Allowing patients to define a medical adverse event

Patients do need the power to complain about bad doctors and, trust me, there are some bad doctors out there.  That being said, the other way for patients to get some retribution is to stop seeing that doctor.   Word of mouth will spread, like any other business, and that doctor’s business goes under.

Right now, state boards allow patients to complain about anything and they have to investigate that complaint.  Many are a waste of time.  I was a victim of this recently when a patient complained that I didn’t give her an antibiotic for a virus.  Her strep test was negative and so was her culture.  Long story short, her complaint was dropped but not after a tremendous amount of angst, stress, evidence gathering and time on my part.  The state boards represent patients and not doctors.  Unfortunately, this has become an antagonistic situation with all the power going to the patients.   Val Jones, MD just tipped me off to another system being set up that can easily be abused.

The Obama administration is creating a pilot program that will launch this fall, which is prototype patient reporting system through a contract with RAND Corporation and the Agency for Healthcare Research and Quality.  It is called the Consumer Reporting System for Patient Safety and the project is designed to collect information from patients “about medical errors that resulted or nearly resulted in harm or injury” and can also secure reports from family members with the data supposedly being available for use by providers and health systems that wish to create or enhance their own local reporting systems.  Create?  Enhance?

This is right from the Kentucky Health News article:

Here’s how the system will work: When a patient recognizes a medical error, an intake form will ask what happened, including questions about the details of the event and the health care provider(s). Providers and patient safety officers are expected to follow up with the patient, which AHRQ estimates would add 28 hours to the provider’s annual work load. The collected data will be analyzed to produce estimates about the patient safety events, which will be shared with health institutions.

Anyone else see a problem with this?  Only 28 more hours to the provider’s workload.  Is that per complaint?  And define a medical adverse event?  That is the key.  Just because you didn’t like the doctor because he didn’t give you antibiotics doesn’t mean it is an adverse medical event.  Just because a bad outcome happen doesn’t mean it is a medical adverse event.  Bad things in life do happen. People do die.  Trust me, this will be problematic because you are banking on patients to discern the definition when that definition is already confusing.

Doug Farrago is a family physician who blogs at Authentic Medicine.

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  • Suzi Q 38

    I would agree with you for minor complaints, but not for major ones.
    What is a minor complaint? It is in the “eye of the beholder.”
    What you would think is minor may not be to the patient.

    If the compliant is unfounded and not verifiable, it will not go forward.

    I still think that some patients need this “safety net” to keep the bad doctors “in check.”

  • Eric Andrist

    You’re worried about 28 hours of work PER patient??? How many patients do you expect to have complaining? If it’s more than one you better start looking at why that is.

    Why should doctors be any less prone to complaints than any other job? The problems you outline with complaints could happen with any job field.

    I’m sick of doctors having this sense of entitlement that they are superior and should be sheltered from complaints and lawsuits.

    • PoliticallyIncorrectMD

      ANYBODY should be sheltered from STUPID complaints and FRIVOLOUS lawsuits. Unfortunately, physicians get disproportionate share of those because of public’s sense of entitlement and class warfare.

      • Eric Andrist

        And doctors ARE protected. Clearly you’ve fallen for the propaganda. Medical malpractice lawsuits, which in most states are hindered by tort reform laws, rarely ever make it to court because the cap on non-economic damages is way too low. Lawyers, who take these cases on a contingency basis (they front all the money to bring the case) won’t take them because they will likely lose more money than anything else.

        Secondly, there is something in law called “Summary Judgment.” With that, a defense attorney can call into question the validity of the case before the judge, before the jury even gets into the court room. If the judge finds the case to be “frivolous” as you say, it will get thrown out of court. If he doesn’t it proceeds.

        If it proceeds and a jury finds the doctor guilty and awards money, it sure as heck can’t be construed as “frivolous!”

        • Guest

          Don’t worry, these evil doctors will soon be put in their place as they are replaced by midlevels and controlled by corp med. In the future, if you have a problem, you will have even less recourse. A midlevel will point the finger at someone else. The supervising physician will be protected by a stringent contract from corp med. The hospital will have lawyers on top of lawyers to block you from getting recourse. The hospital administrators are in bed with the government who through crony capitalism will not give you or your woes one thought as they fly through the air in their private jets.

          But yes, continue to hate on the doctors. Don’t worry, in due time there will be none available for you anyway.

          • Eric Andrist

            This isn’t about “evil doctors.” This is about doctors and hospitals who make egregious errors and mistakes and then are sheltered from suffering the consequences for it like everyone else. If a doctor were to run my sister over in the street in front of the hospital, I could sue for millions and win, but because he supposedly does it inside during his job, I can’t.

            I love my family physician and am very appreciative of the doctors who go the extra mile to do right by their patients, even if they screw up.

          • Guest

            I am a physician who spoke up against a colleague who was incompetent and dangerous…yet refused to retire. Complaint after complaint was made against this physician yet the hospital and medical board did nothing. All it did was worsen relations between myself and this physician who was actually a nice person but refused to acknowledge that he no longer had the skills to practice safe medicine.

            I don’t know if it’s reassuring to patients or more alarming that even fellow physicians can’t get recourse against bad physicians. I wonder if this will change in the future.

          • Eric Andrist

            I actually hear this a lot….it’s very frustrating. The more doctors let other doctors get away with this, the more it makes a bad name for doctors in general. It starts to create the same profiling that ethnic groups go through where one bad apple spoils the whole bunch.

            I just read an article yesterday about how some doctor’s arrogance and treatment of other staff members can have a negative effect on patient safety.

            The doctor that killed my sister is very disliked at the hospital and the head ICU nurse confided this to me when she saw how frustrated I was with him. The doctor never did admit to doing a single thing wrong even though there are multiple, very easily provable mistakes. He was very arrogant and thought he was just the cat’s meow when it came to medicine.

