Not all adverse events are preventable

Medical errors are a real problem. I won’t deny that.

It was bad enough when the often-quoted Institute of Medicine figure that 98,000 deaths per year in the US are caused by medical errors was in vogue, but now a paper in the Journal of Patient Safety states that adverse medical events result in 210,000 to 400,000 deaths per year and 10 to 20 times those numbers of serious harms.

Since the paper disparages the medical profession, it has received a lot of media attention.

Most articles about it simply regurgitate the dismal estimates without any real attempt to dig into the paper’s methods.

Let’s take a closer look.

As is true of many papers, the abstract is a bit sketchy when describing how the paper arrived at its conclusion.

The full text of the paper reveals the author found four studies that looked at what are described as preventable adverse events in US hospitals within the last seven years. All four used the Global Trigger Tool which involves the screening of records for adverse events by nurses or pharmacists and a secondary review by physicians.

Based on opinions by “experts,” the author made a key, but erroneous, assumption that all adverse events are preventable.

The basis of that assumption was apparently this statement in the methods section of a 2011 paper in Health Affairs about the Global Trigger Tool.

“Because of prior work with Trigger Tools and the belief that ultimately all adverse events may be preventable, we did not attempt to evaluate the preventability or ameliorability (whether harm could have been reduced if a different approach had been taken) of these adverse events.”

The “belief that ultimately all adverse events may be preventable” is not supported by any facts, which are not necessary I suppose if one simply has a “belief.”

Personally, I do not share the belief that all adverse events are preventable. Let me give you a few examples of why.

Aspiration of gastric contents is considered a preventable adverse event, yet I can see no way to prevent every single occurrence of aspiration. If you can, please share it with the rest of us.

Leukopenia (a dangerously low white blood cell count), which often leads to sepsis, and is a common side-effect of cancer chemotherapy could be prevented by never using chemotherapy, but is that a realistic solution?

Repeated studies of deep venous thrombosis have found that no measure, be it drug or mechanical device, is 100% effective in preventing DVTs.

Several papers addressing the use of the Surgical Care Improvement Project guidelines for prevention of surgical site infections (SSIs) after colon surgery have found that even when guideline adherence is nearly perfect, at least 8-10% of patients develop SSIs.

Sometimes adverse events are due to patient-related factors. From an editorial in JAMA Surgery commenting on a paper about SSIs:

“[W]e are left with the yet unanswered question about how to remediate the problem [SSI] beyond adherence to SCIP. Short of a large scale public health campaign to address smoking, obesity, and comorbid disease, the findings do not expose a practical way forward.”

Pop quiz.

The Journal of Patient Safety paper estimating 210,000 to 400,000 deaths due to preventable adverse events was based on four papers with a total of how many deaths?

a. 38
b. 380
c. 3,800
d. 38,000
e. 380,000

If you said “c. 3,800,” you would have only been wrong by a factor of 100. The correct answer is “a. 38.”

Adverse events and deaths due to medical errors are serious issues that need to be addressed. But inflating the incidence of the problem does nothing but further erode the already shaky confidence of the public in the medical profession.

And creating the impression that such events are totally preventable leads to unrealistic expectations and unachievable goals.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • karen3

    Not sure how you got to that number. One of the studies used was the HHS OIG review, which found 180k preventable deaths for Medicare beneficiaries each year, based on a records review with an assessment by licensed physicians on the question of error and preventability. Obviously that number would not include deaths due to preventable error for non-beneficiaries or errors that occur that are not documented in the medical record.

    And most certainly there are many deaths that arise from medical error that is preventable. Trolling out a hoary list of possible made up incidences where that a finding of non-preventable error might be found does not prove that that there are not patients who die as a result of preventable error. I know. My mom died of 100% preventable error.

    As for the assertion that the author assumed that all errors were preventable, please provide the exact quote from the study.

    • JustADoc

      There were 1.8million deaths in the US for those aged 65+ in 2010(http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf). Most of those would be Medicare beneficiaries. There are some Medicare benificaries younger than 65 true but for rough math this is probably good enough.
      The claim is 10% of those who died died because of preventable error.
      That just doesn’t come close to passing the smell test. Do errors happen? Yes. Do people sometimes die as a result? Unfortunately, sometimes yes. Does the fact the an error happened and the patient died mean that the error caused the death? That is a resounding no.

      • karen3

        I am going to tell you that from the response I have received from telling people about what happened to my mother, at two thirds of people who have lost a parent believe that physician failure resulted in the death of at least on of their parents. And not everyone’s story seems to be a misunderstand of what doctors do. Ten percent seems low to me. And i think that if you talked to anyone in the shoes of patients who have regular and significant contact with the medical system would think your argument does not meet the smell test. What things look like depends on where you sit. The numbers are 100% credible,

        As to your question, the reviewing doctors in the study in fact made the distinction you are asking about. Yes, the error was a contributor to death, no merely correlated with death. You can try making fine distinctions, but it isn’t gonna work.

