Skeletons in the Medical Closet

Mike wrote this book in an era when doctors did not talk much about medical error. This is still the case, but there’s been a steady drumbeat on the part of some of us in medicine about the problem of medical error and its prevention. It has certainly been a part of my lectures on health care reform for the last five or six years.

The intent of the author was to make available to informed patients, or those about to be patients, just how easily one can fall through the cracks during a hospitalization in spite of every preparation to prevent that. He then did a considerable service for all of us by including an extraordinarily complete report of his personal story, the meaning of terms such as medical error, hospital mistakes, medical negligence, and medical malpractice, the physician industry, the hospital industry, and then he asks the most pertinent question: "Who watches the doctor and the hospital?" An epilogue, two helpful appendices and a letter to the reader complete the treatise.

In late 1999, the National Academy of Sciences published a report on medical error entitled "To Err Is Human" and aroused the media to call to the public’s attention the fact of medical error. Public awareness of the consequences of medical error should make this a welcome book. It not only examines in the light of the Sonis tragedy the anatomy of medical error but also reveals the negligence that made it possible, the callous indifference of the medial culprits in their legal testimony, the dereliction of duty on the part of the office of the Inspector General of the Department of Health and Human Services, whose interest should have been significant because Medicare paid for shoddy care, and finally the lackadaisical attitude of the lawyers who had the opportunity to at least set the record straight even though they could not bring back the life of the patient.

When I was a resident surgeon, one of the best teaching times for me was the weekly morbidity and mortality conference. The hospital where I trained had two surgical services and therefore we were in a friendly, but critical situation when we reported our mistakes to one another. In other words, we were not in a position where we could whitewash them. We discussed every patient death, every critically ill patient, and every mistake that we knew about. It was the individual surgeon’s obligation to diagnose the cause of the problem under discussion one of the following ways: patient’s disease, act of God, error in management, error in judgment, error in technique or institutional error. In this way, nothing was hidden; everything was in the open. We learned from our mistakes and made every effort to prevent them from ever happening again.

Then one day, two of the hospital lawyers arrived unexpectedly at our meeting and told us that in the future, we should not keep minutes because those minutes could be subpoenaed by a lawyer for a plaintiff suing the hospital and/or one of its doctors and we had to prevent all of the malpractice suits that we could. Shortly thereafter, they further instructed us not to have the meetings at specific prearranged times, but to have them on an ad hoc basis. Obviously, the system fell apart, and the one chance we had to institutionalize the study of error disappeared with it.

The present malpractice system in America does not work. It does not work for the patient; it does not work for the physician. The underlying problem is that error does occur in medicine. But we don’t deal with error in medicine as we should. The reasons lie in the combination of the dictum that "to err is human" and the extremely complicated nature of medical interventions, combined with the fear of a malpractice suit.

Fortunately, most errors can be corrected, but when they do lead to tragic outcome, the effect is devastating, notably on the patient and patient’s family, but also on the doctor and other health care workers.

The problem of error is intensified by the general culture of medicine, which has not found effective ways to deal with errors, to learn from errors, to prevent errors. Physicians are trained and operate in a culture that demands perfection, but where mistakes are not only inevitable, but also inadmissible.

Obviously, the current threat of malpractice litigation almost eliminates the opportunity to disclose error, to learn from mistakes, and to receive support from colleagues and even patients when inevitable errors do occur. By sweeping the issue under the rug, medicine is not taking advantage of ways to make institutional structural changes in training and practice that could go a long way to reduce the number of medical errors.

Having said all that, we have to conclude the author’s description that Anne Sonis did not die of the ordinary medical error that everyone tries to prevent. Anne Sonis died because of the lack of close attention by her surgeon to her individual response to the surgery. The resident did not keep him fully informed, sharing with him the concern she should have had about her patient’s downhill course. But the resident also seemed callous, unaware of imminent danger, and unwilling to rally what support was available.

Mike Sonis and his two sons, Bill and Jeff, were all knowledgeable, experienced and understanding physicians, particularly concerned about Anne well before her hospital admission, and especially during her downhill course. Anne herself was a proponent of quality assurance and the necessity of an informed patient. No patient could have gone into her surgical experience better prepared and with better family support. At a time when every force should have been marshaled to bring the best of medical science to bear on her problem, the system failed Anne and her family at every turn.

The chapter on legal affairs is not only chilling but roused in us a sense of outrage. No one in the legal profession seemed to care about the outcome, and the responsible surgeon shunned all responsibility for his resident’s behavior. In medicine, as at sea, the captain of the ship is responsible for the behavior of the crew.

This is a riveting book to read, although it depicts a human tragedy. In these days of slackened responsibility, meager compassion, and dulled sensitivity, let the public be aware of the pitfalls that can occur in a complicated hospital experience. Fortunately, situations such as described here are rare, but the supportive material that Mike Sonis has prepared for his reader is invaluable for anyone who faces hospitalization for self or a loved one.