Malpractice

[Guest CaesarCornelius]

I get really annoyed when I hear people say they would "sue that doc" when people talk about mistakes made in medicine.

 

People make mistakes,

Doctors are people

therefore, doctors make mistakes.

 

Im not sure whether or not this is the right forum to be posting this in, but I was wondering what you guys think about 'suing a doc' if they make a mistake.

 

To spark the conversation here is a scenario: A woman is suspected of having uterine cancer (ie: all indicators point to cancer of uterus). A histerectomy is performed and follow with chemotherapy. The docs conclude in the end that she actually didn't have cancer and her results were incorrectly labelled (ie: she received someone elses results).

 

(Note to clerks/residents: I might have jargon wrong.. Chemo following hysterectomy?...That is beside the point, please ignore.)

 

Should the patient sue the docs? If so, which ones? Should those docs loose thier licence to practice?

 

CC

[Guest chemgirl]

If this happened to me I'd be royally pissed and I would seek legal recourse...

 

A mistake was made, but someone has to be held responsible for the shuffling of the documents. In life and death situations, documents should not be "mixed up" and treated so casually. When documents do get treated casually, punitive actions should serve as a warning to not be so lax about things.

 

I'm not understanding exactly what is going on... they removed the uterus, so wouldn't they have found the uterine cancer? Why wouldn't someone monitor the progression of the tumor during chemotherapy? Wouldn't someone notice that there is no tumor inside this woman, even right before the operation? Truly, if someone was extremely negligent over this, perhaps they should loose their license. I don't know enough about the case to say more than that.

 

These are just the babblings of someone who aspires to be a doctor and really has no idea of how the process of chemo/surgery works, so excuse me if I am wrong.

[Guest moo]

Things like the scenario your described don't bother me. I mean, clearly someone was negligent here. It's the frivilous lawsuits that bother me. In America, malpractice has gotten to be such a crisis that currently, in my state (Illionois) for example there is a severe shortage of docs willing to practice obstetrics just because it will raise their premiums to ridiculous levels (over $150,000 per year). Many ob/gynes have to deliver 100-150 babies just to pay their malpractice insurance! One of our doctors told us that one of his colleagues went back to being a pharmacist because she just couldn't handle the pressure of being sued left and right. There are ads for lawyers who encourage mothers to sue if they've had a "traumatic delivery, a C-section performed, if the baby had cerebral palsy, etc." In one case, a mother sued the doc because her kid had cerebral palsy and claimed that she would've aborted if her doc had told her!

[Guest cracked30]

What if a low level orderly mixed up the samples. thats the most likely answer. Is it fair to sue the docs?

 

Catch a uterine cancer early enough and its not visible to the naked eye chemgirl.

 

Personally I don't think that scenario is likely to happen.

 

Systems problems like that are usually not the fault of any doc. If you have a diagnosis of cancer, you have a responsibility to tell the patient, and offer to remove it.

 

People will sue the doc because orderlies and lab technicians don't have malpractice insurance. It would get thrown out of court though, the doctor practiced due diligence.

[Guest UWOMED2005]

On the one hand, it's disgusting that clerical errors can have such an impact on patients lives.

 

On the other hand, there's so much paperwork shuffled around a hospital that not only are such incidents possible but they are inevitable.

 

I think one of the reasons medical errors get so much attention is the drastic implications they have. But I'd argue they often get blown out of proportion. I've heard people commenting on stuff they heard from the news (usually presenting the story slanted for maximum attention) and remark THAT should NEVER EVER happen. How can that happen in the age we live in?

 

No system is perfect. The question is not whether medical errors should happen at all (ie 'this should NOT happen in the age we live in'), but how often they occur and how can we change it .

 

But medical errors shouldn't be blindly accepted either. One of our profs last year lectured us on medical errors, and made a comparison between the airline industry and healthcare. She argued that healthcare loses essentially the equivalent of a jumbo jet full of passengers EVERY DAY. While I don't think medical error can be completely avoided, setting our sights on matching the aerospace industry might be a more realistic goal.

 

As for suing, a hysterectomy is a tricky question. Would the money bring the woman's uterus back? Maybe she should be awarded the cost of adoption fees. As a hypothetical example, if my chiid was killed by medical error, for example, you'd be damn sure I would want to see if the system could be improved but I probably wouldn't sue. What's the point? The money wouldn't bring back the kid and I'd feel dirty spending it. If my child (or even I) was DISABLED by medical error, I would most certainly sue. Not to punish the doc, but just to make sure the child (or I) had enough resources to get through life if they couldn't work, and cover medical care.