        • PoliticallyIncorrectMD

          For starters, no retrospective study can prove causality (and I doubt the patients were randomized to “error” / “no error” groups).

          Also, what kind of evidence is “two thirds of people who have lost a parent believe that physician failure resulted in the death”? Even if it was true, what people choose to believe and what really happened are two different things – denial is not just a river in Egypt.

          Assuming for a second, you are right – what is your explanation? You can’t seriously think that most of the doctors are either completely incompetent or conspire to kill patients. Perhaps your own experience, no doubt very traumatic and possibly related to a medical error, renders you unable to pass a rational judgement on the issue.

          • rbthe4th2

            I would respectfully disagree due to blacklisting and iatrogenic neglect. If you all would like, I’d bring up places that show how well whistleblowers are treated within the medical profession. Comments on how docs shouldn’t treat malpractice lawyers and their families. Student docs who think doctors should be kicked out of the profession if they testify for the plaintiff in lawsuits. Medical boards and hospitals not policing people like Charles Cullen, the most prolific serial killer in medicine? Do you think these sort of items bring credibility to the profession or give support to that 10% figure being high?
            No they don’t.

          • PoliticallyIncorrectMD

            ???

  • doc99

    Guns Don’t Kill People. Doctors Kill People.

    • Skeptical Scalpel

      Not only is your comment offensive, it isn’t even funny.

  • Thomas D Guastavino

    First of all, I have never heard of any human endeavour, especially one as complicated as health care, that can be made 100% error free. Second, near the top of the list of the numerous politcal failures of our profession was our failure to make clear the distinction beteween an error and a complication. While It may be possible to 100% prevent wrong site surgeries and transfusing wrong type blood, it is not, and will never be, possible to prevent all SSIs, DVTs, pneumonias, etc., etc. I have been in practice over 25 years and it is absolutely insulting to believe that we have turned a blind eye to these issues and not done everything in our power to prevent them. In fact the current policies if anything are placing patients at risk. For example, through time and experience I have developed a protocol that nicely balances preventing DVTs and not causing undue bleeding risk. When DVTs were declared never events, potential bleeding risks ignored. There was a sharp increase in the use of anti DVT meds that added no additional protection but greatly increasesd bleeding complications. Worse still, when these issues were brought up to our hospital adminstration they at first were ignored. It nearly took a threat of legal action to stop the practice.
    Protocols can make things better, worse, or simply verify what you are already doing. I cannot think of a single time when a protocol made things better.

    • karen3

      I have a QIO report and a letter from the Board of Medicine saying that in fact the doctors “turned a blind eye” to seriously deficient care. Try some less sweeping statements, please..

      • Thomas D Guastavino

        And do you believe this is representative of the profession as a whole? If you do what would you do to solve the problem? Try some less sweeping statements please.

        • PoliticallyIncorrectMD

          Great comeback!

        • rbthe4th2

          Unfortunately sir, it is. 3 internists, 3 FPs, 1 endocrinologist, 3 GI’s, 2 PA’s, never tested for the items I suggested would prove the issue. I had one doc, who is not associated with the groups above, figured it out by symptoms and didn’t need my evidence. Again, I’m not the only one this happens too.
          My suggestion: what were you (supposedly?) taught in med school? Judge the patient not the paper. If at first you don’t get it, examine the patient. If the information they bring you is credible, what’s another couple of blood tests? Lab results are not the end all be all of things. If people show signs and symptoms but are maybe high/low normal, they might have a disease that you would diagnose if the computer didn’t tell you it was L or H. Don’t tell someone they’re fine when you see 7 L’s and H’s on bloodwork. If you tell patients you won’t do anything until something is low or high, then you do nothing when it is, do you think that creates trust between you and the patient? If there is an adverse event, be honest about it. I have a link to an item where the surgeon did something wrong and fessed up. The patient let him fix it. Why? He was honest. Someone else commenting on there said they’d want them as a doc. They figured they were the kind of person who would learn from their mistakes and try hard not to do it again. When the ego gets in the way of treating people, when the paycheck does, when the prestige of the “MD” does, and yes, we DO see this, maybe its time to take a break. Most importantly, do something about the suits/administration and lawyers. Publicize some of your events – I had an eye doc who said what his worse case was, he got sued on it, and how he followed procedure (it was one of those events that happened, no ones fault). I will NEVER EVER leave his practice as long as he’s there. Publicize stats. Put some bite into state medical boards and put patient advocates on them (like city/county governments have volunteer boards). Truly police your own – that means not getting rid of nurses who report surgeons who won’t follow checklists.
          Really, this is all simple stuff.

