Tuesday, July 8, 2008

The Deep Satisfaction of Demonizing Our Doctors

Doctors are human.

Just like everyone else.

I would never assert that it's okay for doctors to make mistakes. And I would certainly never want to imply that patients who have been wronged are owed nothing for their suffering. But why do people seem to find it so compelling, almost pleasurable, to blame the doctor when something goes wrong? Do they really hate us so much? Do people really think we can and should be absolutely perfect all the time? Will blaming us, making us pay, taking revenge, making sure we are dragged through as much as punishment as possible, ensure that we are "put in our place?" And will it bring healing of whatever loss has occurred?

I will try not to generalize here. I'll just repeat what The Hunk has to say about it.

The Hunk hates hospitals. And doctors. And medicine. Yes, we are happily married. And yes, he still hates hospitals, and doctors, and medicine.

He also hates...
-being sick
-relinquishing control to another
-being talked down to / the arrogance of others
-not knowing enough about what's wrong
-not knowing what might happen
-adverse events

Fair enough. We all do.

But when those things come into play one way or another, somehow all that dislike of all those things gets channeled into doctor-hatred.

Will our human frailty every be forgivable? Ever?

What doctor HASN'T made a mistake, ever?

Who on God's green earth HASN'T screwed up royally?

And what if our frailty wasn't even to blame?

Sometimes I'm convinced people think we have no feelings at all. When I told someone once that a resident I knew was in the lounge weeping over the suffering endured by a patient and family, because of the patient's injuries at the hands of another, the reaction I got was one of incredulous surprise. We feel just as bad when people get hurt because of something we've done or failed to do. I truly believe the majority of us carry those mistakes or failings with us. We feel terrible about them. We feel deeply sorry for increasing the pain of others where we were supposed to decrease suffering. We practice better medicine because of what we learn, take BETTER care of our patients, and teach the students under our tutelage to learn from our experiences as well as their own. I think the worst kind of physician is one whose arrogance is cultivated, preserved, or increased by the fact (or perception) of never having done wrong or the feeling that s/he has never failed.

Errors in medicine are hot stuff in the press these days. We could do a mini-blog carnival right here on the subject.

There's the latest edition of SurgeXperiences, the surgical blog carnival. Jeffrey over at Monash Medical Student has made "Better" his theme - better practices, getting better as doctors.

Then there's the news from Beth Israel Deaconess Medical Center, about the surgical procedure that was performed on the wrong side, even in this era of checking and double checking and marking and confirming and reconfirming the correct site.

TBTAM at The Blog that Ate Manhattan reflects brilliantly on a nuisance malpractice case that may have more far-reaching consequences than anyone realizes. Doesn't anyone think beyond the pay-out? Is it too much to expect an angry plaintiff to do so? Probably.

But I think it's Mike O'Connor over at The Ether Way who really hits the nail on the head with this example (emphasis mine):

"It is now widely accepted that intrapartum asphyxia is the cause of no more than 10% of the cases of cerebral palsy in our world. The remainder, that is to say the vast majority, seem to be caused by some combination of intrauterine infection and the demise of an intrauterine twin; both of which precede delivery by weeks to months. Given this, it is unsurprising that escalating monitoring and aggressiveness in the management of fetal hypoxia had no effect on the overall incidence of cerebral palsy. In retrospect, the absolute inability to make any forward progress on this problem should have made it obvious: the vast majority of CP is not caused by intrapartum asphyxia...

..Who are the casualties here? Not just the patients. How many doctors and nurses were devastated by the idea that they might have caused CP in a child? How many careers were ruined? How many millions of dollars were paid for events that were beyond the power of those held responsible? Who is going to apologize to those practitioners? Who is going to pay them back? Who is going to make it right? (The answer to the last three: No one.)"

Instead of blame, I wish people would choose dialogue. Because I think what patients and families want (though I could be totally wrong) is for their pain to be known and heard and acknowledged by those who caused or contributed to it, and to hear from those people, and know, beyond a shadow of a doubt, that deep in their hearts they are, in fact, truly sorry.

