Wednesday, March 11, 2015

Blame the patient

The other day some cardiologists on Twitter were discussing whether a patient should be blamed if a permanent pacemaker lead became displaced. The consensus seemed to be that it was probably poor placement (i.e., operator error), rather than patient behavior that caused leads to dislodge.

The discussion reminded me of an attending plastic surgeon of mine during my resident days. He was one of the most obsessive-compulsive people I ever met. When he applied a dressing, he always cut the tape with scissors instead of tearing it. He felt that torn tape looked sloppy, and that if a patient saw a ragged edged of torn tape, she might think that the surgical procedure itself had been done without meticulous care too.

When he wrapped a hand, he used a very bulky dressing with yards and yards of carefully cut, not torn, tape over the ace bandage to prevent from slipping or unraveling.

But my favorite eccentricity was what he told patients who had any sort of facial surgery. He had a thing about the role of movement of skin possibly causing scars to separate and permanently widen.

So he gave this written instruction to every patient who had so little as a facial mole removed, "Do not talk or chew for 10 days."

Think about it. Could any patient possibly comply with that? Some of us more cynical types figured that should a scar not have turned out perfectly, the conversation might have gone like this.

Surgeon: "About your scar, you must have talked or chewed during the first 10 days after surgery."
Patient (sheepishly): "Well doc, I must admit I did say a few words, and I had to eat something."


Anonymous said...


With all due respect, about every surgeon and most every doctor I know blames the patient for everything. I've seen the worst out of surgeons. When it comes to "personalities", every surgeon I have met in real life, has a "very distinct" and "well established" personality. My favorite was one who woofed my food behind the scenes (except for a few healthy treats, healthcare people do not model good eating behaviors) and had the nerve to tell me he was giving me an appointment in 3 months vs. 1 month, and his *office staff* would be sad to miss my food. This is the same one who interrupted me about all the time, etc. except for ONE time, when he came in, sat down, kept his mouth shut and let me talk. I made him a custom doctor bag cake, no appointment/medical care to discuss.

When it comes to instructions, I would ask questions about instructions like the above. I could get no medical basis for a number of instructions.

I get the distinct impression that medical decisions are based on 'am I going to get sued', ignoring that not everyone is looking to lawyer every person they meet, rather than logic, research, or common sense.

No offense to you and Artiger. I don't know you in real life. :)

artiger said...

Anon, I thank you for that disclaimer, and I'd agree that a lot of what we do is defensive. Just one lawsuit (or even hearing about one that a colleague had) tends to do that to you. I was taught (and am still being instructed by the insurance and risk management folks) that documentation is our best defense in the event of legal action. However, as you implied, the paradigm should be more along the lines of...communication is our best defense. I've only been out of training for 18 years, but every day that passes teaches me that. Talk to patients, talk to families, make them understand things before, during, and after as best you can. Apologize if you made a mistake. Explain how you might have done things differently, if you could have. Tell them how you are going to try to make things right. If you still get sued (and you still might), you can live with yourself knowing you made every effort to do the right thing.

Oldfoolrn said...

Plastic surgeons can be peculiar. Most surgeons used a #10 scalpel blade briefly and were done with it. I have worked with plastic surgeons that used a #10, #11, and #15 blade on a single case and even had hand signals for this. One surgeon insisted he could tell if the blade had been used more than once and demanded a new blade for each tiny incision. The end result was a scrubnurse with sore fingers from multiple blade changes and a huge pile of "used" blades.

Skeptical Scalpel said...

Of course there would be no way that any surgeon could tell a blade had been used under most circumstances. If I ever change a scalpel blade myself, I use a clamp to grab the blade because there is less chance of cutting yourself.

Anonymous said...

I am skeptical about whether that scalpel has been used or not.

Christian Munthe said...

The example you relate is, of course, ridiculous, but there are much more common cases of non-adherence, such as not following simple drug regimens for very quotidian reasons (that is, not due to side-effects). It is not unreasonable to argue, I think that, the responsibility for poor treatment outcomes in such cases may be shared between the health professional and the patient. So in that sense, the patient may very well "be to blame". However, it doesn't follow from that the patient should be blamed, since a person being responsible is something else than this person being properly held responsible. There are a number of reasons for the claim that even when the patient is (partly) to blame for a poor treatment outcome, the health professional should mostly blame him-/herself. One of these, is that with that attitude there is a constant moral incentive for professionals top become better at motivating patients to adhere to beneficial treatments plans.

Anonymous said...

Yes Christian, there are more reasons for non adherence. Money being at the top of the list. I had a doctor who completely ignored that I couldn't pay for a treatment without huge financial implications and just smeared me in the records. So who is responsible for that? Sometimes its not just getting mad a patient doesn't follow, but asking them why and treating that issue with respect. Bottom line, I have told a few others doctors (and/or their admin) what I can and can't afford. All but one understood and we worked in different ways, never was I slammed in my medical record for it but by this one doctor. Its not always an issue of motivation on the part of the doctor either, as in financial cases. How do you also chalk up a poor treatment outcome to communication with the patient?

Anonymous said...

My husband was coerced into an unnecessary pacemaker implantation and they knew the next morning the lead was screwed up, probably because they had implanted the pacemaker bizarrely low so that the lead had to go way up and was then pulled taut. (They also partially collapsed his *right* lung, and for about twelve hours threatened to compel him to submit to a chest tube before letting him escape the hospital, even though it was asymptomatic.) They attempted to attribute the poor lead position to "THE thrashing [in his sleep during the night]" but he pointed out that he hadn't been able to sleep all night. They offered him the choice of an immediate revision, again under general anesthesia - probably to be done by the same incompetent trainees; this was a teaching hospital - or trying to make it work by not moving his shoulder for months. Within a month the lead was completely dislodged, causing catastrophic arrhythmias, which led to a further malpractice cascade as the ologists at the second hospital he landed in just could not believe that a device either could cause complications or might not be Needed. (He was left with a re-implanted device stuck in him forever, and believe it or not, he refused to sue any of these people.)

Skeptical Scalpel said...

That is quite a story. If only he could have not moved his shoulder for a few more months, maybe it would have gone back to the right spot. Just kidding. That is a classic example of blaming the patient. I hope he is OK now. Thanks for commenting.

Anonymous said...

Anonymous, part of the problem is the retaliation that occurs from doctors, hospitals, etc. when patients are harmed and the community does all sorts of things to stop the problems from getting out. One of the faves of the local "monopoly" is gag orders.

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