We normally don’t think of doctors as victims. Whether you are in the medical field or not, if you have ever heard a doctor speaking of a malpractice case, you will sense victimhood very quickly—it is the norm in medical culture—at least in the USA.
“My God, I put blood, sweat, and tears into the care of this patient and just because his health deteriorated, this is the thanks that I get, a lawsuit claiming damages.”
When you are sued, you are a victim; no amount of evidence will convince you otherwise while you undergo the process. Obviously, malpractice claims can be justified. Whether they are or are not, the emotional and financial weight they have echoes into your interactions with patients and doctors, not to mention your insurance rates. Defensive medicine is a very real thing and costs us all a lot of money. By this I mean the cost of doing business with respect to what tests are ordered and why. This is often driven by an obsessive need to be absolutely sure as soon as possible that unusual problems are not causing a symptom or condition. For example, my mother, a sun worshiper all her life, showed me Medicare accounting for thousands and thousands of dollars billed by her dermatologist who with some frequency did skin biopsies on sun-damaged skin, “that might be cancer,” for exorbitant amounts of money—ten times more than I charged for the same procedures. To my knowledge, a significant skin cancer was never found. There are more egregious examples; if you have been to an Emergency Room in the last decade, your bill and the tests performed likely reflect just that.
The culture of my training as a physician was one of scarcity. Caring for field workers who may or may not have insurance or the means to pay their bills led to an attempt to be a steward of resources so as to provide as much care as possible, “on the cheap,” and not bankrupt people. The more urgent or catastrophic the problem, the less likely this orientation was to be used. When someone looks seriously ill, you do pull out all the stops trying to be sure of your next steps. Many medical malpractice suits find a lawyer pointing out to the jury that the doctor did not recognize the catastrophe for what it was. Sometimes, they are right. My second malpractice story below follows that script.
I was starting a mid-life career in medical staff “management” for Group Health Cooperative. This reflected a sort of mid-life crisis and was inspiring— not to mention less financially risky than say, having an affair……..another road often taken in mid-life. I left a finely tuned and busy medical practice when I made this jump. I was going to help ‘transform’ healthcare. In my first year of that work, I was served with a subpoena and found that a patient of mine was suing the Cooperative for damages. I was named as well.
The patient will be called Alice—I met her when she was 27 years old. She was impressive in that she grew up in a blue collar family, never went to college, but was a middle manager and important in the business for which she worked. The stress of her work was reflected in her demeanor and a one to two pack a day cigarette habit. She was very serious; I don’t recall ever seeing her smile. She had migraine headaches that could be incapacitating. With all that, her first set of visits with me were for chronic constipation, what appeared to be an obsessive concern.
An impression formed in my mind.
A decade later, she saw a number of providers—including me— in different settings with a constellation of symptoms that were not in a pattern that raised any alarms. When seen, she seemed, “just the same.” Her headaches persisted. She coughed a lot and had shortness of breath when she walked. She developed more and more fatigue which led to a limiting number of activities outside work which was exhausting her more and more. She developed right shoulder, chest, and breast pain. Dizziness with other symptoms led to a call to a consulting nurse who requested that she call 911. She refused and scheduled herself to be seen in the office. A number of people seeing her acutely, believed as did I, that she owed many of her symptoms to her cigarette smoking, bronchitis, and with time, consideration for a condition called fibromyalgia. What found me considering this diagnosis was a new detail in her history which was that she just did not have the energy to climb stairs or even walk a block without needing to sit and rest.
I gave her an article on fibromyalgia and I remember this reassured her. “That sure does sound like me…..” Fibromyalgia’s story is long and winding, but consistently not considered to be a lethal condition. Her lawyer enjoyed this approach quite a bit as it was not the cause of her symptoms. “Do you always ask your patients to validate or approve your diagnosis with articles, Dr. Moeller?” He did not say it nicely.
Alice would present to our local Emergency Room one night having an obvious heart attack. She was 38 years old—this was unusual. The cardiologist came in well within the time line to reverse the effects of the heart attack in the Cath lab—but—he could not catheterize her. Her femoral artery was completely blocked. Her inability to walk a flight of stairs or around the block was because she had virtually no circulation going into her legs.
As I review the deposition I gave, I am flustered with my mental gymnastics set in print. Maybe she had both heart disease and fibromyalgia! Adding to my defensiveness was his baiting me: “How many times do you have to see someone complaining of chest pain before you will even consider the heart as a cause?” I saw this as an over stated criticism despite her diagnosis. Her complaints of chest pain were not typical of heart disease and included heartburn, breast paint, and right shoulder pain along with her chronic cough and poor exercise habits.
There is a saying one learns in medical school: “When you hear the sound of hoofbeats, look for horses, not zebras.” The intent is to stay focussed on the most likely cause for a collection of symptoms, and not look for the unusual. My patient, Alice, turned out to be a zebra and I did not recognized that until after she had her heart attack.
The other metaphor, common in medicine is how hard it can be to separate the wheat from the chaff. A patient with chronic complaints can become something of the boy who cried wolf and blind you to the very real threat they face. All patients have conversational styles and personalities that require interpretation. The skill of being a good doctor is to work through that without bias—AND arrive at a correct diagnosis.
