Franklin A. Michota, MD

Medicolegal review has the opportunity to become the morbidity and mortality conference of the modern era. Each month, this column presents a case vignette that explores some aspect of medicine and the applicable standard of care. I hope to bring a critical emphasis on how physicians think and make decisions, with the ultimate goal of highlighting the lesson to be learned by all.

The more we share in our collective failures, the less likely we are to repeat those same mistakes.

Mr. B was a 76-year-old man with a 2- to 3-year history of umbilical hernia. He presented to the emergency department at 10 p.m. on a Sunday night with periumbilical abdominal pain. The pain began the prior evening when he was lifting something heavy. The pain was rated at a 5/10 intensity and had been fairly constant ever since. There was some nausea with emesis. Mr. B denied bowel motions for the past 2 days.

Mr. B had a past medical history significant for hypertension, hyperlipidemia, asthma, and chronic atrial fibrillation. His medications included simvastatin, Coumadin, verapamil, and as needed albuterol.

On examination, Mr. B had normal vital signs but he looked uncomfortable. He had an umbilical hernia that was red and tender. A complete blood count was normal. A complete metabolic profile was normal except for a potassium of 3.3 mEq/dL. An acute abdominal series was normal.

Mr. B was treated with an intravenous opiate and reported feeling a little better, but he was still having pain. The emergency department physician handed off Mr. B to Dr. Weekend-Nocturnist with a diagnosis of "incarcerated hernia." Dr. Weekend-Nocturnist admitted Mr. B to telemetry and initiated IV fluids, potassium replacement, and IV analgesia. An amylase/lipase, coagulation studies, and a CT of the abdomen and pelvis were included in the admission orders. At 3 a.m., the amylase/lipase were reported as normal and the INR was 1.97. The CT was complete shortly thereafter, and the result is transcribed:

"Impression: small bowel obstruction of the ileum due to an anterior wall hernia; there is distal small bowel decompression. Luminal contrast is only seen within the proximal small bowel. There is no evidence of bowel incarceration, abscess, perforation, or fluid collection."

At 7 a.m., Dr. Weekend-Nocturnist transferred care of Mr. B to Dr. Daytime-Hospitalist. At 9:30 on Monday morning, Dr. Daytime-Hospitalist saw Mr. B on rounds. Mr. B complained of some nausea, but his vital signs remained normal. The abdominal exam confirmed an 8-cm, tender, nonreducible umbilical mass. Dr. Daytime-Hospitalist ordered a routine surgical consult, along with 5 mg of subcutaneous vitamin K, 4 units of fresh frozen plasma, and an unfractionated heparin drip according to a weight-based dosing nomogram. Dr. Daytime-Hospitalist documented informed consent for blood products as "risks, benefits, and alternatives discussed."

The first unit of fresh frozen plasma arrived at the floor at noon. After 50 cc of FFP was transfused, Mr. B turned bright red and complained of difficulty breathing. Within 30 seconds, he was unconscious with no spontaneous respirations. A code blue was called. He was intubated and resuscitated for 17 minutes until he was pronounced dead at 12:50 p.m. No autopsy was performed. Cross-match testing on Mr. B’s blood and the FFP did not reveal ABO incompatibility.

Complaint

Approximately 1 year later, Dr. Daytime-Hospitalist was sued by the widow of Mr. B for wrongful death. The estate of Mr. B asserted that Dr. Daytime-Hospitalist did not have a reasonable indication for the use of FFP in this case, and thus the informed consent was nullified. The plaintiff further asserted that the FFP caused transfusion-related lung injury and was the proximate cause of Mr. B’s death.

The plaintiff concluded that were it not for the negligent actions of Dr. Daytime-Hospitalist, Mr. B would be alive today.

Scientific principles

FFP is indicated for "bleeding conditions." This includes but is not limited to liver disease or failure, dilutional coagulopathy from massive red blood cell transfusion, severe disseminated intravascular coagulation (DIC) refractory to prothrombinase complex concentrates or cryoprecipitate, warfarin overdose, and vitamin K deficiency.

FFP is also indicated to reverse the effects of warfarin in the setting of urgent or emergent surgery. The risks of FFP include but are not limited to blood-borne infection (hepatitis B and C, HTLV, and HIV), volume overload, febrile reactions, anaphylaxis (IgA individuals, ABO incompatibility), and transfusion-related lung injury (TRALI).

Complaint rebuttal and discussion

Dr. Daytime-Hospitalist argued that the FFP was indicated for urgent or emergent surgery in the setting of incarcerated umbilical hernia, and that this benefit outweighed the potential risks. Dr. Daytime-Hospitalist further argued that Mr. B was aware of the risk and wished to proceed. Finally, the defendant also argued that the cause of death was speculative and was unlikely to be related to the administration of FFP. However, in this case Dr. Daytime-Hospitalist ordered the surgical consult as routine, not stat. The CT of the abdomen and pelvis did not support an incarcerated hernia, nor did the physical examination support an urgent or emergent surgical need. Also, FFP has a time-limited clinical benefit due to the half-lives of the coagulation factors in the blood product.

