A doctor gave me an inept diagnosis for a neurological problem. I should know: I’m a neurologist. – The Washington Post

As a profession academic neurologist, I believed a doctor analyzing his own medical condition in his own specialty, planning to inform, would be an illuminating and teachable minute for medical personnel and trainees and a healing chance for me.In 1999, the Institute of Medicine provided its landmark report, “To Err is Human: Building a Safer Health System,” which approximated that as many as 98,000 health center deaths a year were triggered by medical mistakes. In response, lots of hospitals altered their practices and treatments, however two years later, as my experience recommends, even the best healthcare facilities and doctors remain resistant to admitting mistake, in large part because they fear malpractice lawsuits.Recent research reinforces this view. Several years ago, scientists presented 2 theoretical scenarios involving medical error– a delayed breast cancer medical diagnosis, and a postponed response to a clients signs because of uncoordinated care– to 300 main care physicians. Further, when healthcare facility representatives, rather than physicians, react to medical errors by rejecting, lessening or covering them up, physicians frequently conclude that their hospitals have no interest in confronting these mistakes head-on. The aphorism, “A physician who treats himself has a fool for a client,” only applies if competent care is available.For me, 4 years of medical school and five years of postgraduate training had a distinctively personal benefit.

I felt fine later, however within hours I established neck discomfort with feeling numb and tingling radiating down my arms. I went to the emergency situation department (ED) of an elite medical center 2 days later on, telling the staff that I was a neurologist with suspected cervical (neck) spine illness and possible spinal cord and root compression, a condition in my own specialty. I asked to have a cervical MRI scan carried out, plus blood research studies to detect a possible spinal column infection, as Ive had one before.The spine specialist checked my reflexes with the side of his hand. When I inquired about his reflex hammer he responded that he didnt have one or need one– despite the fact that this is tantamount to assessing the heart or lungs without a stethoscope.He at first neglected to analyze for the Babinski indication, a traditional clinical test, which, if favorable, would have strongly suggested spine compression. He performed the treatment incorrectly when I said on this failure. He examined my feeling with his forefinger and did not take a look at other sensations, gait, hand or coordination dexterity.The MRI showed precise spine cord compression due to arthritis, and a neck mass behind the spinal canal. It was an abscess– a pus collection– but the hospitals radiologist read it as a blood embolism. The blood studies revealed active infection: significant elevations in inflammatory markers, plus increased white blood cells of the “must be concerned” variety. These harmful and apparent problems were not pursued and I was not informed of them. I invested 6 hours in the ED, then was released and told to follow up with a spine cosmetic surgeon within two weeks.Two days later, I took a trip home to Maine and evaluated my medical records online. I acknowledged the seriousness and intricacy of my problem and went to my health center, was admitted and went through urgent spine surgical treatment and long-lasting intravenous antibiotics. Left without treatment, these abnormalities may well have triggered a catastrophe: I could have ended up being quadriplegic, not able to move my limbs and even breathe on my own. My reaction to the ED visit can not be anticipated of the typical patient, who would have been in deep trouble.While recovering, I sent multiple letters detailing the specifics of my lacking care to the health centers president. The medical facilitys agents responded, declining to confess culpability or excuse these failures. The spine service manager even excused the expert, stating he “conducted the evaluation to the finest of his capability.”The lack of recognition of the major infection went unmentioned in the representatives letters.In view of the multiple severe medical errors dedicated throughout my ED see, I used to present and discuss my case to emergency and spinal column service personnel. As a career academic neurologist, I thought a physician analyzing his own medical condition in his own specialized, meaning to inform, would be an illuminating and teachable moment for medical staff and trainees and a recovery chance for me.In 1999, the Institute of Medicine provided its landmark report, “To Err is Human: Building a Safer Health System,” which approximated that as many as 98,000 health center deaths a year were triggered by medical errors. The report made nationwide headlines and created much subsequent discussion on the domino effects of medical mistakes, and the principles of openness and disclosure. In reaction, numerous healthcare facilities changed their practices and procedures, however twenty years later on, as my experience recommends, even the finest hospitals and medical professionals remain resistant to confessing error, in large part since they fear malpractice lawsuits.Recent research reinforces this view. Several years earlier, researchers presented 2 hypothetical circumstances involving medical mistake– a delayed breast cancer medical diagnosis, and a delayed reaction to a patients symptoms because of uncoordinated care– to 300 main care physicians. More than 70 percent of the doctors surveyed said they would offer “just a limited or no apology, limited or no description, and limited or no info about the cause.” Even more, when health center agents, rather than doctors, react to medical mistakes by rejecting, decreasing or covering them up, physicians frequently conclude that their healthcare facilities have no interest in facing these errors head-on. Sure sounds like my situation.My experience also exhibits the phenomenon called “the normalization of deviance” discussed by Diane Vaughan in her 1996 book on the area shuttle bus Challenger catastrophe. Vaughan concludes that multiple issues preceding the shuttle launch were recognized, but then justified, and “normalized” when they didnt trigger a catastrophe– till they ultimately did.Since the spinal column expert did not own a reflex hammer, nor think he required this basic tool, nor understand how to do a correct neurological assessment, and he and the ED personnel did not recognize that the elevated inflammatory markers were indisputable proof of serious infection, I might not have actually been the first patient so improperly examined– and, without doubt, not the last. Further, the specialists manager excused his errors, thereby considering his deviances acceptable.The actions to my letters came from health center client service agents, therefore this denial and normalization was institutional, in assistance of Vaughans property “that private habits can not be comprehended without taking into account the environmental and organizational context of that habits.” Vaughan mentions that in some cases the normalization of deviance just ends up being obvious after whistleblower revelation.I am that whistleblower, “the canary in the coal mine.”The healthcare facilitys administrator charged with client interaction and resolution, and an extensively known advocate for these topics, was uninformed of my complaints up until I discovered her by happenstance 18 months later (listening to the TED Radio Hour while in my car) and called her. She was initially helpful of my demand to present my own case for discussion and analysis, now, more than 10 months later on, she has yet to follow through.She wrote to me: “Hospitals do not appear to know what to do with the opportunity you provide. I do not believe the obstacle is special to [this organization] An online forum for these type of conversations– useful, informative client feedback does not exist.”Initially, she informed me that because my SOL is up I might have a better opportunity of making my discussion. I asked: “What is a SOL?” She stated: “statute of restrictions.” I said: “I do not wish to sue, I desire to teach.”Of course, if I had actually been quadriplegic on a respirator I would have taken legal action against. However since I conserved my own skin, that was not required. The aphorism, “A physician who treats himself has a fool for a patient,” just applies if proficient care is available.For me, four years of medical school and 5 years of postgraduate training had a distinctively personal advantage. Im simply sorry that a teachable minute for the benefit of future patients, and a recovery activity for me, was missed.Steven Horowitz is a retired scholastic neurologist who continues to teach medical trainees as an adjunct clinical teacher of neurology at the Tufts University School of Medicine. He is likewise on the teaching faculty of the Maine Medical.

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