Just to balance the medical horror stories thread, I'm sure we all have memories of health care professional who really stood out (in a positive way).

My fondest memories are from when my father was awaiting a heart transplant, and was in hospital for three months flat on his back. His doctors, and the nurses in the CCU were amazing. They treated my father like he was their own father or a good friend, they gave him world class palliative care when it became obvious he wasn't going to make it, and even gave us warning that it "would be just a few minutes" after giving him a slight overdose of morphine to ease him on his way (after consulting with us). Three of them drove 2 hours to attend his funeral. Sure, they didn't save him so you might say they weren't very good, but the man couldn't be saved, and they did everything in their powers to keep him hanging in there just long enough to make the transplant. And they made us feel right at home too. They deserve medals.

Then there was the time my eldest son had a horrific head injury that I felt sure he would never recover from (at least not with all his facilities intact). To put it in perspective, the accident also svered his left foot at the ankle, yet the emergency team said "don't worry, it looks bad but it's the least of his worries.

Anyway, after five days in an induced coma, and five days of the most dedicated and cutting edge ICU head trauma team I have ever met, he came awake, and went on to make a full recovery (even the ankle is fine).

I got a chiropractor that is amazing. I had a jammed shoulder (just like a jammed finger, but your shoulder). Regular docs and they couldn't figure it out, but my chiropractor fixed it first time.

Lynn,

Wow. Was your son's ankle a full traumatic amputation? If so, then reattaching it was going way beyond the call of duty for his orthopaedist, and really only possible at a big trauma center. Send him some wine, or something. :o) Seriously, though, they sound like a great team.

I generally stopped going to patient funerals long ago. I'm not sure what that says about me, but there are just too many of them, unfortunately. Well, that's misleading, because nowadays I'm currently taking care of a generally young and healthy population and deaths are rare. They are also military, so they generally get shipped home for funerals. And, I guess I do still go nowadays if I knew the patient very well- like someone with a chronic illness that I had been managing and they finally lost the struggle, but that hasn't happened to me in a while due to the nature of my current practice. Most of my patients who die come through the ER acutely ill, or are trauma patients. So I guess I should say "Back when I worked at the county hospital I stopped going to patient funerals..."

Your dad definitely sounds like a patient I might have gotten close to, though. That sounds like it was a long, rough road. My condolences. It sounds like his death was handled as well as it could have been.

Doctors rarely talk about how it feels to lose a patient. It is somehow seen as a sign of weakness. Medical culture can be very harsh to its members, that way. As well as dark and twisted. (I have often stated that Scrubs is the most realistic medical TV show that ever was. Just ask anyone who works in medicine...)

I know that many nurses go to funerals pretty often, though- but then they care for the patients all day as long as they are here, and are very nurturing kind of people by definition.
About one in six people admitted to the hospital medical service will die there. (Though, admittedly, most of the deaths are of the very ill very elderly who are already in a bad way, per se.) Surgical services generally have much better survival rates, but it is still a lot.

Now I'm getting depressed. I'll sign off.

Edited by acrosome on 06/29/2009 06:31:45 MDT.

"Wow. Was your son's ankle a full traumatic amputation? If so, then reattaching it was going way beyond the call of duty for his orthopaedist"

Yes, though it was still dangling by a flap of skin. The surgeons did a splendid job, and he was very lucky the injury just missed the growth plate. At the same hospital around 20 years ago, I was admitted with a crush injury to my ankle. They called the fracture an "onion skin" type (beacuse that's how the bone had unravelled), and the tendon and ligament damage was pretty bad too. Again I lucked out and got a top notch orthopaedist to put it all back together. I've had ~20 years of good service from that complictaed repair, though it's finally caught up with me via osteoarthritis. When I think about it, we ARE a major trauma centre for all the ~ one million people on the South Island...

"I generally stopped going to patient funerals long ago."

