,…

(emphasis mine).

Now the seed has been planted, and it germinates in law offices with predictable results.  (He’s not going to sue, but now a lot of doubt has been planted in his mind).  It’s the kind of doubt that makes people go from ED to ED for a ‘second opinion’.

I am NOT advocating a code of silence or anything nefarious, but we ALL need to remember that second-guessing and criticism of other docs is neither constructive nor smart.  I have had complaints in the past, generated when the patient followed up with their doctor who (allegedly) tells the patient ‘you should have had ‘x test’, and that ER doc completely missed it by not ordering one’, resulting in a letter complaining about their care, etc.

So, let’s just save our snide critiques for the politicians, okay? 


Comments

  1. You bring up a great point. Many times the patient isn’t necessarily thinking there is a problem with their care until someone plants that seed. There are lots and lots of very litigious people out there looking to cash in on anything and everything, nothing can likely be done to change them. The ones that you can affect are the people that get goaded into something by a crooked, slimy attorney. My wife is a doctor and we’re fortunate not to have had any issues like this, but I’m sure it will be coming.

  2. The Grand Wazoo says:

    I truly believe that there is no good that comes from bad-mouthing another physician, no matter what the cause. There are always more diplomatic approaches. It fuels the public’s distrust of physicians and it may be ungrounded without further investigation. What comes around goes around.

  3. I had a similar incident to this a few weeks ago. I’m an anesthesia resident and one of my attendings pulled me aside to ask about a case we had done. The patient had said we chipped a tooth (I had noted a chipped tooth prior to the start of the case and noted it on my pre-op). The patient was hard to intubate because of some very narrow vocal cords. The wonderful surgeon told the pt he thought that there was a new chipped tooth and went on to say that the anesthesiologists had a hard time with your intubation. With colleagues like these…

  4. Boy, I agree with this. I had an experience with an older aunt of mine not long ago. She is 81 and was obviously bleeding from her GI.
    I took her to the ER where they called in a GI specialist. I know him well as he has been my GI for years. I think he is a very good Dr….Unfortunately, he did a colonoscopy on her and could not find the bleed. She ended up having something like 5 transfusions over the next few days. When her count came up and it appeared she had stopped bleeding she was sent home.

    About a week later she called me and said she was bleeding again. She was very weak and when I got to her house she was so pale that she looked like death. I called the rescue this time. They called in a different GI who did the colonoscopy and he found three different places in her colon that was bleeding. He did whatever it is you do to correct that. She again received multiple transfusions and the Dr. told me she had severe GI bleeding.

    That has been a few months ago. I took her back to this GI doc. this past week for a check up. He said some things I thought were very unprofessional. He told her to remember that if she has any problems,she is to go to the ER and tell them they are to call HIM in. “Tell them you don’t want no wannabe GI doc. again, you want me!” Those were his exact words. Now, I am hearing from all my family that I need to change GI doc’s because mine can’t possibly be any good. Well, screw it, he has been my Dr. for years and always taken good care of me. That Doc. was out of line with his comments.

  5. Christi Turner says:

    Well, alternatively, my 10 y.o. daughter received excellent care in the ER several weeks ago. During a choral concert performance on a Sunday afternoon, she fainted. We called her pediatrician who said we should take her to the ER to be checked out.

    They were pretty quick about getting her blood sugar checked (by this time she was starving, but we didn’t want to feed her and throw off the results.) When they brought her back, the dr. was very upfront about what could have caused her to faint, and told us he was ordering an EKG to rule out some rare arrhytmias, in addition to urine and blood tests.

    Her blood tests showed that she was borderline dehydrated. Her EKG (computerized diagnosis) showed that she had a borderline case of Long QT syndrome. The dr. was pretty sure that it was the standing (probably with the knees locked) that caused her to faint, but said we should be seen by her pediatrician and a pediatric cardiologist ASAP for further testing and follow up because of the EKG.