          • Guest

            What happened to your sister? I am so sorry for your loss.

          • Eric Andrist

            For some reason this didn’t post yesterday, I hope it doesn’t appear twice.

            She was mentally retarded, I was her full time care giver. Took her to the ER with a stomach ache and she was dead 2 days later. They failed to diagnose a strangulated bowel which burst sending toxins into her abdomen causing sepsis. On top of that, they failed to give her any pain medication for over 15 hours. When they finally did, they gave her Dilaudid which is 7x stronger than morphine and which she had at least 6 contraindications for. Then they had her drink Gastrografin for a CT scan which she aspirated causing pulmonary edema and sent her into cardiac arrest. The hospital wrongly thought she was a DNR (because she was mentally retarded?) and stood around not reviving her. When they finally realized they were wrong, they called a code blue, but it was too late, she was nearly brain dead. She died the next day.

            You can see her story as well as many others on the 38istoolate website.

          • Eric Andrist

            Why does my reply keep disappearing?

    • azmd

      Perhaps if the complaint reporting process being put in place is estimated to result in 28 hours of provider time to respond to the complaint, whether it is valid or not, the patient who is entering the complaint should be required to spend 28 hours of his or her time pursuing it.

      This seems like it would limit complaints to those where there were very serious and valid concerns, ones which would justify having the physician spend that much time in response.

      Also, it would be interesting to know which other jobs out there require that every customer complaint results in 28 hours worth of paperwork and meetings. If this could happen in “any other job field,” let’s hear some specifics.

      • Eric Andrist

        Why? Patients are often charged an entire doctor visit if they miss an appointment, but it doesn’t happen in the reverse, I’ve sat in doctors offices waiting up to 2 hours for the doctor to get to me, I don’t get any break on the fee I pay because he waste the time that was appointed to me!

        Why should complaints be limited? Who is anyone else to tell someone that their complaint is worth hearing or has an invalid concern?

        Further, the article doesn’t say that every doctor must spend 28 hours doing paperwork, it says that it’s ESTIMATED that it would add that amount.

        I would assume that a lawyer up for malpractice would likely spend as much time defending himself as a doctor, especially if it’s in a medical case.

        As victims of medical negligence, we spend way more than 28 hours putting our cases together against the doctors that harm us. My disabled sister who died at the hands of a negligent doctor dies in March 2012. I spent an entire year just trying to find a lawyer to take my case because of California’s tort reform law, MICRA. In that time, I worked nonstop documenting and detailing everything I could about what happened and doing research. The doctor who killed her, I’ll be won’t put in 2 hours defending himself…he won’t even admit to doing anything wrong.

        The point being, there’s always a price to pay with negligence and the judicial system. Doctors don’t deserve any more of a break than anyone else.

  • drgh

    What is most interesting about this idea is how misguided it is. The fundamental flaw here that i might add is not getting addressed is the basic structure of medical care that is being undermined. If there is only 15 min to dx a problem then how will anything ever get resolved? The govt is too afraid of confronting the underlying problem. It is easier to put more restrictions on the medical team to control the dysfunction than reigning in corp med.. Unfortunately what is obvious to us is that it just adds to the dysfunction and burden esp of the PCP.

    • azmd

      IMO this is one of the main issues in our healthcare delivery system. In order to deliver safe and effective care, a physician needs, more than anything else, time. Time with the patient, time to review the literature, time to think things through thoughtfully when there’s a complex problem to solve.

      But what we’re being given is not time. It’s redundant “QI” and “QA” and “certification” and documentation processes that are intended to improve safety and quality, but end up sucking time away from what we really need to be doing. And it only seems to be getting worse.

      A prime example is CME. I spend about 30 hours a year doing “Category 1 CME” which consists of meaningless documentation exercises that don’t improve my knowledge base one little bit. Then I probably spend about 100 hours a year doing real CME which is reading journal articles and books that are relevant to my clinical work, preparing lectures for residents, looking up things about patients with unusual conditions, etc. None of that “counts” for CME any more, however, so I spend the additional 30 hours a year on the “Category 1 CME” that I can submit to all the various credentialing organizations I am responsible to. It’s a complete waste of my time, which takes away from other more meaningful activities I could be pursuing.

      Meanwhile the CME certification process has become so complex that healthcare organizations have entire departments organized to manage CME activities. Any time our state professional society wants to put on a CME event for our members, the paperwork involved is extensive, time consuming and Byzantine. We’re all drowning in red tape, to the detriment of our patients.

      • drgh

        That’s scary. Ditto. I am in Cali and a few years back was mandated to do 12 hours of pain mngt which was pretty much a waste of time. I think there were so many complaints to the board about mismanaged cases that this was their solution. Not.
        A few months later I sadly saw first hand how incompetent the medical bureaucracy was to get diagnosed and treated myself at several local well known academic institutions. It was utterly maddening and crazy making. I eventually, after being unsuccessful, had to fly to the east coast. I pretty much had to diagnose and find the right specialist myself as no one was willing to take the time to accurately diagnose and assess me. I could write a book on it.
        In short, I actually came to realize that different medical systems, not necessarily the doctors themselves, were very different across the country which dramatically affect their ability to function. In California, for example, if I want to schedule an appt with a particular specialist I have seen before, I need to get an MRI and have the specialist review it before an appt can be made. Even though it is not a new problem. It is actually faster to get on a plane and go back east for an appt. the access to care in this arena is so challenging here. It is possible but lots of red tape and wasted time.