I fully understand and sympatise. I think my fathers case was special, as in CCU the nurses and docs really spend a lot of time attending individuals. My father had a full time nurse attending him all the time. So that's at least 4 or 5 nurses that spent up to 8 hours per day with him for three months. And the transplant docs are also pretty intensely involved with the patients. I think the whole team really thought he had an excellent chance of getting that new heart. It kinda sucks to be on a transplant list, even more when your a B+ blood type. Anyway, don't feel depressed. Death is a big and hugely important part of your job. If you got emotionally involved with every critically ill patient, you would probably suffer a breakdown. As I've sadi before, I'm sure you are a very good, diligent and compassionate doctor, as are most.

Mistakes happen all the time (in any profession), but a true professional owns up to their mistakes so others can learn, and systems changed if need be to stop the same mistakes happening again. I really *hope* that GP who sent me off for a biopsy learned from the outcome, and thought to do a mono spot test for any future armpit lumps. I *hope* the GP who sent me to physio with a broken leg learned as well, and that future patients will be better off. I *hope* the GP who couldn't be bothered to do a mono spot on my son before sending him off with two course of antibiotics has also learned something.

>> a true professional owns up to their mistakes so others can learn

That sort of comes back to the harshness of medical culture, that I mentioned. In the U.S. there is a quality assurance process that is protected by law. Anything discussed in a quality assurance meeting or evaluation cannot be used in court- for instance by the patient who is suing you. (Other non-QI investigations, of course, are possible.) The intent is to encourage institutions to examine their mistakes and learn from them, as you describe, rather than to hide them.
So, there is this thing called a "Mortality and Morbidity" conference. It is much more common among my peer group- surgeons- than among others. Essentially it is confession. When one of your patients has a complication or, God forbid, dies you have to stand at a podium before your peers and present the case. All of your decisions are then attacked mercilessly, and you are forced to defend them, including citing relevent literature. Thus, you had better have read up on the literature...

I may not have mentioned this before, but there are certian stereotypes regarding the different medical specialties. Radiologists and pathologists, for example, are widely regarded as having extremely poor people-skills, and that is why they get into specialties where they rarely have to interact with living patients. Internists are the smart guys- they tend to be nerds or ivory-tower academics. Etc.
Well, not to put too fine apoint on things surgeons are generally considered to be abrasive and condescending ba$tards. And there is nobody to whom they are more abrasive than another surgeon...

M&M conference can be very traumatic to the presenter. One generally doe snot forget the lesson, if there is one to be learned. :o)

Edited by acrosome on 06/30/2009 01:07:12 MDT.

"I may not have mentioned this before, but there are certian stereotypes regarding the different medical specialties"

And those with Asperger'ssyndrome end up in pathology!

"All of your decisions are then attacked mercilessly, and you are forced to defend them, including citing relevent literature. Thus, you had better have read up on the literature..."

Most NZ district health boards are moving (have moved) to a "no blame" workplace policy. The *hope* is that under this policy, doctors will be more willing to come forward with reporting their errors, both to the patient and to the hospital. In a culture like you described, the incentive to not mention an error, if you think no one will notice, is very high. In NZ, we are moving towards a system approcah where we need to know about ALL errors, even minor ones, so we can make necessary changes to prevent them in future. Of course, this "no blame" policy also protects doctors from litigation from patients, which is another necessary policy if you really expect docs to fess up to their mistakes!

Well, the intent of the M&M mechanism is to ENCOURAGE reporting. (It is just the demeanor of surgeons that makes it painful, and we're pretty much used to one another. Residency is a fine 5 to 7 years of brutality...)As I mentioned, none of it is admissable in court. This means that the hospital has an interest in promoting the M&M and other QI mechanisms to improve their standad of care. A timid individual surgeon might try to avoid reporting complications, but:

1) There are no timid surgeons. :o)
2) Believe me, other people notice and report the complication. All of my partners sort of keep an eye on one another, out of curiosity about each others' cases, if nothing else. Certainly a complication severe enough to generate a billing code goes through the hospital's QI process!