Maybe this could work. Then we really focus on getting ever-BETTER. Maybe genuine humility expressed by doctors could supplant the humiliation and retribution desired by plaintiffs who feel the latter to be necessary to create justice and healing for their losses...but then again, maybe not. We are all human, after all.
Addendum 7/9/08: this quote from E.R. doc Shadowfax, who writes the blog Movin' Meat, is too important not to share. It describes doctors who are haunted by the fear of making a mistake. Hat tip to KevinMD for the link.

"I don't know what separates the doctors who practice scared from the rest. Maybe there's a difficulty in accepting the responsibility that comes from the life-and-death decisions we make. Maybe there's a fear of or past trauma from the criticism that invariably follows a bad outcome. Perhaps it's a simple fear of failure -- that the patient who does poorly is necessarily a reflection on you and your judgement, and your worth as a physician. Curiously, most of the docs I've known like this have never been sued, but there is a constant genuflection to the altar of 'I don't want to get sued.' I suspect that they use the bogeyman of malpractice as a proxy for their real fear -- the imagined consequences of making a mistake."


Jeffrey said...

thanks for featuring my post. i think you addressed a great topic. the sooner the public realise doctors are still fallible beings, the better. its just unfortunate that mistakes in our (medical) industry have consequences that are more far reaching; they touch on life itself.

Anonymous said...

FWIW, many professions are demonized - lawyers, the media, politicians, to name a few. Although you might feel doctors are being singled out, rest assured you have plenty of company.

I think some people are just angry and critical. It's how they respond to things. Push the right button and the bile comes spewing out.

The Internet has probably made it worse. I'm sure people were angry and critical in the past, but you didn't hear it as much because it was confined to beefing over the back fence. Now like-minded people can congregate on the Internet and the vitriol is out there for all to see. And as a result, the conversation can get really, really shrill.

Re your sense that the media is picking on doctors: You can't have it both ways. If you're going to be transparent, you also have to accept that a certain amount of public scrutiny comes with the territory. You have to accept that there's going to be criticism and disagreement and second-guessing. And it's going to be really uncomfortable... but the tradeoff is that it will help the public better understand the complexities of health care and the reality that mistakes do happen, despite everyone's best efforts.

Some people will probably never get it and they'll continue to bash doctors. Many others, however, will appreciate having the veil pulled back and seeing the humanness of their health care providers. And isn't that what we want? To educate the public?

You don't accomplish this with secrecy. Painful as it is sometimes, openness and accountability are still the best route to go, and the best weapon you can wield against the naysayers.

T. said...

Jeffrey - you picked a timely focus to kick off Season 2 of SurgeXperiences! Thanks for stopping by.

Anonymous - thank you, too, for taking the time to visit, read, and contribute such terrific points. I agree completely with you about the value of transparency and didn't mean to imply so much that I felt the media was "picking on" docs, but rather that sometimes it seems the general public has a certain amount of (understandable, in many cases) underlying resentment when it comes to physicians. You're right, though, that many groups wind up getting demonized sooner or later...

I think you summed it up well: "Openness and accountability are still the best route to go." There have been efforts in a number of efforts to shift M&M conferences away from being "blame games" and toward a more cooperative discussion of, "How could we as a team / system / individuals have done better, and how can we prevent similar adverse events in the future?" I believe this is the most productive attitude on all sides. I would like to see it become the prevailing spirit of most private and public discussions of adverse events...but I think that will take some time and hard work.

Thanks again for your thoughtful comments!

Anonymous said...

Two more things:

If medical errors are "hot stuff in the media" right now, maybe it's because it's such a novelty that they're being openly discussed. Routine stuff doesn't tend to make the news because it's, well, routine.

Re someone's "incredulous surprise" that a doctor would feel badly about hurting a patient: Our common humanity shouldn't make this a surprise, but doctors have a long history of not really letting patients and families see this.

I sustained a medical injury several years ago that caused permanent disfigurement. If the doctor felt badly about it, it's news to me. In fact he was quite flippant about it when he broke the news about the injury - distancing himself, most likely, but it was still very hurtful and disrespectful. No one's ever apologized to me or explained how the injury happened.