  • Megan Lovorn

    Sounds great that you say no inappropriate lawsuits and complaints are made, but my colleague happened to be included in a lawsuit because he covered for another doctor on a patient that was in the hospital 6 months- the event happened 3 months before my friend covered for another colleague who was a rehab doctor, not the original physician who supposedly didn’t diagnose a patient fast enough with pneumonia so he ended up on a ventialtor (which happens a lot!) -he spent at least 100 hours trying to have himself taken off the lawsuit when he had NOTHING to do with it- they just wanted to sue everyone who had put on name in the man’s chart…..so please don’t tell me this doesn’t happen! How does a rehab doctor have anything to do witht he patient getting ICU pneumonia and being put on a ventilator!

  • rbthe4th2

    Everything I’ve seen and heard from is useless. I had a nurse give me the wrong dose of allergy meds. I showed her where she signed off on my sheet the dosage, her initials and date. I asked her could she give me the other half of the dose? Her face got red and she chewed me out. I got my stuff. As I went to leave, a doctor told her (with me in earshot) you can’t talk to a patient like that. I went to the boards and they did nothing about it.
    That is where boards are useless. They should have done something but didn’t. You have a nurse who disobeyed docs orders, when a request was made from the patient (yes, nicely!) here’s the problem, showed her on the page and asked her to give me the other half of the dose, and I’d be good, and chews ME out for it and that’s ok and approved of patient care?

  • Guest

    I had a serious disease misdiagnosed, likely due to a series of communication problems between the doctor and myself, as well as between the doctor and staff. I’ve contacted the doctor several times directly and tried to schedule a visit to discuss the problems. I have made it clear that I’m never going to sue, but I think my even using that word has had the opposite effect than I intended.

    I think I could make a useful contribution to “root cause analysis” and it could be a good learning experience for all, but they won’t respond. I have been through a complaint process to a medical society (not the board) and was unsuccessful. “Appropriate care”. Misunderstandings were cited, but not, you know, any specifics that could help repair the relationship with my doctor. This, after I had expressly stated in my request for review that I wondered if there were honest misunderstandings that could be resolved.

    The doctor may feel that I was very successful in creating a massive headache and time/paperwork vampire. That’s not what I wanted. The way this issue is framed can be problematic, I think. The antibiotic complaint is a good example because I’m sure it happens often. However, it sort of perpetuates the stereotype that patients are unreasonable in their complaints and that creating problems for the doctor would be “success” in their eyes.

    Also, there seems to be no alternative that is not adversarial. I wouldn’t say this should be all about patients having a way to complain about “bad doctors”. Of course, some are, but in my experience there may be many legitimate reasons to be very up front that there’s a problem with the care, when both the physician and patient (and all the staff) are good people.

    If any doctors are still reading this post, what suggestions might you have for patients who are in this situation? How can patients best respond to problems in a way that makes things better for everyone? Everyone on the doctor’s end is still treating this as an adversarial situation.

    • Guest

      I should clarify that the medical society’s website implies that their “complaint” process is more of a non-adversarial resolution process. I took this step only after > 5 tries with the doctor’s office directly.

      After I received their decision, I sent a follow-up e-mail asking if the misunderstandings could be explained and worked out. Their response was No, sorry, blah blah blah legalese blah blah.

      This has reached almost Seinfeldian proportions of absurdity: No hugging, no learning. Except it’s not funny…I’ve been trying for three years. It’s not true that patients will always go running to an attorney.

      • azmd

        It’s certainly upsetting when you or a family member is misdiagnosed. Just off the top of my head I can think of four or five occasions over the last 20 years when I suggested to a doctor that a family member might have a serious condition of some sort, was blown off by the doctor, but was later proven correct when I insisted on testing, or further consultations with specialists.

        I personally have chalked it up to doctors being humans who will make mistakes, and have left it at that. Just out of curiosity, what would you be hoping to accomplish by meeting with the doctor to review the fact that he or she made a mistake?

        • Guest

          Thanks so much for your input. I really appreciate it. I hope all of your family members get better. I guess what frustrates me is the way that the culture of medicine and the legal system push us to either sue or do nothing. I feel a little weird even having to justify wanting to talk with the doctor, but I’ll try.

          The point is not to review the *fact* that the doctor made a mistake. It’s to talk about what went wrong and how it might be prevented next time. Patients are traditionally left out of these discussions, right? I think our input is valuable, though. I have offered to pay for the doctor’s time, to give you an idea of 1) how important this is to me and 2) the attitude with which I’m approaching it.

          Yes, of course doctors are human and make mistakes. I’ve read your comments in various posts about the health care system, e.g. the lack of time to provide quality care, and you make excellent points. But, given what’s at stake for the patient when a major misdiagnosis is made, I’d hope the doctor would care and want to *try* to find ways to do better?

          • azmd

            I think unless it’s a basic communication failure that the doctor is making repeatedly with multiple patients, the fact is that each case is unique, and many mistakes are just not going to be repeated, because each one arises from a unique set of circumstances.

            As a result, many clinicians feel that although they may recognize that things could have gone better with a specific case, unless they are having the same error happen over and over again, it’s of limited utility (in terms of “doing better”) to process the event with the patient, because that particular set of circumstances is likely never to occur again.

            That’s not to say that it wouldn’t be helpful for the patient emotionally, and a nice thing for the doctor to do….

            Also keep in mind that our healthcare delivery system is geared to care for the acutely ill. If you are not acutely ill, and it takes a while to make an accurate diagnosis, although that is quite frustrating, our system does not particularly see it as a major problem, as long as you were not harmed because of the delayed diagnosis. This is not something we are taught in medical school, but it’s my observation based on about 20 years of having children with various medical conditions, some of them fairly serious, but none of them life-threatening.

          • Guest

            Thanks for getting back to me. I was harmed by the delay in diagnosis. Also, the misdiagnosis happened because of a long series of events, many of which were preventable with a little forethought and awareness. It wasn’t just one bad day for the doctor saying “I don’t think you have that disease”.