I have heard of official "no blame" policies for complications. In theory it works like workers' compensation, or something. Basically, if something goes wrong the patient is given money from the central fund. It doesn't matter if it was malpractice, an error, or just bad luck- they get money. But they CANNOT sue. Disciplining bad providers is done through a different mechanism. Some people are advocating such a system in the U.S., due to our often RIDICULOUS medical tort awards, but in my opinion it will never happen. The American Bar Association is the single biggest contributor to political campaigns in the United States... :o)

Also, personally, I'm not sure that a "no blame" system would really result in good policing of bad providers. Would a hospital REALLY have an interest in rooting them out and disciplining them? I think the hospital would only care if they generated more billing than was lost to the fund. I suppose that there are ways to deal with that, but they would be complex. For instance, the fund couldn't "tax" hospitals based upon their complication rate because that would over-impact the tertiary care centers that take on the difficult cases (which would obviously have higher complication rates). The Mayo Clinic might be bankrupted...

Back to the "great medical experience" stories...

I've had what we've called a "swallowing problem" since I was about 12. Lots and lots of appointments with specialists; ENTs, gastroenterologists, asthma/allergy and many more. No one was ever able to figure out the problem. A couple years ago it was getting really bad, and I started noticing problems with reflux. I went to a gastro specialty clinic, admittedly, but the guy who finally diagnosed my problem--correctly, after about 20 years of trying--was a physician's assistant. I still have some problems, some dietary restrictions that are hard for me to stick to, but the problem is finally under control. What a massive relief! That PA has provided exceptional follow-up and more broad-scope care since his initial diagnosis.

" I'm not sure that a "no blame" system would really result in good policing of bad providers. Would a hospital REALLY have an interest in rooting them out and disciplining them?"

Absolutely. Remember that, at least in this country, this is all a matter of public record. If the public gets wind that a particular hospital, or department within a hospital, or particular surgeon is making too may mistakes, the hospital suffers. No blame as a legal concept is not the same a saying no one made mistakes. Anyway, the 'no blame' policy applies across the board to any accident, whether medical misadventure or not. I accidentally drive my car into a tree and injure myself, I'm covered. I sprain an ankle palying rugby, I'm covered. Someone else runs into me and breaks my neck, I'm covered. Now, if that someone also happens to be drunk, then I might have recourse to legal proceedings as it no longer qualifies as just an 'accident', but overall the system does it best to keep mere accidental injuries out of the court system.

"The American Bar Association is the single biggest contributor to political campaigns in the United States... :o)".......Touche

" I'm not sure that a "no blame" system would really result in good policing of bad providers. Would a hospital REALLY have an interest in rooting them out and disciplining them?"

Absolutely. Remember that, at least in this country, this is all a matter of public record. If the public gets wind that a particular hospital, or department within a hospital, or particular surgeon is making too may mistakes, the hospital suffers. No blame as a legal concept is not the same a saying no one made mistakes. Anyway, the 'no blame' policy applies across the board to any accident, whether medical misadventure or not. I accidentally drive my car into a tree and injure myself, I'm covered. I sprain an ankle palying rugby, I'm covered. Someone else runs into me and breaks my neck, I'm covered. Now, if that someone also happens to be drunk, then I might have recourse to legal proceedings as it no longer qualifies as just an 'accident', but overall the system does it best to keep mere accidental injuries out of the court system.

Brad, that IS a horror story. In my medical praise stories I should have mentioned my exceptional expereince in this area. After 50 years of never having any symptoms of reflux, heartburn or anything else, I suddenly started having problems swallowing, especially hot liquids, carbonated beverages and chunky food. I was certain it had to be esophogeal cancer as I had no family history and no previous symptoms to indicate a problem with reflux. I went to my GP (a very good one that I have great repoire with), and he concurred it was unusual. He managed to get me an urgent gastroscopy. Fortunately it was just a hiatal hernia. The thing that made it unusual is that, apparently I am not very sensitive to acid reflux. Upon presentation I had grade 3+ ulceration which the gastro surgeon said was very unusual to wait to present with symptoms. Even so, I am thankful that my GP took my concerns seriously and acted quickly, as waiting around weeks to find out when have been sheer torture.

>> Absolutely. Remember that, at least in this country, this is all a matter of public record. If the public gets wind that a particular hospital, or department within a hospital, or particular surgeon is making too may mistakes, the hospital suffers.

Maybe I'm not expressing my worries very well...

