"Doctors make mistakes. Can we talk about that?" ED physician Brian Goldman's TED talk

Dr. Goldman asks if you know your surgeon's "batting average" of operations with good outcomes. He mentions the three words you never want to hear: "Do you remember?" It's a good TED talk:



Every doctor makes mistakes (just like everyone does). But, says Dr. Goldman, medicine's culture of denial (and shame) keeps doctors from ever talking about those mistakes, or using them to learn and improve. Telling stories from his own long practice, he calls on doctors to start talking about being wrong.

Here are some simple steps to avoid medical errors from a patient's perspective (source: CNN):

1. Say: "My name is Mary Smith, my date of birth is October 21, 1965, and I'm here for an appendectomy."
2. Say: "Please check my ID bracelet."
3. Say: "Please look in my chart and tell me what procedure I'm having."
4. Say: "I want to mark up my surgical site with the surgeon present."
5. Be impolite (this particular piece of advice is obviously controversial).

References:

CNN video: Steps to avoid medical errors

A culture of silence remains about medical errors, but things are slowly improving, physician-activist says

There has been a culture of silence when it comes to talking about medical errors, but things are slowly changing, writes Dr. Kevin Kavanagh, right, in an op-ed piece in the Lexington Herald-Leader.

Kavanagh, who is chairman of Health Watch USA, recalls an incident in which a patient came to be treated for a severe sinus infection. Upon being rushed to surgery, Kavanagh discovered "an old smelly gauze pack" had been left in the sinus from a previous operation. When an assistant asked Kavanagh what he should tell the patient, "I answered, 'The truth'," for which he was disciplined by a senior surgeon.

"Years have passed, and things are starting to change in medicine," Kavanagh writes. "Telling patients that something went wrong is slowly being accepted — a revolutionary idea to medicine."

Studies have shown that hospitals with full-disclosure policies actually have lower patient death rates, which Kavanagh just called "common sense." "If preventable patient harm occurs on a ward and the patient is not told, almost all of the employees on the ward will know about the cover-up," he writes. "How then will the administration garner the respect to effectively oversee the functioning of personnel? If hospital staff are not performing adequately, how do you discharge them when there are skeletons in the closet?"

Full disclosure also lowers malpractice expenses, Kavanagh contends. Stanford University hospitals had a 36 percent drop in malpractice claims and has saved $3.2 million since it adopted a full-disclosure policy in 2007. University of Michigan had a 40 percent drop in new claims and saves $2 million each year.

But full disclosure is not common in Kentucky, despite the Veterans Affairs hospitals in Lexington being the first to implement full disclosure in the country. "Instead of this practice spreading throughout Kentucky, the next health-care system to implement it was the University of Michigan," Kavanagh writes.

Things need to change, especially in the face of superbugs like MRSA. As he looked back at the incident involving the botched sinus surgery, "I am most bothered that I apologized for my actions," Kavanagh writes. "Now I would reserve the words, 'I'm sorry' for the patients who have been harmed." (Read more)

Federal agency is pressured to re-post online database of doctors' malpractice and disciplinary cases

U.S. Sen. Charles Grassley has joined journalists, academic researchers and consumer groups in calling on the Health Resources and Services Administration to put back online the National Practitioner Data Bank, a database of malpractice and disciplinary cases against doctors.

"In a strongly worded letter, the Iowa Republican, who has led investigations of fraud and waste in government health programs, said the now-removed file 'serves as the backbone in providing transparency for bad-acting health care professionals'," Duff Wilson of The New York Times reports. Grassley gave HRSA, part of the the Department of Health and Human Services, until Oct. 21 to hand over documents and answer a series of questions, ending with "What is your timeline for getting the database up and running again?"

For a PDF of Grassley's letter, click here. Under pressure, the agency has scheduled a conference call on the issue for Thursday, Oct. 13, from 1 to 2 p.m. Eastern Time.

The database "was created in 1986 for hospitals, medical boards, insurers and others to share information so that bad doctors do not slip through cracks in reporting," Wilson writes. The law makes doctors' names confidential, but the database has a Public Use File for researchers and journalists, in which doctors are identified only by numbers.

