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Why Doctors Stay Mum About Mistakes Their Colleagues Make

Telling a patient about another doctor’s medical error can mean losing business or suffering retribution. Now, some physicians are looking for ways to break the code of silence.

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A doctor draws medicine into a syringe. Telling a patient about another doctor’s medical error can mean losing business or suffering retribution. Now, some physicians are looking for ways to break the code of silence. (File, Brendan Smialowski/AFP/GettyImages)

Patients don’t always know when their doctor has made a medical error. But other doctors do.

A few years ago I called a Las Vegas surgeon because I had hospital data showing which of his peers had high rates of surgical injuries – things like removing a healthy kidney, accidentally puncturing a young girl’s aorta during an appendectomy and mistakenly removing part of a woman’s pancreas.

I wanted to see if he could help me investigate what happened. But the surgeon surprised me.

Before I could get a question out, he started rattling off the names of surgeons he considered the worst in town. He and his partners often had to correct their mistakes — “cleanup” surgeries, he said. He didn’t need a database to tell him which surgeons made the most mistakes.

By some estimates, medical errors are one of the leading causes of death in the United States. Physicians often see the mistakes made by their peers, which puts them in a sticky ethical situation: Should they tell the patient about a mistake made by a different doctor? Too often they do not.

A new report in The New England Journal of Medicine, “Talking With Patients About Other Clinicians’ Errors,” suggests it’s a common problem.

The report’s lead author, Dr. Thomas Gallagher, an internist and professor at the University of Washington School of Medicine, said he conducted a survey of doctors in which more than half said that, in the prior year, they identified at least one error by a colleague. (The survey, unrelated to the NEMJ report, did not ask what the doctors did about it, Gallagher said.)

There’s wide agreement in the medical community that doctors have an ethical duty to disclose their own errors to patients, Gallagher said. But there’s been less discussion about what physicians should do when they discover that someone else’s mistake.

For the NEJM report, Gallagher led a team of 15 experts who discussed the problem. They identified many reasons why doctors may want to stay silent about errors by their peers.

One is that doctors depend on each other for business. So a physician who breaks the code of silence may become known as a tattler and lose referrals, a financial penalty. Or maybe they aren’t sure exactly what happened to the patient and don’t want to take the time to try and unravel it. In some cases, issues related to cultural differences, gender, race and seniority come into play.

The report notes that doctors also may be wary of becoming entangled in a medical malpractice case, or of causing a colleague to face legal consequences.

Dr. Brant Mittler, a cardiologist who now works as a medical malpractice attorney in Texas, told me that he frequently saw errors made by other physicians during almost four decades in medicine.

Mittler remembers a scan read by a radiologist that said a patient had an “ejection fraction” — the amount of blood pumped by the heart with each beat — of zero. But that would only be possible if the patient was dead, he said. He noted the error to the radiologist, who thanked him.

Many times Mittler stayed quiet, he said. He saw many errors reading electrocardiograms at a 500-bed hospital in San Antonio. He said he didn’t know the details of each case, so he couldn’t tell if the errors affected the outcome for the patient. But he did not go to the other doctors to point out the errors — there would have been hostility if he had, he said.

“There’s not a culture where people care about feedback,” Mittler said. “You figure that if you make them mad they’ll come after you in peer review and quality assurance. They’ll figure out a way to get back at you.”

Gallagher said physicians experience the normal range of human emotions when they find a colleague’s error. They wonder if they can keep it to themselves or whether they’re compelled to tell someone. Or they consider what they would want to happen if they had made the error.

That results in too much leniency toward mistakes, he said.

The bottom line: Too often doctors aren’t learning from errors, Gallagher said. Nor are patients getting the information they need to receive proper treatment or compensation when the outcome is harmful, he said.

Even after patients do learn about an error, the lack of communication by doctors often continues.

Almost 400 people who have completed the ProPublica Patient Harm Questionnaire, and more than 1,800 are members of ProPublica’s Patient Harm Facebook Community. Many reported that they experienced the silent treatment from doctors after experiencing harm during medical care.

The NEJM report stresses that patients come first and recommends that doctors should explore, not ignore, a colleague’s error. They should start by collecting the facts, starting with a one-on-one conversation with the physician who made the error so they can decide how to inform the patient.

Hospitals and other health-care institutions must lead by supporting such conversations, the NEJM group reported.

Dr. David Mayer is vice president of quality and safety at Medstar Health, which runs 10 hospitals in Maryland and Washington, D.C. Mayer said reporting of medical errors is a top priority at the organization so everyone can learn from mistakes.

When doctors identify an error, made by themselves or a colleague, they’re required to tell their supervisor, whether the error resulted in harm to the patient or not, he said.

Each month there are about 1,400 reported safety events, Mayer said. Most are “near misses,” though some involve actual harm to a patient (Medstar declined to disclose how many).

The safety events are analyzed for trends that need to be corrected or that need immediate attention to protect patients, Mayer said. Cases in which a patient was harmed are investigated so that the cause can be disclosed to the patient and family, an apology can be made, and compensation can be offered, he said.

Mayer and Larry Smith, Medstar’s vice president of risk management, said their organization is unusual for its proactive approach to reporting medical errors. Smith said most institutions seem to only report them when it’s obvious the harm will be discovered by some other means.

“Far fewer are doing this kind of work when the information would never surface,” Smith said.

Dr. Humayun Chaudhry, president and CEO of the Federation of State Medical Boards, which provides guidance for how state boards regulate doctors, said that physicians and health-care organizations need to be more assertive about reporting errors.

Failing to divulge another doctor’s mistake undermines the doctor-patient relationship, Chaudhry said. “It makes patients wonder if they can trust their own physicians,” he said, “and the profession of medicine.”

Have you worked in the health-care industry? Please help ProPublica’s reporting on patient safety by completing the ProPublica Provider Questionnaire.