          • Thomas D Guastavino

            Im confused. You state we should “Judge the patient not the paper” (i.e, treat the patient not the checklist) but we should also not “get rid of nurses who report surgeons who wont follow checklists” (i.e. treat the checklist, not the patient). Really, not so simple at all

          • PoliticallyIncorrectMD

            I am trying to understand your reasoning here. Multiple independent medical professionals from several disciplines who have spent years in training concluded that you do not suffer from condition X. You, after on-line search (!), came to opposite conclusion. Do you think it is remotely possible that they are right and you are wrong, or you only going to judge their conclusions based on whether they are in agreement with yours?

  • Suzi Q 38

    I have to agree with you.

    • Skeptical Scalpel

      rb, I am not sure what the preventable medical errors are in your anecdotes. Sometimes even the best doctors fail to make a correct diagnosis. If one does a thorough exam and orders appropriate tests, yet arrives at an incorrect diagnosis, is that a preventable medical error? I am not so sure.

      • rbthe4th2

        If you tell a doc & show them medical literature that indicates you might have a particular issue, & the doc doesn’t check it out, we call that a preventable medical error. The medical establishment may not we sure would. Isn’t the first rule, go back and examine the patient or the patient will tell you the diagnosis 80% of the time? Judge the patient, not the paper, isn’t that true?

        At the very least, rather than poo poo the evidence, do a little more digging you know?

        Not all adverse events are preventable, in a way true. I have had adverse events or complications that no one could have foreseen. Its in the fact that the docs haven’t run “appropriate” tests, asked “appropriate” questions, and just drop it, that there’s an issue. That is a very preventable adverse event. When your patient doesn’t get better, just gets worse, and you blow them off, what does that say about the profession? I don’t have money, its ok for me to die?

  • Skeptical Scalpel

    Allie, thank you for correctly deducing what I was trying to say.

  • Skeptical Scalpel

    rb, forgive me, but I do not understand what you are trying to say.

    • rbthe4th2

      If I gave you articles from various journals that said ‘here is the problem’, and you refused to test for that problem, look at the literature, and I suffer damage from it, that’s an adverse event.

      I would expect a doc to look at it and I’ve found way too often that docs brush it off.

      Or my favorite, aren’t up to date. I had a GI (read 3 years of residency and 3 years of fellowship training) tell me I couldn’t be malnourished because my abumin levels were fine. Go to http://jasn.asnjournals.org/content/21/2/223.full
      The first sentance is “The decision by nephrologists, renal dietitians, federal agencies, health care payers, large dialysis organizations, and the research community to embrace serum albumin as an important index of nutrition and clinical performance is based on numerous misconceptions. ” So I can figure this out but a GI gets mad because I present it to them? That’s not someone keeping up with new developments.
      I don’t have a problem that docs don’t have time to read everything, but that is where a partnership comes in where if we give credible info, be willing to at least glance at it.

      • Deceased MD

        I can empathize rb. I wonder if there is either conflict around the particular illness or the presentation was unusual, but clearly you felt dismissed.

  • Thomas D Guastavino

    I dont quite undestand the point you are trying to make. It is extremely rare that even medical peer reviewed evidence puts things in absolute terms of true or false. Medicine has, and will always be, a work in progress. You cannot take yourself to a physician and expect the same results as you would if you took your car to a mechanic.
    However, the point being made by this article was that it was a mistake to try and label every complication as a preventable error. There will never be any protocol that can 100% preventive. My point was that the attempt has actually made things worse. No protocol will ever to superior to a physicians judjment based on time and experience. True, physicians have to stay aware of new developments but the vast majority of physicians have been doing that since the dawn of medicine.

    • rbthe4th2

      My point, to both Skeptical and Dr. G, is that if patients present symptoms, find the possible answer tying all those symptoms together in peer reviewed medical literature, get told ‘that’s not it and/or we can’t diagnose you’, the patient gets so bad off they suffer permanent damage because the answer they found was the right one, that’s an adverse event that is preventable.
      Wouldn’t you expect a loss of confidence & trust in a group, when presented with their own groups’ experts & advice on an issue, ignore that to the patients’ detriment?
      That’s an adverse event. It happens a LOT. Way more than it should.

      • Thomas D Guastavino

        If this actually happened to you I am sorry but this is certainly not representaive of the profession as a whole. I often encourage patients to research conditions on their own so they have a better understanding of their conditon.
        However, once again, the fact that errors occur is not the point of this article, we certainly acknowledge that. Please re read my previous post.