Imagine a surgeon, who has a higher than normal complication rate. BUT the man is a machine, and churns out twice as many cases as his peers. The hospital is making TONS of money off of him. And, the hospital has to REPORT a complication for it to get into the record. Will they sanction him?

No. I don't think they would have a very intense pressure to do so in a no-blame system. (Of course many still would, because they are run by good people.) In a tort system, though, they will get raped by the courts, so the hospital has a motive to keep an eye on him, run the M&M conferences, and generally try to improve their complication rates. They are aided by the quality-assurance immunity law in which their internal QI investigations are not admissible, so they aren't worried about producing evidence that will be used against them.

I doubt that any system is perfect, actually. Even a no-blame system. That's all I was trying to say.

Personally, I'm divided on the issue. I do live in fear of lawsuits because, as I mentioned, the medical malpractice awards here are getting fantastical. And it is pretty much a lottery in which awards are in no way based upon reality. At least one study has shown that the ONLY factor that is covariant with the size of a malpractice award is how badly hurt the plaintiff is. NOT whether or not there was actually malpractice- just how badly hurt the guy is. Most malpractice here has a statute of limitations of 3 years or so, but for deliveries and neonatal care it is 21 years- so if your kid doesn't get into Harvard you can sue the OBGYN who delivered him for causing "brain damage." As you can imagine, malpractice insurance for OBGYNs has ridiculous premiums. A while ago they were fleeing Washington state because WA tort law had gotten so hostile to them, and most of the state suddenly had no OB services. It was a scandal. Those who stayed used the simple expedient of not purchasing insurance. Thus, when a lawyer tried to sue them and found out that he couldn't get much money out of them, they'd usually drop the (frivolous) suit. There are certainly suits with merit, mind you, but at least 50% are crap, and hospitals will settle just because it is easier and cheaper. (And it is the doctors name that goes into the database- not the hospital's...)
Thus, the idea of a no-blame system that works sort of like workers' compensation does hold a certain appeal to me. Some of our states have systems that are slowly mutating in that direction- I think Pennsylvania requires all MDs to contribute to a fund, for example. (maybe?)

Or are we talking about different things? Because I'm talking about malpractice suits. Are you implying that there is no such thing as a malpractice suit in Oz? -That malpractice is covered by the accident subsidy? I don't think you are. I can't imagine a system in which you cannot sue someone for at least a *blatant* screwup, or negligence, or depraved indifference. In which case it isn't really a no-blame system, is it? After all, you mentioned the drunk driving thing...

But maybe I'm wrong. I am, obviously, unfamiliar with New Zealand tort law.

Edited by acrosome on 07/03/2009 09:14:45 MDT.

> Are you implying that there is no such thing as a malpractice suit in Oz?

Well, Lynn can answer for NZ, but I will comment for Australia. (We tend to be similar.)

The big difference between Australia and USA lies not in the medical system but in the legal and social systems. Very bluntly, where the USA might have 100 tort lawyers and 100 cases, Australia probably has less than 1 'tort' lawyer and 1 case.

In fact, at the risk of overly simplifying things, we just don't have the whole 'tort' philosophy here. The American philosophy of always looking for someone to sue is just not our philosophy. We actually joke about this here in Oz: the American tort lawyers are widely regarded as a blight upon the (USA) landscape.

> *blatant* screwup, or negligence, or depraved indifference
Of course these happen, but not very often. And yes, they go to court. But the idea of suing your obgyn 20 years later because you didn't get into Harvard - utterly ludicrous. It would not even get listed for a hearing.

Hey - maybe you should migrate?

Cheers

Roger, as always, has said it much better than I could have.

>> We actually joke about this here in Oz: the American tort lawyers are widely regarded as a blight upon the (USA) landscape.

Brother, I'm with you. We kind of recognize this, too, but can't come up with a way to fix it while preserving some of the rights we value. Or, overcoming the ABA and its deep pockets. :o)
Oddly, my wife is a lawyer- but obviously not a personal injury lawyer. I just couldn't stomach that. Anyway, she often complains that many JUDGES here are unwilling to throw out the obviously ludicrous tort claims. She also thinks that 99% of personal injury lawyers should be disbarred. She actually has very strong feelings about this. She has, for instance, proposed that having three tory claims thrown out by the judge should lead to an automatic disbarment, even if temporary.