DISCUSSION: On Monday, November 11th, reporter Marshall Allen, the study's lead author Dr. Thomas Gallagher, cardiologist and medical malpractice attorney Brant Mittler and patient safety advocates Patty Skolnik and Helen Haskell joined us for a discussion on why doctors stay silent. See a video recap below:

 

and doctors wonder why medical malpractice insurance goes up…because there is no consequences by the state medical boards when TRUE negligence has been found. Doctors point everywhere except to themselves…lawyers, patients, insurance companies….Texas has passed tort reform, but medical costs have not decreased…Texas did not accomplish what it purported

Teresa Goodell, RN,CNS,PhD

Nov. 8, 2013, 2:48 p.m.

I’m a nurse who practiced in the ICU setting for over 30 years.  If you want to get reprimanded, just talk to patients about their physician’s errors. I once observed a lady in liver failure, swollen so that her face was blown up like a basketball. Her blood sugar was unstable, she could not absorb nutrients, her lungs had failed, and whenever we turned her, her blood pressure bottomed out. When I told the family it appears that the vascular procedure done to shunt blood from her damaged liver did not appear to help, I got a “talking to” by the resident. The message was clear: don’t say the surgery did not work. Even if it’s abundantly obvious.

Every nurse has a story like this. In fact, more than one.

Teresa Goodell, RN,CNS,PhD

Nov. 8, 2013, 2:53 p.m.

Addendum: I should add that the above description concerned a big surgery that simply did not help a very sick person. I did not allege any errors on the surgeon’s part, or any one else’s.  The one time that I did mention an error (without any identifying information), the consequences were much worse. But this is not the place for that story.

Tipping Point

Nov. 8, 2013, 3:17 p.m.

This is the culture of Omerta and it is far more prevalent than just doctors.  It is specifically part of any club of entitlement.  Lawyers, police, doctors, Wall Street, the Vatican, Congress, all have been left to regulate themselves.  And, that creates a secrecy that buries corruption rather than exposes it.

Lawyers reporting to a bar that is staffed by lawyers hides the massive corruption in the legal establishment.  Ditto with police who do their own internal investigations.  Need I even mention Washington?  And, Alan Greenspan operated under the belief that a market is best that regulates itself so they dismantled Wall Street’s regulatory structure. 

A good dose of sunlight and citizen government or citizen watchdog regulation and true criminal punishment would clean up all of this self-interested corruption.  Right now our society is wildly corrupt due to this Omerta dynamic created through self regulation.  Were the truth to actually be brought to light, and if lawyers answered to a citizen-led watchdog group, half of the lawyers in this country would be in prison.

If there are med schools with a culture encouraging students to compete for grade ranking (instead of just working for grades), you can’t expect that kind of competitive drive to end at graduation.

I have not the slightest doubts about both the reality of medical mistakes and the too generalized editorializing about them as is the case here and elsewhere.  That should never ever excuse mistakes no professional should make under any circumstances.  On the other hand or two, the next doctor treating a patient may not know all the circumstances for the problem now face, including how honestly. the patient himself or herself dealt with the previous physician.

It also does not forgive what could be the mistake of the physician who alleges a previous error.

The writer’s final paragraphs are an exercise in excess of his own, as he condemn so many others but wishes to impose greater governmental oversight as if even that will achieve any perfection and/or protection.
In the end, patients and their caretakers also have responsibilities to help both to avoid errors and save lives by taking the time to read the literature given out by most physicians and hospitals that help to review important questions that should be asked and additional help available if patienr/caregivers feel inadequate.

But one thing is very clear:  implying new layers of outside or governmental oversight will do the job is just as dangerous or more so than the wide ranging assumptions and assertions by the writer who, no doubt, meant well.

Tipping Point is correct, and Joe Honick shows how the naive in this world think.

Self-regulation has never, ever worked.  Nor can it work.  Notice early in the article, the doctor *knew* who the problem doctors were.  He didn’t need to be told.  All of the other doctors (and a good number of nurses) know who the bad doctors are.  But the bad doctor’s don’t lose their licenses very often, do they?  And we aren’t talking about a doctor that makes a mistake or two, we are talking about doctors that are constantly making mistakes (again, go back and read the 4th paragraph again and think about the implications).

Independent review (usually by the government), is the only method that this gets curtailed.  Of course it won’t be perfect, but it will be better.  The number of problems and deaths will go down.  I can’t believe the people who don’t want to make any improvements just because we can’t make it perfect…seriously, there is something wrong with you.

Government oversight is why cars got safer.  The auto manufacturers fought all the improvements every step of the way for any change that they didn’t think they could market for higher sales or profits.

Government oversight kept the banks in check for 50 years until congress decided to eliminate the regulations and gut oversight.

You don’t think government oversight is the answer?  Fine.  It has been demonstrated time and time again that self-regulation doesn’t work.  Provide an answer.  Help make the world better.  I’ve had enough of the peanut gallery…contribute or go away.

For those souls who worry about my being naïve, please don’t be concerned.  I’ve had more than enough involvement with a variety of folks with cancer and other stuff.  Nor did I suggest there should only be self regulation and NO governmental involvement.  A little better read of what I wrote will demonstrate that I said patients and their families have much responsibility in the treatment processes and too much reliance on government is in the end not reliable.  It is just as naïve to rely on such help as it is not to.  Fact is all those in governmental and organizational officialdom are pretty much overworked and cannot always know of the individual circumstances of particular situations.  So preaching for more and more governmental rules won’t hack it, and it is frankly not naïve but dangerous to rely on such areas as saviors…they should only be part of the whole.
I am aware of mistakes in the very finest medical offices and hospitals regulated by some of the strictest of both governmental and professional rules, but also note those good places purposely try to educate patients and their families to read those rules and also to ask lots and lots of questions, something too many fail to do.
My biggest objection to these articles is the pompous tone implying something that is not done:  all members of any cure field suffer from the common ailment of being human.  The treatment process is not just from one direction and requires responsible participation by patients, families and anyone with intimate knowledge of what’s going on.  Your writer and supporters just want to blame someone, and that is the true naïve approach.

A teacher fails to teach a student the quadratic equation and what are the consequences to that student?

A doctor doesn’t point out error or tattle on another doctor making an error and what are the consequences to that patient?

Which profession has the media decided to hammer about incompetence?