When this is the attitude that's displayed, it becomes really hard for people to believe you care about them. And my story is a lot more common than you would think.

I'll shut up now. :) And no, I really don't hate doctors at all and I don't believe in bashing or demonizing anyone. Really.

T. said...

Hi again, Anonymous - very glad to have you here bringing up such important points, insights, and stories.

I am saddened that your doctor chose to a distancing stance rather than an openly compassionate one. You're very understanding to take into account occasional physicians' needs for self-preservation in the face of suffering.

I think we collectivey have to reflect on this need to appear "strong," the corollary of which is that showing emotions / sympathy is "weak." (I actually think I've written about this before...)

I find it so ironic that we go into medicine because we feel a deep desire to help people through their suffering, and experience a genuine sense of compassion, only to have it buried under layers of acquired nonchalance, coldness, bravado, or what-have-you in order to either protect ego or project an image of strength. I have in the past attributed it to our training culture in medicine, but perhaps there are many intertwining factors complicating the issue.

I dream of a day when the stereotype of the doctor is not the arrogant, stand-offish, unfeeling person in the white coat but rather a kind, gentle, compassionate human being meeting a patient's gaze, listening intently, perhaps with his or her hand on the patient's shoulder - a mental image symbolizing that true strength is being unafraid to really come into contact with suffering or vulnerability, to learn from it, transform it, and allow oneself to transformed BY it.

T. said...

Just had to say, sorry for the numerous typos/accidentally repeated or omitted words/cut-&-paste mishaps in my comments above - a little too much multi-tasking today! :)

Stephen said...

One of my big surprises in one of the legal cases I was involved in was to discover that critical path analysis reflected that until 1989 going to a doctor was a net risk to your health.

Which is why the strange studies that showed populations that had the most access to medical care were not as healthy as those who restricted their health care to trauma care and inoculations.

In order to practice medicine then one had to submerge an awareness of the net harm one was causing, which led to a mindset that I think still permeates medicine.

In addition, many doctors are focused more on money than on health. Think of the efforts made to destroy public health nursing.

Or what happened with anesthesia, down to determining it wasn't necessary for babies (where the statistics validated the prior practice, which has been returned to) in order to exert more control over the cash flow.

Combine these two factors with the greatly increased lessening of human contact and expressed concern, of how quickly doctors go in and out when they make house calls ... (ok, I'm tossing that reference in to increase the contrast).

Are there exceptions to the rule? Absolutely.

But a kind, gentle, compassionate human being meeting a patient's gaze, listening intently, takes someone who takes significant time with each patient and does not have money for a primary motivator.

My personal doctor acts that way. Takes time, listens, and I like her.

My daughter's nurse practitioner is the same (no one ever sees the doctor who owns the practice, I haven't the slightest idea what he is like, though the young transitory pediatricians he has "supervising" are all pleasant enough).

The children's medical clinic I serve on the board of has similar doctors and the people served by them love them.

But ask yourself. How many doctors wash their hands properly? Why does JACO have such a problem getting handwashing improved?

Every time a doctor doesn't wash hands properly between patients you've seen your answer to the behaviors and attitudes that lead to the public feelings and opinions. We both know what the statistics show, sadly.

Stephen said...

Full disclosure. Two of my three children who died, died as a result of medical malpractice. I did not sue either time and you won't find posts vilifying the people involved.

Anonymous said...

I hear ya. And I agree that we have to stop demonizing people for making mistakes. I think doctors are growing frustrated and looking for outlets for their frustration and are making a lot of attacks on med mal lawyer and on insurance companies. We should all tone down the rhetoric and look for honest solutions.

In their desperation, I wrote on Friday about one outlet some good doctors are seeking for their anger that is misguided. See


If it makes you feel any better, doctors are joining the rest of us. The reality is that there is no other profession in the world other than police and fire fighters (maybe teachers, I'm not sure) where the jury is going to give the professional the benefit of the doubt. Doctors still walk before juries with the rebuttable presumption of having done the right thing with the right intentions.

