WhiteCoat

Dr. Perfect

I occasionally get asked to review charts from other emergency departments in order to determine whether the care provided was appropriate. One of the cases from a visit to a competitor emergency department is below.

A patient with a longstanding history of migraine headaches comes to the hospital for another one of her typical migraine headaches. Light aversion, noise aversion, nausea – all her usual symptoms. She ran out of her Imitrex and when she called her doctor for a refill, she was told to go to the emergency department instead. Her exam showed no physical abnormalities. She got a shot of Imitrex and a shot of morphine. Her headache improved and she was discharged home with her usual headache medications.

Two days later, her headache returned. She happened to be visiting family in a large city and went to the emergency department in a hospital where we often refer patients. This time she was having visual changes. The emergency department physician there gave her more Imitrex and morphine and called neurology to come see the patient. The neurologist evaluated the patient and discovered papilledema on her funduscopic exam. A lumbar puncture confirmed the diagnosis of pseudotumor cerebri.

Fine. The diagnosis may or not have been missed on the first visit. Assume it was.

I got asked to review the chart because the patient complained to the hospital administration. The patient was upset because two of the doctors at the tertiary care hospital told the patient words to the effect of “You’re lucky. If we hadn’t have caught this, you’d be blind in a couple of days.”

Are their self worth that low that they have to make inflammatory statements like this in an effort to aggrandize themselves? You didn’t call the docs involved. I checked. You didn’t request a copy of the chart from her emergency department visit. I checked that, too.

Statements like this, even if they are true, serve little purpose. The patient didn’t lose her vision. Her vision was normal. Woo hoo. You saved her. Don’t dislocate your shoulder patting yourself on the back.

Actually, statements like that do serve one purpose. They make it a pretty good bet that none of the doctors in our department will ever refer another patient to you or your your hospital.
And if a patient tells any of our docs about any of your screw ups, chances are pretty good that the rest of us will hear about it. Chances are also pretty good that our docs will let any other patients who might need your services in the future know about your mistakes and how you aren’t perfect, either.

Good work.

picture credit here

19 Responses to “Dr. Perfect”

  1. JJ says:

    Easy there big fella. As you and I both know what a patient hears and what is said are two completely different things. It is absolutely true the docs should not have in effect told the patient “good thing you saw us or you would be blind”. It is wrong on so many levels from asking to get dragged into a lawsuit, to second guessing what happened at the first exam without records. However, they are correct in that patients with chronic biscuit poisoning can and do go blind (although not in a couple days). While it may be an effort to self aggrandize, it may also be a lack of communication skills on the part of the docs.

    • WhiteCoat says:

      Story was reportedly confirmed by patient and two family members who were in the room. I realize that it is third hand information and perhaps they all misunderstood or were trying to get out of paying their bill, but I doubt it.

  2. ERP says:

    Pathetic (if that’s what was really said). How many ER docs check (or even really know how to check) for Papilledema? How many people with typical migraine sx need a neuro consult? This is a rareity and bad mouthing the other doc does no one any good.

  3. The days when we miss papillary oedema may soon be over, thank God for the ultrasound!
    http://www.ncbi.nlm.nih.gov/pubmed/19328404

  4. Joe says:

    I understand your point, but there are special circumstances. As a specialist, sometimes other doctors attempt to perform assessments or procedures outside of their scope of training. This happens more often than it should. When they realize they are in over their heads, THEN they finally refer to a specialist. Many of their actions actually confuse the situation, raise the patient’s bill, and overall make my job twice as hard as it should be. In these cases, you can be damn sure I’m going to bad-mouth those docs. Word needs to get around.

    • WhiteCoat says:

      Have you ever spoken directly to the physicians about the issues you are having? As in “Hey, I saw your patient and you shouldn’t do x, y, or z when doing that procedure. It makes the situation more confusing and could lead to a malpractice suit if the patient has a bad outcome.”
      Whether the docs screw up or not, just realize that the bad-mouth expressway is a two way street.

  5. paul says:

    please tell me you don’t review charts for lawyers.

    • WhiteCoat says:

      I review charts for many entities – including our state, our professional society, our hospital’s risk management department, other hospitals’ risk management departments, at the personal request of some physicians, and for both plaintiff and defense attorneys. I generally don’t do expert witness work, though.
      Before you do a facepalm, think about who you would want to review a chart of yours if a med-mal suit was ever filed against you … an informed doc with an honest opinion or a hired gun.

      • paul says:

        if you are getting paid by lawyers to review charts, that makes you what? a hired gun with an honest opinion?

      • paul says:

        also, if you “generally” don’t do expert witness work does that mean you do expert witness work or not?

      • WhiteCoat says:

        If I write a fully referenced article about an issue and publish it, that’s a good thing. If I write a fully referenced opinion about the same issue and provide it to a hospital committee for peer review, that’s OK. If I provide that same fully-referenced opinion to an attorney that’s a bad thing? Doesn’t make sense.

        As for expert witnessing, I don’t think I’ve ever testified as a paid expert in a case. I’ve been deposed multiple times as a treating physician both for civil and criminal cases and been paid for doing so. I qualified my statement with “generally” because there are things I do related to my other job that some might consider as being an “expert witness”, but which do not involve court testimony. If you want to know more, write me and I’ll tell you about it.

      • paul says:

        nah, i don’t need to know any more. i’m perfectly capable of reading between the lines, as will be other readers that come across this conversation.

      • WhiteCoat says:

        From your tone, I can tell you that your attempts to read between the lines are way off base.
        Ironic that the way in which you raise innuendos right now is very similar to the way in which attorneys often raise innuendos of malpractice in a med mal lawsuit.

  6. Collin says:

    why can’t the world (or at least ER docs) be friends and have a beer to solve all problems like a college frat party?

  7. It seems that many patients like to put words in other doctors mouths. I have got word many times that a patient has said, “Dr. Throck said it was the biggest tumor he has ever seen!”.

    • WhiteCoat says:

      I agree and have seen this happen in the past.
      The impression that I got is that this was not the case here.

  8. dr ann says:

    I know of at least 2 malpractice cases that went to court because of what other drs said about cases of which they did not know the full story.
    Both cases found in favor of dr but should not have gone to court in the first place. Lay people & lawyers are more likely to pursue if a dr makes such a comment. Plus they lose confidence in all drs and feel they were victimized by a bad doc when that may not be the case.
    I try not to criticize other practitioners esp if I do not know the whole story. And remember hindsight is 20/20!

  9. Hal Dall, MD says:

    We had a situation at our hospital where similar inflammatory language was dictated into the discharge summary.

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