There is a culture of fear on all hospitals. The doctors are afraid of each other. The nurses are afraid of the doctors & vise versa. Everyone is afraid of the administrators. Doctors & nurses spend more time covering their behinds writing reports tha treating patients. The medical system kills, legally. Supporting the system with widespread medical access for all only makes it worse.

Barry Schmittou

Nov. 8, 2013, 5:51 p.m.

The evidence linked below includes quotes from ProPublica and proves the leaders of both parties protect insurance companies and the doctors they pay to ignore life threatening medical conditions in five types of insurance. This evidence and much more has been submitted under oath to two Congressional Committees and is also filed in a Motion for En Banc hearing in case number No. 13-5614 in the U.S. Sixth Circuit Court of Appeals in Cincinnati. I will not have time to respond to the attacks I usually receive when I post on ProPublica : http://www.obamasdeadlycrimes.blogspot.com

Some of these commentaries suggest the medical/hospital world is going to hell in a handbasket because of the lack of moral, ethical and professional standards that the government has to protect.
Among other things, just like the world around us, the whole medical/hospital universe is not operated by charlatans, nor can some federal set of rules and vigilantes rescue patients from those bad people.
I can speak personally about handling of at least two close family members under the most difficult cancer situations that could have taken their lives were it not for the powerful personal and professional commitment of the key physicians in charge of surgery and treatment in both cases, one of which required intensive oversight for close to a year.  It would have been slanderous to attach the commentary here to those professionals and their institutions.

I don’t know who Dr Lee is, but I would suggest he get around a little more.  I do not doubt there are charlatans in the medical or even the clergy for that matter,  But it does not do credit to the accusers to paint an entire universe wit the same black brush.

And for all of us out here trying to pick a competent MD it’s a “shot in the dark” without some kind of publicized/accessable rating system that lets us see which MD’s are making the fewest errors!

abinico warez

Nov. 8, 2013, 6:31 p.m.

Doctors stay mum for a couple of reason. They don’t want to tarnish their God like image and status, but most of all, they shut up cause they don’t want to get sued. I used to work for doctors, oncologist specifically, and they are gold plated muck ups. I come from a family of doctors - I was supposed to be one myself. So yeah, I know a lot about doctors, and you definitely want to avoid all of them. People need to learn about naturopathy - a comprehensive system for health based on nutrition and NO rectal probes.

I had an experience where I had a medical procedure where they put a scope down to look at my kidneys for Berger’s disease and I found out later from the medical staff that the doctor had tapped a young boy’s spinal cord with the scope and put him in a wheelchair for life. The doctor was still out there practicing the same procedure and I was told by another doctor who wanted to assist in the procedure because he was in fear for my physical well being. He knew of the malpractice suit the doctor had in Brooklyn. The doctor was sweating bullets and only went through the emotions and did not do the procedure completely. Tell Joseph S. I said hello. Mike W.

Mr. Honick seems to put a great deal of energy into knee-jerk defense of physicians, utilizing rhetorical tricks to exaggerate or minimize other points of view and then attack them as exaggerated or minimal, while reducing to individual hypothetical a story about published aggregates, and accussing anyone who sees it as being wrong or flawed. 

Sorry, but to this PH.D. who observes behavior and compares it to the words, it won’t wash.

Excuse my amusement with Marek Pyka who has to market a Phd on behsvior.  I don’t know if Matek is a he or she, but I do more than a modicum of behavioral observstion but do not need to diminish others as all your commentators seem to need to do.  And by the way, Marekm I do well in three langusges but cannot translate your comments very well.
Cheer up.

I am a doctor, and I read the NEJM article. In short, a woman suffered a stroke attributed to undiagnosed atrial fibrillation, a cardiac rhythm disorder which allows blood clots to form in one of the chambers of the heart, and then to “embolize” or travel to the brain blocking a smaller blood vessel. Presumably The doctor felt that this was a mistake because the woman should have been treated with a blood thinning medication which lowers the chance of a stroke.
Ah, but only if it were this simple. No where in the article was it explained completely enough so that I could make a decision as to whether it was a mistake. There was no Other information about the patient, no estimations of the risk (what we doctors call a CHADS score) of stroke, no mention of her bleeding risk, her past history of adherence to therapies or her risk for bleeding, only the doctors opinion that a mistake was made.
However we are asked to believe that it was a mistake.

Let’s look at an example from my own experience. You judge whether a mistake is present and who made it.
Twenty years ago I saw a 82 year old doctor with a cough. An x ray showed a lesion on his lung. I told him it might be cancer or it might not be. I told him that because of his heart and kidney problems and because his emphysema had confined him to a wheelchair that we shouldn’t even try to find out, that the tests themselves would do considerable harm.
He agreed, but his son, also a doctor , disagreed. He underwent a biopsy , then lung surgery, then treatment on a respirator complicated by pneumonias and bedsores. After 12 weeks he died a lingering unpleasant death.

Now, let’s ask the questions. If he had died of lung cancer a year later would I have made the mistake?
Did the doctor who advised the surgery make the mistake? Did the surgeon make the mistake?
There will be many who say there was a mistake, others who don’t. This is the position we find ourselves in, no one has the complete information, and a journalist or writer cherry-picking information to make a compelling study or story does us all a disservice.

Uh oh.  Looks like my comment uncovered a narcissistic personality.  Look yourself up.

The physician (who referred the surgeon that disabled me) was outraged at first glance, and then she grew afraid regarding her own liability, and she just didn’t want to be bothered. Her self-interest and lack of character caused indescribable amounts of additional suffering (physically, emotionally, financially) for me. Both the surgeon who surgically battered me and the unethical, incompetent referring physician are both still in practice, but the public doesn’t know who they are. Doctors can use online reputation management companies to clean up their reviews. The state Medical Board is useless. There are huge problems with Medical Injury Compensation Laws, although prevention would be the best route and save immense suffering by all. Specialists don’t want to stand up to others in their field, so they let damaged patients languish in physical and financial ruin, while future patients unknowingly face the same horrible doctors and unsound procedures. Medical lobbyists seem to run the show as far as legislation goes. I’ve been on websites with countless other patients who are disabled and left in excruciating pain; patients are marginalized, and “gaslit”. How in the world can these doctors live with themselves? And all of the supporting staff are aware and complicit. Certainly not every doctor is a horrible, negligent, unethical human being, but way too many are. Every part of the broken system does us all a disservice.

