Why doctors almost never are fired

Press, 26 February 1977, Page 20

Why doctors almost never are fired

Bv BOYCE RENSBERGER OF THE “New York Times” through NZPA New York A sociologist w-ho spent two years observing doctors in three hospitals has concluded that the mechanisms intended to detect medical mistakes and prevent recurrences actually work to relieve individual doctors of a sense of r.epsonsibility for their errors.

The researcher, who was given access to many of the “doctors only” areas of hospital life, watched physicians in the operating rooms, at patients’ bedsides, at coffee breaks, and in meetings .to review mishaps. She concluded from thse observations that doctors “construct their own ideas of reality” and then use the ideas to “ignore and justify medical errors.” “This response,” the sociologist said, “is built into the organisation of hospital life and the professional training and outlook of physicians.” The conclusions are contained in a new book, “The Unkindest Cut,” to be published this month, by Dr Marcia Millman, assistant professor of sociology at the University of California, Santa Cruz."

The book comes at a time when the traditional methods for identifying and preventing medical incompetence are increasingly being called into question. While most reports on the subject are heavy with statistics that, suggest the magniutde of the problem, Dr Millman’s book concentrates on detailed observations of how, she asserts, doctors behave in groups to permit incompetence to continue.

Dr Millman would not name the hospitals she studied but said all three were private, universityaffiliated institutions ranging in size from 350 beds to more than 600. She said that the hospitals, on the United States west coast and in the northeast, were all regarded as good hospitals. She added that two were affiliated with “a very prestigious medical school.” Dr Millman’s observations of doctors grew out of an earlier study of cardiac patients’ attitudes towards the heart. While in

the hospital, she said in an interview, she noticed that the sociologically more interesting phenomenon of conflict between private doctors and the hospital’s “house staff,” its residents and interns.

Encouraged by psychiatrists on the hospital staffs. Dr Millman took up this topic and, with the co-operation of hospital officials, applied standard techniques of field sociology to observing the behaviour of her subjects.

On leave from her teaching post, Dr Millman followed various doctors around throughout the day, making notes. Very quickly. Dr Millman said, she detected the still more interesting phenomenon of how doctors deal with evidence of error and incompetence among their colleagues. “Doctors are very selfconfident,” she said, explaining how an outsider could be allowed to witness such sensitive proceedings. “They believed that even if I disagreed, I would eventually come around to seeing it their way. It was just' a matter of educating me.” One mechanism Dr Millman observed in detail was the monthly medical mortality and morbidity conference, also called “mortality review.” Such meetings are officially intended to examine instances in which patients have died or suffered serious complications, possibly as a result of doctors’ errors. The goal is to prevent similar mistakes in the future. “As one member of the staff after another testifies about how he or she was led to the same mistaken diagnosis,” Dr Millman wrote of the mortality review conferences ’ she attended, “the responsibility for the mistake is implicitly spread around. As in a good detective story, the case is reconstructed to show that there was evidence for suspecting an outcome different from the one that turned out to be the true circumstance.

“Responsibility for the error is also neutralised by making much of unusual or misleading features of the case, or by showing how the patient was to blame because of unco-operative or neurotic behaviour.'*

Dr Millman quoted the chief of medicine at one

hospital, the physician who conducts the conference, as saying that most of the mistakes made by doctors cannot be discussed at the meeting because “it’s got to be a cordial affair.” According to the doctor, “80 per cent of the mistakes made around here are ignored or swept under the rug.”

Dr Millman said that the attitude of doctors at the “mortality review” was one of sympathy with the erring physician. At one meeting, doctors reviewed the case" of a 34-year-old man who had abdominal pain and evidence of intestinal bleeding.

He was diagnosed as suffering from a gastric ulcer and was given tranquilisers. antacids, and an ulcer diet. Ten months later he died of abdominal cancer, discovered only three days before his death.

At the meeting it developed that the man’s repeated visits to the hospital after the initial diagnosis had yielded many more symptoms, including laboratory results, indicating much more serious disease than was first diagnosed. Because the doctors thought the man had psychiatric problems, they ignored or dismissed his symptoms as the product of a neurotic personality.

When the man’s condition deteriorated to the point where a surgeon was called in to do an exploratory operation, looking for cancer, the patient was already near death.

Dr Millman asked hospital officials how often they dismissed doctors who repeatedly displayed incompetence. She found it almost never happened