Pulse: An Invitation to HealthBeat Readers
From time to time, I have quoted stories from Pulse: Voices from the Heart of Medicine, on HeathBeat. This free, online magazine publishes both narratives and poetry. Most are written by patients or health care providers. All are based on true events.
I believe that medical narrative is becoming an important part of health care reform. Too often, when talking about healthcare, we focus only on the numbers, and ignore the stories. As Dr. Donald Berwick, President Obama’s candidate to head the Centers for Medicare and Medicaid points out, “our measurements will mislead us if we forget the stories.” Indeed, "measurement can pluck the heart from a story.”
Pulse aims to capture the experience of receiving or giving care, and it does this very well. The authenticity of the writing is striking and the editing is excellent. Full disclosure: Paul Gross the magazine’s editor and founder, is a friend.
But I am not alone in noticing this small magazine. Just last week, the Washington Post called attention to Pulse: “Subscribers to the free online magazine Pulse (http://www.pulsemagazine.org) receive a weekly essay or poem about health care . . . . Paul Gross, a physician and assistant professor at the Albert Einstein College of Medicine at Yeshiva University in New York, launched Pulse nearly two years ago, frustrated with the chasm between the scientific studies in medical journals and what it's like to practice medicine on a daily basis. The missing link turned out to be the voices of patients, providers and educators.” http://www.washingtonpost.com/wp-dyn/content/article/2010/03/29/AR2010032902931.html
Pulse has now asked subscribers to invite friends to sign up for this free on-line magazine. So I am extending the invitation to all HealthBeat readers. To subscribe, please click here http://www.pulsemagazine.org/signup.cfm
To give you a taste of Pulse, below, a remarkable story from the most recent issue of the magazine. . I should add that this piece is unusual.While all of Pulse’s stories are based on true events, most are conventional first-person narratives. In this case the tale of a hospitalization is told from three points of view: first, the recollections of the patient (who happens to be a physician); second, events as recorded in the medical charts by doctors and nurses; and third, the version put forth by the hospital.
Babel: The Voices of a Medical Trauma
FRIDAY
Patient:
It is fall 2005, and I am nine months pregnant. A healthy 33-year-old pediatrician, I am a longtime patient of Doctor A and Doctor B, who delivered my two young children at this hospital. My husband and I are eagerly anticipating the birth of our third child.
One evening after dinner, the contractions start coming every five minutes. My husband and I pack our bags and drive to the hospital. I am nearly 4 cm dilated. After observation, Doctor C calls Doctor A, makes a diagnosis of false labor and sends us home.
Chart:
9:25 pm: 33 year old gravida 3, para 2, 38 5/7 week seen in office this AM almost 3 cm. Negative PMHx, c/o contractions q 5 min. Cervix 3+. Will ambulate 2 hours.
12:15 am: Continued contractions q 5 min. Spoke with Doctor A–home or stay–patient chooses to go home. Keep appointment Monday for induction.–Doctor C
Hospital:
Your presentation to Triage was discussed with Doctor A by the OB Triage Specialist. Since there was no change in cervical dilation, you were discharged.
SATURDAY
Patient:
My water breaks the following night, and I call Doctor B. After saying "Hold your horses," he grudgingly tells me to return to the hospital. By the time we arrive, my contractions are coming every minute. No one is behind the emergency room desk. My husband finally finds an off-duty orderly willing to get a wheelchair to take me to the birthing center. There, the secretary refuses to call a nurse until I sign papers explaining the hospital's privacy policies.
Chart:
Registration 10:45 pm. Triage admission 10:45 pm.
Hospital:
After 10:30 pm a call bell is present on the counter in case the triage nurse is not at the window. The "off duty orderly" who wheeled you upstairs to the birthing center may not have known the proper sequence to follow. Documented registration time is 10:45 pm and the time placed in the triage room is 10:45 pm which indicates swift placement into a triage room. There are some forms that must be signed for each admission.
Patient:
In triage, Doctor D prepares a fern test to determine whether the fluid that has soaked the bed and wheelchair has come from a ruptured amniotic sac, when that fact is clear even to my lay husband. Nurses are shouting at me not to push, but I am involuntarily bearing down with each contraction. By the time we rush towards the delivery room, the baby is crowning. He is born in the hallway.
Chart:
10:59 pm: Boy delivered 8 pounds, 1 ounce. Spontaneous vaginal delivery.–Nurse A
Hospital:
You delivered in the labor and delivery room 14 minutes after arrival by the OB Triage Specialist.