            I wonder if we could consider the possibility that patients may have sound reasons to want input in these matters beyond just their emotions?

            For example, I have some suggestions for the doctor about how my history might have been taken better to lead to the correct diagnosis. Is that offensive? I’m also interested in my doctor’s point of view, and have been trying to make it easy for the doctor (offering to pay…I didn’t want this to take anywhere near 28 hours to deal with).

            I just want to make sure that “unique circumstances” isn’t code for “patient’s fault”? I have taken responsibility for my part in miscommunications, but there’s much more that was out of my control. I only wanted to make the point here that patients don’t always want retribution, don’t always want to hurt the doctor’s business, and don’t always make frivolous complaints. I hear that doctors are overwhelmed, and I thank you for the insight into their experiences.

          • azmd

            I want to assure you that “unique circumstances” is in no way code for it’s being the patient’s fault that an error was made. What I meant by that was that each patient presents just a little differently, and diseases have many different ways they can manifest. Many times the circumstances under which a patient comes in, and the process by which they are diagnosed (or not) will not come up again. It has nothing to do with anything the patient does or doesn’t do.

            As for whether it is offensive for you to suggest that you meet with the doctor to offer your thoughts on how he can improve his work, I am not sure what to think. It has never occurred to me to want to do that with anyone who didn’t do a good job on something for me, whether it was a doctor, a plumber, a car mechanic…I would regard that as not a very good use of my time, since I had already been affected by whatever error was made, and meeting with the worker would not change the outcome. I generally just find someone I hope will be more competent, and move on.

            If someone reaches out to me for feedback, I will certainly offer it, but if they don’t, I assume that they are not interested in changing their processes, and so are not interested in hearing my thoughts about how they could improve. Since insisting that someone listen to my feedback is not likely to result in their making any changes, I am not sure what the point would be.

          • Guest

            Thank you for taking the time to clarify. I see now what you’re saying re: unique circumstances.

            Since I’m dealing with a serious disease (expected to become life-threatening although it’s not at the moment), I don’t think of my health care in the same terms as I would a plumber or car mechanic. In other situations those analogies might be more applicable.

            It just seems strange to me…I think an important aspect of professionalism is to always try to do better…in any profession. I don’t understand the resistance. It seems like, my health and life and quality of life on one side of the scale, and on the other side…the doctor doesn’t *want* to talk? Because of not *liking* feedback?

            I understand the concern about lawsuits. From what I can tell, the law essentially doesn’t trust patients to be competent to agree not to sue their doctor? It looks like any agreement I could sign would be contestable in court? Hmm…I was competent to figure out my own diagnosis.

            I don’t doubt this doctor’s medical competence, I think people skills are the key issue. This effected information-gathering, referrals, and pretty much every aspect of the care. I hope it’s not off base to think that people skills can improve through interaction with people? Also, I think it wasn’t just with me. I’ve had reason to believe there’s a pattern developing…

            I’m sorry you had such bad experiences getting diagnoses for your children and relatives. It’s one of many examples I’ve seen, how doctors suffer equally in the health care system when it’s their turn to be patients and caregivers.

          • drgh

            How long did it take to get diagnosed? and by whom?-ie another PCP or specialist?

          • Guest

            I’m talking about a specialist here. I was correctly diagnosed by a more specialized specialist from the same specialty area. :)

            How long? Four more years. The new specialist took me seriously much earlier than that. I think there was an extended watch and wait period and testing for other stuff partly because the other specialist’s final opinion carried a lot of weight at first.

            The specialist I’m trying to talk with was really great for awhile, was definitely trying to help, then did a 180 on the previous opinion and care plan. It was a big mess.

          • drgh

            Do you even have a specialist that you trust now?

          • Guest

            Oh, yes, the one who diagnosed me correctly and the others who I see at the same teaching hospital. Despite the delay, I know he based it partly on incorrect information from the previous doctor. Also, to his credit, he was hoping I had this other disease that he’s usually treated successfully.

            Delays and misdiagnoses based on positive regard and consistent desire to help, are a lot less hurtful than ones made out of anger, as with the previous specialist.

          • drgh

            So sorry to hear that. You are right that if you feel they are doing their best that feels better than what it sounds like you went through. Sounds so frustrating.

          • Guest

            Thanks. :) I saw further down that you also had a bad time. Yikes. I hope everything goes well for you from here on out.

          • azmd

            To be brutally honest, medical school admissions do not select for people skills. The skill sets that it takes to get into medical school and succeed once there are much more organized around memorization and synthesis of facts, than anything to do with relating to other people. The type of person who gets into medical school and does well tends to be highly competitive, not collaborative.

            We give lip service to wanting more medical students with people skills but we keep right on admitting the applicants with the best MCAT scores over the ones who have shown actual evidence of compassion for others, or have demonstrated the ability to get along with others by being in the workforce for a while before med school.

            Once we are in medical school, the training teaches us to be ashamed of being wrong, or making mistakes. Shame is deeply ingrained in every doctor, because being humiliated by our teachers is an integral part of our training. Showing weakness or vulnerability is unacceptable when you have to stay up all night taking care of a hospital full of acutely ill patients.

            So most doctors tend not to have great capacity for intimacy with their patients (or anyone) and they are uncomfortable with displays of emotion, two things that are generally involved when you want to process a mistake with them.

            I’m not saying it’s good, or that it should be that way, of course. Just that that’s the way it is.

          • Guest

            Thanks, azmd. You are right about all this.

            The doctor in question had pretty good people skills early on in the care. Certainly was kind and compassionate enough for any reasonable patient. Then, something went horribly wrong and there was a 180 in terms of behavior. Angry outbursts, etc. I just didn’t want to give the impression that a misdiagnosis was made because I expected long, emotional type listening. :)

            I mentioned issues with the history taking. The problems were not apparent at the time, but, for example, in hindsight it would have been extremely helpful if the doctor had let me finish one sentence because the information I gave turned out to be very important. There were some other technical issues with the history also.