I had a heroin addict surgeon. All his colleagues knew he had failed rehab multiple times. Not only did his colleagues look the other way and continue to grant surgical privileges, they left him unsupervised. In CT, skull and crossbones secrecy prevails in part because there are inadequate whistleblower protections for colleagues who report their impaired colleagues’ errors. The good guy reporting the error is sued by the bad guy that committed the error and even if the good guy prevails in court, his life is turned upside down by a nerve wracking, time consuming, and expensive consequence of doing the right thing. And, if a surgeon outside of the keep-quiet-and-carry-on hospital system reports the error, the offending hospital just disagrees with their opinion. Take a look at hospital codes of ethics regarding truth telling—some demand it and others explicitly forbid it. Full whistleblower protections for reporting medical error should be part of any med mal policy discussion.

Mary C McFadden

Nov. 9, 2013, 4:15 a.m.

There are a host of reasons why doctors are protected. Money is a huge impetus for not disclosing errors. Hubris, agism and sexism contribute to the dysfunction as well.

Aside from the lack of choice of doctors and hospitals in many places, it’s a pay-for-procedure health care system, with no payment for talking specifics or getting to know patients. Doing unnecessary, radical surgery on me, the hospital, and a bunch of doctors made more money than they would have had they simply removed my ovarian cyst. The costs of prepping the OR were the same, why not add procedures?

The surgeon, Dr. S—-, had the gall to use agism as a defense. He told me that he performed an obviously unnecessary surgery “for your own good,” because I was over 45, so didn’t need to and shouldn’t want to have sex anymore. Three “expert witnesses” agreed that women were “too sensitive under stress” and said that Dr. S—- didn’t have to abide by my, his patient’s, wishes because he knew better that I did what was necessary and therefore, what I should want.

To add insult to injury, Dr S—- counter sued me for defamation and entered in my chart that I was in need of psychiatric care for my “uncontrollable anger issues” and “unusual sexual appetite.” I cannot erase his statements from my medical record because the record isn’t mine, it belongs to the hospital and to him!

Showing doctors that they’re just human makes them feel less important, less powerful. A challenge to authority and to expertise cannot be easily reconciled with the reality that mistakes happen and, more importantly, often there is no cure, no repair. Simply talking with patients and having very, very specific consent forms would make patients wishes clear and doctors’ liability obvious.

The problem is getting worse, not better.  For profit medicine is driving surgeons and physicians to do more, faster than they are comfortable or sufficiently skilled to do.  Staff cannot ethically say anything to patients in a professional capacity, it is only friendships and relationships with people who work in hospitals, that see the consequences and warn their friends to stay away from Dr. So and So, or go see Dr. Such and Such. 

The problem goes back further, to medical schools and residency programs who move students through the process without ensuring full qualification.  The over-specialization of providers is creating a specialization mindset that allows them to focus only on the information silo they use daily, and forget the broad and general medical knowledge they are expected by the public to know, but never learned or promptly forgot as soon as they got into their specialty.  Specialists become familiar with a handful of profitable procedures, and become more focused on profit than patient care and safety.  Mergers of private practices with health care management groups intensifies the focus on profitability and patients move through they system in assembly line fashion.  Efficiency and profitability are the sole focus and safety is given lower and lower priority.  Even though 9 times out of 10, they get away with it, and everything is fine, there is no margin of time, or staff to manage the human factors that patients bring as individuals, and the system creates by expecting providers to work as “machine like automatons.”  Many GI centers are now so efficient and minimally staffed there are no redundancies left in the system to compensate for emergencies.  Some are in and out so fast that the procedure was not worth the time it took the patient to show up for it-because it’s billable.  It is a system that creates demand for procedures to be done, without accountability to the patient for procedures poorly done. 

Their is no profit in training-shadowing, supervising junior physicians, allowing them to gain experience and judgement as they work up through the ranks of medicine.  There is no profit in collaboration when the competitive model demands that doctors become salesmen rather than learning, practicing clinicians.  They must sell themselves as providers, function autonomously out of the gate, and learn from their own mistakes as they try to make a living and generate sufficient profit. 

Ethics in medicine has been replaced with the business model that puts profit first, making it appear normal to profiteer off the illnesses and misfortunes of the community, causing physicians and surgeons to focus a profit as the only reward for their effort, rather than patient relationships, the community they serve, and the personal satisfaction that caring for others can bring.  It is the system that demands these behaviors from physicians and surgeons who have done well in school and worked hard, only to tell them they will never rest, they will never have time for relationships, with patients or family, they will never enjoy the satisfaction of being able to listen, care and help.  They are little more than highly skilled profit generating automatons for the health care corporations.  Is there really any wonder were seeing the consequences of this model that is producing physicians who have “stopped caring?”

carol bradley

Nov. 9, 2013, 7:09 a.m.

I have survived a mistake from my surgeon.  My life is turned upside down.  I have damage to my lungs due to poor suturing of my esophagus to my stomach. (stomach cancer)  This allowed stomach contents to get to my pleura of my lungs.  I can no longer work as a Registered Nurse.  Thanks to my private disability insurance I still had an income.  It stopped at age 65.  I planned on working several more years.  So a loss in income, extra cost in needing items like a scooter, wheel chair, incontinence products.  Not counting the fact I still have pain and very little endurance.  Should I have sued this doctor?  Probably, but with the statue of limitations I would have had to do this within a year of the surgery.  Hell, I was too busy trying to stay alive, and treating MRSA as well.  No lawyer was interested as there is a limit of $250,000 for a claim.  Not even the amount I would have earned if I was able to keep working.  I feel that this surgeon should have paid out of pocket for these expenses and loss of income.  Now just word of mouth have I let others know to avoid him if possible.  Yes he did remove the cancer, but left me with such disability that I struggle on a daily basis to keep my self going.

