We’re supposed to be perfect
August 24, 2004
I hate writing too many clichés in an article; such as this one you are about to read. However, some of them still seem tried and true. One of them is “With great power comes great responsibility”. Sort of applies in being a physician doesn’t it, although it would apply to anyone. Society has taught us to respect doctors, making the profession prestigious and sometimes unreasonably placing certain individuals in high pedestals. So high that when a doctor finally makes a mistake: perceived or real, the doctor is thrown down and dragged around town and lynched beyond recognition. He or she gets dishonored, tarnished of reputation, and stripped of material possessions. Here comes another cliché: “No one remembers you for all the good you did, but only for the one mistake you commit”. Yes, saving 100,000 lives in the past 30 years of practice can be negated by a single inadvertent mistake or accident that may cause someone “pain and suffering” especially after some prodding from a scrupulous trial lawyer.
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"Medical errors are more pervasive than we may think or accept. Change should start from amongst us: improving medical care and work conditions, updating medical knowledge, better legibility and communication and keeping an eye out for our colleagues."
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Here we go again, harping about medical liability and the crisis affecting US based physicians, and possibly Philippine doctors too if certain litigious laws get approved in the country. But let us speak more about the mistakes we do commit since we actually are not perfect, believe it or not.
Let’s start with the fact that we are all fallible humans. Second, we may have been absent in a certain boring class during med school when a particular lecture was given, or daydreaming during rounds when a certain topic was being discussed. Third, during exams or Board Review, we may have only relied on “spirituals” or “reviewers” especially those faxed just a night before the test. Fourth, we’re overworked, sleep-deprived and underpaid. Fifth, Murphy’s Law states that “If anything wrong can happen, it will” or something like that.
Mistakes do happen, often by accident. Sometimes, we may be responsible for them. Therefore, laws exist to protect the patients against us because we have so much power to harm them using or misusing our skills for healing. Just like anybody else, we are subject to justice and if it is a true culpable negligence, doctors can be punished like anyone else. Of course, we should take responsibility for our faults, but the problem is that the mistakes of the few affect the rest of the medical community. The result is a more litigious society, ridiculously expensive malpractice insurance premiums, and more expensive healthcare costs because of defensive medicine. There are many greedy lawyers out there exploiting this, getting filthy rich at the expense of experienced doctors getting bankrupt and tarnished. And because of higher premiums, many more physicians are quitting, limiting services or transferring, limiting patient’s access to medical care.
It is estimated that about 100,000 persons die of medical errors in the US alone every year. Prescription or medicine errors account for about 2.1 million adverse drug events yearly. These mistakes result into 190,000 hospitalizations annually and cost employers $39 to $74 million every year (source: www.ehealthcareinitiave.org). Many of these mistakes are due to illegible prescriptions. It seems that it is an age-old tradition for doctors to have horrible handwriting. The world of medicine seems to have worsened this further by deciding to use Greek to name everything anatomical and pharmaceutical products are named like tongue twisters. Perhaps if we write better, or print out or electronically write prescriptions, it may actually save thousands of lives.
Many times, we write legibly but indiscriminately. Once we hand out a script or a drug sample, we knowingly expose that patient to the drug including its side effects, overdose and abuse potential. Let’s tease these out. About side effects, we have the responsibility not only to tell the benefits of the drug but also what other problems it may cause. A patient has the right to know this and handing out a script implies tacit informed consent. Warning them about potential problems, especially serious ones, and documenting this in the chart avoids future potential liability. A patient has the right to refuse the prescription if he or she knew the side effects and is not willing to take the risk of suffering them if he or she takes the medicine you prescribe. This includes which drugs or treatments are contraindicated in kids, pregnant women, allergies and certain patient populations. This applies also to surgical procedures: whether it is indicated or not, if the benefits outweigh the risks, possible complications and whether you documented these properly in a written informed consent.
The next problem is drug overdose (or underdose). It is implied that the physician knows the correct dose to begin with. Basic pharmacology knowledge includes adjustment for renal function, hepatic impairment and drug interactions. In this era of polypharmacy, a patient may be taking a dozen medicines or more. Remember which medicines need to be adjusted if a patient has kidney problems or liver problems and modify doses regularly if these functions vary frequently. If the patient is taking multiple medicines and seeing other doctors, always get their list of medicines and see whether one drug lowers or increases the other. Don’t forget about herbal remedies; they too affect drug levels. The left hand should know what the right hand is doing: talk with the other doctors! Take note also of absorption problems in terms of gastric acidity and diarrhea. Lastly, take note of that decimal point and abbreviations! A therapeutic dose of 0.01 mg may be fatal at 0.1 mg and QD may be read as QID.
The third issue we are teasing out is abuse potential. There are lots of junkies out there. Doctors, nurses and pharmacists included. Some drugs as we all know are addicting physically or psychologically. In fact, more people abuse prescription drugs than street drugs. Prescription narcotics, benzodiazepines and barbiturates have “street value” and may be readily sold and bought in street corners if addicted “patients” can’t coax or buy it from their “therapist”. A US government survey reports that each month, 4 million people use prescription drugs non-medically (stimulants, pain killers and weight loss, etc). It is our responsibility as physicians to provide needed relief for pain and alleviate illness but care should be taken to avoid simply supporting an addiction for a feigned complaint.
These innumerable errors medical personnel commit impact hugely on everybody else. Trial lawyers and complainants are getting richer every year: plaintiff recovery rates increased from under 30% in 1996 to close to 45% in 2002 (source: Jury Verdict Research). Medical group practices reported an average premium increase of 37% or more this year, resulting into 15% of physicians quitting in part or in full in the next 3 years. Another 24% will stop certain risky services such as Obstetricians doing only Gynecology and Neurosurgeons doing only spinal but not cranial surgeries (source: Medical Group Management Association).
Because of this, the ire of doctors against trial lawyers have reached a boiling point, short of riots and assassinations. A certain surgeon Dr. J Chris Hawk III from South Carolina even proposed to the American Medical Association (AMA) that doctors could refuse to treat trial lawyers for non-emergency situations! To avoid further “trouble”, Dr. Hawk withdrew his proposal and the AMA threw it out being a “public relations nightmare”. I would have waited for a resolution “to get the attention of trial lawyers” as per his proposal.
Perhaps one way to improve the situation besides bloodshed and getting the attention of trial lawyers is to better police ourselves. Public Citizen, an organization that monitors consumer welfare reported that nationwide, State Medical Boards meted out only 2,992 actions such as license revocations, suspensions, surrenders and probations in 2003 or an average of 3.55 actions per 1,000 physicians (complaints). These disciplinary actions included negligence, incompetence, sexual misconduct, and other crimes.
Medical errors are more pervasive than we may think or accept. Change should start from amongst us: improving medical care and work conditions, updating medical knowledge, better legibility and communication and keeping an eye out for our colleagues. We need to help and police each other lest our skill becomes a license to harm and we in turn become victims of scavengers who want to strip us of our hard earned profession. We’re not perfect after all.
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Views expressed on this column and any other by-lined articles on this site are the authors' own and do not necessarily reflect the views of the organization or its members.