            There were many communication problems between doctor and staff, and the doctor and me. Logistics stuff that fell through the cracks, not emotional stuff. But I see what you’re saying that emotional skills would be required to process a mistake.

            I don’t agree with the way doctors are treated during their training and I can see how that leads to the problems you describe. It’s just that patients don’t know about this on the front end of medical care. We go to see the doctor and our job is to trust, and to build some degree of relationship. But we will be thrown under the bus if a mistake is made?

          • Guest

            Also, I agree if the public expects perfect care, then we’re complicit in this abusive training of doctors and it only continues the vicious cycle.

            I just think we need to be welcomed in discussions about errors and quality improvement. I should add that some of what went wrong in my care was system errors. I see what you mean about unique circumstances, but I’ve had several doctors tell me there’s a lot of pattern recognition, too. And that doctors keep learning from their clinical cases throughout their careers. The medical community underestimates how forgiving many of us are, particularly if we’re allowed to understand the doctor’s side of things. Thanks so much for sharing your perspective.

          • LIS92

            Re: I am not sure what to think. It has never occurred to me to want to do that with anyone who didn’t do a good job on something for me, whether it was a doctor, a plumber, a car mechanic…

          • Guest

            Yeah…I saw your comment on another post and am sorry for your experience. It’s weird, I have just been asked about trust further down the thread. That’s important, isn’t it? When we walk into a doctor’s office for the first time we are supposed to trust them completely. Supposedly the relationship matters. Doctors are often hurt when the relationship doesn’t matter to us, when they bend over backwards to help and we get mad and won’t accept a nuanced viewpoint. All this talk about good vs. bad, competent vs. incompetent.

            If we try to preserve the relationship, we hear “Suck it up! Walk away! Find a competent plumber.” Sorry, azmd :), you put it much more kindly and you’ve been through some exhausting experiences. I’m talking more about the general pressures in response to bad outcomes. Of course, the legal system is there to “help” us :/, but what if we don’t feel that’s appropriate?

            The point of the original post was that patients have a lot of power to stir up trouble for the doctor. We don’t seem to have ANY power to make things better. It’s crazy.

        • Patricia

          What if it is not a mistake but negligence? What if you teenage child could have ended up in ICU or a coma or worse if you had followed the physician’s advice rather than figure it out on your uneducated own?

          • azmd

            If you or a family member has been harmed by a doctor’s negligence, you should sue for malpractice.

          • Patricia

            I called lawyers but the bar is pretty high for one to take a case, even though there was negligence. And even though there was harm. That’s how it is.

          • Guest

            Sorry, Patricia, the above was also to you. It’s ridiculous how patients who are actually harmed can’t get reasonable compensation.

          • Patricia

            Well you know what the studies say…if a doc apologizes people actually would not want to sue for financial compensation. It’s the fact that they don’t want to admit their mistakes. Because we all make mistakes.

          • Guest

            Yep!

          • Guest

            Yes, it is hard to sue, and harder to win. Often the cases that have merit aren’t successful. And what improvements in care come out of it either way?

            I had one other doctor tell me point blank I could easily win on a certain technicality. I didn’t ask, it was just his knee jerk reaction when I told him some facts about what went wrong: “Oh…you could get a lawyer…and a court would…find this in your favor.”

            I can’t talk with the doctor instead? Seriously? I think in some cases a lawsuit is appropriate. For a variety of reasons, it wasn’t the direction I wanted to go. I’ve read about individual doctors who reach out to patients when they make mistakes and some disclosure programs…somewhere…uh, not in my neck of the woods, I guess, and nowhere in this discussion.

          • azmd

            The standard of care from a risk management standpoint (among others) is to call the patient to disclose that a mistake was made.

            I can tell you from my personal experience with the one time I had to make such a call that it is an emotionally difficult thing to do for the doctor, since as I mentioned below, a core premise of our profession that it is unacceptable to make mistakes.

            Add to that the fact that many patients will respond to the news in a way that is best managed by someone with psychotherapeutic skills, which most doctors don’t have, and it is not too surprising that a lot of times those calls don’t get made.

          • Guest

            Thanks…interesting. Don’t sometimes different malpractice insurance carriers forbid doctors to disclose?

            It’s just strange, usually we hear about doctors being all about evidence and facts. The original post mentioned bad doctors “out there”. I sense (in general, not picking on you) that doctors suppress their emotions and kind of project them onto the patient: “the patient will just freak out if I say anything, so…”.

            It seems like reasonable expectations all around are part of the cure? And how can we get there?

          • azmd

            In general, you are right. Doctors suppress their emotions. We couldn’t do what we do if we didn’t and so we are schooled our entire professional lives to present a calm and unemotional face to our patients. Unfortunately, what that means is that many of us have a very low level of tolerance for patients expressing strong emotions, since we are trained to see that as a character flaw.

            It’s a fundamental double-bind in the profession and I am not sure what to do about it. I think one place to start would be for patients to understand that most doctors are not therapists, and that you will get the best results from a doctor almost always by interacting in a matter of fact manner while keeping in mind that in most cases, although the doctor may seem very calm and professional, inside they are feeling extremely stressed, almost always, no matter what the interaction taking place is.

          • Guest

            Great advice. There needs to be more public awareness that doctors must put up a front in order to function.