How is silence NOT Criminal Negligence?

If this “supposed fear” I keep hearing about IS REAL, ... how is it NOT extortion?
Virtually all extortion statutes require that a threat must be made to the person or property of the victim. Threats to harm the victim’s friends or relatives may also be included. It is not necessary for a threat to involve physical injury. It may be sufficient to threaten to accuse another person of a crime or to expose a secret that would result in public embarrassment or ridicule. The threat does not have to relate to an unlawful act.
http://legal-dictionary.thefreedictionary.com/extortion

I am a patient safety advocate and activist.  Somehow I have become a magnet for victims’ stories and I met a woman at DCA airport just a few months ago, from my small Maine city.  She told me about her harm from surgical mesh, and she told me knew 4 women with the same harm…all in my small city. She described how her life has been ruined, her husband has left her and she has had to have many additional reconstructive surgeries done by a different GYN doc.  The doc doing the repair told her “I fix all of Dr X’s surgical mesh messes, but you didn’t hear that from me!”  My opinion is that anyone benefiting ($$$$$$) from surgical harm to women or anyone else, and not reporting the offending doctor is equally guilty.  Sickening.

In the early 1990s, I had a middle ear infection. I sought out treatment at a group practice where the two senior partners were family friends; my doctor was a junior partner and not a friend.

What I had no way of knowing was that he was a cocaine addict. I continue to feel so stupid because I did notice that his behaviour could swing radically during appointments. He’d come in barely dragging, then excuse himself and come back all fired up. Substance abuse never entered my mind, I just thought he didn’t do well without an extra cup of coffee in the morning. How could his nurse not have known? How could his partners not have known?

After the infection moved into the bones around my middle ear and into the mastoid sinus, he did emergency surgery that left me deaf in that ear and with facial disfigurement and a permanent loss of sense of balance.

A few years later, the whole thing blew open when someone realised he had over 150 medical malpractice cases filed against him.

Of the two partners who were family friends, one contacted me personally and begged me to file suit against the doctor who maimed me. He swore he’d testify on my behalf and when I asked “but wouldn’t this be against your own best interests since he was your junior partner?” he said that he didn’t care about that, that he wanted, finally, to do the right thing.

I ran into the other partner who was a family friend in the grocery store. He looked at my facial disfigurement and said “I am so, so sorry about what happened to you.” I asked him the one question that was most important to me “did you know at the time he had drug problems?” He hung his head and said very quietly “yes. I thought since he had gone to rehab that he was okay.” I just looked at him and said “you know, I have to live the rest of my life paying the penalty for his drug problem.”

We both cried then.

I never did file suit. I would have been just another case in line behind over 150 other cases and I did not want to be tied to that doctor any longer. Hatred is not the opposite of love, indifference is. I wanted to be indifferent towards that doctor so I could go on with my life as best I can.

I don’t know how his partners have dealt with it because I cut them out of my life as well. I’m pretty sure they understand why.

Joel Selmeier

Nov. 9, 2013, 8:40 a.m.

Mr. Allen. Is there any way I could persuade you to read the link below to understand what is wrong with using the words “error” and “mistake” to refer to all patient harm problems?
http://patient-safety.com/nequamitis.html

Elizabeth LaBozetta

Nov. 9, 2013, 9:22 a.m.

The doctor-patient relationship is a fiduciary relationship; the doctor has a fiduciary duty to the patient:

http://definitions.uslegal.com/b/breach-of-fiduciary-duty/

A fiduciary duty is an obligation to act in the best interest of another party. For instance, a corporation’s board member has a fiduciary duty to the shareholders, a trustee has a fiduciary duty to the trust’s beneficiaries, and an attorney has a fiduciary duty to a client.

A fiduciary obligation exists whenever the relationship with the client involves a special trust, confidence, and reliance on the fiduciary to exercise his discretion or expertise in acting for the client. The fiduciary must knowingly accept that trust and confidence to exercise his expertise and discretion to act on the client’s behalf.

When one person does agree to act for another in a fiduciary relationship, the law forbids the fiduciary from acting in any manner adverse or contrary to the interests of the client, or from acting for his own benefit in relation to the subject matter. The client is entitled to the best efforts of the fiduciary on his behalf and the fiduciary must exercise all of the skill, care and diligence at his disposal when acting on behalf of the client. A person acting in a fiduciary capacity is held to a high standard of honesty and full disclosure in regard to the client and must not obtain a personal benefit at the expense of the client.

Elizabeth LaBozetta

Nov. 9, 2013, 9:34 a.m.

Missing from this report is the fact doctors in a given area are often insured by the same medical malpractice insurance company—a company that has a rule that its policyholders cannot point out another policyholders malpractice event to an injured patient and expose the company to a potential lawsuit/financial loss.
Too, the doctors/policyholders themselves often own stock in their malpractice insurance company, and, in some instances, the doctors are the ones who actually own the whole company. It is not in their economic best-interests to expose the company to financial loss by telling injured patients the truth and offering proper aftercare/intervention before the Statute Of Limitations and Statute Of Repose expires—or at all if the doctors also own stock in the injured patients health insurance company too.

Elizabeth- so money more important than patient lives, further degrades the “god” or ethical persona of doctors. CORPORATIONS ARE NOT PEOPLE. Maybe they should be prosecuted as “people” would be.
Teresa- I have worked ICU also and would never put up with a resident telling me, the patient advocate, what to tell families. Doctors are not the patients, although they whine about less money.
Why has it taken two hundred years to finally try to deliver “quality” care to patients, instead of procedure based payment. I continue to read about doctors performing unnecessary procedures, like cardiac procedures at a huge hospital system. Unnecessary open heart surgery. THAT IS UNETHICAL AND SELFISH. Those doctors are performing procedures for their own bank accounts. Those doctors should lose their license, nationally and wear orange jumpsuits.

