The Lancet(1) recently published an article referred to as the Patterson report, highlighting the problem of complicit silence in medical malpractice. The problem is one that affects all professions and pointedly in healthcare delivery from physicians, advanced clinical providers, as well as all the technicians and technologists whose duties can create dangers to patients if performed poorly. Further our entire society is faced with myriad examples of citizens engaging in dangerous behavior, from impaired driving to lack of supervision of children which we hope will be reported to avoid harm.
DOCTOR DEATH
There is a long history unfortunately of coworker silence especially physicians in the face of overwhelming evidence of medical incompetence One of the more notorious cases is Dr Duntsch (2) a spine surgeon in Texas who caused multiple deaths and permanent disabilities during surgeries. Ultimately the grossly negligent physician was sentenced to life in prison .
While it seems obvious that observing a coworker and engaging in dangerous practices or obviously negligent practice would be likely to be reported regardless of whether it was in the physician nursing or advanced clinical provider, this unfortunately rarely happens. Why?
There are numerous reasons that people do not identify potentially dangerous behavior of colleagues.
As a society generally, there is typically no duty to disclose behavior which even if predictable could cause harm. There is no legal obligation if one sees erratic driving behavior on the road to call the police or intervene. Fortunately many bystanders and good Samaritan’s will identify this type of potentially lethal behavior.
In unique circumstances especially in healthcare there are defined regulations and snitch laws which obligate caregivers especially physicians to report behavior which they view as putting the public at risk
Rarely do physicians come forward to identify these types of behaviors due to the risk of alienating colleagues or being viewed as a snitch. I am aware of several cases where active surgeons were allowed to practice in spite of long histories of disproportionate complications well beyond expected norms, without intervention. Eventually all the cases that I was personally aware of did come to light and were addressed but only after decades of substandard care and harm. When asking colleagues or OR staff if this was a known issue, there was acknowledgement that everyone was aware of the problem.
One of the most common reasons for refusing to report is that there is fear of retribution as is the case with many whistleblower situations in other venues (government). Fear that the reporting will be viewed as bad faith either anti-competitive or motivated for personal vendetta has been raised. Many fear being subject to potential litigation, or being investigated themselves. There is a pervasive…” thats not my problem, let some one else report it” attitude.
FOLLOW THE MONEY
One of the most shocking and unpleasant aspects of this world is that surgeons generate tremendous revenue for hospitals and there is a strong disincentive from administration to identify potential problems and possibly create bad publicity for the institution or jeopardize their revenue stream. Often times bad outcomes are dismissed or rationalized and attributed to bad faith or understandable result due to the nature and complexity of the case mix.
CONVICTED SERIAL RAPIST OVER DECADES DR NASSAR
Courts have used various standards to identify this type of outrageous behavior including gross negligence, willful and wanton disregard for patient safety, and the use of criminal statute such as manslaughter. The fact scenarios are very similar involving behavior which profoundly deviates from the standard of care. The horrible conspiracy of silence with the sexual abuse case of Olympic team physician, Larry Nassar (3) is another sickening example.
Because the failures to disclose by observers are almost impossible to identify and enforce, there is not much that is done to redress this issue.
Ultimately the recognition that in a bell curve distribution half the caregivers in any institution are below average for their setting in their specialty is a mere statistical fact. The public does not want to acknowledge this nor does the profession. Everyone views their own clinician as being exceptional. By definition of the nature of skills half the population in any profession is below average for that job. In every setting and profession there is the bottom 1%.
What are the solutions to maximize identifying problem area clinicians?
1 Promote anonymous reporting which details specific Instances and events which can be reviewed.
2 Aggressively screening complications and injuries to identify outliers even prior to any reporting by third parties
3 Immunizing all good faith identification of potential problems within the institution regardless of the profession in question physician, Nurses, advanced medical providers or others within the caregiving spectrum including technicians and technologists whose work can directly dramatically impact patient welfare.
4 Creating more comprehensive regulatory reform
5 Making corporate accountability for identification of these trends and remedial action more available
6 Making sure patients are aware of complication rates and experience of providers providing diagnostic and therapeutic interventions
7 Requiring extensive informed consent patient engagement and shared decision-making
8 Enhancing training from medical school through residency and out into the private practice of the need for the highest standards of professionalism and highest ethical duty to protect patients from harm
The conspiracy of silence occurring in the healthcare industry and likely in other public venues and professions must be called out and mitigated. Recognizing a duty to disclose over obvious public dangers needs to be re-emphasize not only in the medical profession but in society as a whole.
Further inquiries may be directed to nargy@nicolasargy.com
copyright nicolas argy 2020
References
1 DOI: https://doi.org/10.1016/S0140-6736(20)30351-2
2 https://en.wikipedia.org/wiki/Christopher_Duntsch
3 https://en.wikipedia.org/wiki/Larry_Nassar