Are surgeons responsible for everything that happens to their patients?

Several months ago, a post called "Everything's my fault: How a surgeon says I'm sorry" appeared on KevinMD. It was written by a plastic surgeon who feels that no matter goes wrong with a patient, surgeons should never blame anyone else.

She gave some examples such as the lab losing a specimen, a chest x-ray that was ordered and not done, a patient eating something when he was not to be fed, and a surgeon having to cancel a case because the patient's blood pressure was elevated. She felt that all of these incidents should be owned by the patient's surgeon.

I agree that if I order a chest x-ray and find out later it wasn't done, I would accept the responsibility to have made sure it was done. I have always believed that you should not order a test if you aren't going to do something with the result.

But if the lab loses a specimen or a patient who was not supposed to eat does so, how is that my fault?

9-year-old boy flies to Vegas without a ticket. System error or human error?

Last week, a 9-year-old boy managed to fly from Minneapolis to Las Vegas by himself without a ticket on Delta Airlines.

According to a CNN report, Delta is reviewing its "policies and procedures to make sure something like this does not happen again." This is the predictable response by most organizations when a screw-up occurs.

Do you think this was a system error or a human error?

I favor the latter. And the errors weren't confined only to Delta employees.

How many people had to have not followed established procedures for the child to have pulled this off?

At most airports, you can't even enter the security line without showing your boarding pass and ID. Children under 18 are not required to carry identification, but someone from the TSA had to have overlooked the fact that the boy had no boarding pass to scribble on.

Another possible check might have occurred as he passed through the metal detector by himself.

At the gate when boarding starts, an agent either marks each boarding pass or scans its bar code to tally the number of passengers on board. Obviously, the boy didn't have a pass so that did not happen.

Once he got on the plane, he had to have picked a seat at random. He would not have known which seats were unassigned. It is highly likely that he had to change seats at least once or twice. Again no one noticed that he didn't have a boarding pass.

The story says the flight crew became suspicious when the plane was in the air. They eventually noticed that he was an accompanied minor that they had not been made aware of.

What happened to the head count prior to closing the door? Most flights I've been on do not leave the gate until the flight attendants have walked through the cabin and counted the number of seated passengers.

Rather than a review of policies and procedures, the airline and the TSA should "counsel" the personnel involved in this event.

For other examples of human errors being thought of as system errors, type "system errors" in the search field of this blog.

Follow-up on whose fault is it if a patient doesn't follow up

My post entitled "Who is at fault if a patient doesn't follow up?" from 7/19/13 has had over 1000 page views. There were several comments on Twitter.

In three parts, here is some follow-up on following up.

1. A surgeon saw a new patient with flank pain. He had undergone an appendectomy a few years before by another surgeon at a different hospital. He said that the surgeon told him the pathology report was "fine."

Physical examination was not enlightening.

A CT scan showed a possible ureteral stone. A urologist was consulted, saw the patient and said there was no stone.

The patient called the surgeon who told the patient to come back to her office to discuss further work-up. He did not keep the appointment. The surgeon made two more phone calls urging the patient to return and documented them in her office records. He was also called by the urologist, a consultant gastroenterologist and his family doctor. He never followed up with any physician.

Two years later he presented to the ED with a small bowel obstruction. At surgery, carcinomatosis from his ruptured mucinous carcinoma of the appendix was found.

The CT scan showing the possible stone was re-reviewed and still showed no evidence of a tumor.

The original pathology report said "mucinous tumor [not cancer] of the appendix."

Everyone except the surgeon who had done the appendectomy and the pathologist was sued. They escaped because of the statute of limitations.

The insurance companies advised all of the doctors to settle, which they did.

So much for documenting your attempts to have the patient seen.

2. Two of my Twitter followers from Australia sent me a link to a case that illustrates that patients in that country are somewhat responsible for their fate.