Assuming that Dr. Daytime-Hospitalist was correct and urgent or emergent surgery was necessary, he never spoke to the surgeon on call prior to Mr. B’s death. Dr. Daytime-Hospitalist would need to know the timing of the surgical intervention to know when to give the FFP. The plaintiff argued that the informed consent process requires accurate information to be provided before any consent can be given. In this case, there was never any indication to give the FFP, and whatever Dr. Daytime-Hospitalist told Mr. B was not accurate as a result.

Finally, to argue that the cause of death was not related to FFP, you would have to assert that Mr. B would have had shortness of breath followed by a respiratory arrest and death at 12:50 p.m. regardless of whether FFP was given or not. TRALI is a rare but known complication of FFP, and there was not an alternative explanation as likely as TRALI to explain the cause of death.

Conclusion

Anticoagulation poses significant challenges for the hospitalist.

Cessation of anticoagulation puts our patients at risk for thromboses, but to continue anticoagulation throughout a hospital stay increases the risk of bleeding, along with our ability to perform procedures or otherwise react to changes in clinical condition. Hospitalists must remember that anticoagulation reversal with blood products should not be taken lightly, and should never be used for expediency or "just in case."

In this case, Dr. Daytime-Hospitalist was "prepping" the patient for a presumed surgery. However, the use of blood products should have waited until the need and timing of the surgery were further defined. This case was ultimately settled in favor of the plaintiff for an undisclosed amount.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.

Medicolegal review has the opportunity to become the morbidity and mortality conference of the modern era. Each month, this column presents a case vignette that explores some aspect of medicine and the applicable standard of care. I hope to bring a critical emphasis on how physicians think and make decisions, with the ultimate goal of highlighting the lesson to be learned by all.

The more we share in our collective failures, the less likely we are to repeat those same mistakes.

Mr. B was a 76-year-old man with a 2- to 3-year history of umbilical hernia. He presented to the emergency department at 10 p.m. on a Sunday night with periumbilical abdominal pain. The pain began the prior evening when he was lifting something heavy. The pain was rated at a 5/10 intensity and had been fairly constant ever since. There was some nausea with emesis. Mr. B denied bowel motions for the past 2 days.

Mr. B had a past medical history significant for hypertension, hyperlipidemia, asthma, and chronic atrial fibrillation. His medications included simvastatin, Coumadin, verapamil, and as needed albuterol.

On examination, Mr. B had normal vital signs but he looked uncomfortable. He had an umbilical hernia that was red and tender. A complete blood count was normal. A complete metabolic profile was normal except for a potassium of 3.3 mEq/dL. An acute abdominal series was normal.

Mr. B was treated with an intravenous opiate and reported feeling a little better, but he was still having pain. The emergency department physician handed off Mr. B to Dr. Weekend-Nocturnist with a diagnosis of "incarcerated hernia." Dr. Weekend-Nocturnist admitted Mr. B to telemetry and initiated IV fluids, potassium replacement, and IV analgesia. An amylase/lipase, coagulation studies, and a CT of the abdomen and pelvis were included in the admission orders. At 3 a.m., the amylase/lipase were reported as normal and the INR was 1.97. The CT was complete shortly thereafter, and the result is transcribed:

"Impression: small bowel obstruction of the ileum due to an anterior wall hernia; there is distal small bowel decompression. Luminal contrast is only seen within the proximal small bowel. There is no evidence of bowel incarceration, abscess, perforation, or fluid collection."

At 7 a.m., Dr. Weekend-Nocturnist transferred care of Mr. B to Dr. Daytime-Hospitalist. At 9:30 on Monday morning, Dr. Daytime-Hospitalist saw Mr. B on rounds. Mr. B complained of some nausea, but his vital signs remained normal. The abdominal exam confirmed an 8-cm, tender, nonreducible umbilical mass. Dr. Daytime-Hospitalist ordered a routine surgical consult, along with 5 mg of subcutaneous vitamin K, 4 units of fresh frozen plasma, and an unfractionated heparin drip according to a weight-based dosing nomogram. Dr. Daytime-Hospitalist documented informed consent for blood products as "risks, benefits, and alternatives discussed."

The first unit of fresh frozen plasma arrived at the floor at noon. After 50 cc of FFP was transfused, Mr. B turned bright red and complained of difficulty breathing. Within 30 seconds, he was unconscious with no spontaneous respirations. A code blue was called. He was intubated and resuscitated for 17 minutes until he was pronounced dead at 12:50 p.m. No autopsy was performed. Cross-match testing on Mr. B’s blood and the FFP did not reveal ABO incompatibility.

Complaint

Approximately 1 year later, Dr. Daytime-Hospitalist was sued by the widow of Mr. B for wrongful death. The estate of Mr. B asserted that Dr. Daytime-Hospitalist did not have a reasonable indication for the use of FFP in this case, and thus the informed consent was nullified. The plaintiff further asserted that the FFP caused transfusion-related lung injury and was the proximate cause of Mr. B’s death.