One person below says two of his three children died as the result of medical malpractice. Awful. Can anyone imagine? He didn't bring a lawsuit. Would I? Put me in the shoes and I'll tell you; otherwise, I would not have a clue. But assuming what he is saying is true, could anyone blame him for bring or no bringing a lawsuit? Of course not.

Our law firm sues doctors. Does this mean I hate them? Hardly. I have three kids. I would like each one of them to be doctors (certainly not lawyers). But, look, if my fantasy came true and they all became doctors in high risk specialities, there is a good chance that one of them would hurt someone by making a mistake. And I would expect them to be accountable for that mistake even if 99.999999999% of what they had done was miraculously beneficial to their patients.

Supremacy Claus said...

Ron: What fraction of your claims goes anywhere, and at every stage of litigation from first pleading to appeal? If you are typical, the majority are weak cases, and you are playing the land pirate lottery.

I have proposed a black list for the enemies of clinical care. To protect clinical care from the massive plunder from all sides. No service or product provider of any kind should do any business with you.

Supremacy Claus said...

Ron: The field of medmal is a bunco operation. If you have opposing experts testifying in good faith, you have a scientific controversy. Only additional data can resolve a scientific controversy. The court has no competence to resolve a scientific controversy. You put on a bogus show, and juries pick whom they like better.

Only cases within the knowledge of the jury and with an expert supporting one side have any validity.

Most claims contain massive cognitive biases that violate the procedural due process rights of the civil defendant.

Yet, the system is rigged airtight. You have no accountability. If torts are good for medicine, why don't you waive your immunity for legal malpractice practice claims by the adverse third party, you hypocrite? Why doesn't the judge waive his immunity for the massive damage he does to doctors by his judge carelessness?

I do not appreciate your mealy mouthed, misleading, crybaby message. It makes you look cheap. Be proud of you bunco, devastating, land pirate operation.

T. said...

Hi, all - I truly appreciate everyone's willingness to engage in debate over a topic that arouses many complex responses including frustration on all sides. Thanks for taking the time to read and respond on this blog.

I ask, however, that the comment board not turn into a forum for bitter name-calling - I welcome opposing view points, controversy, even assertive debate, but I wouldn't want vented frustration to turn into the bashing of individuals.

Everyone is welcome to present his or her view here, and to interact with other readers; the corollary is that I DON'T want anyone to be made to feel unwelcome or insulted.

Supremacy Claus - I am deeply thankful for your support of clinical care and totally agree with so many of your points. I almost cheered when you pointed out that no judge or court has the competence to resolve scientific controversy. But I do think it's helpful to know Ron's thoughts on these matters too, and I sincerely appreciate the fact that you both took the time to express your thoughts here. I'd love to see more readers engage in lively, passion-filled, strongly- but respectfully-worded debate on the issues called forward by posts like these. There's no need for name-calling.

Thanks for keeping the discussion going.

Supremacy Claus said...

T: Ron gets too much credit from you.

He is the mortal enemy of all productive sectors of the economy. Should we hear out the Taliban? The Taliban have a lot of good features, from which we can learn, generosity, hospitality, family values, loyalty, courage, strong faith. Do they have something to say to us? No, they must just die, at our hand.

Docs are quite privileged as defendants. If you belong to a group making $5 mil a year, you get upset if you have 4 lawsuits at a time. Another doctor would be setting the standard of due care, and would know the nature of what you face.

If you owned a welding business making $5 mil a year, you would have 400 lawsuits everyday, forever. Strangers off the street, members of the leisure class, welfare queens, oblivious to the welding business would be setting the standard of welding business due care. It is far worse for all other enterprises.

Ron deserves no consideration from any doctor. I have proposed a total shunning and boycott of all trial lawyers and their judges, by all product and service providers. As they seek to destroy the economy for their enrichment, so should the economy return the sentiment.