Briefly, it concerned a man who needed a Q fever vaccination for work. A skin test for Q fever was negative, but serology was weakly positive. An infectious disease specialist recommended that vaccination not be done. He was told to return in a month for a repeat serology. He failed to do so and contracted Q fever about 4 years later.

He sued. A judge ruled in favor of the physician saying the patient "understood the advice he was given by [the doctor] that he was low positive, that he needed further testing and that he could not be immunized. There was nothing in [the patient's] presentation in court or within his evidence that suggested he did not comprehend what was said to him by [the doctor]. He denied being told to return by [the doctor]. I reject his account for the reasons already mentioned."

3. This last one is hard to believe.

A brief "Viewpoint" article in JAMA from May of 2013 tells of the discovery of a new disease. It is called "Medication Nonadherence" and it has six different phenotypes.

They are as follows: "(1) the patient does not understand the relevance of medication adherence to continued health and wellbeing; (2) the patient has concluded the benefits of taking medications do not outweigh the costs; (3) the complexity of medication management exceeds the information processing capacity of the patient; (4) the patient is not sufficiently vigilant; (5) the patient holds inaccurate, irrational, or conflicting normative beliefs about medications; and (6) the patient does not perceive medication to have therapeutic efficacy."

I had trouble getting past the above portion of the paper.

However, the authors advocate screening all patients for this malady and treating it when found. They say, "Each medication nonadherence phenotype requires different diagnostic tools and treatments in the same way that subtypes of a medical condition, such as heart failure (diastolic vs systolic), require them."

I thank God I am no longer in practice.

Who is at fault if a patient doesn't follow up?

In keeping with the mind-set of most Americans today, the answer to the question posed in the title of this post is, "the doctor."

American Medical News reports that "Medical liability experts say missed appointments and failures to follow up pose some of the greatest legal risks for physicians." And these problems are increasing with more hand-offs and more people being involved with the "team" taking care of the patient.

The article began with an anecdote about a patient who needed at cardiac catheterization but wanted to think about it. He went home and died. The family sued and said the doctor did not tell "them how critical it was for him to have the procedure.”

The doctor did not document the conversation about the need for the procedure in the chart and lost the case.

Failure to make sure that appropriate follow-up was done and failure to contact patients about missed appointments are among the most frequent deficiencies cited as big legal risks for physicians.

Get this. "A common claim in lawsuits that involve missed appointments is lack of informed refusal. The allegation arises when patients admit they declined or ignored treatment recommendations, but allege they were not adequately educated about the medical risks of their decision."

Lack of informed refusal. That's a new one on me.

The article says that adequate documentation by the doctor will support his version of events.

What is to prevent any patient, who is explained any plan or procedure and declines, from simply saying, "I didn't realize how serious this was"?

And where does this end? Should a doctor call all her patients every day to ask if they took their medications?

"Hello, Mrs. Balotelli. Did you take your Placebolol today?"
"No, I didn't think it was important."

"Mrs. Balotelli, I wouldn't have prescribed it for you if I didn't think you needed it. I told you that you have to take it to prevent you from having a stroke."
"Well, doctor, I didn't understand that a stroke might be a bad thing. And I don't think my blood pressure is that high today anyway."

Whatever happened to personal responsibility?

I guess it's always someone else's fault when anything goes wrong.

The article ends with a list of 16 things that a doctor and her staff should do for every patient to try to counter this disturbing trend.

Here are a few of them:

    Maintain a current list with dates of problem identification, reviews and resolutions.
    Use the patient's own words when documenting.
    Indicate in writing or electronically that all results of tests, consultants and referrals were reviewed.
    Document all after-hours patient calls.
    Document all advice in the patient's record.
    Detail the patient's level of understanding during the informed consent process.

I'm sure these tasks won't take much time or effort.

And some lawyer will probably say that what the doctor wrote on the chart is not what the patient remembers him saying.

See  this follow-up post on following up.