The plaintiff concluded that were it not for the negligent actions of Dr. Daytime-Hospitalist, Mr. B would be alive today.

Scientific principles

FFP is indicated for "bleeding conditions." This includes but is not limited to liver disease or failure, dilutional coagulopathy from massive red blood cell transfusion, severe disseminated intravascular coagulation (DIC) refractory to prothrombinase complex concentrates or cryoprecipitate, warfarin overdose, and vitamin K deficiency.

FFP is also indicated to reverse the effects of warfarin in the setting of urgent or emergent surgery. The risks of FFP include but are not limited to blood-borne infection (hepatitis B and C, HTLV, and HIV), volume overload, febrile reactions, anaphylaxis (IgA individuals, ABO incompatibility), and transfusion-related lung injury (TRALI).

Complaint rebuttal and discussion

Dr. Daytime-Hospitalist argued that the FFP was indicated for urgent or emergent surgery in the setting of incarcerated umbilical hernia, and that this benefit outweighed the potential risks. Dr. Daytime-Hospitalist further argued that Mr. B was aware of the risk and wished to proceed. Finally, the defendant also argued that the cause of death was speculative and was unlikely to be related to the administration of FFP. However, in this case Dr. Daytime-Hospitalist ordered the surgical consult as routine, not stat. The CT of the abdomen and pelvis did not support an incarcerated hernia, nor did the physical examination support an urgent or emergent surgical need. Also, FFP has a time-limited clinical benefit due to the half-lives of the coagulation factors in the blood product.

Assuming that Dr. Daytime-Hospitalist was correct and urgent or emergent surgery was necessary, he never spoke to the surgeon on call prior to Mr. B’s death. Dr. Daytime-Hospitalist would need to know the timing of the surgical intervention to know when to give the FFP. The plaintiff argued that the informed consent process requires accurate information to be provided before any consent can be given. In this case, there was never any indication to give the FFP, and whatever Dr. Daytime-Hospitalist told Mr. B was not accurate as a result.

Finally, to argue that the cause of death was not related to FFP, you would have to assert that Mr. B would have had shortness of breath followed by a respiratory arrest and death at 12:50 p.m. regardless of whether FFP was given or not. TRALI is a rare but known complication of FFP, and there was not an alternative explanation as likely as TRALI to explain the cause of death.

Conclusion

Anticoagulation poses significant challenges for the hospitalist.

Cessation of anticoagulation puts our patients at risk for thromboses, but to continue anticoagulation throughout a hospital stay increases the risk of bleeding, along with our ability to perform procedures or otherwise react to changes in clinical condition. Hospitalists must remember that anticoagulation reversal with blood products should not be taken lightly, and should never be used for expediency or "just in case."

In this case, Dr. Daytime-Hospitalist was "prepping" the patient for a presumed surgery. However, the use of blood products should have waited until the need and timing of the surgery were further defined. This case was ultimately settled in favor of the plaintiff for an undisclosed amount.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.

Medicolegal review has the opportunity to become the morbidity and mortality conference of the modern era. Each month, this column presents a case vignette that explores some aspect of medicine and the applicable standard of care. I hope to bring a critical emphasis on how physicians think and make decisions, with the ultimate goal of highlighting the lesson to be learned by all.

The more we share in our collective failures, the less likely we are to repeat those same mistakes.

Mr. B was a 76-year-old man with a 2- to 3-year history of umbilical hernia. He presented to the emergency department at 10 p.m. on a Sunday night with periumbilical abdominal pain. The pain began the prior evening when he was lifting something heavy. The pain was rated at a 5/10 intensity and had been fairly constant ever since. There was some nausea with emesis. Mr. B denied bowel motions for the past 2 days.

Mr. B had a past medical history significant for hypertension, hyperlipidemia, asthma, and chronic atrial fibrillation. His medications included simvastatin, Coumadin, verapamil, and as needed albuterol.

On examination, Mr. B had normal vital signs but he looked uncomfortable. He had an umbilical hernia that was red and tender. A complete blood count was normal. A complete metabolic profile was normal except for a potassium of 3.3 mEq/dL. An acute abdominal series was normal.

Mr. B was treated with an intravenous opiate and reported feeling a little better, but he was still having pain. The emergency department physician handed off Mr. B to Dr. Weekend-Nocturnist with a diagnosis of "incarcerated hernia." Dr. Weekend-Nocturnist admitted Mr. B to telemetry and initiated IV fluids, potassium replacement, and IV analgesia. An amylase/lipase, coagulation studies, and a CT of the abdomen and pelvis were included in the admission orders. At 3 a.m., the amylase/lipase were reported as normal and the INR was 1.97. The CT was complete shortly thereafter, and the result is transcribed:

"Impression: small bowel obstruction of the ileum due to an anterior wall hernia; there is distal small bowel decompression. Luminal contrast is only seen within the proximal small bowel. There is no evidence of bowel incarceration, abscess, perforation, or fluid collection."