            Most of us don’t expect emotional therapy from our doctors. Often we 1) are out of our element or 2) our illnesses make it hard to communicate. Heck, until recently the fact that doctors often have only 15 minutes was a big secret. :/

            You all actually have a lot of power to set the tone of the interaction. Give people a chance to behave appropriately. It will save you energy if you can refrain from getting mad at us. If we are very emotional or get off track, we can be gently redirected:

            “I’m sorry you are stressed, I don’t have much training on the emotional side of things, but I’ll do my best to help you solve your medical problem. In order to do that, I need to know…”

            When it comes to discussing errors, many patients could contribute facts and ideas, not just emotions. We also want to understand the facts of what happened to us. At this point, it adds insult to injury if the doctor who harmed me assumes I have nothing better to do than scream “How could you let this happen?”

          • azmd

            I don’t want to sound jaded, but when you say that “most of us don’t expect emotional therapy from our doctors,” and “give people a chance to behave appropriately,” you are probably saying that because you have no idea how many people out there have vast and unmet emotional needs. Those needs are so pressing that frequently, people lose awareness of whether what they are expecting of their doctor is reasonable or not.
            In my job, I regularly extend myself to patients’ families because I work in a field where the illnesses are devastating, and the patients need their family’s full support and engagement. Although I have a full-time social worker one of whose jobs it is to return calls from patient’s families and communicate with them about their care, I will frequently call a family member myself. In about 70% of cases, the result is that that family member will then start calling me every single day for updates, although obviously if they stopped to think about it, there’s no way that I could possibly provide daily updates to family on every one of my patients. That would be an hour and a half a day of phone calls, which by the way is completely unreimbursed work.
            Just yesterday, I called the father of a patient and instead of eating lunch, spent 30 minutes explaining to him my reasoning in arriving at a complex diagnosis on his child. He appeared very appreciative and voiced gratitude for the call, but then five hours later arrived on the unit and asked me to be paged to come meet with him face to face, although there had been no change in his child’s condition. This was at about 5:30 when I still had residents in my office needing supervision and all my notes for the day yet to write.
            My point is that I think doctors attempt to avoid signaling to patients that they are emotionally available to be supportive, because when they do, it very often is interpreted as opening a door to future requests for more time and attention, when your intent was to attempt to satisfy the patient’s needs and move on to the next person who needs you.

          • Guest

            Yes, I see what you’re saying. It’s good that you explain this so hopefully people will see how badly it gets piled on to doctors. I completely agree that the boundaries need to be set. I only suggested that this can be done in a way that reaffirms the desire to provide *appropriate* help, and avoids rejection/judgment.

            The stigma against mental health care *does* lead some to their primary care doctors and certain specialists for, essentially, psychotherapy under the guise of a medical problem that the doctor actually is qualified to deal with. This can happen either consciously or unconsciously on the patient’s part.

            I was speaking from my own experience as a formerly “anxious” patient who sometimes had my doctors almost tearing out their hair. Once I started to get correct diagnosis and treatment for different problems (e.g. endocrine which can cause anxiety and confusion), all of a sudden, I’m reasonable, my doctors like me just fine, and I’ve had enough experience with the health care system to communicate effectively, respect the time constraints and boundaries. I did not mean to do this badly before, I just didn’t know what was expected. I think many people are unintentionally self-absorbed when ill, but they can be gently redirected. It won’t work for everyone, but it would work for someone like me.

            It’s only very recently with health care reform that there’s much information in the media so that people can learn how packed the doctor’s schedule is, what needs to be done for efficient “flow” in a medical office, etc. And we need to learn way more. The old messages we heard (from media, family, etc.) were more like “tell the doctor everything, let him sort it out”, which can lead to the boundary violations you describe.

            Also, my experience is that doctors will sometimes go hunting for emotional problems at the start of a visit, often quite aggressively. It’s as though they want to root out any chance that a patient might do what you describe, azmd. That’s a tough one, because we’re supposed to answer a doctor honestly, and everyone has deep, unmet needs and problems. But many of us know we shouldn’t subject the doctor to those, we’re just answering the questions, and not knowing where the doctor is headed in the interview. That’s what I meant by “Give people a chance to behave appropriately”.

          • azmd

            I am in complete agreement that there is a pressing need for better access to psychotherapy for all of us, doctors and patients alike.

            I am not sure what to say about doctors who “hunt aggressively” for emotional problems. I have actually experienced that myself as the mother of a child who needed specialty care and am not sure where it comes from, but I agree that it is deeply offensive. I can only surmise that it is somehow related to our training which paradoxically, IMO, makes us much less tolerant of other people’s emotional needs.

            As for your comments, made elsewhere, that doctors are not receptive to suggestions made by patients to improve care: I think a problem with most of those suggestions is that they almost always involve, somehow, the doctor spending more time than he or she has available for the encounter. Since none of us really has more time to give, such suggestions tend to create the internal response ‘That would be great if I or anyone else had time to do it.” I think suggestions that involved ideas about how we could do our work more efficiently and at the same time help our patients feel more satisfied would interest lots and lots of us.

          • DoubtfulGuest

            I bet you’re right that these “pre-emptive strikes” are rooted in the training. Re: doctors’ stress, I agree that patients should try the calm, matter of fact approach as much as possible. I have spent hundreds of hours reading to try to understand what the doctor who harmed me might have been going through.
            Re: the time factor…I think I understand and am willing to adapt to that. I don’t know what would be legal or allowed since I previously had insurance on file, but I have offered to pay cash up front for every minute of this doctor’s time to discuss what happened. Some of my suggestions do involve efficiency. Other ideas, such as how to get past certain biases that affected my care, would take time to think through initially but would likely save time when put into action during patient visits.
            Do you have any suggestions for how patients can prepare feedback in a way that would be helpful to doctors? I have written several letters, but I think the tone was misinterpreted (as adversarial when I didn’t mean it that way). Also, I think face to face discussion can be much more productive, as in “Okay, I see how that might not be feasible, so what about this way?” Thank you, and I hope you are getting lunch these days.