Joe Honick, I think you are confusing the issue.  The point of the article is that mistakes happen, but for whatever reason, Doctors will not acknowledge these mistakes.  Whether their own, or another physician’s.  You say the patient should be more aware…. read the literature, ask questions.  I think you need to take your blinders off.  I am a mother of a baby who died at 8 1/2 months old due to numerous mistakes.  In my case, the first mistake was caused during surgery.  The surgeon did admit what went wrong.  I respected him for it, and felt good about him performing the next two (which were a direct result of the error).  In my case, this was only the first of many mistakes though.  My daughter was OD’d on heparin for over 10 hours.  THIS mistake was not admitted or acknowledged until the DHS performed an investigation a year later.  I only knew at the time because I walked in as a nurse was discussing a brain CT with a Resident.  I had to ask 15 questions to get any information out of her.  I did read the literature.  I did ask questions.  But my being aware of what was going on neither prevented their mistakes, nor did it make their mistakes any less harmful to my daughter.  The article is not discussing side effects of surgeries or procedures.  Your advice would be great, if that were the topic.  But to blame the patient for medical errors is simply ignorant.  Many mistakes are simply because of lack of staffing or trying to rush as many patients through in a day as possible.  If these doctors truly believe in “do no harm”, they will recognize that they are no longer the doctor they meant to become.  They will step back and see that most of these mistakes are preventable.  They will change the system.  But unless someone forces them to see it for what it is….  this system will only continue to get worse.

Sophie Hankes, LL M

Nov. 9, 2013, 11:58 a.m.

Compliments to Marshall Alan! Keep up the good work.
Very important issue of patient safety, which causes addtional unnecessary medical harm to victims of medical errors & relatives.
Doctors not only stay mum about medical errors of colleagues they also refuse to give adequate remedial medical care to the victims of these errrors. Thus no honest registration in the medical record, no adequate diagnostics, all to prevent any harm to the responsible doctor-colleague. The Omerta mafia-like internal agreement amongst doctors to be silent about medical errors is international, in Europe, USA It is all about the financial interests of the doctors, not about the welfare of the patients.
Since 2003 I became active as a patient safety advocate setting up a Dutch http://www.sin-nl.org and a European organisation http://www.ieu-alliance.eu to improve the position of victims of medical errors and prevent medical errors. All their experiences confirm: doctors stay mum about their colleagues errors, and the responsible doctors are silent. Judges forbid websites with facts and documents about negligent doctors, contrary to the freedom of expression, as formulated in the European Convention for Human Rights.
Since experimental neurosurgery 13 years , done without my consent I have become wheelchairbound and the neurosurgeons who are responsible immedeately abonded me, never informing me, never, giving me remedial medical care. Almost all other colleagues whom I consult, refuse honest info, honest, diagnostics & adequate care.
Let us continue our struggle for medical honesty & adequate care.

Opinions> Many doctors seem to be concerned about having a big monetary income. But some people, in addition to doctors, also have this concern. When I get a letter from a doctor, it is an impersonal statement about how much money I owe. It would be nice to get a doctor’s letter which says: “I would like to inquire about your health. How is your family?”. When I was growing up, doctors were friends of our family, and members of our religious congregation. Now, most of the talking is with papers-processors, and a very few minutes with the doctors. Mental, emotional, and social factors are a big, yet ignored, part of medicine. People are not just physical machines. People have feelings, and they do have some valid opinions about health. <Opinions. Thank you.

For Marek, I am beyond laughter at your need to diagnose jy personality…I should say:  your unprofessional diagnosis.  What you do not seem to like is anything that counters your thinking which in itself jay denote some narcissism.  Most who have disagreed with me here have not had to descend to your approach.
Most also seem to misunderstand that I do not svoid the need for stricter enforcement.  Whaf I do warn against is assaulting an entire sector of anything for the faults of some.  It is that kind of approach that exemplifies racial and other prejudice.
In short, the whole medical profession and hospital field are bot made up of charlatons as Doctors Without Boundaries, or my friends who fly to Africa each year to render pro bobo eye surgery or the surgeon who saw my son through many months of life threatehing cancer, searching daily for new and more effective treatments tht ultimately got him through.
Hate and misinformation attsched to an entire universe is as dangerous as those whom you accuse.

For Marek, I am beyond laughter at your need to diagnose my personality…I should say:  your unprofessional diagnosis.  What you do not seem to like is anything that counters your thinking which in itself jay denote some narcissism.  Most who have disagreed with me here have not had to descend to your approach.
Most also seem to misunderstand that I do not svoid the need for stricter enforcement.  Whaf I do warn against is assaulting an entire sector of anything for the faults of some.  It is that kind of approach that exemplifies racial and other prejudice.
In short, the whole medical profession and hospital field are bot made up of charlatons as Doctors Without Boundaries, or my friends who fly to Africa each year to render pro bobo eye surgery or the surgeon who saw my son through many months of life threatehing cancer, searching daily for new and more effective treatments tht ultimately got him through.
Hate and misinformation attsched to an entire universe is as dangerous as those whom you accuse.

And did I mention the need for Patient Advocates, who are well-trained and protected by immunity?  They would be the first line of defense before ombudsmen, and more proactive, getting involved by being available to the patient from the beginning.

Oh, the stories…  Obviously, this is a subject of concern to many.  The NEJ report is a good one.  What I didn’t see mentioned (perhaps I missed it) is the very real problem of drug/alcohol abuse.  As a medically licensed clinician, I’m used to seeing state board reports with such censures. It’s not that uncommon. While the NEJ advises an initial encounter with the perpetrator, that doesn’t work so well with addicts. 

Medical mistakes lead to a complex dilemma, and it’s not all black and white. It’s often a continuum of opinion, although medical education should set the bar that there’s always a preferred protocol in any medically difficult situation.  So there should be some major agreement, once all the facts are known (if possible).

The insurance industry must play a part.  Non-physician medical staff must be respected as peers.  It has taken decades to shake off the white, male hierarchical programming of physicians, compounded by the almost constant stress and fear involved in training this profession.  And it’s not over yet.  Many of the problems discussed here smack of that secretive, almost masonic, approach inculcated from the medical schools onward.