Patient:
I am left lying there, waiting for Doctor B. When he arrives I ask, "Where were you?" He answers, "I can't come until they call me." He yanks the placenta out, and I bite my lip. At one point, while he is sewing my laceration from the birth, I exclaim, "Ouch! I can feel that!" He replies, "Aww, that's just the deepest one," and keeps on going. He disappears as soon as he is done.
Chart:
11:25 pm: BP 136/76, HR 85. Hemoglobin 14.
Delivery Note: Precipitous labor, arrived at triage 8 cm, dilated and delivered on arrival by Doctor D. I arrived in room just after delivery. Placenta spontaneous and repair of second degree laceration under local. Group beta strep positive–no antibiotics given.–Doctor B
Hospital:
Doctor B was on-call for his practice that night and was physically on the premises. However, since your delivery progressed so quickly he did not make it from his prior location. He does not recall "yanking" your placenta.
SUNDAY
Patient:
We are moved to the postpartum floor. Seven hours later, I suddenly feel weak, dizzy and nauseated. I say, "Somebody help me, I don't feel well." The next minute, I'm hemorrhaging. There is blood spurting everywhere, clots the size of frying pans. I think I am going to die. Panicky nurses and residents crowd the room. The crash cart is wheeled in, my baby is wheeled out. My husband is shouting, "Somebody get Doctor B!" I am being stuck everywhere for an IV. Someone says that there will be a "procedure," and then my underwear is cut off, injections slammed into my buttocks, my legs are forced open and somebody shoves an entire forearm into my uterus and pulls out clots. Three times. I scream and scream and scream. The pain is unbearable, and I feel brutally violated.
Chart:
7:30 am: Called to see patient passing clots. Passed two medium size clots. Blood pressure 110/67…100/60…90/58. Pulse 88…96. Patient uncomfortable, vomited x 2. Bimanual evacuation lower uterine segment with 3 large clots. Orders: IV, Pitocin IV, Methergine IM, Morphine IM, Zofran prn. Discussed with Doctor B.–Intern
Hospital:
Once again, we refer you back to your private physician for a detailed discussion about the hemorrhage you outlined.
Patient:
Everyone flees the room.
I am curled in a fetal position, crying and shaking. No one comes to explain why, how or what has just happened. When my husband stumbles down the hall afterwards, other new mothers stop him to ask if his wife is okay after what they have heard. They are the only ones who ever ask if I am all right.
Chart:
7:40 am: BP 90/58. Will continue to observe.–Night Nurse B
8:00 am: IV running. Patient medicated with Zofran for nausea. Resting comfortably. Will monitor.–Day Nurse C
Hospital: [no response]
Patient:
Doctor B makes rounds. "You doctors make the worst patients." Then he asks if I am up for an early discharge. He stands in the doorway, making more eye contact with my chart than with me. I never see him again.
Chart:
8:40 am: Hemoglobin 11. BP 90/60.
Afebrile, vital signs stable. Fundus firm, lochia moderate, perineum ok. Doing well. Orders: Discontinue Pitocin at 12 noon if lochia normal. Heplock IV.–Doctor B
Hospital: [no response]
Patient:
My husband notices that the expiration date on the bag of Pitocin–the intravenous medication used to treat postpartum hemorrhage–is fourteen days overdue. A nurse quickly removes the bag and assures me that Pitocin is good for two weeks past its expiration date anyway.
Chart:
1:50 pm: IV infilt
rate right forearm. Catheter discontinued.–Nurse D
Hospital:
Each unit where Pitocin is supplied is checked on a monthly basis. The Pitocin label has two dates on it. One date is the compound date, and the other is the expiration date. Is it possible you noticed the compound date?
Patient:
I lie dazed and in shock, unable to eat or drink. When my baby is brought in to nurse, I numbly put him to my breast and go through the motions. Patient-care assistants come in once per shift to chart my vital signs. Nurses avoid the room and act as if nothing happened.
Chart:
12 pm: BP 100/70. 4 pm: 90/60.
Intake: Regular diet. Quantity sufficient. Output: Voided. Quantity sufficient.
Infant weight 7 pounds, 10 ounces. Breastfeeding score 10/10. Assessment within normal limits.–Nursing notes
Hospital: [no response]
MONDAY
Patient:
Doctor A rounds. "I'm surprised you decided to leave that first night." I am stunned. When I finally answer that we were discharged from the emergency room on his orders, he replies, "I thought you came in looking for a sneak induction." He writes my discharge orders a day early and leaves, also never to be seen again.
