As time passes, we have more new names for what we used to call quality assurance, but it appears to me to now be a public relations issue and have very little to do with quality.
Years ago, I returned home about 10:00 p.m. on Sunday night. I had spent the weekend at my lake cabin for some sorely needed time off. As I usually do when I arrive home after a trip, I called the hospitals to be sure none of my patients had shown up there while I was gone. At one of the hospitals, the nurse reported that a woman who claimed she was term with spontaneous rupture of her membranes had been admitted. The nurses noticed she was small and had no leaking of amniotic fluid.
When the patient came in, the nurses notified the on-call OB. He did not come to the hospital to examine the patient, but did order Pitocin. The patient, then, at that time was under the care of the on-call OB. But the nurses reported to me that the patient claimed I was her doctor. When they told me the woman’s name, I knew I had never seen her before and she was most definitely not my patient.
Since there was no evidence of membrane rupture and the patient was not responding to the Pitocin, I told the nurse to stop giving the patient the Pitocin the on-call doctor had ordered. The story I was being told was certainly beginning to look fishy. I made plans to see her again in the hospital first thing in the morning.
The next morning when I went to the hospital to see the patient, I could tell her uterus was much smaller than 40 weeks. Much more like 24 weeks. An ultrasound exam indicated the baby was 24 weeks. with normal amniotic fluid level. This supported my clinical assessment of intact membranes.
I arranged for the patient to see me the next day in my office to discuss what was going on. Before I left the hospital, the nurses volunteered that this woman had two boyfriends. The first one, the one she wanted to marry, had ended their relationship. She had since taken up with another boyfriend, but this second boyfriend was the father of the baby. The first boyfriend, the one she wanted to marry, was not the father. So she deliberately schemed to deliver this baby early to make it appear the first boyfriend was the father of the baby. I later learned she was a medical technology student so had the knowledge to be able to try to scam the system.
Later, on the day of discharge, I got a call from one of the doctors who was a member of the clinic that used this hospital for their main place of care. He warned me not to deliver this lady. He told me that the baby was too young to be delivered and that I shouldn’t be trying to induce her. I said I understood she was 24 weeks, not 40 weeks, and I told him I had no intention of delivering her or for that matter taking care of her. I explained to him that I had turned off the Pitocin and that I was most certainly not the doctor who had started the Pitocin. And further, I had discharged the patient without rupturing her membranes or pursuing any other type of induction.
As I concluded my conversation with this doctor, I couldn’t help remarking, “I don’t think you need to worry about this lady being induced right now. Nobody is stupid enough to induce her at 24 weeks.” Well, I was wrong. Two weeks later the patient presented to another hospital in town. She did finally find an OB who induced her at 26 weeks. Why they swallowed her story hook, line, and sinker I couldn’t say. Being a relatively small town, news traveled fast, especially in the obstetric community. With this length of induction, the patient would have been seen by at least six shifts of nurses and three different doctors. Because the three days of induction failed to produce the baby, the doctors delivered the baby at 26 weeks and five days by C-section. The pediatric intensivist reported the baby’s age to be 32 to 33 weeks.
The management of this case has layers and layers of problems. I expect the insurance paid the bill for the failed induction and the C-section. Even at that time, the insurance for the C-section and the lengthy induction would probably have been $30,000. Furthermore, an unnecessary induction and delivery could clearly be looked upon as malpractice.
Then there is the $ 2,000-a-day cost of the baby in the neonatal intensive care unit (NICU), probably for 90 if not 120 days. Again, I expect insurance paid that.
Some days after these events, I attended the hospital board meeting where this case came up for review. The very same people who had ordered the induction and C-section were sitting across the table from me on the review committee. Most of us are human and can make mistakes from time to time. But the real issue here is not quality insurance, but self-interest. The hospital wanted to preserve and secure its “good name” and reputation, and of course, avoid having to return the payment to the insurance company.
With any quality assurance review, there is tremendous face to be saved. Nobody wants to think they practice with a bunch of buffoons. When protecting their associates, they’re also protecting themselves. The conclusion of the quality assurance review?
“Difficult case managed well.”
Because the doctors called this a “difficult case managed well,” all of the problems with the care of this patient disappeared, and nobody was the wiser. This is really the story of having friends in the right places, which is a very common occurrence and unfortunately plays a large role in degrading the quality of medical care in the U.S. Why does any hospital go out on such a limb? Because it can.
The bad news for the public is there is no really good way to get at any of these coverups. Even if the incident were sent to the state medical board, all the “defendant” needs is a friends on the board to repeat “difficult case managed well.” And that’s the end of it. Med boards are no more immune to these kinds of “friendly” matters than hospital boards. To the contrary, that’s how they work. As I’ve written here before, that’s why the big clinics will always have “friends” on the state medical boards.
The public remains unaware of the decisions about medical practices that stay behind closed doors. There are many similarities between the decisions of hospital boards made behind closed doors and what goes on behind the closed doors of state medical boards.
In the meantime, the public has absolutely no protection from these kinds of self-serving decisions about the quality of the medical care provided by hospitals or decisions made by state medical boards.
There’s no doubt the whole process of quality assurance needs to be completely redesigned if it’s going to be successful in protecting the quality of medical care provided patients.
Transparency would be a good place to start.
Perhaps it’s time to open these closed doors and have teams of citizens with no vested interest in the hospitals or medical boards sit in on the meetings, much in the way women in the League of Women Voters sit in courts and observe court proceedings.
Politics and friends in all the right places should not be allowed to derail quality assurance.
Alan Lindemann is an obstetrics-gynecology physician and can be reached at LindemannMD.com, doctales, and Pregnancy Your Way. Follow him on YouTube, Twitter @RuralDocAlan, Facebook, Pinterest, Instagram @ruraldocalan, and Substack. He is the author of Pregnancy Your Way: Choose a Safe and Happy Birth.