When Providers Criticize Other Providers; Recognizing the Difference Between Medical Errors and Jousting
Case Study 1
A neurologist sees a patient for a stroke follow up. In reviewing the medical records, he sees that she had complained to her PCP about palpitations prior to her stroke. The EKG at that time showed atrial fibrillation, but the issue was never addressed. The neurologist believes that the atrial fibrillation was causative of the stroke and the patient will need anticoagulation.1
Case Study 2
A 35-year-old man with a comminuted humerus fracture is treated surgically by Doctor A. The patient moves to another state and follows up with a different orthopedic surgeon, Doctor Joust. Upon reviewing the X-ray, Doctor Joust asks “Why did Doctor A use this hardware? That’s crazy. What an idiot!”
These case studies present two situations where a physician sees a patient who has apparent medical misdiagnosis or mismanagement by a prior provider. In the first case, there appears to be a medical error and an ethical responsibility to be transparent with the patient. The second case represents a scenario where “jousting” occurred and the subsequent provider is critical of a previous provider’s care without a full understanding of what happened.
WHEN A MEDICAL ERROR OCCURRED
Talking with patients about other clinicians’ errors was the focus of a New England Journal of Medicine (NEJM) article1 which notes that even though physicians recognize the ethical duty to be transparent with patients, there are uncertainties with fulfilling this responsibility. Was the error due to a systems breakdown? Is there a back story you don’t know about? Who should tell the patient and how should one do that? The AMA Code of Medical Ethics Opinions 9.4.2 notes that “Reporting a colleague who is incompetent or who engages in unethical behavior is intended not only to protect patients, but also to help ensure that colleagues receive appropriate assistance from a physician health program or other service to be able to practice safely and ethically.”
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Certainly, a direct but caring discussion with the PCP is strongly suggested. The NEJM article also strongly states that the patient and families come first. If a disclosure is required, the fact that it is challenging should not stand in the way.
JOUSTING
Jousting is casting negative comments on prior care without complete knowledge of the facts. The American College of Physician Ethics Manual2 states, “It is unethical for a physician to disparage the professional competence, knowledge, qualifications, or services of another physician to a patient or third party or to state or imply that a patient was poorly managed or mistreated by a colleague, without substantial evidence.”
The issue of criticizing other providers is further highlighted in a Journal of General Internal Medicine
article3 about a study where recorded patient interviews showed that 30% of physician’s comments were critical of prior care, often in an ad hominin fashion. The lead author, Dr. Susan McDaniel, stated that “doctors will throw each other under the bus. I don’t think they even realize the extent to which they do that or how it can affect patients.”
Jousting comes in both subtle and obvious forms. Subtle could be a hallway conversation with a nurse that the patient overhears. Also, there can be nonverbal communication that casts doubt about the prior care. While jousting can be obvious (as in the second case), it also extends to chart criticism which is fodder for plaintiff attorneys.
SUMMARY
In both situations—perceived medical errors by other providers and jousting—there are some key principles to keep in mind:
Review the medical record of the patient. If there are concerns, make sure you examine the record thoroughly and clearly identify areas of concern.
Avoid using the patient’s medical record to raise concerns about a potential error. This approach is counterproductive to the aims of improving the patient’s medical care and provides evidence that could be taken out of context in a subsequent liability action.
Talk to the previous provider. Do this from a position of open inquiry and caring. There should be an attempt to resolve the factual history and the correct subsequent course before the patient disclosure process.
If concerns persist, make a referral to appropriate peer review bodies to do an independent evaluation.
1 N Engl J Med 369;18 1752-1757 (case study was adapted from this article)
2 www.acponline.org/clinical-information/ethics-and-professionalism
3 J Gen Intern Med. 2013 Nov; 28(11): 1405–1409.