      • guest

        What you need to keep in mind is the level of acuity of the problem you are bringing in for assessment. If you are asking the doctor to assess you for a condition that is not that serious, or for which there is no real recommended treatment (i.e. your interest is really more academic than therapeutic) then it is true that a busy clinician will not be that motivated to read articles and have an academic discussion with you about your symptoms.
        Without actually knowing the specific problem you were asking about, or the nature of the “permanent damage” you sustained, it is somewhat difficult to tell if your doctor missed something serious that he or she could have caught if they had listened to you, or whether something else happened, clearly something that you feel bad about, which is regrettable, but not necessarily the same as you getting substandard care.

        • rbthe4th2

          Condition slowly progresses to life threatening, with longer periods of non treatment making certain damages to the organs/nervous system permanent.
          So far, for issues warned about & not diagnosed, treatment has cost in the $13K range (possibly more). It costs about $700 I think for the tests.
          Maybe we should define substandard care. I would say substandard care is: patient presents with issues. Doctor tests a few general items (CBC, basic stuff) & says everything is fine or something isn’t that low or high, etc. Patient requests tests that actually, scientifically proven, will help diagnose the issues. CBC doesn’t do that. Doctor refuses because generic CBC is good enough for them.
          Doc says he tested, but the tests are inappropriate. Is that standard of care in medicine? If so, it would explain why I’ve seen missed diagnosis and misdiagnosis rates up to 20-30% now. The fact that PCP’s are now getting hit with more lawsuits due to the above.
          The funny part in all of this: I won’t take antibiotics, pain pills, etc. unless I have to. I never ask for them and in about 5 or 10 years, I think I may have gotten them twice – and that was based on the doc. Not me asking. I also patronize docs who advocate healthy eating and exercise. Now the one doc I have who does supplements, etc. OH BOY I have checklists and he KNOWS I salute when tells me something.
          So in case any one is thinking I’m one of those who believes substandard care is not giving me antibiotics for the winter flu, nope, not me. Some of us do have a pair. :) ;)

          • guest

            Again, without your being specific about the problem that you feel has been misdiagnosed or underdiagnosed, it is difficult to make a judgment about whether you have receive care that is substandard.

            Reading between the lines, it sounds as though you may have a concern about a possible nutritional condition. If that is true, than the problem is not that you have been receiving substandard care, the problem is that you are going to allopathic physicians, who receive almost no training in nutritional issues, since subtle nutritional and metabolic abnormalities are not considered to be acute medical problems that warrant a lot of focused attention.

            You may find that a naturopathic doctor would be a better fit for you, but that does not mean that you have not received what the traditional medical world considers to be adequate care and it does not mean that “mistakes” have been made in your treatment. As an example, I hired a fashion photographer to take pictures at my wedding many years ago. Funnily enough, I ended up with wedding pictures that were a little unconventional, but I didn’t consider that the photographer had made “mistakes.” He just wasn’t trained or experienced in the type of photography I wanted done.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    In all fairness, the author of that “study” assumes (not sure why) that “the average percentage of preventable adverse events among all adverse
    events in the 3 studies where this was reported or postulated was 69%”.

    What bothers me more is the inconsistent terminology regarding the outcomes. First he is using a “death rate from adverse events of 0.89%”. Then he is concluding that there are “210,000 preventable adverse events per year that contribute to the death of hospitalized patients”. So which one is it, “contribute” to death or cause death? If the former, then what is the magnitude of said contribution? Was the life expectancy of the patient prior to the event measured in years, months or days and maybe hours?

  • ErnieG

    I believe this line of thinking form Payne Hertz is flawed, and likely a result of distrust or poor outcome from a past event from the Payne Hertz. Occasionally post like this bring out anti-medial care sentiment.
    1) There is a 100% mortality.
    2) Patients are people who suffer from disease, and are more likely to have an early mortality, compared with healthy people
    3) In the US, it is increasingly common to die under medical compared with dying at home (i.e. away from medical care)
    Therefore, it is going to look like medical care kills people, when in fact people who seek medical care are more likely to have disease and early mortality.
    4) The study cite by the OP blame medicine for causing death, yet does not recognize successes- i.e. Does not talk about the delayed mortality or reduced morbidity of medical care. What if medical care “killed” X many people, but “saved” many more people than X? That does not mean we should simply accept “preventable deaths”, the definition of which is debated by the OP, but that does not turn into the assertion that medical care has killed more people than the last 10 wars.
    5) I suggest that if you think medical care kills people, then stay away from hospitals and doctors; as a physician I have no desire to treat someone who distrusts me from the get go, or who harbors an inner desire to catch me in a Gotcha moment– a malpractice case waiting to happen because as we all know doctors get sued by patients because of perceived (rather than actual) wrong. I am under no allusion that I can help everyone. Stay away from medical care, and all will be happier.

