February 2, 2011
The threat of malpractice means doctors cannot acknowledge their fallibility
We all make mistakes. To err is human—unless you are a doctor. This is a lesson that began in med school. If something went wrong, someone else was to blame. Attending physicians blamed the residents, who blamed the interns, who blamed whomever else was within range—med student, nurse, patient. We gave lip service to learning from our mistakes, but in morning report or on rounds, those left standing were the ones who most effectively pointed the finger at someone else. There is no greater pain a doctor can experience than that which comes from making a mistake that causes harm, so we try anything to convince ourselves we did nothing wrong, to protect our sanity. Once we are out in practice, this unhealthy denial goes beyond the personal. The threat of a malpractice suit means we must never, ever acknowledge our fallibility. The wolves are at the door.
I made a terrible mistake when I was an intern in internal medicine at Bethesda Naval Hospital. I was on call in the coronary care unit—the CCU—supervised by two residents. B. C. was the junior resident, two years out of medical school. The senior resident, Roy, was responsible for B. C. Roy reported to the chief resident, who took call from home. Roy and B. C. must have been very busy that night with other patients in other parts of the hospital, as I was left alone with the CCU nurses minding a very busy store. There were six patients in the unit, each of them lying almost motionless on a mechanized bed behind glass walls. A web of lines connected their arteries and veins and chest walls to banks of screens and monitors that flashed around their rooms and across the nurses’ desk in a constant illuminated display. Large flow sheets the size of opened newspapers sat at the foot of each bed, documenting pulse and oxygen levels, IV fluid rates, and medication orders. The constant electronic beeping was reduced to a background noise in my brain. The scene took on a certain eeriness at night, with overhead lights dimmed to help the patients rest, and the staff talking in hushed voices. The beeps and monitor lights rose to fill the void in an uneasy standoff between vigilance and catastrophe.
I moved quietly from patient to patient that night, watching the watchers—the blood pressure monitors, the EKG tracings. I scanned the elaborate flow sheets to assess vital signs and urine output. Looking at the patient was almost superfluous.
One of the patients, Mr. P, began showing signs of decreased cardiac output a little after midnight. He had been admitted earlier that day after suffering a heart attack. Now the catheters that threaded far into his arteries and veins were transmitting signals that his heart was not pumping blood as effectively as it had been. I paged B. C., but he must have been tied up because he didn’t answer right away. So with Mr. P’s nurse hovering anxiously over my shoulder, I called Roy. We agreed on a medication, Nipride, that would help Mr. P’s heart pump better. I calculated the dose by hand and wrote the order. His nurse efficiently sent the order down to the pharmacy “stat,” meaning we needed it urgently, and in a short while a small plastic bag containing the Nipride arrived in the unit and was connected up to Mr. P’s IV. In all those transactions, no one noticed that I had written for ten times the recommended dose.
I watched that patient closely for the next several hours. Mr. P showed signs of improvement, and I let Roy know that when he called to check in. By 3 am, all the beeping and buzzing and tracings had settled into a constant reassuring rhythm, and I crawled into an empty bed so I could catch a nap. I dozed uneasily over the next two hours, so when the nurse jostled me awake just before dawn, I wasn’t sure if I was dreaming. She looked worried and told me the chief resident wanted to talk to me; there was a problem with Mr. P.
I hopped off the bed and into defensive mode. The chief resident, Carl, was a brilliant superhuman who rolled his filing cabinet around the hospital with him so that he would have instant access to all his cutting-edge journal articles in this pre-cyber world. I imagined that with black-rimmed glasses he would even look like Clark Kent. He didn’t usually waste a lot of effort on facial expressions, but as I hurried toward him across the CCU I could read fury and contempt in his face.
“Nice dose of cyanide you gave Mr. P,” he said as soon as I was within civilized earshot.
I was still trying to shake the half sleep from my brain; I couldn’t make sense out of what he was saying. One of the dangers of using Nipride is that it is metabolized to cyanide in the body. Even appropriate doses of Nipride need to be monitored with blood testing for cyanide. An overdose could be lethal.
“You wrote for ten times the correct dose.”
“No way,” I protested as my shaking finger ran down the order sheet. I blinked at my handwriting—the neat feminine cursive so appreciated by the nursing staff—and began to recalculate the dose, but Carl had already done that and shoved his scratch sheet in front of my face. My stomach contracted, and my own pulse roared through my head as I took in the enormity of my mistake. I stood defenseless as he drove his message home:
“You could have killed him, you know. Didn’t you wonder why his oxygen requirements were increasing?”
“I didn’t know he was having a problem,” I answered weakly. I glanced over at the nurse—I would have expected her to let me know if the patient’s oxygen levels were dropping—but she just stood there, tense. There would be no help from her corner.
B. C., my phantom resident, had been hovering off to the side with the medical students but now chimed in. “Why didn’t you notice? What were you doing?” Of course, he knew perfectly well what I had been doing, so this was a safe avenue to chase me down. “I was asleep,” I mumbled, as if I was admitting to getting high off the anesthesia machine while my patients screamed for help. “No one notified me . . .” I trailed off. The nurse waited silently at the bedside now, watching closely to see which way this ill wind would blow.