Some journalists have been able to identify doctors using information from other sources, such as lawsuits. "After a complaint by one doctor identified by The Kansas City Star, the agency threatened the newspaper reporter with a fine, pulled the doctor’s file from its Web site on Sept. 1 and began a review of how to hide the identities better," Wilson reports. "Its actions provoked protests" from the Association of Health Care Journalists, the Society of Professional Journalists, the Reporters Committee for Freedom of the Press and other groups. In a letter, they told HRSA, "Nothing in the Public Use File can be used to identify individuals if reporters or researchers don’t already know for whom they are searching."

Grassley wrote, "It seems disturbing and bizarre that HRSA would attempt to chill a reporter’s First Amendment activity with threats of fines for merely 'republishing' public information from one source and connecting it with public information from another. A journalist’s shoe-leather reporting is no justification for such threats or for HRSA to shut down public access to information that Congress intended to be public."

The Public Use File can be downloaded from the website of Investigative Reporters and Editors, one of the groups, protesting its removal from the HRSA site, but "that file will be more and more out-of-date as the dispute goes on," Wilson notes. She also reports that Robert E. Oshel, associate director for research and disputes in the Division of Practitioner Data Banks, says the agency is misinterpreting the law. (Read more)

Nursing student successfully challenges dissmissal from school because of Facebook photo

A Kansas college is facing a legal challenge over its dismissal of a nursing student who posted online a photograph of a human placenta studied in class - the WSJ video is embedded above.

The lawsuit includes a letter that Ms. Byrnes wrote to the college apologizing for what she called a "lapse in judgment" but asking that she not be dismissed.

The school said the four students are allowed to reapply to continue their nursing studies in August 2011.

Most reader comments on the story follow this pattern: "I fail to see why this posting should result in dismissal from school. The student broke no confidentiality, and the posting was certainly not obscene."

References:
Odd Facebook Post Leads to Student's Ouster, Suit. WSJ.

Lawyers Opinion: Risky Business - Tweeting the Symptoms of Social Media

From Risky Business - Tweeting the Symptoms of Social Media (PDF):

"To date there are at least 540 hospitals in the United States utilizing social media tools: Hospitals account for 247 YouTube channels, 316 Facebook pages, 419 Twitter accounts, and 67 blogs.

The number of individual and independent medbloggers is in the thousands.

In December of 2009, a hospital employee was forced to resign because of a single tweet.

On October 29, 2008, a patient provided what is believed to be the first live tweet from the operating room. “Bad bad stick. Ow ow ow ow ow.”

In response to online physician rating websites, like Yelp, RateMD, and others, a company now offers physicians an antidefamation service, including contract provisions restricting a patient’s right to make negative comments on rating websites.

There are a number of other scenarios that could lead to liability. For example, what happens if an “off-duty” physician responds to a health question by a neighbor while doing yard work? Suppose the same exchange occurs through online “messages” between a physician and one of the physician’s “friends” on Facebook, creating an electronic record of the exchange that could potentially support the existence of a physician-patient relationship, thereby creating certain liability arising therefrom (e.g., HIPAA, medical malpractice, patient abandonment, etc.).

The authors of a National Law Journal article warn that bosses who “friend” are begging to be sued."

References:

AHLA Connections: Legal Implications of Health Care Social Media.
"If a patient bashes a physician on rating websites there is little that doctor can do", says Medscape, 2012.
Guide to Winning Your Malpractice Lawsuit - Medscape http://buff.ly/UTaWOq

Image source: public domain.

Dr. Flea Blogged His Malpractice Trial, Settles When Outed

Dr. Flea and His Blog

Dr. Flea was the alias of a pediatrician who blogged anonymously on Blogger.com. I have visited the site occasionally following links from Grand Rounds but his writing was a bit too bitter for me to become a regular reader. Recently, Dr. Flea started to blog extensively about his malpractice trial and then suddenly, all his blog entries were deleted although the placeholder URL still remains in place.