Chart:
12 pm: BP 90/60. 8 pm: 96/58.
No complaints. Feeling better. Doing well breastfeeding. Orders: Home tomorrow AM.–Doctor A
Infant weight 7 pounds, 5 ounces.
Infant nursing well at frequent intervals. Exam significant for icterus [jaundice]…facial bruising…Precipitous delivery, maternal group beta strep positive without antibiotic treatment. Discharge planned for Day Five if course in hospital remains uneventful.– Doctor E
Hospital: [no response]
TUESDAY
Patient:
On the morning of discharge, I tell the nurses repeatedly that my baby is very sleepy, not nursing well and starting to vomit. He has lost 10 percent of his weight in the forty-eight hours since birth. The discharge nurse tells me to "stop worrying like a pediatrician mother," his vomit is just spit-up, and he is not sleepy, just "content." We are handed formula samples and hurried out the door.
Chart:
1:45 pm: Infant weight 7 pounds 3 ounces. Bilirubin 12.7. Report given to Doctor F via Nurse E. Patient discharged to home with infant after discharge instructions and supplemental nursing that patient requested in case she decided to supplement infant. Patient's condition stable.–Nurse F
MD verbal order: Discharge home with mother. Cancel home health.
Hospital:
There was no emesis or spitting documented. Status reports were given to Doctor F and nursing notes indicate that Doctor F wanted your baby to be supplemented. The nursing notes indicate that you were informed of this and were provided instruction on supplemental nursing.
Patient:
Within one hour of getting home, my baby throws up again, drenching the bassinet. We rush him to the pediatrician's office and are sent immediately to the emergency room of another hospital. He is jaundiced, lethargic and dehydrated. The ER staff struggles for IV access, sticking his arms, legs and scalp. He is admitted that evening, five hours after our hospital discharge, still wearing his hospital leg bands. It is my thirty-fourth birthday.
Chart:
6 pm: Infant weight 7 pounds, 3 ounces. Bilirubin 16.9. Sleepy, floppy, jaundice to umbilicus. Admit.–Emergency room notes
Hospital:
Once again your pediatrician can address your concern in this matter as well.
WEDNESDAY, THURSDAY, FRIDAY
Patient:
My son remains hospitalized, lying in an incubator receiving intravenous fluids and phototherapy. He doesn't come home for good until he is nearly a week old, requiring yet another week of home phototherapy and daily home care visits before regaining his strength and weight.
Chart:
Diagnosis: Obstetrical Trauma Not Otherwise Specified.
Disposition: Return in approximately one year.–Doctor G
Hospital:
We are sorry that you were so unhappy with your stay. After a thorough investigation of your allegations, we have concluded that the care you received was appropriate. Thank you for taking the time to express your concerns.
———-
In the months after my son's delivery, it was as if a curtain had descended over my life. In addition to a terrible feeling of numbness, I was haunted by flashbacks and nightmares about what had happened. Billboards for the hospital where I'd delivered, people dressed in scrubs, pregnant women, a favorite red velvet cake that now resembled to me a large blood clot and, worst of all, my own baby–the sight of any of these could trigger flashbacks and bouts of heart-stopping, sweat-drenched panic.
For my postpartum checkup, I saw a new obstetrician, who listened uncomfortably to my tearful story and ultimately dismissed my symptoms as hormone-induced baby blues, "Mother Nature's way of kicking women when they're down."
After five months of worsening symptoms, I finally self-referred to a psychologist who began treating me for post-traumatic stress disorder (PTSD). It was only then that I started bonding with my infant son.
On the eve of my son's first birthday, the first anniversary of the event, I wrote a letter of complaint to the hospital and to the physicians who'd been involved in our care. It had taken me that whole year to verbalize what had transpired. Even as I mailed the letter, I struggled with feelings of disbelief, anger, shame and betrayal that something like this could have happened to me, a physician, "one of their own."
I wrote the letter because I wanted the doctors and hospital staff to understand my perspective and to appreciate the devastating impact that this event had had on my life and family.
I also wanted them to consider the inept and unfeeling care we'd received from first to last–including the failure to get me into a delivery room quickly enough, the brutal response to the hemorrhage (which better care might have prevented in the first place) and the inappropriate discharge of my ill newborn.
I wanted them to change the way they conducted business so that no one else would have to endure what I did.