    We saw the pediatrician the next day, and the pediatric cardiologist on Friday. Fortunately, the cardiologist was able to rule out Long QT Syndrome, but we were very, very pleased with the professionalism and quality of care we received from all the people in the ER.

  6. In the case cited, it’s certainly understandable that having presented with lower abdominal pain, gallbladder disease was not strongly considered; and that a CT would have been ordered. And being human, the radiologist would have focused on the area in question, especially in the middle of the night. If, in retrospect, the CT showed signs of gallbladder inflammation that was missed, the thing to do would be to let the radiologist know, privately. And yes, we all have a tendency to forget our own list of omissions in making offhand comments about somebody else’s. In this case, it sounds like, except for a slight and non-harmful delay, no harm was done. Fact is, we can all act like idiots sometimes, especially the doc who has the benefit of the most hindsight.

  7. I disagree. I think there is already a conspiracy of silence that harms patients and we should not be contributing to it.

    The reaction to patient stories should be the same as if the incident had happened to someone in your immediate family. If a colleague had a bad outcome with someone in your family and you felt, as a physician, that it was an unavoidable outcome or an honest mistake, you would not advise your family member to get a new physician. However, if you thought the evaluation or treatment of a family member was substandard and would send your family member to a new physician next time, you can and perhaps even should, share the information with the patient if something similar happens to her.

    I think physicians do ourselves a tremendous disservice when we try to protect colleagues who are giving substandard care. It harms the reputation of the rest of us who are doing are level best, because it lowers the overall quality of medical care and because patients believe that we care more about our colleagues than about their health.

  8. Amy,

    Your right in one sense that I don’t think physicians do well enough in peer review and discipline.

    But….most of the time you don’t know exactly how things initially presented. I am quite certain that you have missed a diagnosis or prescribed a wrong treatment that was more obvious to another physician the next day or week or year. You sound like you could make a lot of money as a so called “expert”.

  9. Goatwhacker says:

    I had much the same thoughts as Amy. Most of the time I give the other doc the benefit of the doubt – I wasn’t in his shoes at the time so it’s hard for me to pass judgement on him. Once in a while it’s pretty obvious someone screwed up big time, though. What’s funny is the patient often doesn’t realize it, as opposed to with lesser problems where you can tell the patient is thinking about a lawsuit and it’s probably not warranted.

    There have certainly been situations where if the patient had been a family member I would have told them malpractice had probably been committed. There have been a handful of times I have been asked straight out if I think they have a legal case – I tell them the truth as I see it but also tell them I’m not a lawyer.

    There are certainly docs out there who seek to elevate themselves by criticizing others and I try not to be one of them. I don’t have a good answer to the larger question of the “conspiracy of silence”.

  10. Amy,
    I don’t know which post you read, but it wasn’t mine. I specifically said I am not advocating a code of silence, but rather not playing “look how smart I am compared to another doctor”, which happened in this case.

    For the record, I don’t think there is a ‘conspiracy of slience’. I’ve never been in a hospital where people didn’t like to hear themselves talk (and usually at length), and straight questions always get (from me, anyway) straight answers. The whole idea of a ‘conspiracy of silence’ gets patients (and their lawyers) excited: without cause, IMHO.

  11. Dear Grunt Doc,

    I did not mean to imply that you “advocated” a code of silence, but I do think that in our efforts to give our colleagues every benefit of the doubt, we expose patients to substandard care.

    Unfortunately, I and several close relatives have been patients in the past several years, and I have been APPALLED by the level of practice in some of the nation’s finest hospitals (I live in the Boston area). When my son was hospitalized 18 months ago, my husband and I were afraid to leave him alone, because I caught and prevented so many mistakes while we were sitting there.

    The most striking thing is the dramatic change in care once you announce that you are a doctor. In several cases, I have been told that a complication was unavoidable, inevitable, etc. Then I have asked to see the films or test results personally and find that the most crucial detail was missed the first time around.