    • Payne Hertz

      Sure, because the rightness or wrongness of the study presented here hinges on me and my experiences.

  • Thomas D Guastavino

    When the numbers that were quoted in these studies were first released we in the medical profession were also shocked because we knew that that had to be something wrong as the numbers could not possibly be true. As stated in this report a big problem turned out to be mislabeling as to what was an avoidable error and what was a complication.
    I will once again emphatically state that it is absolutely insulting to believe that the medical profession turned a blind eye to these problems. As stated, this mislabeling has the very real potential of actually worsening the kinds of problems that the vast majority of physicians have dedicated their entire careers trying to avoid and do the best they possibly can for their patients.

    • Payne Hertz

      Nowhere in the report does it state there was a problem distinguishing between errors and complications. They explained their methodology and the research tool they employed tends to underestimate errors, not overestimate them. You’ve given no evidence to back your claims here.

      I’m sorry you feel insulted by the facts, but the evidence I am seeing right here on this forum is that doctors don’t take reports like this seriously…they seem to regard them as some sort of gratutitous attack against the medical profession with no basis in reality. Multiple studies confirm the same thing, but it’s all just a conspiracy to demonize doctors. Judging by the usual response to criticism of the system many doctors go way beyond merely turning a blind eye to studies they don’t like but actively attack critics instead.

      It is a logical fallacy to state that the inability to fix things 100 percent is somehow justification for ignoring problems or making only token efforts to correct them. Imagine if the airlines had that philosophy: “we can’t prevent all air crashes so we’ll just ignore them and attack our critics instead.”

      I’m reasonably certain it is a vastly more complex problem to keep a single 747 in the air without it failing constantly than it is to design a system that will reduce medication errors to near zero. The proof of this is that the VA has reduced medication errors to near zero. All it takes is the will. The problem is that the will isn’t there.

      • Thomas D Guastavino

        Then I must be missing something. I may not have done any official studies but from what I have seen from first hand experience provding direct patient care , the mislabeling of complications as errors has led to more harm then good. I site just one example in my first post. There are many more.

      • PoliticallyIncorrectMD

        “I’m reasonably certain it is a vastly more complex problem to keep a single 747 in the air without it failing constantly than it is to design a system that will reduce medication errors to near zero.” – this alone demonstrates the degree of your understanding (or lack thereof) of the problem. You are neither aviation nor medical expert (please correct me if I am wrong), nevertheless you are “reasonably certain”. I am sorry, but this is not an intelligent discussion. You were obviously mistreated (in your opinion) by the healthcare system, but engaging in doctor bashing would not solve any problems.

  • ErnieG

    I suggest the best course of action for you is to stay away from hospitals.

    • rbthe4th2

      Trust me, we try!!! That includes docs of all kinds! I changed my eating habits (yes, it IS possible to live VERY WELL without McD’s, BK, Wendy’s), drinking habits (NO SODA, yes it is possible!), no smoking or drinking, exercise. Its gotten rid of all the problems but the ones we tried to fix surgically.

  • Skeptical Scalpel

    Thanks everyone for a very lively and engaging discussion. I am really sorry that some of you who have commented have suffered. It’s true that some doctors don’t listen to patients. And we all have made mistakes which we sincerely regret. We try to get the diagnosis right every time and use the proper treatment every time, but we are human.

    Whether a bad outcome is truly preventable or not is extremely difficult to define. Yes, some bad outcomes are preventable. It is very easy to second guess when the outcome is known.

    • rbthe4th2

      We know SS. There are some great docs. I’ve mentioned an eye doc I will never leave because he said the worst case that’s he has done, got sued for, etc. His honesty and how he worked thru that, says VOLUMES for his character. He didn’t make a mistake and that helps.
      You know, I find that a simple apology can work. I have a doc who I think the world of. One of the things he did, he came in late for our appt. He apologized, shook my hand, and got down to business. I’ll never leave him and I talk him up to everyone I know. Why? Because he recognized that my time is valuable: he demonstrated that his patient was human, and respected my time. He did that and then got down to business. I couldn’t ask for more.
      When things happen that aren’t a problem, if you demonstrate (or have demonstrated in the past) that you are a human being, it makes a difference. I had a doc who said he hoped I didn’t have a particular disease. Did I believe him? No. He couldn’t apologize for chewing me out several times when he lost his temper at me. We all have bad days, but you know, some of us, even if we’re professional guys, etc. do understand that. What we don’t understand is pretending that you don’t. What do you think that says about character?
      You are human before you are docs. Act like it, in spite of the inhumanity committed to you and passed down in medical school.