And patients must speak up and educate themselves.  They should have access to an ombudsman in any medical venue.  Better physician/patient communication from the git-go is essential.  The tedious 20-pg. legal forms that we all must sign before undergoing procedures are ridiculous.  We all know what that’s about.  (1) there’s no lawyer handy; and (2) what’s the patient’s alternative?

Solutions must include increasing transparency, documentation backup (including video), and whistleblowers’ protection. But the peer system is so profound in this industry that it will take decades to change.

The answer must include group oversight and censure if necessary.  And this must have legal ramifications.  “Accessory to a crime” is a term we’re all familiar with.

Elizabeth comes close, but Prof. Lucien Leape MD said it best in his landmark report, “To Err is Human” (1999):

“There’s no economic incentive for hospitals to reduce errors because they make more money by treating the resulting problems, researchers say… If insurance companies paid 20 percent more for patients in (intensive-care units) where there were no infections, they’d cut costs substantially…”

http://omsj.org/reports/Leape 1999.pdf

Thank you Marshall Allen for bringing this code of silence to the forefront.  Transparency will save lives!

Jean-Claude Jacquin

Nov. 9, 2013, 5:29 p.m.

We all knew abut the omerta among ALL professionals, specifically doctors and lawyers, but few of us suspected the width and depth of it….....THAANKS FOR BRINGING IT TO OUR KNOWLEDGE…It is simply shocking,disgusting and what else!!!Add to this what happens in the pharmaceutical world, inducements by multinationals for promotion rewards,coverup of side effects of medicines etc and one has the explanation why our money and power driven world is at risk of social explosion . People’s watchdogs ? Maybe the last hope until….......

The medical/legal cabal is very strong and powerful in the United States of America. It is corrupt.

Marcie Jacobs

Nov. 9, 2013, 8:12 p.m.

“The bottom line: Too often doctors aren’t learning from errors, Gallagher said. Nor are patients getting the information they need to receive proper treatment or compensation when the outcome is harmful, he said.”

That’s right the bottom line.  Who is paying for the millions harmed by medical harm?  In my case GE’s product Omniscan was injected into millions. Their product is the most toxic in that it leaves 25% of the toxic metal gadolinium behind.  Many are sick and don’t know why.  I’m on an employer sponsored healthcare plan and that employer is self-insured.  It irks me to the marrow that an employer has to pay for GE’s faulty product.  And because they also paid for the diagnostic guidelines among other manufacturers that are being sued no one is getting a diagnosis anymore of gadolinium-induced systemic fibrosis.  So far the self-insured employer-sponsored plan has paid over $250,000 for my treatment and GE is walking away and still injecting other victims with their faulty product Omniscan.

Many doctors feel that they too should get away with this behavior after all we do live in a predatory capitalistic society so why shouldn’t they profit as well.  It’s unconscionable but profitable.

This problem is most acute in small towns, or communities with small populations - under 100,000. The cordial, friendly buddy relationship, where doctors’ wives become friends, their kids go to the same school, they play golf together on Sundays or go to the same church…can be most “mafia like” in the doctors’ tendencies to be silent when their colleagues commit errors, or mismanage their own hospitals, clinics or spas.

If doctors rely on their peer for referrals then their silence, diplomacy and ambiguity in confronting their peers over serious errors and mismanagement can be even more acute.

Some immigrant doctors do not have the spine to stand up to big local doctors who err, some women doctors are not assertive or confrontational enough and some doctors do not want the hassle of anything to do with possible lawsuits so they just avoid even treating people who have been hurt or burnt.

In small towns the dependency on few doctors, respect that turns into reverence and awe, and a sense of compliance and obedience, can make it difficult for ordinary people to bring up certain issues with doctors or their peers.

And if doctors make huge contributions to local charities and all kind of local organizations then the patient or the client who has been hurt becomes the pariah that others tend to isolate or judge harshly. It turns out that the client or patient who has been hurt or wronged is the one who has to do all the lobbying for help and justice. That is a pretty screwed up system.

Some people just leave…because they cannot stand the silence, the injustice and the mafia like obedience, compliance, cooperation or cover ups from peers towards their own erring or incompetent colleagues.

Sometimes cities, and bigger towns, have better doctors because there is a bigger choice and better peer reviews and professional accountability.

I’m sorry about the problems in small towns, but I do not believe that cities and bigger town have better doctors or better peer review. That is not my experience or the many others in big cities that I know that have been severely damaged and had other doctors ignore or cover up for the offending ones.

