It happened decades ago so I’m probably safe to tell it now without legal repercussions. But I will never forget the pit in my stomach as it happened. I wandered into the room of a young female patient who had presented to the emergency department with the complaint of abdominal pain. I knew the family was looking at me with a strange quiet confusion as I took the history and performed the physical exam. But I didn’t quite know why.
I was just about to reassure the family that the patient’s clinical picture was benign and required nothing more than observation and a clear liquid diet when suddenly one of the nurses burst into the room and announced that Dr. Woodruff (not his name), one of the surgeons on staff, had already seen the patient and she was being prepped to go to the OR.
I gave the nurse a look of confusion. “He sent her in here from his office, she has appendicitis,” she said rolling her eyes while looking away from the family. “She’s going to the OR tonight.” The family was studying my face for a reaction.
“Uh,” I stuttered. “Well I guess she’s all taken care of then…” And I exited the room with a grimace.
“What the heck?” I said grabbing the nurse as she came out of the room. “That girl is not sick. And she sure doesn’t have appendicitis.”
“He does this all the time,” she said with a sigh of frustration. “We don’t know what to do. We’re just glad you guys are here finally.”
Let me back up just a bit. No, let me back up several decades. I hate to say it. Let’s back up before CT was the used to diagnose appendicitis. I know some of my readers may not have even been born yet at that time and may be asking what this could possibly have to do with today. But just wait, you’ll see.
You see children, in the good ole days, appendicitis was a diagnosis made by the history and physical exam. You needed to have a history that had some elements of nausea, vague abdominal pain that localized to the lower abdomen over about 18 hours that was then associated with guarding, and possible rebound tenderness. It was acceptable to take out up to 25% normal appendices to make sure that you were taking out all the bad ones. So it was accepted that no surgeon was perfect.
But this young lady had none of the above. I chalked it off to an overly cautious surgeon. After all I was a young and relatively inexperienced physician and had never been sued for missing an acute appendicitis. But then it happened again. And this time the patient had come to the ER without going to Dr. Woodruff’s office.
Oh, just one more historical footnote. This was before enactment of the Consolidated Omnibus Reconciliation Act of 1985 otherwise known at EMTALA. Emergency physicians were not required to see every patient presenting to the ER. In fact, we weren’t “allowed” to see them if they had a private doctor. Even if they were not sent from a doctor’s office, if they stated that Dr. X was “their” doctor, that physician had to be called first to see if he/she wanted to see them in the ER. If not, they were released to be seen by the ER staff. We’ve come a long way, folks. But you’ll soon see that the same problem is still with us.
In any event, the patient came to the ER and made the mistake of saying they were a patient of Dr. Woodruff. Three hours later, Dr. Woodruff presented to the ER in his golf gear, talked to the patient for less than two minutes, pushed on the abdomen briefly, then announced that the patient needed to be prepped for the OR. You got it. Acute appendicitis.
Each time it happened the staff would look at us, the new, young freshly trained ER docs, with looks that begged us to intervene. And finally we did. Subtlety at first, by asking the patients if they knew any other surgeons. But eventually we went to the head of the department of surgery and asked him to look in Dr. Woodruff’s cases. After a thorough review in which over 90% of the appendices removed by Dr. Woodruff were found to be pathologically normal he was mandated to have every case reviewed by another surgeon. We did a good thing right? Six months later, Dr. Woodruff organized other doctors who had a beef with our group and our contract was terminated. Oh, we weren’t fired. The administration saw a wedge and offered us a contract renewal at 60% of our previous agreement. We dug in our heels and poof, we were gone.
The financial and professional recovery took over a decade. The emotional recovery never happened. I ended up going to law school and got my revenge helping patients go after truly negligent physicians like Woodruff. But one thing I didn’t do is talk to patients about care that they had received that I felt was substandard. Why? Because I was a coward. I had lost a big chunk of my professional life by doing that once. And I wasn’t going to do it again. But frankly I felt terrible about it.
And that brings us to today. What do you do when you see patients presenting with substandard or even negligent care? Now that we have EMTALA we always get to see the cases first, so there is not the situation of standing by with hands wringing while we watch an incompetent colleague mismanage a case. And cases are seldom as clear cut as those treated by Dr. Woodruff. But we still see patients come in who have been misdiagnosed or mismanaged by another clinician. Do you speak up?
The pages of this magazine have lit up clinicians in the past who testified falsely against another emergency physician. So no one needs to worry that we have suddenly turned on our colleagues in EM or those in other specialties either. And I’m not talking about debatable subtleties of care. I’m talking about seeing negligence or incompetence and remaining quiet about it.
Lawyers have no problem finding doctors to testify for the plaintiff’s case when they are paying $500 per hour. But what do we do when we have nothing to gain and everything to lose. A cynical public expects doctors to protect each other at all cost. Do we?
Is there a mechanism in your hospital, your medical society, your state board of medical practice, where you can raise a concern anonymously about the care rendered in a given case? Have you ever used it? Would you?