“But you’re the doctor,” B. C. hammered at me. I wanted to smack him.
“You know, we generally don’t try to kill our patients here,” added Carl in disgust.
I was utterly defeated, just a white coat and scrubs draped over the shell of a lousy doctor. “I’ll change the order right away.” My voice sounded as if it were coming from far away.
“Never mind,” spat Carl. “I thought I’d stop the drip myself before he started turning blue.”
I turned without another word and walked into the break room, shutting the door behind me, and began to sob as quietly as I could. I had the sudden feeling that over the past four months I had been fooling everyone into thinking I was a good doctor. In fact, I had even fooled Georgetown into thinking I should have been admitted to medical school. What would that admission committee think now if they could see what a danger they had unleashed upon the world?
A few minutes passed, and then B. C. walked in, closing the door behind him and settling into the opposite chair. “Shouldn’t you get out there and see to your patient?” he asked gravely, a caricature of a wise old TV doctor—though only a year older than me.
Screw you! I thought. I was in no mood for melodrama.
“You know,” he restarted, “I almost wrote a wrong antibiotic order once.” There was a hesitation as he chose his words. “But then I caught it before I sent it off. But still, it could have been serious, I suppose.”
My breath caught, and I stopped crying. A slow burn worked its way up my chest and into my face. “Are you consoling me by telling me that once you almost made a minor mistake, but then you were smart enough to catch yourself?”
“Well . . . yeah.” He shrugged. I could tell he had no idea how furious I was—or that I had just found him out. B. C. had made a mistake last night, too—maybe even bigger than mine, because he should have known better. He should never have left an inexperienced intern in charge of six critically ill patients. He should have been checking on us all night or called for help if he was too busy. It turned out he had been too involved in an “interesting case” from the ER; he would make a big splash at morning report.
“Leave me alone, B. C.” My voice had gone flat and cold. “Mr. P is fine now. Carl took care of him. I’ll be out in a minute.” He tried to offer another pearl of wisdom, but I cut him off. He had already helped me more than he realized.
What an asshole! I thought as I washed my face and blew my nose. These guys weren’t any smarter than I was (except maybe for Carl), but now I suspected that B. C. had made plenty of mistakes, and I was pretty sure that everyone else had, too. But nobody was talking. Blame was deflected, rationalized, minimized, swept under the rug—anything to avoid the horrible epiphany I had just endured: We were all capable of royally screwing up, and that was as good as we were ever going to get.
Mr. P did miraculously well—so well, in fact, that he was transferred out of the unit to a “step-down” bed the following afternoon. His cyanide levels had risen briefly but then cleared. My troubles lingered. On attending rounds later that day, shaken and exhausted, I had to relive the experience with the cardiology attending. Later that evening, I asked the senior resident if the cardiologist had said anything to him about me. Roy was a kind soul and took no pleasure in squashing an errant intern. He hesitated but then opted for the truth. “He said, ‘If I ever collapse from a heart attack, don’t bring me here.’” I swallowed hard, and moved on to finish my tasks so I could go home. It had been a long thirty-six hours.
I trudged home alone that night, slowly making my way across the large expanse of lawn that rimmed the navy base as the sun set behind the high-rise buildings across the way. I was parched, and my head throbbed as I walked in slow motion toward the traffic lights of Wisconsin Avenue. I kept playing the course of events over in my mind, trying to find a way to let myself off the hook. The residents had left me alone with desperately ill patients. Why hadn’t one of them stopped by the unit to check my orders, see for themselves how this critical patient was doing? And that nurse must have transcribed hundreds of orders for Nipride in her career. Did she think we were treating a gorilla this time? What about the pharmacy? If they didn’t know drug dosages, who the hell did? This reasoning might have held up in a court of law, but none of it relieved the sickness in my stomach, the ache in my chest.
Blame was a tricky thing. It didn’t get rid of guilt. It just wrapped it up in a package, stored it safe from the light. There was so much I had to learn; finger pointing and making excuses wasted precious time. As much as I hated to admit it, B. C. had been right about one thing. I was the doctor now. The fear of making a mistake would follow me the rest of my career. It would be the caution that made me double-check orders, the defensiveness I would have to keep under control when patients questioned me, the meticulous documentation that would follow every clinical encounter. I had discovered the greatest and loneliest burden a doctor carries.
Fortunately, in all my years as a pediatrician, I was never sued. Pediatricians have some of the lowest rates of malpractice suits in the profession and therefore pay the lowest premiums. By the time I left practice, I was paying about $13,000 a year for malpractice insurance—a drop in the bucket for obstetricians or neurosurgeons, who pay that much in a month. There are a number of theories for why pediatricians are the specialists least likely to be sued. One is that we are more likely to have connected with the family on a personal level. But meticulous charting helps, too, even before an issue has the chance to land on a lawyer’s lap.