    I don’t know why they think they are going to get away with hiding their mistakes from another physician. If they tried to hide that much from me, I can only imagine what they are hiding from patients who are not medically knowlegeable.

    I have absolutely no desire to be a plaintiff’s witness, because the courts are a terrible place to go if you want the truth about something. On the other hand, I would love to see state boards of registration in medicine given money, investigators and subpoena power so that they could actually protect the public from substandard doctors.

    People who are excellent doctors often assume that everyone else must be trying as hard as they are. That’s not the case, though, and all you have to do is be a patient to find that out.

  12. TheNewGuy says:

    Ah… but what is a substandard doctor, Amy? That’s the question… and who decides?

    Does one mistake make you a substandard doctor? How about two? In the state of Florida, you get three before the state pulls your medical license.

    You and I both know that much of medicine is a judgement call, and there are so many human factors (and care is provided by so many hands), that it’s virtually impossible to deliver perfect care to every patient every time. We have to try of course, but it’s not going to happen; it’s a consequence of the human condition.

    I’ve seen about a gajillion errors in the ten years I’ve been in pratcice, and some of them have been mine. If you litigated every single one of them, there would be no healthcare system left.

    Sorry, but this is a sore point for me. I generally keep my mouth shut if I wasn’t there, and didn’t see what happened… everything else is just hearsay and speculation. All of my malpractice near-misses were in cases where I delivered good care and/or made a reasonable judgement call on a case, but some loudmouth nurse or physician just had to open their big fat piehole in an attempt to sound smart or authoritative. There’s no better way to get a family to go ballistic than to say something stupid like “They took too long to get you here… you’re lucky to be alive” (thanks, cath-lab nurse!)

    Medicine is no place to have ego issues. Anyone who has to prop up their own personal/professional self-worth either by snarking at their colleagues, or by passing sight-unseen and events-unwitnessed judgement, needs to get out of this profession. Medicine is humbling enough without insecure backbiters pontificating to make themselves look good.

  13. “but what is a substandard doctor, Amy?”

    How about a doctor who gives substandard care on a routine basis?

    Let’s be honest here. We all know that there are substandard doctors in our midst who are hurting patients. A combination of weak Boards of Registration, and strong legal protections for individuals makes it virtually impossible to discipline a bad doctor. That’s reality.

    I am not talking about people who make occasional “honest” mistakes. Many of us know who the substandard people are in our own communities. It is not our personal obligation to discipline them, but we are not required to protect them, either.

  14. I agree that doctors should be careful of the things they say, but sometimes they don’t say enough. I almost died after a surgery, and I just wanted answers. No one would talk to me–no one (except the patient advocate who was only trying to protect the hospital). Everyone was afraid that I would sue. I didn’t sue the doctor or the hospital (against the advice of friends and family) because I healed quickly, and I agree that people are too quick to sue. However, sometimes we just want honest answers regarding our care, and we can’t get them because of the fear of being sued.

  15. I side with Amy on this one. There are plenty of things I could have sued doctors for, but I never had. There are a couple of apologies Id really like to get though.

    When my dentist’s hand slipped and he cut up my mouth (16 stitches) and then forgot to give me antibiotics (do I have to tell you what my face looked like 3 days later?). I didnt sue. I even paid for the office visit. I figured, everyone makes mistakes, I didnt die. I got sick (lack of nutrition) and Im deathly afraid of dentists, but really, mistakes happen.

    Then 2 years later I see him in my bar every day, at lunch, 2 bourbons and right back to work.

    And I have to wonder if by NOT suing him I helped him hurt other people.

    I know plenty of people with similar stories about health-care professionals, but you (naturally) are really only gonna meet the ones who sue. You may want to consider that it skews your view somewhat.

  16. TheNewGuy says:

    I can completely understand wanting answers.