At 7 a.m., Dr. Weekend-Nocturnist transferred care of Mr. B to Dr. Daytime-Hospitalist. At 9:30 on Monday morning, Dr. Daytime-Hospitalist saw Mr. B on rounds. Mr. B complained of some nausea, but his vital signs remained normal. The abdominal exam confirmed an 8-cm, tender, nonreducible umbilical mass. Dr. Daytime-Hospitalist ordered a routine surgical consult, along with 5 mg of subcutaneous vitamin K, 4 units of fresh frozen plasma, and an unfractionated heparin drip according to a weight-based dosing nomogram. Dr. Daytime-Hospitalist documented informed consent for blood products as "risks, benefits, and alternatives discussed."

The first unit of fresh frozen plasma arrived at the floor at noon. After 50 cc of FFP was transfused, Mr. B turned bright red and complained of difficulty breathing. Within 30 seconds, he was unconscious with no spontaneous respirations. A code blue was called. He was intubated and resuscitated for 17 minutes until he was pronounced dead at 12:50 p.m. No autopsy was performed. Cross-match testing on Mr. B’s blood and the FFP did not reveal ABO incompatibility.

Complaint

Approximately 1 year later, Dr. Daytime-Hospitalist was sued by the widow of Mr. B for wrongful death. The estate of Mr. B asserted that Dr. Daytime-Hospitalist did not have a reasonable indication for the use of FFP in this case, and thus the informed consent was nullified. The plaintiff further asserted that the FFP caused transfusion-related lung injury and was the proximate cause of Mr. B’s death.

The plaintiff concluded that were it not for the negligent actions of Dr. Daytime-Hospitalist, Mr. B would be alive today.

Scientific principles

FFP is indicated for "bleeding conditions." This includes but is not limited to liver disease or failure, dilutional coagulopathy from massive red blood cell transfusion, severe disseminated intravascular coagulation (DIC) refractory to prothrombinase complex concentrates or cryoprecipitate, warfarin overdose, and vitamin K deficiency.

FFP is also indicated to reverse the effects of warfarin in the setting of urgent or emergent surgery. The risks of FFP include but are not limited to blood-borne infection (hepatitis B and C, HTLV, and HIV), volume overload, febrile reactions, anaphylaxis (IgA individuals, ABO incompatibility), and transfusion-related lung injury (TRALI).

Complaint rebuttal and discussion

Dr. Daytime-Hospitalist argued that the FFP was indicated for urgent or emergent surgery in the setting of incarcerated umbilical hernia, and that this benefit outweighed the potential risks. Dr. Daytime-Hospitalist further argued that Mr. B was aware of the risk and wished to proceed. Finally, the defendant also argued that the cause of death was speculative and was unlikely to be related to the administration of FFP. However, in this case Dr. Daytime-Hospitalist ordered the surgical consult as routine, not stat. The CT of the abdomen and pelvis did not support an incarcerated hernia, nor did the physical examination support an urgent or emergent surgical need. Also, FFP has a time-limited clinical benefit due to the half-lives of the coagulation factors in the blood product.

Assuming that Dr. Daytime-Hospitalist was correct and urgent or emergent surgery was necessary, he never spoke to the surgeon on call prior to Mr. B’s death. Dr. Daytime-Hospitalist would need to know the timing of the surgical intervention to know when to give the FFP. The plaintiff argued that the informed consent process requires accurate information to be provided before any consent can be given. In this case, there was never any indication to give the FFP, and whatever Dr. Daytime-Hospitalist told Mr. B was not accurate as a result.

Finally, to argue that the cause of death was not related to FFP, you would have to assert that Mr. B would have had shortness of breath followed by a respiratory arrest and death at 12:50 p.m. regardless of whether FFP was given or not. TRALI is a rare but known complication of FFP, and there was not an alternative explanation as likely as TRALI to explain the cause of death.

Conclusion

Anticoagulation poses significant challenges for the hospitalist.

Cessation of anticoagulation puts our patients at risk for thromboses, but to continue anticoagulation throughout a hospital stay increases the risk of bleeding, along with our ability to perform procedures or otherwise react to changes in clinical condition. Hospitalists must remember that anticoagulation reversal with blood products should not be taken lightly, and should never be used for expediency or "just in case."

In this case, Dr. Daytime-Hospitalist was "prepping" the patient for a presumed surgery. However, the use of blood products should have waited until the need and timing of the surgery were further defined. This case was ultimately settled in favor of the plaintiff for an undisclosed amount.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.

Every physician knows that we learn more from our personal mistakes than our successes. But the total burden of error felt by our patients is but a small percentage of what an individual physician will see in practice. How can we all begin to learn from the mistakes of others?

Medical error reporting remains a sensitive topic for physicians, institutions, and patients. In a profession where the individual and collective expectation is infallibility, it is decidedly unnatural for physicians to share their personal medical mistakes. In fact, physicians who do share personal medical errors with their peers do so for altruistic reasons only. There is certainly no financial or academic benefit to publicly admitting your mistakes. However, the shroud of secrecy that continues to surround medical error deprives health care providers of knowledge that may help prevent similar adverse outcomes for patients in the future.

