Serious Physician Errors Might Go Unreported: Here’s Why

A recent headline, and an older book, offer cautionary tales. The NBC News headline, “Florida hospital ignored years of complaints about surgeon, patients and families allege.”

The story asserts that an orthopedic surgeon in Florida allegedly caused hundreds of devastating injuries. The allegations include that between 2016 and 2020 patients noticed the doctor was slurring his words, having difficulty with balance and concentration, having angry outbursts, demonstrating erratic behavior, and more. 

The article indicates various physicians and nurses expressed concerns about this doctor. One nurse asked never to work with the doctor again, but the hospital declined her request, forcing her to continue participating in his surgeries. I don’t know the other side of the story, and it is certainly possible the allegations are unfounded, but for purposes of this article the details are not important. This is a story about the importance of recognizing zebras. In medicine there’s a saying when you hear hoofbeats, think horses not zebras. But the reality is zebras can occur and focusing on platitudes or norms can result in zebras going unrecognized for far too long. 

Here are two quick stories, one from a client’s experience, and one from a book I read. The personal experience involved a patient who complained she received a bill for a physical, a 99215, but she never removed any clothing. The clinic administrator looked at the women’s chart and saw that a full exam was documented. Under the horse/zebra view of the world, it would be easy to assume that the patient was mistaken or lying, and dismiss her concerns. But this administrator was thorough and open-minded. She also had had some nagging doubts about the doctor. She dug, and the investigation revealed that the physician was using templates and was frequently recording examinations that had never occurred. There was documentation of her physical, but it was fabricated. The woman had been right and dismissing her complaint would have allowed a major problem to continue.

The second story is from “The Blind Eye” by James Stewart. I highly recommend the book.  In fact, it would make a great “book club” book for risk management, compliance, legal, and quality teams. It tells the story of Michael Swango, a physician/resident at Ohio State University. An unusual number of healthy patients died while Swango was on the team, and a nurse saw him injecting something into a patient. Nurses voiced concern but the initial investigation cleared him. It shouldn’t have. It took a decade for OSU to admit its error. I am somewhat sympathetic to OSU. As the book makes clear, most observers had a very difficult time believing that the physician could be intentionally overdosing patients. Some didn’t want to believe it because it seemed improbable, others figured that the PR result would be so bad that learning the truth wouldn’t be worth it.

Basically, incredulousness and incompetence worked in concert. I should add that wasn’t his last gig. He worked, and killed, in several more spots. Read the book. You won’t regret it.

That sort of event is, quite fortunately, a unicorn zebra. It’s hard to think of a bigger “zebra” than a physician serial killer. But while incredibly rare, and difficult to believe, that’s exactly what was occurring here.

A good investigator has to detect the rare. I often think of whether I have dismissed as non-credible an allegation because it seemed too wild or problematic. The truth is, I don’t know. All I, or anyone, can do, is keep an open mind but remain vigilant. I guess we want to pray, or dare I say, “bray” that we properly recognize a zebra when we see one.

Programming Note: Listen to healthcare attorney David Glaser’s Risky Business segment every Monday on Monitor Mondays.