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Finger Pointing

November 11, 2013

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.”

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From → Healthcare

4 Comments
  1. Hello Sheri:

    I totally agree with your take on the issue of providers not reporting errors. What is practice if one does not make mistakes? I think the reason we have a shortage in health care, especially the lower paid specialities like primary care where both physcians and advanced practice clinicians are migrating away from is that the risk of exposure to being sued and career destruction is just as high

    Here is a great TED talk on how medicine and health care need to have a cultural and social shift away from blame and conquer, in that is in failure that we are able to learn. Here is the link. Hope you enjoy! Debi

    • Thanks Debi. Yes, it’s the blame and punishment that doctors are afraid of. Our human instinct for self-preservation is as strong as anyones. Let me be clear though. The piece is about doctors reporting OTHER doctors. If a doctor makes a mistake in the care of his own patient, to whom he has a duty, no question he must report it and make amends as best he can. My point is that no doctor wants the role of putting someone else in that position against their will.

  2. Hmmm. My feelings on this: your next to the last paragraph focused on the reasons not to report. They all focused on “I” the doctor, not “ME” the patient. I’ve had docs who focused on ME the patient. They made mistakes. Never ever reported them and actually (since they all apologized, made things better) reported how wonderful they are/were. I only report those who’s focus isn’t on the patient. If you aren’t focused on the patient and everything is about “I” (as you listed above), what are the chances we can make medicine better, both for MD’s and the patients? What are the chances I’m going to feel you are invested in my health and not your wallet?

    Think about it. Not all of us are the enemy. Not all of us want to sue you. We don’t think your Dr. God. You are human like us. Granted you lop off the wrong leg, that’s one thing, but there are so many other things that I would feel confident on that you caught the error, that you fixed the mistake, That I got a feeling that you were going to be honest with me, and I could trust you, because you were strong enough, human enough, and respectful of both of us, enough to work with me through a mistake.

    Randy

    • Thanks for reading Randy. I fully agree with you that the doctor who makes a mistake absolutely has an obligation and a duty as the patient’s doctor to report it, and studies have shown that such doctors have no greater a chance of being sued, and sometimes less of a chance, if they are open and honest. No question. The point of the piece was in relation to doctor reporting OTHER doctors, and in this as you point out doctors are human, and the human instinct for self-preservation is as strong in us as it is in anybody else. In cases in which the duty does not directly exist, we will be no more altruistic than anyone else.

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