©viperagp/Fotolia.com

Although reporting individual medical mistakes to involved patients is obligatory by most professional codes of conduct for physicians, no laws or professional society guidelines mandate widespread reporting of errors to professional colleagues. In addition, one of the unintended effects of the patient safety movement is the de-emphasis of any individual physician culpability. In an effort to create a "blameless" culture, physicians have been told that the majority of errors are the results a flawed health care system. In a surprisingly passive voice, the Joint Commission has stated repeatedly that medical error reduction is fundamentally an information problem. Dr. Dennis O’Leary, former president of the Joint Commission, famously said, "The solution to reducing the number of medical errors resides in developing mechanisms for collecting, analyzing, and applying existing information."

As a result, significant attention and resources have been placed on health care systems and the identification and elimination of the organizational weaknesses that contribute to the individual mistake. Yet, there is no escaping the reality that virtually all errors involve the active failure of someone – not something – at the point of health care delivery.

It is within this context that I propose we turn our attention to the medicolegal system.

As a physician involved in peer review both within and outside the legal system, I have reviewed cases where bad outcomes have occurred. While I would prefer to tell you that every case was an unavoidable complication or the adverse patient outcome was predetermined in some fashion, that would be untrue. I have seen examples of flawed diagnostic or therapeutic decision making by individual physicians. And while the physicians involved routinely deny wrongdoing and confidently declare that if the circumstances were to repeat themselves, they would do nothing differently – I know and they know, that is untrue.

Medicolegal review has the opportunity to become the morbidity and mortality conference of the modern era. Certainly, we begin with the understanding that an unexpected or untoward event has occurred. However, if we do our best to put ourselves in the position of the providers, knowing the facts as they were available at the time, we do have an opportunity to critically evaluate the decision making process. How thorough was the differential diagnosis? Was there confirmation bias? Did the physicians involved perform and/or document the expected history and physical examination?

Hospitalists today are extremely busy multitaskers facing increasingly complex and acutely ill patients. I believe there are invaluable lessons to be gained by walking in the shoes of those who have fallen into the maladaptations of heuristic thinking. Beginning next month, there will be a new column titled "Medicolegal Lessons." I will present a case vignette that will explore some aspect of medicine and the applicable standard of care. I hope to bring a critical emphasis on how physicians think and make decisions, with the ultimate goal of highlighting the lesson to be learned by all.

The more we share in our collective failures, the less likely we will repeat those same mistakes.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.

Every physician knows that we learn more from our personal mistakes than our successes. But the total burden of error felt by our patients is but a small percentage of what an individual physician will see in practice. How can we all begin to learn from the mistakes of others?

Medical error reporting remains a sensitive topic for physicians, institutions, and patients. In a profession where the individual and collective expectation is infallibility, it is decidedly unnatural for physicians to share their personal medical mistakes. In fact, physicians who do share personal medical errors with their peers do so for altruistic reasons only. There is certainly no financial or academic benefit to publicly admitting your mistakes. However, the shroud of secrecy that continues to surround medical error deprives health care providers of knowledge that may help prevent similar adverse outcomes for patients in the future.

©viperagp/Fotolia.com

Although reporting individual medical mistakes to involved patients is obligatory by most professional codes of conduct for physicians, no laws or professional society guidelines mandate widespread reporting of errors to professional colleagues. In addition, one of the unintended effects of the patient safety movement is the de-emphasis of any individual physician culpability. In an effort to create a "blameless" culture, physicians have been told that the majority of errors are the results a flawed health care system. In a surprisingly passive voice, the Joint Commission has stated repeatedly that medical error reduction is fundamentally an information problem. Dr. Dennis O’Leary, former president of the Joint Commission, famously said, "The solution to reducing the number of medical errors resides in developing mechanisms for collecting, analyzing, and applying existing information."

As a result, significant attention and resources have been placed on health care systems and the identification and elimination of the organizational weaknesses that contribute to the individual mistake. Yet, there is no escaping the reality that virtually all errors involve the active failure of someone – not something – at the point of health care delivery.

It is within this context that I propose we turn our attention to the medicolegal system.

As a physician involved in peer review both within and outside the legal system, I have reviewed cases where bad outcomes have occurred. While I would prefer to tell you that every case was an unavoidable complication or the adverse patient outcome was predetermined in some fashion, that would be untrue. I have seen examples of flawed diagnostic or therapeutic decision making by individual physicians. And while the physicians involved routinely deny wrongdoing and confidently declare that if the circumstances were to repeat themselves, they would do nothing differently – I know and they know, that is untrue.

Medicolegal review has the opportunity to become the morbidity and mortality conference of the modern era. Certainly, we begin with the understanding that an unexpected or untoward event has occurred. However, if we do our best to put ourselves in the position of the providers, knowing the facts as they were available at the time, we do have an opportunity to critically evaluate the decision making process. How thorough was the differential diagnosis? Was there confirmation bias? Did the physicians involved perform and/or document the expected history and physical examination?