Naively enough, I wasn't even thinking of a lawsuit–that is, until I received the hospital's letter of reply three months later, the one extensively quoted above. In that infuriating moment I suddenly understood why patients sue. The response, with its defensive, denying, callous tone, was like a slap in the face–like being traumatized a second time.
The following week I called a malpractice lawyer and told him my story.
He listened sympathetically and then zeroed in on the key word–damages. Aside from my psychotherapy bills, it was hard to pinpoint a lasting physical injury to me or to my baby. "This case would be worth a lot more if we had three motherless children or a brain-dead baby in a wheelchair," he said. That's when I politely thanked him for his time.
I wanted an apology, answers and change–not money.
I never did receive a response from any of my physicians.
As someone who has been on the receiving end of care that felt both incompetent and uncaring, if not cruel, I'm sure that we medical professionals can do better. As someone who looked for explanations and received none, I'm hoping that we can change, getting beyond blame-shifting, defensiveness, denial and complicit silence–and moving instead towards transparency, disclosure, apology and healing.
As a physician, I hope that we can learn to more actively engage our patients in their own care. I hope that we can reexamine the ways in which we respond to our own errors and share the lessons we have learned with our medical students and residents.
If we can do this, perhaps then we could rise above the babble of Babel, our voices joined in a common language of human care and compassion.
About the author:
Before the events described above, Tricia Pil MD worked for six years as a pediatrician in private community practice. In the aftermath of the trauma, because of PTSD triggers present in the healthcare environment, she was unable to return to clinical practice. She went back to college, rediscovered a love of writing and earned a second undergraduate degree in English literature. She is now a science writer and health sciences project coordinator at the University of Pittsburgh School of Medicine. She hopes to use her professional background as a pediatrician, her personal experience as a patient and her skills as a writer to continue advocating for patient safety and for increased awareness of postpartum PTSD.
She wishes to thank James Conway, Jane Roessner PhD and Frank Davidoff MD at the Institute for Healthcare Improvement and Linda Kenney at Medically Induced Trauma Support Services for their steadfast encouragement and support. And she thanks Karen Katunich PhD "for saving my life."
Interesting how this post seems to contradict earlier posts on this blog regarding the deficits in anecdotal medicine and emphasizing the need to implement “evidence based medicine” (ie regarding mammography). How can you argue against anecdotes in some situations, but then endorse them here. Or are you just trying to blindly promote the magazine of a friend/colleague?
Rose:
I can’t answer for Maggie, but she has considered your question in the past in her discussion of this:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1621095/
Rose-
With WaPo praising Pulse, Paul doesn’t need my help.
(My readership is significantly smaller)
We need evidence-based medicine to help create guidelines for the best treatments for patients who fit a particular medical profile.
Too many doctors simply do things the way they have always done them -ignoring new medical research which suggest that the old way might be dangerous–or not best for all patients.
Medical narrative has nothing to do with laying out guidelines for treatment.
(And doctors who resist evidence based medicine never claim that they practice medicine by following “anecdotes.”
And nothing in this story argues against using medical evidence. To the contrary, it seems that doctors were ignoring “best practice” at every turn.
As a FP in 6 years of solo private practice, and a total of 25 years in practice under a group of docs, a staff model HMO, and hospital owned primary care group, I much prefer my model of primary care/immediate response medicine, where I know my patients and my patients know me.
The average 7.5 min doctor visit does NOTHING to stop the experience above, and shows the worst in us as docs, yet also the later care shows the best in us.
Dr Matthew Levin
Pittsburgh PA
matlev@comcast.net
RE Would guidelines stop this from happening?
“Too many doctors simply do things the way they have always done them -ignoring new medical research which suggest that the old way might be dangerous–or not best for all patients.”
On contrary, EVERYTHING resported done “followed the rules,” but should NOT have been done (in restrospect):
1) 3rd pregnancy pt felt things were going too quick “guidelines said send pt home” –doctor must COUNTERMAND guidelines to keep pt.
2) Recipitous delivery “may have mandated uterine exploration” yet (I defer to OB here) better to go with experience and pt that she had decompensated unexpectedly and pt was KEPT IN HOSPITAL.
Guidelines used instead of experience can get you in serious trouble… next time have your computer deliver you??
Dr Matlev
Here is another anecdote that might inform some and is relevant to a recent prior post. It is an anecdote about giving health care.
A patient chokes on a piece of meat at dinner on New Years Eve. The patient goes to the hospital ER and the Gastroenterologist on call tries to remove the piece of meat from his esophagus. The meat is successfully removed but with difficulty.