Thinking about Alice, I clearly had bias with time. I thought she was depressed and exaggerated her symptoms. People who are depressed and hypochondriacal have heart attacks and strokes and cancers too.
I googled her name after I read the deposition this month. She is alive twenty years after her heart attack and the discovery that she had a rare condition that led to advanced atherosclerosis; her cardiologist in his deposition noted that at age 38, she had the, “Aorta of a ninety year old.” The same cardiologist who by virtue of the lawsuit could not speak to me directly about it, got word to me eventually that, “you were screwed, she had such an unusual and profound problem at such a young age…..”
He was right. This same cardiologist would tease me about why it was so hard for family doctors to have so little success getting people to lose weight. When he saw people after their heart attacks, he commonly could help them lose twenty or thirty pounds in just a few months. Easy, right?
Nothing focusses the mind like the threat of a hanging.
I have some conclusions looking at this deposition. The symptom that was most glaring in retrospect was her detailed history that she could not climb stairs or walk a block without her legs aching so badly that she had to stop. This is a classic symptom of claudication (impaired circulation in the legs). Were she fifty-five or sixty years old, I would have heard that history and checked her feet for signs of impaired circulation. The pattern would have fit. Fibromyalgia patients get tired, but their legs don’t ache and then recover with rest. The examination of two feet with circulation in mind takes less than a minute to do. While it left a bitter taste, the settlement in her case was accomplished without trial. It was for a lot of money. She deserved every penny.
Doctors are by-and-large smart people. By this I mean, they learn a lot of things and prove by virtue of testing that they can retain and apply lots of information to problems. In the day-to- day of most practices, the pattens that emerge when seeing patients become a useful tool for arriving at diagnoses quickly and efficiently. When you start telling the patient what symptoms you think they might be having after they have shared thirty seconds of information, you can look brilliant when you are right. What you really are doing is recognizing a pattern, showing off, and cutting to the chase so you can move on to the next patient. Confirmation bias is a very real problem in medicine. Smart doctors use pattern recognition and move quickly to diagnosis and treat. The obese sixty year old man who feels like an elephant is sitting on his chest with shortness of breath is such a pattern— a no-brainer. Such a patient is sent to the ER and then the Cath Lab quickly. Really smart doctors stop when the pattern recognition does not appear to solve the problem and then apply some thought and reasoning to a broader set of possibilities. A man with a hemorrhoid and blood in his poop can still have a colon cancer—even if he is only 38 years old. How one teases out the unusual from the typical is what makes for a good vs a great doctor. Of interests, I did refer Alice to specialists: a rheumatologist and a neurologist. The old adage that to a carpenter, all problems look like a hammer and nail held true. They had ideas on what was wrong, but did not sort it out any better than my partners or I.
Another part of medical culture that gets less attention is peer relationships. I am a generalist with a broad scope of practice. I do things to diagnose quickly. For example, it is hard to see a Dermatologist in my community—there are not enough of them. I do skin biopsies to sort out if skin is cancerous or not. On that basis, they may not need to see a dermatologist or if they do, it is clear why. My ego is tied to this but also, this is an efficiency ie it allows the specialist to sort things more quickly if I have the appropriate testing already done. My reputation with specialists was mostly good because of this. They knew if I made the referral, it likely had been worked up and I was out of ideas or procedures to make the diagnosis. The generalist with a narrow scope of practice will refer patients to specialists quickly. Thirty eight year old women with right sided chest pain being referred to a cardiologist can find the generalist the object of some (usually unspoken) scorn. This hurts! It is bad for the ego! In the case of Alice, there would have been a hesitation on the part of the cardiologist—they would have to work through the wheat and the chaff just as I had and likely would have been skeptical. If I had referred when I might have, they would initially thought it strange but with testing, have thought me genius! “He managed to sort out an unusual condition in a 38 year old woman with a symptoms that were hard to put together. What a guy!” Opportunity missed!
Lastly, I am not the first physician to miss unusual symptoms that reflected heart disease in a woman. The deposition finds me describing “classic” symptoms of angina for the lawyer. What I learned the hard way, along with a lot of other doctors, is the reality that “classic” was code for what aging men experienced two centuries ago. These symptoms are real and help with quick diagnoses but it turns out that women have a very different set of symptoms on presentation. Fatigue, heartburn, and ill-defined location of pain all make the list. The experience of being sued as well as seeing harm come to a patient for my lack of —-time, patience, or discipline to stop and reconsider—contributed to developing yet a new set of patterns to be considered as well as the occasional time-out when things were not following the expected course.
Sometimes you get help breaking a dysfunctional pattern of evaluating problems; my favorite T shirt reads, “Be Nice To Nurses—They Keep Your Doctor From Killing You.” Medicine is a team sport. I once had an ICU nurse call me with a question regarding the dosing of a dangerous medication. The recalculation made me realize an error that would have been deadly. Nurses will occasionally weigh in on difficult-to-sort patients—and sometimes they have helped me get on the right path. The patient assumes when I am on the right path, that it is all about me. My T shirt along with many many thanks to my parthers—doctors and nurses- sets the record straight.
Comments