As to bunco, the core of duty is foreseeability of harm. Can you foresee rare accidents or rare, unexpected complications? If you can you have supernatural powers to predict the future of rare events. That is correct, the core doctrine of torts is a supernatural power. Every plaintiff expert should be asked for tonights lotto number. They have a better chance of being correct, than of retrospectively predicting the outcomes of most weak cases filed from the facts known at the time. Plaintiff experts should not be provided with the outcome of the case. The record should be cut off at the time of the mishap. They should also provide their records of similar cases. If their testimony contradicts their records in any way, they should be held in criminal contempt by the judge and forced to pay all legal costs to both sides out of personal assets.

You are addressing a bunco artist abetted by judges dependent on litigators of both sides for their campaign contributions, and totally biased in favor of generating false cases, and of having them go to trial. To remind you of high school social studies, the Establishment Clause does not permit government laws that involve supernatural doctrines, in this secular nation.

By the way, I know that Ron loves this characterization. He will be back with his misleading, crybaby, lying case.

T. said...

Supremacy Claus - as much as I appreciate some of the points you have expressed, I have to reiterate my request to you and all readers to refrain from name-calling and fingerpointing here. I don't want to delete comments because I think communicating with each other on tough issues can be fruitful learning opportunities for those who are interested; but I also object to open hostility in this forum.

While I agree with some of what you've written, I strongly disagree with both the substance and the tone of some of the other things you've written.

I don't know Ron and therefore am not in a position to either defend or criticize his work, ethics, character, etc., and I have no reason not to show him the same consideration I try to show all visitors to this site.

What I do know is that to make blanket generalizations about ANY group - "ALL malpractice lawyers are crooks," "ALL judges are corrupt," "ALL doctors are arrogant and uncaring," "All African-Americans are this," "All Asians are that," etc. - smacks of the same bigotry and fanaticism for which we find entities like the Taliban so repugnant.

Supremacy Claus said...

T: You can rebut my over-generalization with a single exception. Find one. There is none. Ask Ron, can the defendant foresee a harm? Ask any random working lawyer. Ask all 1.3 million.

They all have supernatural beliefs which are fraudulent, and violate the Constitution. Not a single lawyer in the US has overcome the indoctrination of law school in supernatural doctrines.

Negligent torts have future forecasting as a core. Intentional torts have mind reading as core doctrine.

Feel free to delete my comments on the chance they offend a medmal plaintiff lawyer. Ron is offense proof.

Anonymous said...

Supremacy Claus point is simple: if you are a lawyer, you are worthless. No, take it a step further. Garden variety murders are worthless; lawyer are the Taliban. I especially like that one.

T, this guys spends a lot of his day on these blogs, making these kind of comments. You agree with him probably in the main on these issues. Have a beer with both of us. I bet you would find we agree on more things than we disagree and I bet you would think his views are far removed from yours.

There are a great many people much smarter than I that believe that medical malpractice tort reform is what we need. None of them hang on to the notion that there is no foreseeability of injury. None. Zero. There is not a single judge in the country that has ever suggested this. No one has suggested eliminating the FDA as Supremacy Claus. I could go because I see this guy's comments everywhere. But you get the point. Reasonable people who share your views in the main, T, don't follow along with this guy.

My preference is not for comparing the other party to the Taliban, which Supremacy Claus would have said famously if he not already made so many wild allegations/suggestion. Instead, I think healthy dialogue, acknowledging that there are good people smarter than us on both sides of these issues, is the best path.

I'm a lawyer. In my life, that has to get in line behind father, husband, son, brother, uncle and friend. Which is why the whole "you are one of 1.3 million evil humans" stuff does not even resonate with me.

T, I appreciate you are trying to have meaningful dialogue. I like this blog.

T. said...

Ron, thank you for continuing the discussion, and for having the maturity and professionalism to do so in a gracious manner, as I would expect of any adult.

I agree with many of your points as well. There is a great deal of harm that IS foreseeable; my own profession is all ABOUT trying to prepare for foreseeable complications and protect patients against them.