>> Hey - maybe you should migrate?

Perversely, it seems to be your doctors emigrating to the USA, not the other way around.
Odd, that.
When I worked at Harborview Medical Center in Seattle basically the entire anesthesia department was Aussies.
I can't understand that. Australia is an entire CONTINENT with only 20 million people or so- and they are all packed on the east coast. Lots of wilderness to go walkabout in- if you will. Why move to the USA? :o)

Edited by acrosome on 07/04/2009 06:00:48 MDT.

> I can't understand that. Australia is an entire CONTINENT with only 20 million people or so

Yeah, many people have made that mistake before getting here. The answer is that the inland, which is about 90% of the country, gets negligible rain. A lot of it is harsh desert land.
.
(Central Australia, Larapinta Trail. Water is trucked in to tanks at locations along the route. The trees manage, but they have had hundreds of millions of years to adapt.)

Some of it supports cattle - one cow per N square miles, where N can be large. In good conditions.

> many JUDGES here are unwilling to throw out the obviously ludicrous tort claims.
That's where you probably have to start. Difficult, especially against the ABA.

> basically the entire anesthesia department was Aussies
Ah - ALL their assets were in Australia, so maybe they didn't bother with insurance? In case of trouble, they just went home? Very clever trick!

Cheers

"In fact, at the risk of overly simplifying things, we just don't have the whole 'tort' philosophy here. The American philosophy of always looking for someone to sue is just not our philosophy."

Sorry, as an Australian lawyer I have to weigh in.

Australians do like to draw a distinction between the situation here and in the US, but the difference is of degree, not kind. In point of fact a couple of years ago the Federal government had to implement tort reform because a lot of community organisations - sports clubs, charities, the Country Womens Association ect - just could not get insurance to cover their activities.

The same situation exists for obgyn doctors too, which is one reason why even in country Victoria I have friends who've had to drive hundreds of k's to see a obgyn.

The problem is not with a class of tort lawyers - although we do have a lot of "ambulance chaser" firms - the problem is with the risk control models of the insurance companies.

There are three underlying reasons why Australia does not have the level of litigousness you see in the US: first, there is a system of universal health care that by and large, albeit imperfectly, covers the medical costs that in the US would mean huge personal expenses and lead to litigation to find a deep pocket to pay for it; second, in Australia, as in the UK, if you sue someone and lose then you pay the other parties legal costs - that's a huge disincentive to frivolous litigation (arguably it is too much of a disincentive and discourages legitimate litigation); third, we have Government-run, compulsory, accident insurance schemes - if you are in a car accident then you will be covered for medical costs and permanent injury. The same situation exists for workplace injuries.

We also have a system of official judicical inquiries into medical deaths that should not have occurred that saves the victims familes the need to take things through the civil courts.

For the record, doctors here screw up all the time and in the most egregious ways. As an example, my oldest son was delivered in a crash caesar by a famous paediatrician (my son had an agpar of 1 when delivered). However the paediatrician forgot to clear my son's lungs and as a result half an hour later he went into toxic shock due to meconium inspiration. It was very, very close for the next day and that my son is here at all is due to the fanatical care given by a paediatric intern and several NICU nurses.

Would I have sued the paediatrician if my son had not made it? Maybe: I was very aware that he had brought hundreds of children into the world who might not have otherwise made it and had pioneered techniques in use worldwide. How to balance that against one mistake? But what value a life? The reason why I never took it any further is that I saw his face when they'd got my son into a humidicrib: he looked gutted and if I can judge character and emotion at all then I knew that he was devastated by his mistake.

Edited by Arapiles on 07/05/2009 05:08:05 MDT.

Hi DW

Your insight is appreciated.

Perhaps there are lessons for the USA here, although recent attempts to introduce genuine nation-wide health care (Oz model) into the USA seem to have run into vested interests (again).

Cheers

"Perhaps there are lessons for the USA here, although recent attempts to introduce genuine nation-wide health care (Oz model) into the USA seem to have run into vested interests (again)."

