When medical practice goes wrong, who is to blame? The traditional answer in journalism has been unambiguous: the doctor. If the press found out a person had died from improper care or had had the wrong leg cut off, the reaction was predictable. A clamor went up for the incompetent physician's head--or at least his license. And doctors everywhere cringed. There but for the grace of God go I, each of us would say. For all of us make terrible mistakes. Only the unlucky few are publicly exposed.
So I've been intrigued by the increasingly popular alternative explanation--"the system did it." In many cases, this is the right way to go. Bad systems are more often at fault than bad doctors. I worry, however, that we have already begun to take this explanation too far--so far that we are introducing a dangerous murkiness into the question of who is ultimately in charge when it comes to taking care of patients.
T ake the recent horror story in which Christopher Sercye, a 15-year-old gunshot victim, lay bleeding to death 35 feet from the door of a Chicago hospital while the staff refused to help, citing hospital policy prohibiting workers from leaving the emergency room. (If you somehow missed or have forgotten the details, click.) The case provoked a national outcry. This time the white-hot light of publicity focused blame more on the administrators than on individual caregivers. City, state, and national officials demanded to know how a medical facility could maintain such an appalling policy. In an unusual step, President Clinton personally announced that the policy was so outrageous that he would seek to have the Ravenswood Hospital Medical Center expelled from Medicare.
In this particular case, however, the impulse to hold the CEO more responsible than the doctors seems wrong. What shocked me was not so much the hospital's policy as the fact that doctors and nurses would stick by the rules rather than help a person in desperate need. News organizations demanded an explanation from the hospital CEO, John Blair, but I could find no reports that mentioned so much as the name of a staffer who had refused to help.
This was not an isolated instance of medical personnel providing bad care in obeisance to a policy. The Los Angeles Times recently uncovered several cases in which doctors at Northridge Hospital in Southern California refused to provide epidural anesthesia during childbirth to women on Medicaid unless they anted up $400 on the spot. The reason? It was "hospital policy," patients were told. One patient offered credit cards, a check, and finally had her mother wire in the money, but the epidural was denied. The cash hadn't arrived in time.
C ertainly, these policies deserve scrutiny. But the real issue here is who, ultimately, is in charge of patient care. By putting all the blame on the rule makers, the public is implicitly accepting that sometimes the rule makers are in charge instead of the caregivers. That is a very recent phenomenon, and it should be resisted.
Hospital policies, after all, are not federal laws. They do not demand slavish devotion. In odd cases, rules adopted for the best of reasons can make for bad medicine. And real life is full of odd cases. I remember one not long ago when, late at night, a patient came into my hospital at death's door because of a rupturing abdominal aneurysm. Understandably, our hospital forbids residents to start operations without an attending surgeon present. But none was around, and this guy would have died waiting. So we didn't hesitate to break the rules and operate on our own. It was his only chance.
Ravenswood's policy may also have been well intentioned. According to a hospital spokesman, it is an old policy maintained by most hospitals to make clear that staff should not be expected to sacrifice the care of sick patients in the ER to go hither and yon. But the dying boy presented a case where the staff should have broken that rule. (Indeed, the Chicago Tribune reported that a year earlier, an emergency worker at a partner hospital with the same policy had done just that. He ran outside to help a woman suffering a brain hemorrhage in her car.)
As for just plain barbaric policies, like the one at Northridge Hospital, I see no way in which the doctors who follow them are not ultimately culpable. To say they were obeying an administrator's instructions is not even the slightest defense. Patients still can (and should) insist on holding doctors responsible for providing proper care.
The managed care debate presents this issue in a slightly different context. The recent clamor in the press and among some politicians to allow patients to sue insurers for medical malpractice makes it sound as if we are going in the wrong direction here, too. But the semantics are important. The laws under consideration would not actually make insurers liable for malpractice. Instead, they would make it easier to sue insurers for failing to pay for proper care. I'm all for giving patients a fair chance to contest improper refusals of payment, but we should not lapse into calling such refusals malpractice. Just because an insurer won't pay for a treatment doesn't free a doctor from providing it. Essentially, a patient in this position is uninsured. And doctors are still ethically obliged to offer appropriate care to uninsured patients in need.
This might sound like I'm calling for a return to olden times, when medical decisions were nobody's business except the doctor's and the patient's. I'm not. That fragmented system without oversight had its problems: deviance (not all doctors provided good care) and cost (the doctors drove up the bills). Hospitals, government insurers, and private insurers have stepped in with standard guidelines for care, review of medical decisions, and changes in how doctors are paid. Much of this systematization of care has clearly been to public benefit. But not all of it has, and not all of it will be.
At the margin, we doctors have found ourselves being asked to do things that make us queasy. A new guideline, for example, may tell us to send heart surgery patients home earlier. It forces us to justify doing otherwise. It's a big pain in the butt. But it is not a command, and we should not let it become one. Perhaps the previous way was based on nothing more than fusty old habit, and being forced to rethink it is good for us. However, if I know the new way is inappropriate, I cannot be permitted to cave. In Chicago and in Northridge, the doctors should have known that blindly following policy was bad. The buck still stops with them.
Missed our link to the sidebar recapping the Ravenswood case? Click.