It turns out the plaintiff's attorney used Dr. Flea's blog against him in court. When outed, the pediatric pulmonologist decided to settle the case within 24 hours. New York Personal Injury Law Blog points out that the Flea story was printed on the front page of the Boston Globe, above the fold. "Which is to say, his patients and colleagues will all see it." This is regrettable. I am sure many of us feel sorry for Dr Flea as well as for the patient and his/her family, of course.

Blogging and Your Career

Blogging can be a dangerous business. If it is done right and in a positive way, it can help advance your career. If blogging involves poor judgment, it can have undesirable consequences. Just ask Mark Jen, reportedly the first employee to be fired for blogging. He worked for Google and was blogging about the company's upcoming products. It did not take long for Google, famous for its somewhat secretive corporate culture, to decide that Mark Jen was not the best fit. Since then, Google teams and employees have launched multiple blogs (both work-related and personal) and I have not heard of anybody running into problems because of what they have written online.

I would encourage anybody to write a blog if they have something interesting to say and add value to the online conversation. Just be smart about it. Write to share and educate not to blow off steam. We live in a Google world. What you post online today can come back tomorrow to haunt you. According to LifeHacker:

"A new study shows that one fourth of human resources people have decided against hiring a job candidate based on information they found online about that person. Luckily, you can have a say in what Google says about you."

Some Advice for Medical Bloggers

- Write as if your boss and your patients are reading your blog every day
- Comply with HIPAA
- Do not blog anonymously. List your name and contact information
- If your blog is work-related, it is probably better to let your employer know
- Use a disclaimer, e.g. " All opinions expressed here are those of their authors and not of their employer. Information provided here is for medical education only. It is not intended as and does not substitute for medical advice."

Updated in November 2010: Interview with Dr. Flea. ScienceRoll, 2010.

References:
Blogger unmasked, court case upended. BostonGlobe.
Doctor Blogs Own Malpractice Trial, Settles When Outed. WSJ Health Blog.
Flea. Kevin, M.D.
Make Yourself Google-able
Flea's fall sobering for other bloggers. White Coat Notes.
Simply Fired - How NOT to Blog About Your Job. Especially If You Are a Doctor
A new study shows that... LifeHacker.com.
Case Reports and HIPAA Rules
Anonymous Medical Blogger? Not Anymore
Guide to Winning Your Malpractice Lawsuit - Medscape http://buff.ly/UTaWOq

Image source: Boston Globe.

$ 30 Million Lawsuit for Complications of Pressors Use in Septic Shock

A 47 yo female was awarded $30 million to recover past and future medical costs, lost wages and pain and suffering for complications of treatment of septic shock by a Florida court.

A plastic surgeon performed a "tummy tuck" (abdominoplasty) in 2001, soon after that the patient began to to have fever. According to the newspaper story, she went to the ER and the on-call surgeon "removed some fluid from her stomach area and... she was given medicine that focused blood flow to the inner part of her body to protect her vital organs.

Yerrid said this medicine can be given only after fluids have been administered; otherwise, the flesh in the extremities will die. Haedicke never ordered fluids for Lucia.

Haedicke's attorney said Lucia's kidneys were shutting down. Had he administered fluids, she could have died.

The lack of blood flow to her extremities had caused severe damage to her hands and legs. Doctors at Tampa General were forced to amputate fingers from both hands and her legs below both knees."

Of course, it is difficult to impossible to comment on a medical case without examining the patient and reviewing the chart but we usually give IV fluids (IVF) before and during pressors administration.

The rationale of "filling the tank" before using pressors (which can cause peripheral ischemia) is well-illustrated in this clinical case: Pneumonia and Septic Shock. As you can see from the labs, this patient also had acute renal failure which actually improved with IVF.

Early rapid and appropriate treatment of septic shock is extremely important in order to decrease morbidly and mortality in this very sick patient population.

References:
Patient Wins $30 Million. The Tampa Tribune, 5/2007.
Pneumonia and Septic Shock. ClinicalCases.org.
Link via Kevin, M.D.
Image source: CDC, public domain.