After the procedure, it is discovered that the patient has a ruptured esophagus (a very serious complication). The patient is stabilized at the local hospital and transferred to a University Hospital for treatment. The treatment is successful at University Hospital and patient is discharged after several weeks.
The Gastroenterologist visits the patient at the University Hospital and apologizes to the patient and family.
• Despite the apology, the patient sues
• During discovery, an xray is found that shows that the patient’s esophagus was perforated BEFORE the endoscopy
• Plaintiff pursues case anyway
• Defense refuses settlement
• Case goes to trial
• Defense wins case
• Gastroenterologist stops taking ER call
These are the facts from the most recent malpractice case that I went to court on as an expert witness.
Matlev–
You write: “The later care shows the best in us?
I take it you are referring to the psychologist who she eventually saw.
First, the psychologist was not an M.D.–and has gone through very different training.
Secondly, she had to self-refer to a psychologist– the M.Ds she was seeing wouldn’t do that. (In my experience it’s very hard to get M.D.’s to refer to a non-M.D– a physical therapist, a psychologist (rather than a psychiatrist), a nutritionist, etc.
Where’s “the best in us”???
Matlev —
I’m troubled that your response to this horrific story is so defensive.
The doctors didn’t do what they should have done because they were following evidence-based guidlelines?
Guidelines say that someone should shove a forearm into a woman’s uterus– without warning– to remove blod clots?
Give me a break! Please show me the guidelines.
It’s fine to use drugs that have expired? Show me the guidelines.
If a woman calls her doctor to say that her water has broken, it’s appropriate for him to say “Hold your horses.” Show me the guidelines.
If a newborn has lost 10 percent of his body weight in the 48 hours after birth, and is vomiting, it is appropriate to discharge him from the hospital? Show me the guidelines.
Legacy,
You have made your argument about fear of malpractice as the root of all health care problems so many times that I am afraid it has become terribly boring.
We all know where you stand on this issue. You made all of your best arguments more than a year ago.
And frankly, as a response to this particular story, your knee-jerk comment is, at best totally insensitive, at worst, deeply offensive.
If you have something else that you would like to talk about (other than defensive medicine, malpractice and fear of malpractice suits) I would welcome your comments.
Maggie,
Surprisingly (?!?), It seems that certain anecdotes – ones that illustrate and promote the authors prejudices – are welcome but others are not.
Tricia Pils story is certainly sad and frightening and I have a great deal of sympathy for her.
Was her story chosen at random from all the stories out there by someone with no axe to grind? I think we both know the answer to that question. Have you EVER posted an alternative view/anecdote – one in which a malpractice case was not justified or deserved? If so, I have not seen it – and I have been reading this blog for a while.
I am sorry that you are bored by what I have to say. However, what you and many of your readers have to say about this topic is also VERY predictable (EVIL, INSENSITIVE DOCTORS HURT PEOPLE). I am not on this blog to say what you or many of your readers want to hear. I am on this blog to present information/opinions to readers that have not made up their minds in an attempt to present “the other side”. And my presentation of “the other side” is informed by many years of experience – admittedly filtered through my own lens.
Finally with respect to saying that fear of malpractice is the root of all healthcare problems – wrong again – I never said that and don’t believe it. What ails healthcare is a combination of ignorance, fear and greed. By publishing anecdotes like Dr. Pils’ story but not publishing others you add to the ignorance.
You write: “The later care shows the best in us?
** The compassion and care given every day in many settings is often the best we can give at the time, but not the perfect; the perfect is sometimes the enemy of the good.
I take it you are referring to the psychologist who she eventually saw.
First, the psychologist was not an M.D.–and has gone through very different training.
** I would include ANY HEALTHCARE GIVER a contributor, wouldn’t you?
Secondly, she had to self-refer to a psychologist– the M.Ds she was seeing wouldn’t do that. (In my experience it’s very hard to get M.D.’s to refer to a non-M.D– a physical therapist, a psychologist (rather than a psychiatrist), a nutritionist, etc.
** Most care in this country IS given in a TEAM APPROACH, referring to many different “health care professionals” with every aspect of their care. I am sorry that has not been your experience.
Where’s “the best in us”???
Matlev —
I’m troubled that your response to this horrific story is so defensive.