Hospitalists today are extremely busy multitaskers facing increasingly complex and acutely ill patients. I believe there are invaluable lessons to be gained by walking in the shoes of those who have fallen into the maladaptations of heuristic thinking. Beginning next month, there will be a new column titled "Medicolegal Lessons." I will present a case vignette that will explore some aspect of medicine and the applicable standard of care. I hope to bring a critical emphasis on how physicians think and make decisions, with the ultimate goal of highlighting the lesson to be learned by all.

The more we share in our collective failures, the less likely we will repeat those same mistakes.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.

Every physician knows that we learn more from our personal mistakes than our successes. But the total burden of error felt by our patients is but a small percentage of what an individual physician will see in practice. How can we all begin to learn from the mistakes of others?

Medical error reporting remains a sensitive topic for physicians, institutions, and patients. In a profession where the individual and collective expectation is infallibility, it is decidedly unnatural for physicians to share their personal medical mistakes. In fact, physicians who do share personal medical errors with their peers do so for altruistic reasons only. There is certainly no financial or academic benefit to publicly admitting your mistakes. However, the shroud of secrecy that continues to surround medical error deprives health care providers of knowledge that may help prevent similar adverse outcomes for patients in the future.

©viperagp/Fotolia.com

Although reporting individual medical mistakes to involved patients is obligatory by most professional codes of conduct for physicians, no laws or professional society guidelines mandate widespread reporting of errors to professional colleagues. In addition, one of the unintended effects of the patient safety movement is the de-emphasis of any individual physician culpability. In an effort to create a "blameless" culture, physicians have been told that the majority of errors are the results a flawed health care system. In a surprisingly passive voice, the Joint Commission has stated repeatedly that medical error reduction is fundamentally an information problem. Dr. Dennis O’Leary, former president of the Joint Commission, famously said, "The solution to reducing the number of medical errors resides in developing mechanisms for collecting, analyzing, and applying existing information."

As a result, significant attention and resources have been placed on health care systems and the identification and elimination of the organizational weaknesses that contribute to the individual mistake. Yet, there is no escaping the reality that virtually all errors involve the active failure of someone – not something – at the point of health care delivery.

It is within this context that I propose we turn our attention to the medicolegal system.

As a physician involved in peer review both within and outside the legal system, I have reviewed cases where bad outcomes have occurred. While I would prefer to tell you that every case was an unavoidable complication or the adverse patient outcome was predetermined in some fashion, that would be untrue. I have seen examples of flawed diagnostic or therapeutic decision making by individual physicians. And while the physicians involved routinely deny wrongdoing and confidently declare that if the circumstances were to repeat themselves, they would do nothing differently – I know and they know, that is untrue.

Medicolegal review has the opportunity to become the morbidity and mortality conference of the modern era. Certainly, we begin with the understanding that an unexpected or untoward event has occurred. However, if we do our best to put ourselves in the position of the providers, knowing the facts as they were available at the time, we do have an opportunity to critically evaluate the decision making process. How thorough was the differential diagnosis? Was there confirmation bias? Did the physicians involved perform and/or document the expected history and physical examination?

Hospitalists today are extremely busy multitaskers facing increasingly complex and acutely ill patients. I believe there are invaluable lessons to be gained by walking in the shoes of those who have fallen into the maladaptations of heuristic thinking. Beginning next month, there will be a new column titled "Medicolegal Lessons." I will present a case vignette that will explore some aspect of medicine and the applicable standard of care. I hope to bring a critical emphasis on how physicians think and make decisions, with the ultimate goal of highlighting the lesson to be learned by all.

The more we share in our collective failures, the less likely we will repeat those same mistakes.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.

Recently, the Society of Hospital Medicine and the Society of Critical Care Medicine released a position paper that proposed a 1-year expedited training pathway for experienced hospitalists to achieve critical care board eligibility. This proposal was in response to the worsening shortage of intensivists in the United States and the reality that the vast majority of hospitalists already report working in the intensive care unit. The primary goal would be to increase the pool of qualified intensivists to better meet the LeapFrog safety standard of 24/7 ICU coverage by critical care specialists and thus improve patient outcomes.

The SHM/SCCM position paper acknowledges that such a cohort of hospitalist-trained intensivists would need to be formally evaluated and studied against patient outcomes, but presumed that the hospitalist-trained intensivists would improve care compared with the gap that currently exists (J. Hosp. Med. 2012;7:359-64).

I commend SHM for engaging subspecialty groups seeking solutions to a problem that is clearly affecting us all. However, I am left with an overall sense that SHM is putting the cart before the horse.

By current numbers, hospitalists are 34,000 strong with a good chance to reach nearly 50,000 some day. We have come a long way from the 200 or so names on the Win Whitcomb and John Nelson Rolodex of 1997. Yet despite being woven into the very fabric of the U.S. health care system, we remain a heterogeneous workforce with no standards for training, no board certification of our own, and ultimately little consistency from one hospitalist to another. Board-eligible internists with little practice experience are otherwise called hospitalists just like board-certified (and recertified) internists with 15 years under their belt. The variability in procedural competency is even greater than the cognitive divide. If the prerequisite for an expedited training pathway to board certification in critical care begins with an experienced hospitalist, don’t we need to address what a hospitalist is first?

