American College of Physicians: Internal Medicine — Doctors for Adults ®

Tuesday, February 12, 2013

Medical malpractice, tort reform and James Bond? Let me explain

Sometimes, I feel like I belong in law enforcement.

There was a time in my life that I seriously considered a career where I would haul in the bad guys and make society a better place. Of course, every American male youngster fantasized that he would one day drive the Aston Martin, get the girl, defuse the bomb, and sip on a martini that was shaken, not stirred. I was no different.

I was 10 years old then when my pal Lewis and I were secret agents with the requisite weapons, invisible ink and secret codes. At the risk of disclosing that I have a tincture of obsessive compulsiveness, I still retain the files of our secret organization. While Lewis has expressed concern that these files in the wrong hands could threaten international order, I have reassured him that the enemies of mankind will be unable conquer our layers of sophisticated encryption. At risk of being accused of hyperbole, Israeli and American intelligence agencies studied our secret files as a template for the Stuxnet worm.

I have had many patients who are law enforcement professionals. I respect them and the work they do. I have had patients who served in the FBI, the Secret Service and all levels of local law enforcement. I feel a kinship with these folks. Like a community gastroenterologist, much of what they do is routine. We both endure endless paperwork that often seems to serve no useful function. We both are exposed to extremes of the human condition. We both get scared. We both serve a public that is sometimes skeptical of our biases and motivations. We both may need to make urgent decisions relying upon our training, experience and instincts. We both deeply understand that sometimes the right decision leads to a dark result.

Last November in Cleveland, two people were killed by police after a harrowing high-speed chase. It was a tragic finale that left many painful and raw questions. Thirteen officers fired 137 rounds that killed two citizens who were ultimately found to be unarmed. Understandably, there was outrage in the communities, and the matter continues to be under investigation. As expected, the initial facts were murky and in dispute. Anger and haste are poor catalysts to develop the truth.

I have no opinion at this time if law enforcement personnel should have held their fire and pursued a non-lethal strategy of capturing these two individuals who were fleeing from them at high velocity. A dispassionate investigation will determine this.

But, while it absolutely necessary to investigate this tragic episode, as a doctor, I am very sensitive about being judged after the fact by investigators who have endless manpower, resources, audio and video evidence and months of time to evaluate the propriety of a split second decision. A catastrophic outcome is not evidence of negligence, despite the ease of reaching this conclusion, particularly by those who have been injured and their families.

In addition, a fair judgment on what transpired must consider the context of one who had to make an immediate decision to act. If an investigation requires a four-month inquiry involving dozens of professionals to conclude that an officer erred, could the policeman be expected to reach the same conclusion in two seconds in the field?

When football referees review a call on the field, sometimes the call is reversed. Of course, the review offers instant replay in slow motion at various angles, none of which were available to the official who first made the call. Get the point?

None of us envies a cop who faces a situation where he must discharge his weapon. Sure, there is training, but as every professional knows, one can't train for every contingency. This is not a board exam; this is real life with lethal consequences and no time to ponder the alternatives. Was the suspect reaching for a weapon or an innocuous item? I can't imagine the lifelong trauma one would endure after killing another person, even if this was a necessary act. I suspect it would be a greater trauma if a policeman didn't pull the trigger when he should have, and missed the opportunity to save innocent lives.

I was raised to respect law enforcement, and I do. While their job is tougher than mine, I can personally relate to their profession. We both serve and protect the public. We both make decisions based on what we know at the time, which is often less than we want to know. We agonize when something awful happens and wonder if we contributed to the outcome.

There's something else that binds our professions. We both are often judged retrospectively by those who weren't there when we were blinded by white heat and couldn't see then what later seems to be in such clear focus.

We learn from our errors and misadventures. As readers know, I believe that the negligent must be accountable for their actions and resultant consequences. The process to determine this, however, must operate at the highest level of fairness and integrity. Too often, this standard is not achieved or even reached for.

And now, my thoughts wander back to Miss Moneypenny, "Q", boat chases and ejector seats, when I contemplated a profession that I know now is better left to other others.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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