** It’s NOT being defensive. This is the hardest part in responding to these statements. My point is that the “magic” GUIDELINES can be cold and uncaring — in the original piece, the attendants at the second hospital where infant care was given “looked at the patient” and made a CLINICAL decision to treat, where “perhaps” the initial treating physicians did NOT do so!, ignoring the family’s concerns. Studies show that 80% or more of a family or patient’s concerns indicate a clinically important issue that MUST be addressed and SHOULD be. As a clinician, doctor or otherwise, it is your FINAL JUDGEMENT, not necessarily the “guidelines,” that have to make the difference in care.
** My point was that IF the guidelines had been considered BUT the first clinical contact had led to a more extended stay, the precipitous delivery might have been avoided. With the guidelines as LAW, then the outcome listed is sometimes MORE common, as clinicians do NOT make a decision otherwise.
The doctors didn’t do what they should have done because they were following evidence-based guidlelines?
** Yes, the discharge of a patient with 4 cm dilation of cervix without rupture of membranes was PROBABLY THE GUIDELINE. The clinical decision to keep the patient another 24 hours would probably been AGAINST THE GUIDELINES; I must defer to OB experts however on exact guides being an FP not delivering babies (did so in the past).
Guidelines say that someone should shove a forearm into a woman’s uterus– without warning– to remove blod clots?
** Awful sounding, but the options would possibly have been an emergency hysterectomy. This is the issue of description of a medical emergency, in graphic, vulgar terms. I could describe it differently; the aggressiveness of the description does not change the needs and outcome, of a patient with a noncontracting uterus and exsanguinating mother.
** a similar description could have been “manual D&E” of a postpartum in shock patient but we didn’t describe it — the patient did.
** my focus here was that the patient’s primary concern here was NOT the action but the lack of sensitivity of the clinicians to recognize the psychological effect on her, and the lack of effort to debrief the patient.
** it truly is the fault of us in the medical profession not to recognize the importance of offering and discussing our understandings and to be available for feedback. It is my stated concern here that as time pressures are brought to bear more and more, that doctors, esp in primary care, spend on ave 7.5 min a visit with our patients and that this is NOT acceptable and lead to the sadness of the story stated.
Give me a break! Please show me the guidelines.
** discussed major things above. Guidelines have their place, but the doctor patient relationship ABOVE ALL ELSE, protects us from the calumny of medical care.
It’s fine to use drugs that have expired? Show me the guidelines.
** Of course not, and it should have been corrected.
If a woman calls her doctor to say that her water has broken, it’s appropriate for him to say “Hold your horses.” Show me the guidelines.
** Of course not, but if an OB is overworked, overstressed, these comments can be offered and should not be. Clinicians help each other to be available 24/7, noone can do it all and should not try to do so.
If a newborn has lost 10 percent of his body weight in the 48 hours after birth, and is vomiting, it is appropriate to discharge him from the hospital? Show me the guidelines.
** Of course not, but pediatricians and child caregivers all know that if something “appears wrong” you take a second look and err on the side of caution. I suspect if you look at the stated guidelines, it IS acceptable to send home a child like this, it would be the EXCEPTION to keep them!
** Guidelines canNOT be the end point, and I’m sorry you cannot see this for the point I am making.
Guidelines are NOT laws, they can be a help. They change ALL the TIME.
Dr Matlev
What I find very boring is the format of point by point, line by line, rebuttal of every single sentence. I would rather converse. I do read posts when they are written as thoughtful essays. Some maybe long, but very readable. Trying to read someone slicing and dicing and dissecting every sentence is boring. The tit-for-tat rebuttal style is indeed fundamentalism.
RE point for point rebuttal
Sorry, I was asked questions and prefer to respond.
If you are bored, I suggest you not read.
What is your general response to “Guidelines vs thoughtful conversation with medical professional in the event of unanticipated outcome?”
My contention is NOT to forget that outcomes are not all we are trying to accomplish, but compassionate care with adequate time.
My contention is that in an effort to get to “better care” we force the decision making out of the process, making more of a “corporate medical effect” than someone to interact with.
My contention is that somewhere along the line, we must balance what we do, acknowledge our shortcomings, and “do the best we can.”
How’s that for an essay?
Time for me to go see some patients….
Dr Matlev
One of the things that stands in the way of making medical care better and working on the problem of malpractice is the alarming tendency of many doctors to respond to stories like this defensively.
Doctors do make mistakes. There are doctors who are poor at their job. We can only begin cleaning our own house and improving quality of care when we become able to accept these facts.
The story is not an attack on all doctors. It is an attack on a few doctors who did a very bad job and then refused to admit that and work to correct it.