In 2006, SHM developed and published the Core Competencies in Hospital Medicine. This seminal work should have become the foundation for a 1-year hospitalist fellowship and a requirement for board eligibility in hospital medicine. Instead, you may complete any residency you wish and call yourself a hospitalist if your primary professional focus is the general medical care of the hospitalized patient. The Focused Practice in Hospital Medicine Maintenance of Certification program developed by SHM in concert with the American Board of Internal Medicine and the American Board of Family Practice was a landmark achievement, but we continue to set the bar too low. This program is voluntary and lacks the supervised practice experience that a fellowship would provide.

It is interesting to note that the SHM/SCCM proposal mandates that the hospitalist participate in the Focused Practice in Hospital Medicine Maintenance of Certification program (i.e., it is not voluntary) – thus ensuring that hospitalists are certified in their primary board, that hospital medicine modules are completed, and that scholarly work in the form of quality improvement is accomplished. But I can’t help but agree with the recent response from the American College of Chest Physicians (ACCP) and American Association of Critical-Care Nurses (ACCN), which states that they "believe that 1 year is an inadequate training period for hospitalist physicians to achieve competence in the subspecialty of critical care medicine" (Chest 2012;142:5-7).

Why do you suppose that the ACCP/ACCN feels this way? Could it be they have worked with "hospitalists" who are not up to par? Could it be they have observed variability in both cognitive and procedural skill?

I appreciate that the critical care shortage is not going away and that the SHM/SCCM proposal will produce more trained physicians to work in the ICU. But creating a new variability among intensivists may not be much of a solution. Five years ago, Larry Wellikson, CEO of SHM, referred to the hospitalist with ICU training being potentially viewed as an "intensivist-lite." I doubt any hospitalist who is critical care boarded will appreciate this moniker.

(Continued from first page)

Any training pathway to critical care board certification must be as rigorous as the existing pathways. We must resist replacing rigor with expediency. The frenetic pace of hospitalist growth is the reason we never developed hospitalist fellowships and our own board in the first place. We have taken the path of least resistance in regard to our own identity and training. Before we look at a new expedited training path for another subspecialty board, I propose we get our own house in order. SHM should put the horse back in front of the cart.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.

PDF: Training a Hospitalist Workforce to Address the Intensivist Shortage in American Hospitals

Recently, the Society of Hospital Medicine and the Society of Critical Care Medicine released a position paper that proposed a 1-year expedited training pathway for experienced hospitalists to achieve critical care board eligibility. This proposal was in response to the worsening shortage of intensivists in the United States and the reality that the vast majority of hospitalists already report working in the intensive care unit. The primary goal would be to increase the pool of qualified intensivists to better meet the LeapFrog safety standard of 24/7 ICU coverage by critical care specialists and thus improve patient outcomes.

The SHM/SCCM position paper acknowledges that such a cohort of hospitalist-trained intensivists would need to be formally evaluated and studied against patient outcomes, but presumed that the hospitalist-trained intensivists would improve care compared with the gap that currently exists (J. Hosp. Med. 2012;7:359-64).

I commend SHM for engaging subspecialty groups seeking solutions to a problem that is clearly affecting us all. However, I am left with an overall sense that SHM is putting the cart before the horse.

By current numbers, hospitalists are 34,000 strong with a good chance to reach nearly 50,000 some day. We have come a long way from the 200 or so names on the Win Whitcomb and John Nelson Rolodex of 1997. Yet despite being woven into the very fabric of the U.S. health care system, we remain a heterogeneous workforce with no standards for training, no board certification of our own, and ultimately little consistency from one hospitalist to another. Board-eligible internists with little practice experience are otherwise called hospitalists just like board-certified (and recertified) internists with 15 years under their belt. The variability in procedural competency is even greater than the cognitive divide. If the prerequisite for an expedited training pathway to board certification in critical care begins with an experienced hospitalist, don’t we need to address what a hospitalist is first?

In 2006, SHM developed and published the Core Competencies in Hospital Medicine. This seminal work should have become the foundation for a 1-year hospitalist fellowship and a requirement for board eligibility in hospital medicine. Instead, you may complete any residency you wish and call yourself a hospitalist if your primary professional focus is the general medical care of the hospitalized patient. The Focused Practice in Hospital Medicine Maintenance of Certification program developed by SHM in concert with the American Board of Internal Medicine and the American Board of Family Practice was a landmark achievement, but we continue to set the bar too low. This program is voluntary and lacks the supervised practice experience that a fellowship would provide.

It is interesting to note that the SHM/SCCM proposal mandates that the hospitalist participate in the Focused Practice in Hospital Medicine Maintenance of Certification program (i.e., it is not voluntary) – thus ensuring that hospitalists are certified in their primary board, that hospital medicine modules are completed, and that scholarly work in the form of quality improvement is accomplished. But I can’t help but agree with the recent response from the American College of Chest Physicians (ACCP) and American Association of Critical-Care Nurses (ACCN), which states that they "believe that 1 year is an inadequate training period for hospitalist physicians to achieve competence in the subspecialty of critical care medicine" (Chest 2012;142:5-7).

