Today’s Medical Science Is Spectacular. But, Why Are Patients Dying From Easy-To-Treat Diseases?
by Robert Kotler, MD, FACS
Today’s Medicine performs miracles every day. Cataract and LASIK surgery to improve vision; joint replacement to reduce pain and restore mobility. Pinpoint, invisible-beam radiation to destroy cancer. Childhood leukemia cured by chemotherapy. Stomach ulcers healed with antibiotics. Coronary bypass and heart valve replacement. Minimally invasive, robotic surgeries. Heart, lung, liver, and kidney transplants; surreal operations. Non-invasive CT and MRI scans, mammograms and ultrasound exams that have replaced exploratory surgeries. Within minutes — not days — come early discovery and accurate diagnosis of serious conditions. Operations that lengthen limbs or re-form misshapen faces and skulls. Mighty drugs for arthritis, infections, infertility and even for impotence and hair loss. I am in awe of my profession because all this — now taken for granted — was unimaginable when I started medical school 45 years ago.
That is the good news: medical science is awesome. However, I am sorry to report there is also bad news: the delivery is now often indifferent, inefficient, sloppy, and sometimes so dysfunctional that patients are dying needlessly. And particularly worrisome and perplexing to this veteran physician is that some blunders and oversights are not necessarily occurring in the difficult or exotic cases. The easy ones are being blown; that’s baffling.
What’s wrong with this picture? After 50 years of spectacular leapfrog technical and pharmaceutical advances, there is a disconnect between the science and the beneficiary. Physician ball-dropping, communication breakdowns, misjudgments and fuzzy thinking in this era of magnificent drugs and clever surgeries that should be making all of us look like saints.
The shocking stories that friends and patients relate to me make me shake my head in disbelief. They disturb me because I am proud to be a physician, part of a profession that has ¾ in a blink of man’s timeline ¾ dramatically extended life’s years and improved its quality. Remembering when, for many serious conditions handily treated today, we could offer only sympathy.
Respectful of Medicine’s spectacular accomplishments, I cannot understand why we are striking out on the easy pitches. Actor and producer Michael Douglas trudges from one throat specialist to another with classic symptoms of throat cancer for months before the diagnosis is made. As an admitted heavy smoker and drinker with months of pain, the diagnosis is cancer until proven otherwise. Apparently, none of those hot-shot doctors did a complete exam which includes feeling the tongue and back of the throat. It should have been done. Had an experienced finger been employed to feel the back of the tongue, the rock-hard cancer would have been revealed. What happened to the medical adage: “Listen to the patient for he is giving you the diagnosis?”
Here’s another soft-pitch case. A 37-year old husband and father with persistent rectal bleeding and a family history of colon cancer remains undiagnosed until the colon cancer spreads to become incurable. I assumed every doctor – young and old – knows at least this about rectal bleeding: it calls for an immediate colonoscopy. A quick, painless, and life-saving procedure. This man should not have died.
Joan River’s death concluded an almost surreal series of acts of medical stupidity and lack of common sense. Why would a throat surgeon and the anesthesiologist think it was safe to do even the most minor voicebox procedure in a colonoscopy clinic? Looking into the esophagus, stomach intestines and colon with long snake-like scopes is a world apart from operating on the voicebox where there is always a risk of bleeding and/or swelling which can lead to asphyxiation if not promptly recognized and managed. Would a colon clinic be expected to have all the sophisticated tools and equipment necessary to deal with voicebox surgery and the complications thereof? Of course not. And that is why the New York Endoscopy Clinic was not licensed for anything but the colonoscopies and other non-invasive procedures. And the throat doctor was never accredited to work there. And, that no MD could or would perform a life-saving tracheostomy boggles the minds of all of us experienced surgeons. The inappropriate facility choice surely was not Joan’s fault. She placed her trust and her life into her doctors’ hands and they performed pitifully. Celebrity or no celebrity, an avoidable tragedy.
Another preposterous medical tragedy was recounted by one of our office staff members. She joined us, in part, as a means to displace her personal sadness. Her 20-year old son – burdened with muscular dystrophy (incurable, slowly progressive muscle weakness) – died not from his disease but from daily doses of unpardonable medical stupidity. This still strong, vital, Karate black-belt exhibited early signs of weakening of his heart muscle. Not unexpected given his condition, nor necessarily fatal. Easy to treat.