Moreover, there is a place for malpractice lawyers who approach their profession with integrity and dignity. A family that has been harmed because some surgeon showed up to work drunk and cut off the wrong leg or enucleated the wrong eye needs a good advocate to seek some kind of accountability and justice. That said, I do understand why medmal lawyers can be stereotyped as hyperbolic, antagonistic, disrespectful weasels - some can be, I'm sure. I happen to be good friends with a brilliant, articulate woman in medmal who is just the opposite, though, and who argues her well-researched cases with grace and poise.

I will never agree with Supremacy Claus's blanket assertion that ALL members of a particular group are evil or have evil intentions. Likewise, I would never claim that ALL members of a particular profession have integrity or are trustworthy or incompetent. I think there's always more to any story, and not a lot is that black-and-white. And again, I think making sweeping generalizations is a symptom of a kind of bigotry.

Thanks again for your remarks.

Supremacy Claus said...

T: Ron has confirmed my argument. He correctly said it, "none." And there is not a single exception in rebuttal. If there is no exception, then the sweeping generality is accurate, and not bigotry.

That means the entire group believes in future forecasting of rare harms, a supernatural power, forbidden by the Establishment Clause. I invite Ron to sit on the worst ward or at the worst traffic intersection, and to predict the next harm.

This supernatural doctrine promoting cult controls the three branches of government. They have granted themselves absolute immunities from any accountability for the foreseeable and intended harm done by the mostly weak claims they make. For your information, T, the filing of a weak claim is legal malpractice. It foreseeably harms the defendant, as reliably as the sun rises in the East. This forecasting is like forecasting the sunrise in reliability, not like forecasting a lottery number or a bad outcome. Yet, the lawyers exempt themselves from the benefits of torts. Ron has yet to support ending the privity obstacle to a legal malpractice claim by an adverse third party. He never will because he is a self-dealing unjust land pirate, with no ethos of justice or equal treatment, just piggish self-dealing. The lawyer has dozens of duties to the adverse third party (the other side) clearly enumerated in the Rules of Civil Procedure, of Evidence, of Conduct, and in 100's if not 1000's of appellate decisions. Not only is this immunity self-dealt, and unfair, it is also unlawful. But judges forbear this illegality to promote the interests of their campaign contributors.

Nor will Ron engage in debate on the legal or policy merits of the airtight rigged immunity system under whose protection he files most of his weak claims.

Ron can start by honestly telling us something very simple. What fraction of claims that he formally files result in any money damages, at any stage of litigation?

T, what is the fraction of your clinical decisions that you would tell yourself privately represent a deviation from your own professional standards of due care?

I know the answers, but would like to hear an honest number. They are an order of magnitude apart.

Supremacy Claus said...

T: Forget Ron.

Ask your dignified medmal plaintiff lawyer how many cases that she files ever pay out a dime. If it is around 25%, it means that 75% of her carefully researched claims are weak.

Contrast that to the professional standard of due care of the criminal prosecution, where the reverse statistic is true.

Your public toadying to Ron embarrasses the medical profession.

T. said...

Res ipsa loquitur.

Supremacy Claus said...

T: I am interested in the failure rate of your dignified, careful, and ethical medmal plaintiff lawyer friend. If she represents the best, most ethical segment of the specialty, what is her failure rate?

If her failure rate is 75%, it falls way below the standards of due care for the lawyer profession. Their self-dealt immunity is not just unfair but detrimental to the quality of their work.

You mention wrong site surgery. Most doctors would settle such a case. No doctor would resent paying for such an error.

It is the majority of cases, which are weak cases, which anger doctors.

David Behar, M.D., E.J.D. said...

Ron: The lawyer is the Taliban inside our shores. All political correctness is case. That is why employers will fire someone for making an ethnic remark, or a sexual joke. The penalty is draconian, enforced by judges and their thugs with guns.

This oppression is insurrection against the Constitution. It intellectually and morally justifies self-help remedies. You have 1.3 million people oppressing and controlling 300 million by the powers of government. The latter is a wholly owned subsidiary of the lawyer profession, making 99% of the policy decisions. That is why government does nothing well, except lawyer rent seeking.

I find you misleading statements unhelpful.

Supremacy Claus said...

Ron knows his success rate. He refuses to provide it.