I don’t want this piece to be the green light for every self righteous know-it-all to start tattling on everyone with whom they disagree. But we have been given a certain public trust, by our colleagues and our patients to be observers of what is and what possibly is not quality care.
Over 150 million patients will pass through the doors of an emergency department next year, many of whom have already been seen by or who are currently under the care of another physician. The breadth of our training and experience puts us in the best position to simply raise the question whether those patients are getting the best our profession can offer. We should not be a hyper-critical Monday morning quarterback. But, as the social responsibility warning goes, when we see something, we must say something.
4 Comments
Thank you, Mark. Many, I think all of us have faced this at one point or another. I haven’t dealt with the ramifications you did .That said, I have had the safeguard of anonymous reporting mechanisms. Interestingly, my colleagues newer to the profession have the same worries we did. Even with anonymity, the fear of retaliation is still powerful.
All good… and godspeed with your work. I enjoy reading your stories.
Just a quick sharing: I, too, saw a ‘well’ patient, a grandmother (who at the time was an ‘undocumented alien’) was brought to the ER by her daughter at 5am. History was difficult to get, and exam findings even more so, as the grandmother would only say CASA, SU CASA; she had on her mourning black garb worn for years since her husband had died and she was not removing them.
Vital signs, blood tests (still awaiting UA) were not helpful… but about 8:30, her daughter asked me what my plan was … and I asked why was she asking. The reply: I have to take my daughter / the granddaughter to the clinic.
Now… my real diagnostic inquiry: If you were going to the clinic today at 9am, why did you come to the ER this morning?
Oh, my daughter (the granddaughter) has an earache, but my mother (the grandmother) is VERY, VERY sick.
I called the admitting MD and was told to send the patient to the university hospital as they took care of the undocumented alien population.
I convinced him that this woman was very, very sick and was concerned that she might not get there or that she might readily be sent home.
She was admitted with a bradycardia strip obtained when she was sleeping.
That afternoon, the surgeon came down and kindly chastised me “Most expensive dinner anyone every had … she is up there eating.” My reply: Her daughter said ‘very, very sick.’
The next morning as I was leaving the ER, the same surgeon passing through said “Suppurative Appendicitis… good pickup.”
Dr. Plaster-
I work in a fairly rural location in Ohio so we have an inordinate number of NP’s. I spend a significant amount of time fixing or educating patients based off of the borderline reckless medical care they have received. I find fault in the fact there is no true governing body in regards to the training of NP’s but even more so on the physicians who are supposed to be supervisors. It’s quite unfortunate to see the harm that is being done to these patients for no reason whatsoever
I was new to a West Texas hospital and a local doctor who was a favorite of the country club set seemed to show up and often diagnosed ectopic pregnancies and took his patients up to the OR. One of the nurses who everyone depended on saw my puzzled look one afternoon and clued me in that these young girls early pregnancies were actually normal and everyone just looked the other way,
I never said anything and soon was accepted at a large urban hospital elsewhere in the state. I often think of that doctor and the new restrictions that Texas had put in place. The doctor was practicing legal nullification. When the governor required all abortion clinics to have privileges with a nearby hospital, it effectively closed down all but 4 clinics in the entire state and they were owned by one group. The new law was not a safety measure, it was a political favor to a close friend who has a major stake in that group’s clinics.
I am not saying I agreed with that doctor’s ethics. I certainly don’t like the practice of medicine being a political football. This “Opiate Crisis” is a political football. I look at the statistics and I see the fear, the anxiety, and the pain in Chronic Pain Patient’s eyes when they show up in the ED and I am not allowed to help them. The heroin addict OD’s on Fentanyl laced heroin an hour later and because he also uses prescribed controlled medications, the statistics for prescription OD’s goes up depending on who and where the reporting is done. I don’t know of any doctors prescribing heroin or pharmacies dispensing it.
I am advocating for different reporting standards when illegal street drugs are the major factor in an overdose, death or not. The quality of life for patients in intractable chronic pain is being ruined and they are the collateral damage because some groups of politicians won’t call this heroin crisis a heroin crisis. That is what it is once you separate the heroin and fentanyl-laced heroin into its own statistic.
We’ll always have some kids abusing alcohol and pills out of mom’s medicine cabinet, or someone using pills to commit suicide. How can we convince the CDC, the FDA, the DEA, the AMA, and the politicians that the current standards or lack of reporting standards are hurting more people than it is helping? Prescriptions are down, the number of pills in those prescriptions are down, the potencies are down, but the death toll from overdoses are up because they are fighting the wrong enemy? And why has heroin production in Afghanistan quadrupled, supplying over 70% of the world’s heroin since the U.S. has occupied Afghanistan?
I love practicing medicine. The thrill of helping a sick patient get better and enjoy a better quality of life makes my day. I have written to all the groups listed above. Only the DEA wrote back in support of the idea of standardizing the reporting methods. Nobody else bothered to write back.