Oh boy. Propublica has really gotten into it now. This non-profit investigative reporting agency, which does some great in-depth work, really has the medical error bone in it’s teeth and isn’t letting go. It’s new interest is in doctors not reporting errors committed by OTHER doctors. Here’s the link: http://www.propublica.org/article/why-doctors-stay-mum-about-mistakes-their-colleagues-make?utm_source=et&utm_medium=email&utm_campaign=dailynewsletter
There are several scenarios at issue here. It is true that everyone at an institution knows who the “good” surgeons are and who the “bad” ones are. Everyone knows who the skilled anesthesiologists are and who is clueless. Same for nurses, same for every level of every specialty. “Good” and “Bad” are hard to define, however. I’ll use surgeons as an example but it could be any specialty. I could say a surgeon is really good because he’s fast and confident and doesn’t have a lot of complications. I could say a surgeon is bad if they are slow or hesitating or if they have to all in other doctors for help. I don’t do surgery. I can tell if something isn’t going well but not necessarily the reason for it. I don’t have the technical expertise to say exactly WHY this surgeon is a “bad” surgeon. I just have a gut feeling that he/she is unsure of him/herself and that I would not personally go to that person for my surgery. Everyone knows, and everyone rolls their eyes at each other when the bad surgeon does cases, but no one is going to report this surgeon to anyone. There are too many variables. Maybe I don’t understand the technical difficulties. Maybe this surgeon is just out of training. Maybe they were poorly taught. They’ve been hired by the department of surgery so presumably some sort of vetting process has gone on. Maybe you can’t put a finger on a specific error. Or you aren’t really sure if it was an error. Other surgeons don’t want to remove the bad one from the call rotation since it makes more work for them. As long as nothing really bad happens, no one is going to say anything. Ideally, the chairman of the department should be involved enough in clinical practice to hear the way the winds blow and do his own investigation but that is generally not done. A word from anyone would likely cause way more pain for the reporter than the doctor or even the patient.
Egregious errors are generally recognized by all and reported to the patient by the surgeon who made the error. In these cases there is no doubt and it would be a very rare doctor who didn’t report his own obvious error. Although even that is not necessarily true. A doctor could be absolutely sure in his/her own mind that the thing that went wrong was NOT their fault. It could have been circumstance, the physical state of the patient, the available assistance, erroneous information given to them by someone else, etc. Excuses yes, but sometimes absolutely true. In these cases it is often the courts who make the determination of blame.
There is also the professionalism and hierarchy of medicine, which is very necessary but also impedes communication. Very few doctors are going to report the error of another, even if they are absolutely sure the error was done and the patient was harmed. There are several reasons for this. Sympathy: It could have been me. Protection: I know what a lawsuit is like and don’t want to involve myself or my colleague in one. Ass-covering: I don’t want others to think badly of me as a snitch. Rationalization: Yeah but it was a hard case and there were other factors. Job security: I don’t want to lose my job by calling out a superior or colleague. If you look at these reasons you will see that these things are true in any profession. Doctors are not doing anything that any human wouldn’t do in any field when faced with this problem. The issue for doctors is that sometimes people get hurt.
One more thing. The NEJM article about this ( https://www.documentcloud.org/documents/813486-talking-with-patients-about-other-clinicians.html ) is written by a lot of really smart guys in clinical practice and ethics and worth a read by patients as well. One thing they point out is that we can learn from our mistakes. That’s true, but the culture of medicine and malpractice is much more likely to focus on harm and blame than education and learning. It’s unlikely a mistake is going to be reported and then everyone says “Oh, thank you for pointing that out, we all learned so much from it.”