Santayana has the best take on this: “those who refuse to learn from the mistakes of the past are condemned to repeat them.”
Pat S.. Legacy, Matlev
Thanks for the comment.
I agree.
Defensiveness is a real problem in the profession.
It’s worth noting that this doctor attempted to have her story published in several medical journals–all refused to print it.
Physicians need to acknowledge that there are some very bad doctors out there, and they need to be weeded out. Given the facts in the story, it would seem to me that Doctor B. should have lost his privileges at that hospital. I hope they didn’t back him up because he “brings in business.”
What bothers me is that so many medical professionals failed her.
It would seem that someone should have intervened– the head of Ob/Gyn?– and spoken to Doctor B: “What’s going on here?”– and the patient.
Perhaps a nurse who saw what was going on should have gone to the hospital administration . . . But I realize nurses are usually afraid of complaining about dcotors.
But other medical professionals were there– an intern is mentioned.
And the notes from “Hospital” indicate that someone in administration was aware of her complaints, though that person didn’t talk to her.
Hospitals–and medical professonals– need to do a better job of policing their own. In this story, too many people seemed to just look the other way.
Legacy–
The story was chosen by Dr. Paul Gross– as the lead story for the anniversary issue of Pulse.
Matlev–
Nothing in this story suggests that “guidelines” got in the way of compassionate care. Since the patient is a M.D., she would have known what the guidelines were and would have mentioned it if this was the problem.
Clearly, the problem was that two uncaring, callous physicians failed to treat her, and her baby with concern, kindess and compassion.
“The story was chosen by Dr. Paul Gross– as the lead story for the anniversary issue of Pulse.”
It was not chosen by Paul Gross for inclusion into Health Beat – it was chosen by you. And you chose it for a reason.
A little honesty would be refreshing.
RE she would have known what the guidelines were and would have mentioned it if this was the problem.
Clearly, the problem was that two uncaring, callous physicians failed to treat her, and her baby with concern, kindess and compassion.
** I would agree that this patient should have been treated more compassionately.
** I wanted to point out, however, that the initial response to my statements was that “guidelines were clearly not followed.”
I submit that as a medical objective professional, guidelines were followed, but in an unprofessional and utilitarian manner. The risk of applying guidelines indiscriminately was:
1) The pt was sent home in “early labor” with the impression something was done incorrectly (even if not done incorrectly, retrospectively the patient’s care was perceived as inadequate and documented incorrectly — the birth took place in the hallway).
2) The guideline issue is very much IN this story, as guidelines in medicine are often used in place of real knowledge and can therefore be abused. For example, discharging a vigorous infant at 10% less than their birthweight is much different than discharging a floppy baby, which the patient, a pediatrician with 2 prior children, should have been listened to in depth.
Thus my point.
I’d rather listen to your financial medical and corporate analysis, at this point.
Think I’ll go back to lurking and leave the posting to the other docs here…
Dr Matlev
Legacy–
I’m sorry, but accusations of dishonesty aren’t acceptable on this blog.
I chose the piece because it was Pulse’s anniversary issue, becuase they were asking subscribers to invite other subscribers, and because they had just been writtin up in WaPo.
So I decided to write about Pulse even before reading the story (all of their content is excellent, and I knew that if Paul chose it for the anniversay issue, it would be very good.)
In the meantime, since you feel this blog is anti-doctor, and that I am dishonest, let me suggest that you find another healthcare blog to follow.
Everyone–
I’ve been thinking about this story—and hoping for more comments on the story itself.
I am very sorry that two people chose to take this thread off-track. (The story isn’t about guidelines; it isn’t about malpractice.)
I would still like to hear from people responding to the patient’s story– maybe women who have had children? Maybe women who had a midwife attending their birth? Maybe Ob/GYNs
who have opinons about how we could make the birthing experience better in our hospitals?
When I had my first child, the OB/GYN happened to be a woman, and she was great.
She didn’t just come in at the end– she was in and out of the room throughout a 10 hour labor. Checking on me, reassuring, cheerful. She was comfortable hopping up on the bed, sitting cross-legged, checking how I was dilating.
Are women OB/GYNs more attentive, more comfortable with women giving birth?? I have no idea.
When I had my second child, I woke up in the middle of the night and almost didn’t make it to the hospital in time. I had the baby in the hospital ER.
In contrast to the doctor who wrote the story, I had a good experience. My husband drove up to the ER, ran in, someone ran out with a wheelchair, got me onto some sort of bed, and began preparing to deliver.