[Guest bcdentalgirl]

It's called putative damages. The awarding of damages sends a message that if mistakes are made, the responsible party must pay for it in the only way that is really possible - financially. Potential loss of money is a huge motivating factor in ensuring that very high satndards are maintained, so I argue that suing docs/hospitals for negligence would have a huge impact on the way they carried themselves in the future (ie the proper changes are made). It's idealistic to think that you can change the system in any other way. If you want hospitals to have more safer screening procedures, hang the threat of huge lawsuits over their heads. If they don't heed the threat, their lawyers will make damn sure they do!

[Guest Elliott]

I really disagree and don't think that doctors or hospitals should be scared into avoidance. I think that often so much emphasis is placed on avoiding malpratice that physicians become preoccupied and their judgement can be affected as a result.

Personally, I think the bulk of the problem lies within the medical system itself. When you are pressured to push through a higher volume of patients and cut backs on funding cause physicians to reconsider taking extra precausionary measures, how can you possibly do your job to the best of your ability with these things hanging over your head?

It makes me sick the amount of people that sue over "mal-pratice", it as if health has a fixed price tag and money can solve those problems. It just goes to show our move towards a less personal and more capital based society. Sueing is there for people who really require that service, and I know that a lot of people sue just because they believe it is their right.

What the heck is wrong with us? Have we become so ignorant that we think modern medicine is a right, as opposed to a priviledge? Apparently some of us have forgetten about the other 80% of the world who don't have any of their basic medical needs met.

I think people need to get with it and start taking responsibility for their own lives and existence. If you had a surgical procedure (which was not done without consent under life threatening circumstances), then you had to agree. I think it is ignorant to assume that you need to know nothing about what you are about to undergo.

 

Elliott

[Guest macMDstudent]

There is no doubt mistakes happen in medicine and there is no doubt that many are avoidable; however some are unavoidable in that medicine is a PRACTICE and although we like to think of it as an exact science, there is much ART to medicine and sometimes the "grey area" is huge and unfortunately clinical judgement and technical skill play a role. Therefore, experience matters.

 

Studies have shown that there is a procedural skill level involved in outcomes. That is, a physician who does more of a certain procedure they have better outcomes than physicians who do procedures less often. It follows that people with less experience (ie. learners like clerks or residents) will make the most mistakes and that even experienced physicians who venture outside their realm of expertise are likely to make technical mistakes due to lack of expertise. Therefore, we have specialists and sub-specialists. Practitioners should stay within their scope of practice as they are trained. This is difficult as a learner when we have to do new procedures all the time. This does put patients at risk!

 

Having said that, my courses in health care jursiprudence, my previous health care experience having been insured under a malpractice organization (and reading the disciplinary hearings and updates from my insurance carrier over the years) and in converstations with practicing physicians; most lawsuits arise not because an error has occurred but because of a breakdown in communications between providers and the patient either before of after the error occurred.

 

The first step in good communication is INFORMED CONSENT. Every medical test and treatment carries a risk. The patient has to be informed of possible negative outcomes and alternatives, as well as what could happen if the procedure was not done. If the patient is incompetent or unable to give consent emergency lifesaving consent is legally defensible but otherwise a legal guardian or substitute decision maker must be consulted. There is a legal heirarchy of who can make a decision, unless a specific advance Power of Attorney exists. My experience in medicine so far is that this is not usually done very well. If patients are aware of adverse potential outcomes before hand then this can reduce an adversarial relationship when predictable poor outcomes occur.

 

The second part of good communication is disclosure. The patient has a right to know what has happened and why something went wrong. When a mistake has been made; simple disclosure and open discussion with the patient and/or family can and often will prevent legal action. This is not to say that if someone screws up by total incomptetence or that we should get off the hook by saying "sorry" but being perceived as trying to hide something or having an unapproachable, egotistical demeanor would seem to increase the adversarial relationship. There is nothing to be gained by concealment of information from the patient.

 

See the article:

Philip C. Hébert, Alex V. Levin, and Gerald Robertson

Bioethics for clinicians: 23. Disclosure of medical error

Can. Med. Assoc. J., Feb 2001; 164: 509 - 513.

 

So if a physician is truly incompetent and did not follow the standard of care for a particular case, then that would seem to indicate they are unfit to practice and the regulatory College of Physicians would have a hearing into their fitness to practice. Also, civil court action as both punitive and compensatatory (i.e. providing the injured patient the costs to live with disability incurred) are a method of enforcing high standards. There is a difference between "error" and "negligence."

 

On the other hand, if an error was made that was a true accident or "human error" then malpractice insurance exists for a reason so that doctors and their families are not left bankrupt; and the doctor can continue to practice and provide services to the public. If doctors are afraid to practice; or practice "defensive medicine" to such a degree that the system is overburdened with many unnecessary tests by doctors trying to cover their a** the whole system will grind to a halt.