David’s heart, a muscle roughly the size of one’s fist – the body’s essential pump – was becoming weak. The condition is known as heart failure. His normally air-filled lungs were soaked with his own body fluids; predictably he became short of breath. David’s doctor, a fully-qualified family practitioner, first treated him with antibiotics over the telephone without an examination. She broke the first rule; treating over the phone without a physical examination, and thus no diagnosis, is a formula for trouble. Particularly in a patient known to have a serious and progressive disease.
David’s parents, noting his worsening condition and failure to respond to the antibiotics prescribed, were then advised by one of the doctor’s associates to take a different antibiotic, a nose spray, and an antihistamine. Again, no office exam advised; more unacceptable blind medical guesswork. While David continued to become weaker with increasingly difficult breathing, his parents had to lobby hard for him to be seen. The doctor finally relented and saw David on the fifth day of his illness. His father describes that examination as “superficial”. However, properly, a chest x-ray was ordered. The next day, David was finally admitted to the hospital – six days after he became ill. But David’s doctor never bothered to learn the results of that critical x-ray. Had she done so, she would have learned immediately that the radiologist read the x-ray as suggesting heart failure. The signs were clearly there; the lagging heart-pump was the cause of David’s condition.
A family’s worst nightmare had begun; an unfathomable trip down the wrong diagnostic and treatment road leading to a child’s death. In the hospital, David’s condition deteriorated rapidly. He could not lie flat (that worsens the heart’s burden). Right there, in front of any open eyes, was the classical, diagnostic sign of heart failure: shortness of breath improving with sitting, worsening when lying flat. David’s heart-pump, functioning inadequately was causing a back-up of fluids in his lung; he was drowning in his own fluids, David was gasping for air. His doctor, having missed the early and ideal chance to diagnose and treat correctly, postulated a long list of dubious and unrelated diagnoses. A list that never included heart failure, a known consequence of muscular dystrophy. High on the list of wrong diagnoses entertained was the least likely: dehydration. There was no reason why David would be dehydrated. Nonetheless, the doctor inappropriately ordered that David’s body be loaded with quarts of intravenous fluids.
The incompetent captain had now ordered the ship 180 degrees off course. David needed to have fluids removed from his body, not added. The doctor was further ballooning her patient and didn’t even realize it. David’s treatment was the medical equivalent of forcing water down the throat of a drowning man. The clueless nurses – supposedly trained and licensed to recognize common medical conditions such as heart failure – obediently and blindly carried out the death sentence orders. Not one nurse questioned why their patient was getting worse under the reigning treatment plan. David was not even transferred to an Intensive Care Unit, as his condition warranted, and where certainly the more sophisticated staff would have smelled the unfolding catastrophe – and could have saved his life.
Now the topper: despite her patient’s declining condition despite treatment, David’s family practitioner physician, who, by now, should certainly have recognized she was working beyond her scope of ability, never requested a consultation with a specialist. And this in a big city, medical school-affiliated, teaching hospital bulging with internists, cardiologists, and every other specialist. After one day in the hospital, and eight days after the start of his symptoms, David’s heart stopped beating. The coup-de-grâce had been delivered, via remote control: the inept doctor telephone-ordered an inappropriate drug that immediately erased David’s little remaining heart and lung function.
SOME MIGHT CALL IT MEDICAL MANSLAUGHTER.
Under this doctor’s care, David never had a chance. The great and unforgiving tragedy: he died from a common, easy-to-diagnose, and readily reversible medical condition. Nothing rare. A not exotic condition that most awake, third-year medical students are capable of recognizing and treating. Heart failure has been treated successfully by MDs ¾ without miracle drugs ¾ since an English physician discovered a foxglove plant extract that cured what was then called “dropsy”, now heart failure. The year? 1785!
David’s life was allowed to slip through the fingers of failing medical hands. How did this happen in this era of miraculous medical treatments? And that’s what bothers me. We have the great science. But have we lost the art of the delivery? Today’s medical grads, still the pick of the academic litter, are smart. I can attest to that; I teach at two medical schools. But I am concerned that something happens after graduation. Are today’s doctors wearing out? Have they become non-thinking robots? And if so, why? Is it because they are so beaten up by our complex, maze-like, fragmented insurance company-run medical care system? Don’t doctors care? Are they coldly discarding that special life mission with its unique, enormous responsibility that comes with the title “Doctor”?
Perhaps there are just a few villains who are lowering the profession’s batting average. Nonetheless, inexcusable. I wonder how a licensed MD, eight days in a row, missed an easy diagnosis. As a former licensure examiner for the Medical Board of California, I know that heart failure is one of the core diagnoses the State expects all its licensed doctors – regardless of specialty – to recognize. The common, everyday conditions: heart attacks, strokes, diabetes, pneumonia, common malignancies such as lung or colon cancer, and heart failure.