There is a large proprtion Americans who vehemently resist any kind of socialised health. I think ALL of my family (in USA) are of that inclination. Basically "why should I have to pay to provide health care for some lazy drug addict"? It's definitely a problem with 'vested interests'. My mother has finally come around to the dark side, after a visit down her where she was injured and got the full treatment, no cost and wonderful standard of care. She kept telling them "but I have insurance, I can pay...."

I met an American general surgeon once on a tramping trip. From his point of view, the NZ system is just so much more humane and sane. He would never go back (plus his family love it here). We lose the majority of our medical graduates, at least for a while. Many of them come here as foreign students who then go back to their home land. Kiwis just go because the can earn more in just about any other western country than they can here. Money is a pretty big incentive when you've got a big student loan to pay off!

>> in Australia, as in the UK, if you sue someone and lose then you pay the other parties legal costs - that's a huge disincentive to frivolous litigation (arguably it is too much of a disincentive and discourages legitimate litigation);

Yes, I've proposed this system to my wife, and her objection is exactly the one that you mention- it disproportionately discourages the poor from seeking justice through the courts. I rather agree with her. Imagine suing a tobacco company and paying for their army of lawyers because you lose! I'm all for backing up the little guy, whenever possible. That's also one of the things I was talking about when I said there were rights we weren't willing to give up.

In the USA there are situations where you can countersue after you win a suit and try to recoup court costs, etc., but they tend to be pretty narrow situations. You basically have to prove that the suit was malicious, or they were trying to use the expense to intimidate you into settling, or something. I'm sure that there are many other situations in which you can collect such costs, but in general it is not common, unless it was already in a contract or something. (Many companies that you will sign a contract with- telecommunications providers, etc.- will specify in the contract in which state's courts any disputes will be judged in- and of course it is a state that is corporation friendly- and that they get to collect court costs from you if you loose. I never sign such contracts. It just strikes me as too predatory.)

Any American lawyer who is brave enough to chime in here and correct me, feel free...

And, yes, the NZ system sounds sane. What DOESN'T sound sane (to my American mindset) is the British system, though in fairness they have been getting much better. The NHS, after all, is the fine system that sentenced to death anyone who was over age 50 and uremic in the 1970-80s, due to a shortage of dialysis capabilities. Yet, of course, the rich or politically connected who were over 50 and needed dialysis somehow still got it, eh? (Even if this meant flying to the USA and paying out of pocket...)

And there are still occasional scandals about triage in the NHS.

I refer you also to the recent blowup about cancer drugs- I.e. the NHS was not going to pay for some of them because they "cost too much" relative to the life-years they produced.

* Shudder *

If there is one thing that I don't want a politician in charge of, it is my daughter's healthcare! And, I suppose, that is a very American thing to say...

Edited by acrosome on 07/06/2009 08:09:11 MDT.

In my view, as British, I have to say that I think the NHS is about as good and egalitarian a health care system as is possible while the US system is appalling and frightening. Of course the NHS isn't perfect but it's better than any alternative. Being able to go and see a doctor and have hospital treatment without having to worry about the cost or insurance is wonderful. I've had treatment that I wouldn't have been able to afford otherwise - without the NHS I might not be here or certainly not healthy and active.

The NHS, in fact no system, is perfect. I applaud the NHS (and NZ and OZ equivalents) who puts limits on what they will fund. It is ultimately taxpayer money, and can't afford to cover everyone for everything. For every one woman given a year of Herceptin for her breast cancer, you have a LOT of people waiting for hip replacements, cataract surgery, hernia repairs, etc...so a balance needs to be struck. Plus the individual has the options of paying privately for treatment (just like the US), and fund-raising for such costs is a popular and well supported way of getting there is you can't personally afford it. Not sure about the NHS, but here, for example, if I need a hip replacement, I go on a waiting list. It WILL get done eventually. If I want it done more quickly, I may have private insurance to cover it, or be able to borrow or raise funds to have it done quickly. The public funding is just a safety net that doesn't exclude impoverished people from obtaining quality health care, but it may not be the world's best and quickest private health care.