I cry reading your report. I was injured at an ER room during a blood draw. Not only was the hospital litigating over me while I was experiencing the worst pain known to man/woman, five years later, no neurologist in my city will see me. they all say because they don’t want trouble with UCSF, they won’t see me. Being turned away from health care after being injured is one of the worst experiences I’ve ever had. I became disabled within weeks of the injury. I didn’t know what was happening to me, but they did - while they pretended not to know and wouldn’t do any tests and I kept asking why if they didn’t know why I was losing my ability to walk. 5 years later, I don’t even have a wheelchair because they didn’t want it to seem I was ‘disabled.’ They lied to SSDI and didn’t tell them what they did and my son and I lost our home and went hungry for two years before a SSDI judge granted benefits. I don’t have enough to eat even with SSDI and I try to work as much as possible because I have a career I love and I’m try to save as much of it as I can. I simply can’t believe this hospital got away with disabling someone and lying and hiding. Now, and for the last 4 1/2 years, the doctors turn me away, they’d ask me if I had been sexually abused, did I have mental health problems. I didn’t realize what they were doing, I still trusted doctors. I’d become totally demoralized over time, and I simply could not understand how this could happen. I still can’t some days. Three weeks ago, a woman turned up dead in the stairwell of that hospital and no knows anything. I tried warning my city and state and federal representatives, and said they had a responsibility to protect their citizens. This was before what happened to that woman. Do you know what happened to me? They sent APS services, cut housing aid and I lost my home again. What kind of America have we become when doctors can look us straight in the face and allow this? I no longer give Drs a pass. Man up or be called the civil rights breaking cowards that you are! Stand up and protect your patients! Its like we live in some communist country and no one does the right thing anymore bc they might get ‘told on!’ And, don’t think I don’t know what its like to lose for speaking up. Something has to be done! I’m alive and that’s what drys my tears. Two weeks ago when my GP tried once again to get me into a Neurologist - again we were trying - once the Neuro heard I was injured at UCSF, he didn’t want to see the MRI or any other tests showing the impact of the RSD on my body. No, not one. ‘What do you want me to do? ‘there is no cure and no treatment?’ Well, guess what - there are treatments. there are things to be done. Not to mention the spine damage on the MRI. Instead, he pulled out the referral to the UCSF pain doctor who 4 years ago, instead of an evaluation asked if I filed a lawsuit and then wrote the report to SSDi to say I had nothing wrong instead of RSD. It would be another 3 years before I’d be able to get to Stanford that confirmed it but once they knew of the spine damage, they didn’t want to see me either, and called me a ‘problem’ patient. Oh really. I get injured and disabled and seek medical attention and I am the Problem? I have a child to raise and can’t work. That hospital needs to have a consequence for its actions, has to take responsibility, and even now, when I go to other hospitals my emails to my doctor are routed through UCSF so I don’t have any medical care they don’t influence. Five years later, with a progressive neurological condition, no medical care to attend to my health, even apart from the RSD. That neurologist two weeks ago - I told him I didn’t want the referral and I told him why. He chased me out of his office with this doctor’s referral insisting i see her. I said I found his following me abusive and he shouted ‘why do you have full SSDI?’ So this ‘medical doctor’ who has take not a second to review my medical record is so concerned about my SSDI? Really? ACTIVIST DOCTOR. I’m stronger now, thanks to your project and sharing my story with you a few years ago. Your reports help me feel hope, someone is noticing what is happening to American patients, maybe things will change. Maybe doctors will get some courage. Me? I started a meditation: ‘I am the doctor’ If there is no cure, no treatment - I surely have as much ability to find a cure as these Medicare cash machines that don’t do a damn thing but litigate on my body knowing full well what the records show. I was an attorney after all, and I did document what happened to me. Guess what? Attorneys in San Francisco are scared of UCSF too. Must be nice having that much power to not have to answer for anything. Even killing people.

Having a quality CQI policy is imperative.  All medical providers “practice” medicine and no two situations are identical.  Accordingly, every case/patient/person is unique.  Therefore, while there are protocols and treatment modalities, every case must be handled individually and looked as a a unique situation.  As a practicing Pennsylvania paramedic and CQI coordinator, I urge my peers to always practice with the highest index of suspicion.  In addition, I want crew members to be open with me about discussing errors/mistakes/calls that did not go right.  It’s understood that people are not perfect and occasionally mistakes are made.  To some extent, this is unavoidable and expected because every call and every patient are their own unique situation.  What I find inexcusable is when the same practitioner does not learn from previous mistakes and continues to practice the same way, repeating mistakes and not practicing with the highest index of suspicion.  Lastly, medicine is not black and white like a spelling bee. There are many gray areas.  These gray areas are open to interpretation where I may see it as gray and you may see it as silver.  Am I wrong or are you wrong?  We can’t both be right.  However, we can learn from each other, not make the same mistake a second time and further our knowledge with meaningful continuing education.

Brant Mittler MD JD

Nov. 10, 2013, 10:38 a.m.

Thank you, Marshall, for an excellent article which has stimulated a vigorous, healthy discussion. A few points of clarification:
1. When I saw the EKG reading errors, they were mainly stimulated by the underlying computer software program ( the most widely used in the industry) that made errors the reading EKGS that physicians failed to correct. When I read EKGs, ( we read one week at a time) I would save the preliminary tracings that showed errors in the software program to show to the administrators in charge of the department and to present at our monthly hospital department meetings. The doctor members of the department for the most part expressed concerns. I never saw the software programs corrected.  The administration counted on conscientious physicians to overread the computer generated errors and get it right. This is an added burden on doctors. Rather, than placing blame with specific doctors or hospitals, it shows the complexity of dealing with error in the hospital setting. And as Marshall points out—in the hospital, even though error occurs, it is often difficult to determine if an error leads to harm. To be sure, errors must be minimized. But it’s not so simple as finding and throwing out a ‘bad apple” doctor.  And, also one should consider that Community Boards—laypeople not doctors—have the ultimate legal authority to run hospitals. What are they doing about errors? Who is putting pressure on these community members to limit errors?

2. Since I represent plaintiffs in lawsuits against doctors and hospitals, it is possible to assign blame for negligent acts that lead to harm. But proving causation is always the crux of the lawsuit. Even if negligence is obvious, proving it led to harm is often the most contested part of the lawsuit. For sure, every time a victim of medical error that caused harm tries to prove that, defendant doctors and hospitals line up a group of defense experts from the finest medical schools, with the best credentials, and with the longest CVs to say that there was no negligence and no causal link.

3.To add even more context to the discussion of medical errors, consider the science of interobserver and intraobserver variability in the reading of diagnostic tests. There is a rich medical literature on this subject showing that, for example, for chest-xrays the variability for the same radiologist reading the same chest x-rays multiple times is about 25%. For a group of different radiologists reading the same set of x-rays multiple times, the interobserver variability is about 25%. Maybe that’s the way our brains are wired. And that “error” is built into the system. So things like EKG reading software were developed and refined. But there is always some baseline error. I realize that Marshall and most commenters are talking about a much grosser level and kind of error—like botching a surgery or operating on the wrong body part.

4. Finally, consider this: How do we know the right way to practice medicine and who gets to define that.

So where do people go who understand the imperfections usual to humans who practice anything but seem to do pretty well for those in my fsmily and group?
Bottom line of the complainants here is thst we have a terrible country full of bad prctitioners.  So to who do they go for help since they must assuredly avoid doctors, hospitals and all the rest of the facilities and people who work pretty hard and are imperfect?
Just asking.

This article is part of an ongoing investigation:
Patient Safety

Patient Safety: Exploring Quality of Care in the U.S.

More than 1 million patients suffer harm each year while being treated in the U.S. health care system. Even more receive substandard care or costly overtreatment.

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