Perspective: “I removed the spleen! What do you mean it’s a kidney?!”

More transparency needed in medicine

By Charles A. Pilcher MD FACEP
March, 2016

What if we didn’t have the NTSB to investigate plane crashes? What do we do with the medical or surgical equivalent of a “plane crash”? Why does the airline industry learn from their mistakes but the medical profession does not?

Here’s an example of why we need transparency in med mal settlements:

During a laparoscopic procedure to remove an accessory spleen in December, 2005, a surgeon in Illinois instead removed an organ described in his operative report as a “kidney-shaped spleen.” The tissue was sent to pathology and confirmed as actually being the patient’s left kidney.

Over 7 years later (February, 2013) the patient’s medical negligence lawsuit against the surgeon was settled for $2 million.

Not until September, 2014, was the incident finally investigated by the Illinois Department of Financial and Professional Regulation (IDFPR) and the surgeon reprimanded and fined $2500. In the meantime, he had practiced for nearly 9 years without the Department (or the public) being aware of the incident.

Why? Because the injured patient had filed only a lawsuit and did not file a formal complaint with the IDFPR. Because Illinois courts do not report the filing of a medical malpractice case, the IDFPR only became aware of the alleged medical wrongdoing after the settlement was reached. Source

According to the IDFPR’s website, its mission is to “serve, safeguard and promote the health, safety and welfare of the public by ensuring that… standards for professional practice are properly evaluated, applied and enforced.” It only begins a disciplinary investigation when it “becomes aware of a complaint against a licensee.”

I mention this case because it is an example of the lack of transparency we experience not simply in disciplining doctors but in educating doctors. There is much to learn when something goes wrong. How can physicians avoid making the same mistakes if they never learn what mistakes are being made? Our goal should be to assure that those mistakes don’t keep happening. We have a National Transportation Safety Board that investigates plane crashes. Why is there not be a National Medical Safety Board to investigate the medical equivalent of the most egregious of our “plane crashes”? The goal would be the same for both boards: to investigate incidents, report findings and educate the profession when correctable error is identified.

Yes, not all med mal cases lead to a great teaching point. But many do. Some are the result of actual incompetence, inexperience or stupidity. But most are correctable errors in medical thinking to which every doctor can be susceptible. These are the cases from which we physicians can all learn.

Were every malpractice case  reported to a state or national agency when filed, and then monitored as it progresses, we might sooner identify correctable behaviors or situations that could prevent harm to other patients. This approach would likely be prohibitively expensive and interfere with litigation.

As an alternative we should at least consider starting with required reporting on closed cases with a teaching point.

In fact, the IDFPR did in fact receive information regarding the example above in a reasonable timeframe after the settlement and deal with the offending physician. For that they deserve credit. Most states rely on voluntary reporting by physicians at the time of relicensing – and the National Practitioner Data Bank.

Both in Illinois and throughout the country our mission should be to protect the public from medical harm. That would be best accomplished by proactively educating both the public and physicians regarding medical error rather than focusing on reprimanding and disciplining doctors after the fact. And whatever approach is taken, the outcome should not take 9 years or more to surface.

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