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Letter to the editor

Let doctors fix mistakes

By Richard Karl
Published November 21, 2004

Every Monday morning at 7:30, the University of South Florida's department of surgery convenes in a nondescript cinder block classroom on the university's Tampa campus.

Surgical residents, medical students and attending surgeons who work at Tampa General Hospital, James A. Haley and Bay Pines VA Medical Centers, H. Lee Moffitt Cancer Center and All Children's Hospital gather to examine the problems that have occurred across the department during the previous week.

By problems, we mean adverse events that have affected our patients; errors in diagnosis or treatment and just plain bad outcomes where no errors appear to have been made. The object is to rigorously review the care of each patient who has had a complication (morbidity) or death (mortality). We call this conference M&M for short. Everybody comes.

Until Monday, Nov. 8, that is. As a result of the passage of Amendment 7 to the Florida Constitution, our university counsel recommended that I suspend the conference and cease collecting records that might be "discoverable."

I was stunned and deeply dismayed. You see, this conference is the staple of surgeons' efforts at every medical school in the country to do root-cause analysis of adverse outcomes. It is the backbone of our education program, for it teaches young doctors to question how things are done, to defend surgical and medical decisions by knowing the published literature, to step up to the direct ascribable responsibility that every surgeon must bear, and to think on their feet. It is a noble, rigorous, thoughtful process.

We often find that no mistake has been made in a patient's management, but the patient had a complication or died anyway. An example might be a patient, a known heavy smoker, who despite adequate pulmonary care develops pneumonia after a heart operation. Sometimes we find small errors that probably didn't affect the outcome but still require investigation, analysis and correction. This could be delay in diagnosis because the wrong X-ray was ordered before the right one was. This error might cost somebody his life the next time, and we want to learn from the near-miss.

Sometimes a surgeon will injure another organ while doing a difficult case. This type of error, even if the damage is repaired, must be reported to the state of Florida. Mandatory reports are made in several instances, including inadvertent injury, operations on the wrong organ or patient, or when a piece of equipment like a "sponge" is left behind. The report is called a "Code 15."

It may seem inconceivable to you that such errors occur, but they do. Medicine has been slow to find ways to reduce error, and conferences like M&M are essential if we are to do better.

The reason Amendment 7 was filed had to do with Amendment 3, which limits the amount lawyers can collect while representing patients who have been victims of malpractice - or, in some cases, no malpractice but adverse outcome. The lawyers and the doctors are fighting, and the people of Florida were asked by each side to pass amendments designed to hurt the other party. The populace obliged.

Amendment 7 essentially says that anybody who has sought "medical care in a health care facility or from a health care provider" can have "access to records of a health care facility or health care provider's adverse medical incidents, including medical malpractice and other acts which (sic) have caused or have the potential to cause injury or death." I'm no lawyer, but every act I take as a surgeon falls into the category of having the "potential to cause injury or death."

The public should know about malpractice judgments against physicians and surgeons. They should not know about every suit that is filed against a doctor or hospital. In many instances, no malpractice has been committed and no judgment will ultimately be made. Many suits are filed because our society seems to feel that no bad outcome could ever occur without somebody being at fault.

There is another subtlety to the problem: Many hospitals and doctors settle (or are forced by malpractice insurance carriers to settle) suits because it is much cheaper than going to trial. An example is a child born with a birth defect when every medical effort seemed appropriate. The family will likely get a large settlement despite the absence of malpractice, because the emotional impact of a beleaguered child in front of a jury is a risk nobody on the defense side is willing to take.

I'm not proud of medicine's safety record. It could and should be better. I am not sympathetic to my colleagues who think the problem is just the legal profession. We doctors have work to do. I am not proud of the lawyers, either. Many do little more than traffic in the misery of man. Malpractice costs are way too high. They drive up the cost of medicine, and they adversely affect the way doctors view their patients.

Most objective studies have found that many lawsuits have no malpractice basis and that most malpractice "events" never lead to a suit. As a way to insure medical safety, the system of law doesn't work. This is a different matter from the issue of what a malpractice victim is due when he or she has been injured by mistake. As a safety tool though, lawsuits are ineffective.

Trading amendments is no way to deal with the problem. Medicine needs to get its house in order. Law does, too. The people of Florida have unwittingly joined the battle by passing both Amendment 7 and Amendment 3. Predictably, many hospitals and universities have filed suit seeking clarification of the broad powers invoked by Amendment 7.

On Monday, you'll find us back at M&M. The written record may be a little more generic than in the past, but I can't traduce the tradition of inspecting our work for error. Residents and faculty will still be held accountable for the lives that have been entrusted to them. They will have to explain why they did what they did. They will have to tell the others how the problem developed and what they would do differently next time. All of us there will learn from this process.

When the meeting breaks up, we will go back to the patients we mean to serve. We will do the very best we can. Someday this week, a surgeon colleague of mine will find herself deep into a difficult operation. Malpractice costs, constitutional amendments and lawyers will not cloud her mind. I know her. She will do the right thing. Will we as a society?

Richard Karl is the Connar professor and chairman of the Department of Surgery at the University of South Florida College of Medicine, and the author of a book of surgical stories, Across the Red Line.

[Last modified November 21, 2004, 00:16:21]