          • Alice Robertson

            Quote: ” I have actually experienced that myself as the mother of a child who
            needed specialty care and am not sure where it comes from, but I agree
            that it is deeply offensive”

            From a patient’s perspective it would appear to be a modern medicine evolutionary mode where it’s survival of the fittest:)

          • Guest

            Also, I totally agree that anything more than an occasional phone call (weeks or months apart? not hours) is inappropriate. I was referring to interactions during scheduled visits only.

          • Dustin Salzedo

            A suggestion to chew on: devise, in concert with the staff who will participate, a communications guide/action plan for your patients/families. Include specific steps to take with:

            Emergencies (call 911, home health agency, hospice, etc)

            Diagnostic questions (secure medical portal email messaging, practice email, dedicated voicemail, social work or practice RN contact, etc)

            Medical orders/care plan questions
            Appointment scheduling (one number telephony/secure portal electronic scheduling, etc)

            Modes of contact with expected response times (email, Twitter, FB, secure medical portal, practice website, etc) and associated fees for any of the above

            You can always customize it for specific needs (write-in space for your pager/cell number, team access pager, etc). Every patient/family should get this guide at first contact. You can also keep it posted on your practice website.

            When people have both the resources to get perceived needed help and the structure in which to do it, they are more likely to respect and participate.

          • anon3

            perceived help? This is exactly the problem with egos like you. Who in their right mind would go anywhere near you disgusting invalidating pieces of scum were it not for the PERCEPTION that we needed help? That being we need help when we need it, which perceptions dictate. It’s a need regardless of your agreement with us and your death-bed standards. Buy a dictionary.

          • anon3

            I don’t agree that medical professionals have to supress their emotions. I know rudeness when I see it. There is no excuse to go so far putting on a front, so terrified of emotion, that you are insulting the patient the entire time, acting alien. I have spoken to plenty of staff who seem like normally functioning humans and who express appropriate emotions. I will also say that it is subtle, but that staff often display inappropriate emotion and the emotion they express the most is frustration, anger / contempt.

            Please note: You are probably right, and you are a / the doctor.. but these are just my observations and strongly held opinion. I think that anyone going to their doctor an emotional wreck, unless it is about the actual pain or suffering of their illness(es), is being extremely rude, inappropriate and unfair on the doctor.

          • Guest

            Haha, anon3, I kept meaning to say that…there is PLENTY of strong emotion expressed by doctors but it is often anger. The “display of strong emotion” by the doctor who misdiagnosed me was not subtle.

          • karen3

            You aren’t working with any of the risk management people folks who have been harmed work with. The responsibility of risk management is to rewrite the medical records to get the doctor off of the hook and then to bully the family with guilt so they wont sue.

          • Guest

            You got a risk management person to even talk to you?

          • karen3

            Wouldn’t it be better to learn from cases where there was an error, that didn’t result in harm enough to sue? That perhaps involved a person that society doesn’t view as meriting damages, such as children, mothers, and grandparents? Why should a doctor get a “free bite” just because the mistake was not so bad as to cause enough to sue? Don’t you think patient safety is more important that doctor egos or even careers?

        • karen3

          That is how people learn. What someone else sees in a situation may not be what you saw. So to truly understand, you have to listen.

          I agree that for many doctors, such a process would be pointless — in many cases the error occurs because of physician arrogance and poor listening skills — and a conversation surely is not going to change that. But for the rest, doing the right thing for the patient and hearing what went wrong from an equally valid viewpoint should be viewed as valuable,

          • Guest

            Yes, I have trouble believing they could learn nothing useful from our experiences. Weeeellll, let’s just check to make sure, right? Have they tried it?

  • anon3

    Do you really think you are so above patients, and untouchable, that you should be able to not just make mistakes, but do things well, and not have to explain this to patients who don’t know what happened, when you are the only possible person who has the power to do so? It is precisely for this reason of power over people, that you want to retain the upper hand by not allowing patients any control over things, especially things that would not make you look as good as you want to portray.

    • Guest

      It would be nice if a doctor would respond to you…their reaction to their own mistakes is chilling and disturbing. It’s not a grown up way to handle things. It sure looks like a power trip. I think it only rarely is, though. They go into medicine to ease suffering, and they’re just people. They are damaged by their training and all the pain, illness, and death they see.

      Some hide the damage well, and a few have a great support system that keeps them sane. Patients only see a small part of a much bigger picture because we think these are the great doctors who would never hurt us, and the others are “bad”.

      That said, I’ve spent hundreds of hours learning about this stuff, while the doctor who harmed me has done…?…(taking care of thousands of other patients, to be sure, but I guess it’s cool that I fell through the cracks?)

      • anon3

        what is it about training that damages them?

        • Guest

          azmd explains really well below, I’ve also read about it…late nights/sleepless nights, being yelled at and embarrassed by their supervisors (“attending physicians”-their professors, and also people ahead of them in training, such as residents), being treated as though they’re idiots and totally worthless if they make one mistake, or forget one detail of the human body that they learned in courses, not having time to eat or go to the bathroom, working when they are sick (with a high fever, between bouts of throwing up, etc.), watching someone die for the first time and feeling helpless, then it happens over and over again, being yelled at some more…

          Because the training takes so long, this continues to some extent until the doctor reaches his/her 30’s. Only then do they have some hope of being respected for their work and earning a decent living. And many can’t even do that anymore. I’m
          aware that at least one of my doctors is barely getting by. We pay a lot for care, but often most of the money goes everywhere but the doctor’s income.

          Basically they are taught that they have to be superhuman, and it’s just not possible. We
          somehow need to change the system. The way it is now, most of the time, if a medical error happens, someone gets the shaft. Either the doctor is punished way too much, and no one looks at how to prevent the mistake next time, or the patient just has to accept that they were harmed. Even wanting to talk over what happened is viewed as a huge threat. You’re right that it really looks like they just want to maintain power over us. But, it’s mostly a defense
          mechanism.