  • Rob Burnside

    AND SOMETIMES or HOW A MEDICAL ERROR SAVED MY LIFE After a biopsy found prostate cancer in one of twelve cores, a bone scan was ordered. The bone scan, indicating extensive spinal metastasis, was misread and I was sent for an MRI. The MRI ruled out PC metastasis but reveled a sizable abdominal aneurysm that could easily have killed me.
    (My maternal grandfather died suddenly, in 1958, at my same age–62 years at the time all this happened). It’s not a stretch to conclude the boo-boo bone scan saved my life. And yes, I know– I’m very fortunate.

  • PoliticallyIncorrectMD

    Here we go again – evil doctors are conspiring to torture and kill poor patients, deprive them of pain meds, yadda yadda yadda. Time to change the tune.

  • PoliticallyIncorrectMD

    Completely agree. I made the same point multiple times in this forum. Unfortunately, as you can see form the comments, many are not interested in this distinction, which make is harder to vent and assign the blame.

  • EmilyAnon

    This is the great divide.

    Patients with bad outcomes think they could/should have had better care.

    Doctors, in response, think their noble intentions should trump any blame.

    • PoliticallyIncorrectMD

      Blame is dysfunctional / nonpractical. It serves to channel negative emotions but never helps to solve the problem. Blaming doctors or patients will not get us anywhere. Trying to define the problem, find the cause and work on solutions might.

  • rbthe4th2

    This is exactly what we’re talking about when we say the rate of adverse events is too high. Its still going on. I do have a doc who has listened. There’s not a lot he can do though. I think the best thing to do is to keep putting these docs out that do it. While the gentlemen above indicate it isn’t true of their profession, I’ve met way too many people that were told ‘its all in your head’ (hmmm they operated on their abdomen and the problem got fixed) or didn’t tell some patients that they had other option choices before surgery (3 that I know of documented). That’s just in one group. The issue at hand is to get docs to realize its a problem and what we can do to fix it that preferably doesn’t require lawyers.

  • Deceased MD

    How many GI specialists did you see? Did you feel like they were not taking in your ideas and article you brought in? Or were they explaining why they thought your article was not your diagnosis?

    I think more thought should go into why certain patient’s have delayed or in your case seriously delayed diagnosis that caused you significant morbidity. That makes sense what you are saying. It sounds like it is unclear to you how this even came about or why this even happened?

    • rbthe4th2

      Ok from 10 years ago …
      GI specialist 1: after several tests, diagnosed issue 1. GI gave me meds for it, had a couple of problems, requested guidance. Took a week a couple of times to get back to me. I stated concern about that. GI had stated in the past that if I kept having certain reactions they might need to put me in the hospital. Hence my concern about their response time. I got told that they’re a “busy practice”, they have patients they have to see in the hospital, procedures to do, etc. and don’t always have time for questions in 24-48 hours. Ok … I never went back.
      2. Finally after 10 years, had surgery to fix the problem. Various issues started cropping up. Went to GI 2. GI didn’t do really any testing and his office staff, it was a different answer with different people. Tried to work things out with the staff and admin so everyone would be on the same page and I wouldn’t get appts cancelled on me that the office didn’t tell me were cancelled (among other things). Didn’t get anywhere. Asked to see another doc in the practice.
      3. Doc 3 basically didn’t want to talk with me (obvious from the manner) and when I asked him a few blood work test questions, it was obvious he didn’t know consequences of blood lipid tests, etc. He also didn’t want to do further testing, except for one item that would not prove/disprove what the surgeon who did my surgery suggested might be an issue. Ok on to another one.
      4. Checked another place out. This place was recommended by the surgeon. However, again I got 3 different answers for could I see a doc or not, my paperwork getting lost. On top of this, they gave my records to the doc I wanted to see. Doc said I was a 2nd opinion because doc 2 said I had disease X, and of course, those are put out months away (think 1/2 year timeframe). I said doc 2 never said I have X. (I got doc 2′s records and sure enough, he was guessing but wasn’t sure I had disease X. I actually spoke with Doc 2 and he said no, I never officially diagnosed you with disease X.). So I call back the office and say look, this is what doc 2 is telling me. I ask can we get on the same page please? They don’t want to talk to me now. (The worst part is there is another doc I would consider seeing there, but when this is how the office is, and one recommended doc isn’t reading my records right, well … think about how you would feel.)
      5. I now have one last office I go to. The first doc, the more senior one, recommended, I meet with him. He wants to do some tests and when I told him my concerns (doc 1 years ago was with this office) about whether or not that would be a problem, he addressed me the same way. So I backed off asked for another doc.
      6. Meet current GI. Current GI is nice, immediately did tests to prove/disprove a bunch of things. Now that that is done, he does nothing for me. If there are any problems, just go to the ER. Doesn’t appear to want to do anything outside of scheduled procedures. I don’t even get recommendations, and its obvious he doesn’t even look up anything. I can do better reading my sources on the internet.
      The basic issue otherwise is, go bother some doc at Duke, Johns Hopkins, etc. because they don’t want to go to the trouble of anything outside of my 830-6 workday.