I must have had the baby within 5 minutes –maybe less. But everyone seemed calm, organized, in good spirits. (This was Yale/New Haven, a very good hospital that I’ve always liked.)
I also wonder– do doctors sometimes receive sub-par care because other doctors don’t bother with the bedside manner that they reserve for other patients? Would that doctor have said “Hold your horses” to another patient who called to say her waters had broken?
Sometimes we don’t treat our famlies as well as we treat acquaintances. Could this help explain the abusive behavior? The shoemaker’s children have no shoes???
Maggie,
I have enjoyed reading and participating in this blog for the past several years and at your request will depart. Perhaps you are also correct that my best contributions to this blog are behind me – and if so, it is probably the best reason for me to stop participating.
I have learned a fair bit from reading your blog and even more from doing the research in areas where we didn’t agree – of which there were many.
As for the specific reason you are asking me to stop participating, perhaps you are correct and your choice of the particular anecdote was by chance – if so I apologize. However, being a somewhat cynical person, I do not believe that a writer of your caliber and experience chooses content at random.
I do detect what I believe is an anti-doctor bias on your blog and I bet that most of the docs who read or have read it would agree with me. I also detect a significant bias in your coverage of issues related to malpractice – but as you point out, you and most of your readers will be happy not to hear any more from me on this topic.
Like many other physicians, I feel that there are serious problems with our health care system. Although for some things and in some respects it works well, in other ways it is in bad shape and needs a major overhaul. I am not at all convinced that the recent Health Care Reform will do much to fix the major problems, particularly the cost, but do agree that something needed to be done.
Good luck to you.
Legacy —
Both you and I are doctors and diagnostic radiologists, but we have a basic disagreement on the issue of an anti-doctor bias in this blog.
Maggie is frequently critical of doctors on the blog. She is also critical of politicians, drug companies, insurance companies, hospitals, and many other people.
However, many of the people she cites to support or make her arguments are also doctors. In fact, her hightest praise is often for doctors who are working to improve the health care system.
Doctors are the single most powerful group in health care in the US. We are responsible for many of the institutional decisions that make US medical care what it is, including some of the poor decisions leading to poor performance and increased costs. We are responsible for most of the decisions that effect patients on the individual level.
When doctors make decisions that lead to poor results, excess costs, bad experiences for patients, and bad results for society, doctors need to be held accountable for those decisions. When I personally am critical of doctors making what I see as poor decisions, that does not mean — taking a page from the Israel lobby — that I am a “self hating physician.” It means that I think that what some doctors do sometimes is wrong, and that it is right for other physicians to point that out or to agree with critics.
I will readily grant that their are specious lawsuits and complaints — the example of the gastroenterologist you gave is a good example, but there are valid complaints as well, and the example Maggie relayed to us seems to me to be one of valid complaints.
I will reiterate what I said earlier. It is important for doctors to get past the notion that any complaints about doctors is a personal attack on them. I understand very well the feeling of many doctors that “there but for fortune go I.” However I do not really believe, once I work past my initial paranoia, that that is true. I have made mistakes, but I believe those mistakes were not due to being careless or uncaring, and I believe that when doctors are careless or uncaring they should be called on it.
I firmly believe in the importance of quality review in medical practice, and of taking negative results seriously. In my own experience, careful quality review is an important tool in improving performances, including my own.
I do not think Maggie has a bias against doctors or politicians or others. I think she has a natural tendency to be critical of poor medical or political practice. All of us should, and doctors most of all should be critical of poor practice by themselves and others. That is how we can make progress, both institutionally and individually, toward doing a better job — the job that I believe most doctors really want to do. And that is what the young doctor-patient in the story was asking for — not for people being fired or for money damages, but for the institution to take her complaints seriously and examine the complaints and themselves honestly in order to try to make efforts to improve the experiences of future patients. Both she and Maggie are right to complain that their refusal was wrong.
Maggie:
Thank you for posting this interesting story. As a nurse (who happens to be male and who graduated from an accelerated nursing program at age 52), what bothered me most about this story was the response of the nurses. In fact, I find it hard to believe, but I’ll assume it was true. ‘Being with and doing for’ is the heart of nursing, and avoiding patients or their concerns (unless the patient is abusive) has no place in a nurse’s 12-hour shift. I wish the nurses in this story could be interviewed – and preferably by the author.
Brad Stephan RN, BSN, BA
Omaha, Nebraska