    However, consider that there’s a good reason why physicians are not forthcoming with information when the “potential lawsuit” balloon goes up. With a potential malpractice claim in the air, they will tell you not to talk to the patient, your colleagues, your nurses, or anyone else. If you talk about it with people, they can be dragged into the case, since they now have knowledge of it.

    Anyone who has ever had contact with the criminal justice system (either as a principal or in the course of working) knows that most people hang themselves in court. How/Why? Because they don’t avail themselves of their right to remain silent. Get in any kind of legal hot water, and shutting up is the very FIRST thing your criminal defense lawyer will tell you to do.

    People love to talk, whether to get things off their chest, or to justify their own actions… but it can get them into trouble. It’s very tough to keep quiet, particularly when there’s a bad outcome and your professional reputation is at stake… who wouldn’t what their side of the story told?

    There’s a reason nobody talks when people start making malpractice noises; it’s nothing personal, and it’s not an evil conspiracy. You might not sue, but plenty of others have.

  17. Diff Pt: You “almost died,” but “healed quickly.” Your friends and family wanted you to sue. They must have been mighty disappointed that you recovered so well. Please make sure they stay away from my office.

    That girl: There are other things you could do besides suing. Please consider reporting this misbehavior to your state board of dentistry.

  18. Amy,

    You are actively contributing to the hysteria. Why?

  19. Because it’s not all hysteria.

    I am an obstetrician and I know more about being sued than I ever wanted to know, but I’ve also been a patient and it is horrifying.

    We aren’t doing ourselves any favors by obsessing about lawsuits while at the same time refusing to weed out bad doctors. There is no way for people to assure themselves that the doctor they choose is a good doctor, since no one will warn them if he isn’t.

    I don’t know if it is a result of more time pressure or less training, but I have seen doctors commit mistakes that would never have been tolerated where I trained. What’s worse, they look the patient in the eye and lie about it.

    It’s happened to me, it’s happened to my relatives and friends, and if you ever have the misfortune to be hospitalized with a serious medical problem, it will likely happen to you, too.

  20. Well…..a CT isn’t the method of choice to DX GB disease…so maybe it wasn’t missed in the first place. Was the GB c/w Chronic or acute Cholecystitis?

  21. AlreadyReady says:

    If we could get the court system out of medicine, more docs would open up and share information with patients. The threat of loosing your ablity to practice in cases where no malpractice was committed is what put up the perceived wall of silence. Although rare, we’ve all seen it happen.

    Amy- I agree with you whole-heartedly. There is BAD medicine being practiced. I often wonder about how nonphysician-patients get through the system. This is just a reality in an overly complex outdated medical structure.

    8 years in the ED has given me multiple opportunities to render 2nd and 3rd opinions and discover “missed” (using the term loosely) diagnoses. However, I am happy to report that I make a concerted effort NOT to critize to previous MDs. I just tell the patient I wasn’t there for your previous visits and the other docs didn’t have the luxury of all of these tests results that you’ve accumulated in your doctor shopping. I also hear from other patients that my effort not to badmouth is seldom shared by my collegues in the community. I hear not infrequently about the poor care given in the ED. We need to face the fact that feeling important/authorotative is the main reason lots of folks go to medical school. (I guess my childhood must have been a lot happier that other docs.)

  22. I guess being in Canada I have a different perspective.
    We have a much lower rate of litigation unless you are an OBGYN ofcourse.
    We also have some controls in place..you can’t sue for a billion dollars.
    What is interesting is this doesn’t make doctors anymore inclined to reveal errors.
    I do not believe it is solely a fear of litigation.
    It’s a culture where errors are “not allowed”. The fear of error is too great, it cannot overcome the need to disclose.
    Medicine wants only to punish and humiliate for mistakes so ofcourse no sane person wants to put their hand up to get beaten.

    We constantly talk, talk, talk about changing the culture, we have meetings about near misses but we wont use names or cases..we play the as if game.