“Dr. Kozel,” accused Mrs. C in an imperious voice through the phone line, “we told you months ago that Jamie was having headaches, and you told us it was nothing. Now the neurologist is sending us for a CT scan. Why didn’t you do something back then?” I could tell over the phone that this mother was loaded for bear.
“How did she end up seeing a neurologist?” I asked.
“Well, I had to do something. The poor child was suffering.”
“Mrs. C,” I began, already fighting the anxious defensiveness that flared up reflexively, “I am looking at her chart right now. Jamie had a very normal neurological exam at that visit. If you remember, I went over her from head to toe. You have a family history of migraines. We talked about that and the likelihood of this being childhood migraine, especially since they seemed to be triggered by sleepovers. I asked you to have her avoid sleepovers, use ibuprofen as needed, and call me in two weeks if things were not improving. It doesn’t look like you called back. But I agree with the neurologist. If she’s continuing to have problems, she should have an imaging study.”
Mrs. C mumbled her way out of the conversation, my record keeping having removed most of the wind from her sails. Even if the CT scan, God forbid, showed an abnormality, my records would support my stepwise evaluation—although I would still almost certainly get sued. But I hardly felt vindicated for doing a good job, just adequately armored. I sat staring into space for several minutes, feeling defeated by something unseen, knowing I had to switch gears, see the next patient, try to connect. Two weeks later, I got a letter from the neurologist stating that the CT scan was normal and he had diagnosed childhood migraine. Brilliant. Mrs. C started taking her daughter to another doctor in the practice.
For surgeons and obstetricians, lawsuits are a way of life, like broken noses to boxers. But all kinds of doctors can get sued, and when they do, it can suck the lifeblood out of them. One highly regarded colleague, a close friend of mine, was asked to consult on a patient of his who had been hospitalized with an infectious disease. The consult was for a minor intestinal problem the patient had had for years, unrelated to the mysterious fever for which she was admitted. Her current doctors were checking to make sure they didn’t need to address that intestinal condition while she was being treated for this infection. The family later sued about some controversy around the diagnosis of her infection; the gastroenterology consultant was named in the suit. He was sure there was some mistake. When he asked his lawyer why he was included, the answer was quite simple: “Because your name was on the chart.” It cost that doctor over a thousand dollars in legal fees to get his name dropped from the suit. The greater, hidden cost was the bitterness and frustration that settled into his gut. “I gotta get out of this goddamn business,” he said.
So when I sat down at the end of the day to fill out my charts, it was with more than healing in mind. I had come a long way from my teenage image of a doctor, from that naive image of a gifted healer, reaping the gratitude of patients. Much of what I put down on paper was written because I might need protection from the very patients I was trying to treat.
The relationship between healer and patient, which relies so heavily on trust, has become too often, in a very fundamental way, adversarial. The cloud of mistrust is such a constant in daily practice that its wisps and curls go almost unnoticed in the day-to-day business of treating patients and documenting events. The defensiveness I felt as I constructed my chart entries—and for that matter in all my professional encounters—was not enough to suck the lifeblood out of me. It was more like a slow, barely noticeable trickle.
We have to deal with the reality of medical malpractice, but the process needs to focus on caring for the injured party and improving quality of health care. The current process is driven by how much the malpractice lawyer stands to gain (on average, over half the award), with secondary emphasis on the patient’s well-being and none on improving medical care. Cases should be arbitrated by an independent panel of health experts, lawyers, and patient advocates who can assess the circumstances in the context of acceptable standards of practice. Disciplinary or remedial action should be directed toward doctors who have practiced negligently, and victims should receive capped compensation from a general fund that doctors pay into. Medical schools could teach, right from the beginning, constructive ways to critique ourselves and our colleagues; once we are no longer target practice for lawyers, trends in poor outcomes could be made transparent, and they could be studied so that we could find more effective ways to deliver care.
It is a sad paradox that the politicians who are most willing to tackle health care reform also tend to be the least likely to take on medical malpractice. They will say it is because malpractice suits do not have a significant impact on health expenditures, but such arguments are just grasping at statistical straws. Doctors spend billions in tests every year for no other purpose than to protect themselves from lawyers. It is why so many of us still order MRIs for uncomplicated back pain. It is why the C-section rate in this country has been on a steady rise. A recent study in the Archives of Internal Medicine reported that 91 percent of physicians admit to ordering more tests and specialist referrals than they think are necessary because they are practicing defensively. A 2008 Pricewaterhouse report estimated the cost of such defensive medicine to be $210 billion annually.
Politicians are, for the most part, lawyers, and they rely on the support of their fellow lawyers. By their very nature, most cannot imagine a bad situation that would not improve with a lawsuit. Tort reform gives them acid indigestion. I say to these political leaders, grab yourself some of those expensive reflux medications that your excellent insurance plan pays for, roll up your sleeves, and do the tough work that needs to be done. Provide this country with a rational, responsible approach to medical malpractice—one that will protect the health of both patients and medical practice.
This excerpt appeared originally on the web at KevinMD.