Words mean what I say they mean

Apparently a few years ago someone decreed that “non-compliant” was no longer a politically correct term to describe patients who did not take their medicines or follow instructions. The newspeak to use is now “non-adherent.” This was recently brought to my attention by cardiologist-blogger Dr. John Mandrola, who humorously blogged about his own non-compliant-adherent behavior after a hand injury.

I googled “non-adherent vs. non-compliant” and found references to the former used in medicine from as far back as 1998 but most hits were from this century. I could not identify the origination of the switch or why the term non-compliant was perceived to be judgmental.

I suppose compliant has a more submissive connotation, and God knows, we should not consider patients as subjugated, but adherent really means sticky as an adjective and follower as a noun. Is a patient who takes his meds “sticky” or a “follower”? The difference between the two definitions, compliant and adherent, is minor at best.

Who decides these things anyway? I don’t remember this being discussed anywhere.

This phenomenon is not unique to the US. Public health workers in the UK were recently informed that the use of the word “obese” could be viewed as derogatory by obese people. The workers were told “that patients may respond better if they are encouraged to achieve a ‘healthier weight.’” The full story is here and is worth reading if only for this amusing mixed metaphor uttered by an opponent of the UK advice, “If you beat around the bush then you muddy the water."

There is research on this subject. A 2012 paper from the journal Obesity [soon to be renamed “Healthier Weight,” I guess] describes a survey of a lot of people whose weight formerly would have been termed obese but now should properly be called unhealthily weighted. The term fatness was rated as significantly more undesirable than all others and excess fat, large size, obesity and heaviness were rated as significantly more objectionable than the remaining terms, such as weight problem, BMI, excess weight and the best of all, weight.

It’s not clear how just describing someone as “BMI” or “weight” will get the message across, but then I didn’t perform the study.

Question: what do you do with a person who needs to achieve a healthier weight but is non-adherent?

This post appeared on Sermo yesterday and attracted 28 comments. As you might expect, most did not like the idea of politically correct terminology.

It’s always someone else’s fault

Here’s a story about a 15-year-old boy who was traveling alone on a Southwest Airlines flight from Phoenix to Tulsa. When the plane arrived at his destination, the boy was sleeping with headphones on and didn’t hear the announcements or notice that passengers were disembarking. He slept through the ensuing take-off and landing as well as the litany of annoying announcements that accompany those events.

The plane continued to its next and final stop, St. Louis. The boy awakened and noticed that St. Louis is not Tulsa.

For 24 hours, he wandered around St. Louis until finally a kind person helped him call home.

The boy’s mother was not happy with the airline saying, "The child wakes up in St. Louis with no family, no money, no cell phone and no help,"

Southwest apologized and refunded the cost of the ticket. Yes, they should have noticed the sleeping boy, and they need to figure out how this could have happened. [System error or human error? I say “human,” but Southwest will probably say “system” and develop a new policy. See my previous blog on system vs. human error.]

But wait a second. I have three sons, who thankfully all are no longer teenagers. What parent in her right mind would send a 15-year-old boy alone on a plane with no money? What if weather or equipment trouble had forced the plane to divert from Tulsa? I guess mom assumed that Southwest would notify whoever was meeting him in Tulsa and feed the child until his journey resumed. Also, he must be the last 15-year-old boy in the United States without a cell phone.

Did he even know who was picking him up in Tulsa? Did he speak to any Southwest employee in St. Louis? Did anyone report him missing? Was there an “Amber Alert”? The plane had to have been on the ground in Tulsa for at least 45 minutes. Did the person who was to meet him in Tulsa call the mother and say he didn’t show up or better yet, ask someone at Southwest in Tulsa where he was?

So let’s list the stupid people in this drama—the mother, the boy, the person picking him up in Tulsa, unknown numbers of Southwest employees [cleaning people, flight attendants] and KPHO-TV in Phoenix for its “blame the airline” slant on the story.

This country is circling the drain right now. The future is grim. God help us all.