Why do you suppose that the ACCP/ACCN feels this way? Could it be they have worked with "hospitalists" who are not up to par? Could it be they have observed variability in both cognitive and procedural skill?

I appreciate that the critical care shortage is not going away and that the SHM/SCCM proposal will produce more trained physicians to work in the ICU. But creating a new variability among intensivists may not be much of a solution. Five years ago, Larry Wellikson, CEO of SHM, referred to the hospitalist with ICU training being potentially viewed as an "intensivist-lite." I doubt any hospitalist who is critical care boarded will appreciate this moniker.

(Continued from first page)

Any training pathway to critical care board certification must be as rigorous as the existing pathways. We must resist replacing rigor with expediency. The frenetic pace of hospitalist growth is the reason we never developed hospitalist fellowships and our own board in the first place. We have taken the path of least resistance in regard to our own identity and training. Before we look at a new expedited training path for another subspecialty board, I propose we get our own house in order. SHM should put the horse back in front of the cart.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.

PDF: Training a Hospitalist Workforce to Address the Intensivist Shortage in American Hospitals

Recently, the Society of Hospital Medicine and the Society of Critical Care Medicine released a position paper that proposed a 1-year expedited training pathway for experienced hospitalists to achieve critical care board eligibility. This proposal was in response to the worsening shortage of intensivists in the United States and the reality that the vast majority of hospitalists already report working in the intensive care unit. The primary goal would be to increase the pool of qualified intensivists to better meet the LeapFrog safety standard of 24/7 ICU coverage by critical care specialists and thus improve patient outcomes.

The SHM/SCCM position paper acknowledges that such a cohort of hospitalist-trained intensivists would need to be formally evaluated and studied against patient outcomes, but presumed that the hospitalist-trained intensivists would improve care compared with the gap that currently exists (J. Hosp. Med. 2012;7:359-64).

I commend SHM for engaging subspecialty groups seeking solutions to a problem that is clearly affecting us all. However, I am left with an overall sense that SHM is putting the cart before the horse.

By current numbers, hospitalists are 34,000 strong with a good chance to reach nearly 50,000 some day. We have come a long way from the 200 or so names on the Win Whitcomb and John Nelson Rolodex of 1997. Yet despite being woven into the very fabric of the U.S. health care system, we remain a heterogeneous workforce with no standards for training, no board certification of our own, and ultimately little consistency from one hospitalist to another. Board-eligible internists with little practice experience are otherwise called hospitalists just like board-certified (and recertified) internists with 15 years under their belt. The variability in procedural competency is even greater than the cognitive divide. If the prerequisite for an expedited training pathway to board certification in critical care begins with an experienced hospitalist, don’t we need to address what a hospitalist is first?

In 2006, SHM developed and published the Core Competencies in Hospital Medicine. This seminal work should have become the foundation for a 1-year hospitalist fellowship and a requirement for board eligibility in hospital medicine. Instead, you may complete any residency you wish and call yourself a hospitalist if your primary professional focus is the general medical care of the hospitalized patient. The Focused Practice in Hospital Medicine Maintenance of Certification program developed by SHM in concert with the American Board of Internal Medicine and the American Board of Family Practice was a landmark achievement, but we continue to set the bar too low. This program is voluntary and lacks the supervised practice experience that a fellowship would provide.

It is interesting to note that the SHM/SCCM proposal mandates that the hospitalist participate in the Focused Practice in Hospital Medicine Maintenance of Certification program (i.e., it is not voluntary) – thus ensuring that hospitalists are certified in their primary board, that hospital medicine modules are completed, and that scholarly work in the form of quality improvement is accomplished. But I can’t help but agree with the recent response from the American College of Chest Physicians (ACCP) and American Association of Critical-Care Nurses (ACCN), which states that they "believe that 1 year is an inadequate training period for hospitalist physicians to achieve competence in the subspecialty of critical care medicine" (Chest 2012;142:5-7).

Why do you suppose that the ACCP/ACCN feels this way? Could it be they have worked with "hospitalists" who are not up to par? Could it be they have observed variability in both cognitive and procedural skill?

I appreciate that the critical care shortage is not going away and that the SHM/SCCM proposal will produce more trained physicians to work in the ICU. But creating a new variability among intensivists may not be much of a solution. Five years ago, Larry Wellikson, CEO of SHM, referred to the hospitalist with ICU training being potentially viewed as an "intensivist-lite." I doubt any hospitalist who is critical care boarded will appreciate this moniker.

(Continued from first page)

Any training pathway to critical care board certification must be as rigorous as the existing pathways. We must resist replacing rigor with expediency. The frenetic pace of hospitalist growth is the reason we never developed hospitalist fellowships and our own board in the first place. We have taken the path of least resistance in regard to our own identity and training. Before we look at a new expedited training path for another subspecialty board, I propose we get our own house in order. SHM should put the horse back in front of the cart.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.

PDF: Training a Hospitalist Workforce to Address the Intensivist Shortage in American Hospitals