          • EmilyAnon

            I’ve never understood this ‘pimping’ of med students or junior doctors. Why, just because the senior doctor went through it too, so they have a right to slap down those below them. Will this tradition of humiliation make future doctors more humane when they’re in charge? I think there’s a big chance that remnants of this degrading custom will be passed to the lowman on the totum pole – the patient.

          • Guest

            Yes, ‘pimping’!, I forgot the word for it. I think that’s exactly what happens. They don’t even realize it, but they do to us what was done to them. I think some medical schools are trying to do better. I see doctors at a teaching hospital and have heard at least one of them is equally kind to his students. (Well, that’s an n of 1, but i’ve read about the culture of med school slowly changing…maybe?)

            When mistakes happen, it looks like doctors are afraid of being humiliated again and they kind of shut down. There’s this attitude of “Hey, I made it this far, don’t you tell me how to do my job”.

            I think they need to feel understanding and respect coming from us. It would be easier to show them that if they would actually talk with patients, and help us through it in the event that they unintentionally harm us. And not just for our emotions…we might actually have something useful to contribute.

          • Patricia

            Imagine having a job where you are never respected and you are perennially pimped out for only the value your body’s physical labor could offer. Then imagine having to pay for costly medical insurance and dealing with some poor overburdened doctor … Get real.

          • Guest

            Good point. I have had jobs like that, without the insurance part. Some doctors go months without any paycheck, and they may not have health insurance, either. Six-figure debt from medical school, too.

            Don’t get me wrong, many of them are still talking down to us from a point of privilege, or…memories of privilege? Who knows? It needs to change, but I think that’s more likely to happen if we try to understand one another’s viewpoints.

          • Patricia

            I disagree; the physician should always try to understand the viewpoint of the common person not the other way around. Getting an education, regardless of the price tag (plus the esteemed title of “doctor”) is a privilege. Plus the power differential. Oh and many docs are now making money in other lucrative fields (e.g. medi-spas).

          • Guest

            Fair enough…it’s just my way of coping with things (I had a serious diagnosis missed for a long time). The doctor who screwed up the worst is in a pretty bad place, financially, and probably doesn’t sleep much. None of what I’m saying applies to the lifestyle specialty docs who are doing well.

            I do agree with you that doctors in general will continue to have a serious PR problem if they don’t work on how they talk to and about patients.

          • Patricia

            Yeah,times have changed and the medical world, I think, should quit complaining and get up to speed. But that’s just me…

  • Patricia

    Are you kidding me?? A patient’s retribution is to leave the practice? This is totally absurd. If you doctors were better at policing your own then patients would not NEED to complain to any board of file malpractice suits. I really think that if you were interested in “doing no harm” you would find ways to hold your own accountable. After experiencing so many despicable and harmful actions from doctors I have no sympathy whatsoever for them and find this totally offensive. As a matter of fact these actions have so disillusioned me that I have lost trust in my own doctors and have decided to figure out my own problems and do my best to get the tests and medications I and my family need through the ‘gatekeepers’ who I find really insulated and insular.

    • Guest

      Sorry to read about what you went through with your kid’s diagnosis. I wish doctors would take parents’ instincts more seriously.

      I also thought this article’s tone was off-putting. So much black and white thinking, and us-against-them words in the first two paragraphs. I’d feel better if I knew that he took a moment to explain to this patient why the antibiotics weren’t appropriate, and check her understanding. It comes across as “silly patients and their frivolous complaints, takes too much time”. Maybe we could come up with a better system if the complaints didn’t all run together in the doctors’ minds:

      “You missed a life-threatening disease and, um…I didn’t like the magazines in the waiting room?” :/

      • Patricia

        Thank you and you know I wonder if there is more behind the story than a simple strep vs antibiotics complaint. I honestly wonder why people go into medicine if they don’t want to deal with actual people.

        The problem is that I have no real recourse against my son’s doctor because malpractice doesn’t apply I guess (even though he missed a year of school and was prescribed psychiatric medications that caused him significant problems). If I complain (which I WILL once I get him to an adult physician since he is 18 now) I am sure it will go in a sort of dustbin of “complaining moms”.

        This is not a one-off either. And we are in a different era of patient-doctor relations and doctors better get used to it and become aware of it because if not, it will be troublesome for them. And hopefully costly.

        • Guest

          Yeah, that sounds pretty serious. I think it’s worth it to complain/bring it to their attention however you can. Maybe the mom dustbin will overflow and then they’ll rethink their approach?

          Re: antibiotic lady, sometimes we tell doctors stuff and I swear it goes in one ear and out the other. You may be right that there’s more to it. The post is just so smug. The hypothetical “bad” doctors are always someone else, far away. It would have been nice to see a more balanced piece about complaint processes and how they’re set up to waste *everyone’s* time while improving nothing.

  • Guest

    What about the patient who suffers from a medical error but isn’t aware of that until well after the fact?

    Also, your comment about “leaving the practice” is rather short sighted as this is not an option with certain specialists (interventional radiologists, anesthesiologists) as you get assigned a consultant at the time of your procedure (unless you are savvy enough to request someone ahead of time which most patients are not). Also, this is likely not an option in rural areas or blighted neighborhoods.

    I reported a fellow physician who was dangerous and incompetent. This was an individual who the rest of us found ourselves bailing out time and time again. No sanctions were taken against him; he retired voluntarily (after some pressure but without any sanctions).

    Patients need more protection against dangerous practitioners. Your example is a poor one, and I’m sorry for the stress you went through. But there needs to be more oversight into weeding out the dangerous practitioners.

  • usvietnamvet

    It’s sad that many bad doctors make it worse for the good ones. But until the good doctors start policing the bad we will have such systems.