 

Sometimes, something as simple as not being able to read handwriting can lead to error. Double and triple checking drug labels, orders and patient information are also necessary. There have been wrong legs amputated! However, there are many pressures to be work quickly and the whole medical system with its emphasis on long shifts (who can possibly be sharp for 30 hours in a row?) mean that changes from within the system are necessary for errors to be reduced.

[Guest Kirsteen]

Hi there (from Kampala, Uganda, no less)!

 

I picked up a book at the airport that was a National Book Award finalist last year: "Complications: A Surgeon's Notes on an Imperfect Science" by Atul Gawande. It's an excellent read and filled with elements and anecdotes that are very relevant to this discussion.

 

One interesting study surrounding physician error that was cited in the book was a 1996 initiative that pitted the efforts of one of Sweden's leading cardiologists against a computer--both of whom could read EKGs. Both were required to read a total of 2240 EKGS, half of which showed confirmed heart attacks. The cardiologist was permitted to read these EKGs in ideal conditions, i.e., those of his choice in which he felt most comfortable. The result: the computer correctly identified 738 of 1120 heart attacks and the cardiologist... 620.

 

Cheers,

Kirsteen

[Guest Ian Wong]

I agree. It's an interesting book from someone who I believe was a chief resident in General Surgery at the time the book was completed (it was a while back when I read this, so the details might be a bit hazy).

 

As far as computers diagnosing things like EKG's, our EKG's come back with a computer "diagnosis" in addition to the actual tracings themselves. The trouble is that while computers are great at measuring things, and calculating probabilities based on those measurements, they aren't so good at the actual decision-making tree process, nor at incorporating all the outside information into the test results. If you were to trust the computer's diagnosis for more complicated EKG patterns, you'd end up misdiagnosing all sorts of things.

 

Of course, this begs the question of "what is the gold standard?" that allowed you to state with certainty that the computer was wrong. At this time, I still believe it's a cardiologist armed with both the EKG, a history and physical, and any other ancillary test results relevant to the discussion (ie. echo, coronary angio, cardiac enzymes, etc).

 

The same deal is true in radiology, where CAD, or computer aided diagnosis, is being employed in screening mammograms. The big problem though, is that these programs currently have very poor positive predictive values. Even when the CAD states that there's a suspicious nodule in the mammogram, way more often than not, a biopsy shows that the nodule was benign and not malignant. At the present time, the computer AI just isn't complex enough to diagnose using the same mental process that a radiologist goes through, and that leads to a lot of over-calls which diminishes the utility of the CAD program.

 

Ian

[Guest UWOMED2005]

Yeah, I trust the computer readout for the rate, PR interval, and QT interval only. . . and even then I'll doublecheck if it's a complicated or poor quality EKG. I had a number of nurses page me after reading "Possible inferolateral MI" on the computer analysis without looking at the actual strips, looking at past EKGs or checking the patient's physical condition. . . almost every time this message was due to T wave abnormalities that were present on previous EKGs. In other words, the EKG (and patient) were completely normal in that particular clinical context.

 

One thing that still completely baffles me about medicine is the idea of gold standards, and sensitivity for a gold standard test. For those of you who don't know, sensitivity is essentially a measure of how many abnormalities a test will pick up relative to the number that are out there: for example, if a X-raying for Lupus was 80% sensitive and you had 100 patients with Lupus, then theoretically 80 of those patients should have a positive X-ray.

 

Now, in order for this to work so you can figure out the sensitivity of a test you need to know that the patients you're using actually have the disease you're testing for. So studies that examine sensitivies for tests will use a "Gold Standard," the best/most accurate test available as the comparison measure. For example, MRI is the gold standard for Aortic Dissection so if you wanted to study how accurate Transesophageal echocardiography (TEE) was for Aortic Dissection, you'd find 100 patients diagnosed by MRI as having an Aortic Dissection and do Transesophageal TEE to see how effect the TEE was in catching the Aortic Dissections.

 

Now this is what baffles me and noone has ever given me a good response: I've heard people quote sensitivities (and specificities, something different) for a number of "Gold Standard" tests, including MRI for aortic dissection. But what in the heck are they comparing the gold standard to in these studies? For the 100 patients they ran through the MRI with an aortic dissection, how did they know they had an aortic dissection?

 

Or to relate to Kirsteen's example. . . for those EKGs the cardiologist was reading, how do they know the cardiologist wasn't right. . . that the answers for the EKGs weren't wrong?