    The culture needs to change and patients need to catch a clue.
    Medical providers aren’t robots with no needs..so patients need to start taking some responsibilty for their care to take up the slack. Patients don’t need to get a medical education but how about they know why they are taking the pills they are taking?
    I cannot tell you how often I have asked and had patients say “oh I take the little blue one with the the big red one and I have no idea why” Or they can’t remember there own medical history..any surgeries? oh no..then you lift their shirt and see a huge sternotomy scar…and then you get “oh yeah I had a new valve last year but I don’t know why..”
    Then with a crappy history and a bunch of unidentifiable meds we are expected to use ESP to determine what the hell is going on.
    Then when you can’t figure it out or take the most easily solvable problem and get that under control they go see their family doc with his complete history who is all “why how could they have missed that?…

    I admit my mistakes because I have learned it makes my patients trust me..anyone who is up front with everything is going to have better luck because we all know SOMEONE is going to yap..it better be you.

  23. I guess in order to fully appreciate this issue for what it is you have to have, at some point in your life, been on both sides of it.. or as close as one can get.

    Yes, we do live in a very litigious society, and i think that is the crux of this problem. It’s such a subjective topic because, as someone said earlier, you never know just how a person presented. The 46 year-old woman who comes in to your ER with unrenlenting nausea turns out to be in the middle of a non-stemi that you only happened to catch because you ordered enzymes goes up to the cath lab and suffers a reperfusion arrythmia. Luckily for her she has an illustrious tech on the tele floor who just happened to read an ACLS book tell her that it never would have happened had she not waited 3 hours to see a doc in the er and Viola! instant lawsuit. Meanwhile she waited 3 hours because she walked in and told the triage nurse she “had butterflies in my stomach” so she took a backseat to the 2 traumas and 3 respiratory distress pts that came in at the same time.

    I dont think it is so much that people are afraid of getting dragged into lawsuits that keeps up the code of silence (which, by the way, is absolutely real). In my observation it is the fear of being human that keeps us quiet. Everyone makes mistakes, some more serious than others. Mistakes, however, do not make people bad providers. Unfortunately, once you hold that title you are no longer viewed as human and capable of error by the general public. You are expected to be perfect. Now, knowing that everyone misses something at some point, why would we casually point these errors out to patients. Karma is a (insert expletive here). You could be the best doctor in the world, have one off day, and because you made a habit of selling out your collegues for the last 5 years they will be looking for a reason to throw you under the bus. As much as i hate to be negative, time has taught me that the days of singing kumbaya around the campfire are long gone.

    Does this mean i advocate keeping patients in the dark, or becoming selectively mute whenever a potential malpractice situation arises, absolutely not. There is a line to be drawn between simple errors and bad medicine, and those practicing bad medicine should not be permitted to continue, which brings me full circle back to Amy’s post and the subsequent “what is substandard” post. The question my friends, is actually what is STANDARD, and by whose definition?

    On the other side of the coin, from the patient perspective i know how frustrating it can be to not get answers. I suffered an anaphylactic reaction which began while standing in the ER of the hospital i work for, and a series of “errors” resulted in respiratory arrest, atelectasis, 2 weeks in MICU on a vent, and 2 vocal cord surgeries to date along with a good case of retrograde amnesia (thanks to versed and diprovan), and it took me almost a month to find a doctor that would even level with me as to what happened.

    The other issue is that the “appropriate” treatment for any given illness or ailment changes depending on what literature is en vogue at that particular moment in time, and whether all parties involved have received the latest updates.

    Point is, it’s a very complex issue that has an unlimited amount of variables on both ends, and each side has either the inability or the unwillingness to look at it from the perspective of the other.

    Before anyone retaliates to this i would like to offer up a little disclaimer: I am not, nor have i ever claimed to be, a doctor. I don’t pretend to have the knowledge or experience that those of you who are have. Please take what i say at face value, as these are just opinions and observations. Thanks for putting up with the crap that you do and being there to help all the whiney self-empowered people who have to large of an ego to thank you themselves