      • Deceased MD

        well it looks like this thread is ending but i am sorry for what you went through.

        • rbthe4th2

          Thank you. I’m sure a lot of the docs on here feel the same way. Maybe we can swap stories again and learn from them and do things together. I think it would be a lot easier on all of us, don’t you?

  • Thomas D Guastavino

    Then what happens when there is something on the checklist that the physician diagrees with? Dont say it doesnt happen because it does and and that is precisely the problem that was created when conmplications were mislabeled as errors. Please re-read my first post. There are other examples.
    By the way, I have known, and have been very citical, of physicians that have a tendency to treat labs instead of pateints. Thats where judjment and experience come into play, traits that no computer or checklist will ever replace.

    • rbthe4th2

      I would be delighted to know that doctors disagree with a checklist and what items there were on there. Have you thought about partnering with patients and patient advocate groups as for reasons why certain checklists aren’t working, don’t make sense, or whatever, and together we try to get things changed? How about working with places or doctors that are known to bring these items up and see if they can help? I’d help in finding those.
      I am sure you are. There are physicians that do – and I’ve got a couple. The problem is that there are a lot of them out there that just go ‘oh we can’t prove there is a problem unless your labs are low’ and this is in the face of medical literature showing that’s blatantly incorrect. We’re talking docs with experience (> 5 years & passed the boards). I know docs are pressed for time. I’ve actually been lauded by some docs that say no one takes the time like I do to give them objective data to help make a decision. I had one nurse who was worried about prescribing a prescription strength vitamin for me. She did give it to me, and I came back after a week or so and gave her a medical study that showed what she did was right. I will do all in my power to make life easy for docs in giving them specific details (for X days I’ve had symptoms Y, P, Q with no/only changes in medications/diet/exercise for B days) and in giving them medical based support in the actions they take would be appropriate in the circumstances.
      Its just when docs ignore it, then make life hard for me, what do you expect in return?
      In my case, how can you show me someone who has passed internal medicine boards, with a patient with a history of malnutrition, lost part of their digestive organs, documented issues in functionality with what remains, documented neurologic problems, bleeding problems, can’t come up with a reason to check vitamin levels?
      This is why adverse events happen, more so than is documented.
      Plus, it doesn’t help the cause any when you have people that straight out tell you they won’t complain because they’ll be retaliated against. Blacklisting and iatrogenic neglect, there is a reason why docs have that reputation. Medical boards not disciplining docs over obvious errors (signing off they gave me dose C of medicine when the doctors orders say C+D is the dosage, and when requested to give me D dosage, chews me out, then no medical administration doing anything but supporting that what was done was right – how can that be justified?).
      RB IV

      • Thomas D Guastavino

        My patients do not come to me to get involved in a poliitcal fight. They come to me because they are in pain or are injured and are asking me for help. My ability to help them has been hindered by the misleading conclusions brought about by the very studies that you seem to have accepted as gospel truth. By simply standing my ground I have limited the potential damage.

  • rbthe4th2

    How many patients bring in medical, peer reviewed literature? Getting thru med school requires you to digest vast volumes in a short time, getting through a couple of paragraphs is a problem?

  • PoliticallyIncorrectMD

    If medicine was as simple as looking up articles on certain condition we would not need medical professionals. Unfortunately, the things are bit more complicated than you might think. Many articles (including those published in peer reviewed journals) only present an opinion and frequently there are many opinions on the same subject. What we actually spend lots of time doing in medical training is learning to critically evaluate medical literature and decide whether certain reported conclusions are applicable to the particular patient. That is why our conclusions might differ.

  • Thomas D Guastavino

    I gave a very good example in the my first post as how the misleading conclusions of this paticular study hindered my ability to help. There are more. A good physicians opinions are based on what you are taught, what you read, and what your experience teaches you.

    • rbthe4th2

      Ok. I appreciate the explanation! Docere = to teach. :)
      In the comments here, someone (maybe you?) said that nutrition is not taught in MD schools. So that rules education out from your comment above. If they don’t read my information from RD and nutrition journals, endocrinology, that should rule out the ‘what you read’ you talked about. If you haven’t experienced malnutrition (one of my old PCP’s who’s no longer around, I happened to see, said that American docs see obesity, not malnutrition), then no experience.