Did David’s doctor, ill-managing the case described, slip through the licensure exam cracks? It’s possible; California has nearly 85,000 licensed medical doctors. The system probably cannot always detect the brainy incompetent, the charlatan, the “good test-taker.”
Here’s another unsettling feature of David’s case: none of the hospital’s medical professionals familiar with the case – and at the very end, after the predictable cardiac arrest, there were plenty of nurses and doctors on site – ever questioned the doctor’s ability or reality state. Wasn’t anyone incredulous? Was no RN alert enough to realize that a well-muscled 20-year old should not be going downhill? That may be “something was wrong”? That perhaps some questions need to be asked? Medicine is supposed to be a self-disciplining profession. All who care for the patient should be involved, should care and should always act as an advocate for the patient. Some RN could have saved David’s life with a single call to the hospital’s MD Medical Director.
No one took action to prevent a similar calamity from visiting that doctor’s next patient, either No report to the Medical Board. No report to the California Health Department, which oversees hospital quality. Where was the accountability? Who is protecting the public? Didn’t anyone care?
Only when David’s still-distraught parents, five years later on July 10, 2000, through a physician friend, notified the Medical Board, did California’s slumbering medical quality assurance process awaken. Fifteen months later, on October 30, 2001, the California Attorney General, the judicial representative of the Medical Board, suggested that the doctor’s license be revoked. But, that revocation process, never quick, simple, or automatic; slowly crept through the legal system. David’s doctor hired a blustery lawyer who held the disciplinary process at bay. Then, inexplicably, reversing its original position, the Medical Board quietly dropped the charges. Case dismissed. Everybody back to work. As if nothing happened. Good luck to that doctor’s next patient.
The doctor, never apologetic or contrite had testified under oath that “it was becoming very inconvenient to be checking on him (the patient) all the time.” How’s that, doctor? It was “inconvenient”? A burden? Does a pilot not check the fuel level and the weather before take-off? Checking patients is what doctors do. That’s all we do. It is the core of our work. Our treatments are based on examinations; medical conditions fluctuate and we respond accordingly. Is this doctor for real? If our pilot friend told his superiors that he does not routinely check the fuel level or the weather before taking off ¾ because it is inconvenient ¾ would he still be flying? What an insult to other licensed MDs, the conscientious ones, unburdened by “inconvenience”, who toil at all hours but in a normal reality state.
Despite these tragedies and my concerns with our current delivery of medical care, I remain in awe of the medical sciences, optimistic and see accelerating progress in the treatment of many of today’s incurable diseases. I expect some to be capable of cure within my lifetime. But, the contradiction between our profession’s expanding knowledge base (it doubles every ten years), its daily-demonstrated successes yet its occasional but troubling substandard performance is alarming. As if we built the finest car in the world, but left off the tires. Something is terribly wrong in Medicine if there are problems with the deliverymen.
To protect yourself and your loved ones, until the profession’s problems are repaired, you must keep on top of medical care system. You need to be involved. Your common sense tells you when the doctor is not the right captain. Heed the early warning signs: poor communication, unreturned phone calls, unavailability. Beware when the doctor won’t take the time to meet face to face and explain in English, not medical-ese, the diagnosis and available treatments.
Dedicated physicians listen attentively to you and respect your wishes. Then, a decision should be made – jointly – between you and the doctor. And the doctor should keep you informed of progress or problems.
When it’s not going well, the wise doctor automatically requests a consultation with another physician ¾ before the patient or family does. If not offered, it is your right to demand a second or even third opinion. There’s no downside to a fresh overview of the case. There are always relief pitchers in the bullpen. And if you don’t know another appropriate physician to call upon, here’s a reliable “insider’s” way to get good leads in five minutes: speak with the hospital floor’s “Charge Nurse”, or the hospital’s Director of Nursing. Ask whom they would choose for themselves or their family. They know. Ask for two or three names, ranked in order of preference; one or two may not be immediately available.
Yes, it’s uncomfortable to change the leader in the midst of the campaign, but it’s your or a loved one’s life. A doctor has many patients; you have only one. And remember, the doctor is a professional for hire. He works for you and there’s no lifetime contract. When you have lost trust, change doctors quickly. Better early than late.
Is anything more important than good medical care? No, because your health and life ¾, unlike cars, refrigerators, or other “things” ¾ are irreplaceable. So, take the time, expend the energy and do your homework. Demand the best care possible.