 

* I would also like to remark that I've also met nurses whose ability to read the actual EKG is vastly superior to mine own. I do not mean to pick on nurses at all.

[Guest mydream88]

Hi all,

Kirsteen I hope that you are having a nice trip so far! It's great that you can still check in on this site and hopefully tell us how you are doing . I look foward to reading this next suggested book 8o .

 

In terms of sensitivity: as a biostatistician I would look at a number of papers that determined sensitivity to get a idea about the range of values for sensitivity/specificity for a given test, rather then just keeping in mind the gold standard. You make an excellent point UWOMED2005, if your patient is not comparable to the group in which the sensitivity was determined, sensitivity for a particular test may be different for your particular patient. That's the danger in relying on numbers, they entirely depend on the context in which they are determined.

 

a question: is it not standard practice to always check past test results of the same diagnostic test and a patient's health record before deciding ultimately on new test results?

 

Have a great evening,

mydream88:)

[Guest macMDstudent]

From my understanding, the gold standard often results from comparing the diagnostic testing results from before death with autopsy results (or surgical pathology/biopsy results) in a large trial with a large sample size. Part of the problem today, from what I understand, is that fewer families release bodies of loved ones for autopsy. As a result fewer clinical correlations are being made between what was seen before death (or surgery) with diagnostic testing and what was actually found on autopsy or in the pathology report. So then we end up comparing the results of one test to that of another, which we may not know is truly a "gold standard" at all, as opposed to comparing the cause of death at autopsy which is usually fairly conclusive.

 

I do not have a reference handy but this was a "personal communcation" from a pathologist I was talking to.

[Guest strider2004]

to relate to Kirsteen's example. . . for those EKGs the cardiologist was reading, how do they know the cardiologist wasn't right. . . that the answers for the EKGs weren't wrong?

 

They probably compared it to angiography, since angiography is the gold standard

 

It makes senses that some imaging modalities are very accurate like an MRI picking up an aortic dissection. It's like using an x-ray to look for fracture. There's no better way besides pathology.

[Guest Kirsteen]

Hi there,

 

It is not mentioned in the novel how the EKGs were confirmed as being MI or non-MI prior to handing them over to the cardiologist and computer. If you're interested, the study was led by Lars Edenbrandt and published late 1997.

 

On a surgical note, I just spent the day meeting, chatting, dining, and generally pow-wowing with a large number of the 150-odd surgeons present for the Association of Surgeons of East Africa conference here in Kampala, Uganda. Here is a mix of the old school, new school and wild school. Not that I've been exposed to a litany of surgical tales before, but the ones I'm hearing here are remarkable. Honey and ghee (yes, clarified butter) or the alternate, potato peels, to very effectively dress burn wounds. The different bites that one can receive from African wildlife, e.g., hippos and the like, and how to treat them. How hanging-basket approaches to managing burn patients in China are often superior to those in commonly practiced in Toronto given that the Chinese patients with extensive burns do not generally require ventilation, and suffer less lung trauma, whereas the Torontonian patients generally do (on both counts). This and more: it's enough to make you want to be a surgeon when you grow up.

 

Cheers,

Kirsteen

[Guest mydream88]

Hello everybody,

I hope you are all getting through the week nicely. Kirsteen, I am happy to hear that you are having a fantastic time over there! Those surgery stories and burn treatments sound very unique and interesting.

 

About gold standard: I raised this issue today at my weekly 'journal club' 8o meeting to my excellent boss, an interventional radiologist. According to her, for diagnostic imaging, the gold standard IS the reference test which is historically (and currently I suppose) considered the most sensitive i.e. angiography. In terms of determining gold standards by confirming results on autopsy, to eliminate selection bias i.e. these patients tend to be sicker since they have died (assuming it was not due to a plane crash!) and therefore if they had for example pulmonary embolism, the emboli (if this is the correct syntax ) would tend to be larger and therefore easier to see upon imaging. Thus it is current practice, when determining gold standards, etc. to use animal models in which the animals are euthanized thereby avoiding selection bias (and unfortunately killing a few animals :rolleyes )

 

any thoughts?

 

mydream88:)

[Guest UWOMED2005]

Wouldn't it be funny if the angiography ended up being only 60% sensitive. Than a test which was 90% sensitive using angiography as the gold standard would end up being in fact only 54% sensitive.

 

But seriously, I'm probably just quibbling over a few percents. . . I'd agree many/most gold standard tests in the early 21st century are 95% sensitive or specific.

[Guest mydream88]

That's what I thought as well UWOMED2005! I suppose that if one were to discover that the 'gold standard' turned out to not be as robust as a newer test, then they would enthusiastically publish such results 8o :rollin 8o !

 

mydream88