      So where does that leave any one? Basically that would mean docs get their training in med school and then it stops there. If they don’t have the experience, where are they going to get it? They would see diabetes I & II, hypertension, etc. but outside of the common items, if you pass it off to others, and others haven’t seen it, what happens then?
      BTW for ALL MD’s who have contributed to the conversation, THANK YOU. Sheds an interesting light and its helpful to see the viewpoint. We may not agree but at least I learn something from this.
      Where does the buck stop in who takes care of the patient? Don’t get me wrong, I had the battle between 2 specialists over me early this year. I’m no longer with both of them because I got caught in the middle with Doc 1 saying I had a problem and go see doc 2. Doc 2 said no you don’t and I said well Doc 1 wants me to work with you on this problem. Its in my records, I requested an appt, Doc 2′s office said the doc isn’t expecting to see you until your regular time. I said ok cancel the appt. That’s when Doc 1 got mad at me because I wasn’t working with Doc 1 or my PCP (who said they didn’t know what it was and it was Doc 2′s responsibility) on the problem.
      Seriously, when this happens, do you really blame someone for taking issues into their own hands? Trust me it aint the first time …
      Btw, having low albumin and total protein, BUN, anemia, etc. should have been a giveaway on the malnutrition issue (ok a few other clues too). Or at least an idea to going … hmmm … maybe should check a little further. Like ask for a food diary or what makes me think I have a problem (outside of all my health issues have malnutrition or undernutrition as the common denominator).
      In this issue, do I think I’m wrong, after reading and pouring thru hours of journals (even if they are opinions)? Nope. That’s why I’m not backing down.

      • Thomas D Guastavino

        I simply do not believe most physicians are as bad as you believe. Our jobs are being hindered by misconceptions that are leading to irrational policies. Keep asking questions. Most physicians welcome the dialog. If you are not satisfied, seek additional opinions. until you are satisfied. Good luck.

        • rbthe4th2

          Um … the tally so far:
          I’ve lost 3 docs because they said I didn’t trust their judgment when I asked them how do I know when I’m having a problem so that I come to them when I do, can they define malnutrition, under nutrition. I have one doc who is doing nothing for me but just saying everything is fine (how many GI’s would say all is fine & not check you out if you say you have a swollen abdomen, blood sugar is up, some pain, indigestion, with a history of 4 abdominal surgeries, gastritis, esophagitis, GERD, IBS)? I’ve had another not want to see me because I said I really need to be seen and I was trying to jump the queue. I’ve got another one who I went to, noted my abdomen issues but said well I need time to look this over, I’ll see you in 3 months. Yes, he knows about the issues I put above.
          With all due respect, when I repeated this to one of my 2 decent docs, the staff’s jaws dropped. It is as bad as you believe.
          Its all in my records, I make sure to document that. That includes refusals to give me my records and not being able to see them because I have to wait to get paid so I can pay my copay. I either pay right then or in the case of the ER visit, am on a payment plan.
          Thank you for your wishes. To be quite honest, again, I’ve received more education on here, a better explanation, on here from the doctors – and “guest” – than I have in real life. Thank you all.
          Maybe someone can get Kevin to do a “discussion” forum. I found the information you all spoke about VERY enlightening.
          Randy

  • guest

    I hate to say this, but it sounds as though you are receiving completely standard medical care. This is the state of our current healthcare system, and it is really not the fault of the practitioners. They are doing what they are trained to do, which is not do million-dollar workups on patients who are not acutely ill.

    I share your frustration; I have a child who has a chest wall deformity which is causing him exertional chest pain and shortness of breath. I cannot get his pediatrician to refer him for a complete set of appropriate tests to assess whether he requires corrective surgery. On the other hand, I recently took our cat into the vet for an episode of irritable bowel syndrome which she has had for three years and the vet implied that I was a negligent pet owner for not agreeing to a $400 ultrasound to rule out lymphoma and another several hundred dollars to sedate the cat and draw blood to rule out pancreatitis. The bottom line is that my cat, for whose medical care I pay cash, gets better access to care than my child, who is covered by United Health Care.

    It does no good to argue and fight with the doctors. They are not the ones who are withholding care for you. In my opinion you would be better served by researching for yourself which allopathic physicians in your area specialize in nutritional issues, and trying to work with one of those, although your insurance will likely not pay for it. Trying to force other practitioners to become educated to provide a type of medical care that is outside their scope of practice can only result in your feeling frustrated.