Even for those people who were not well acquainted with the humor and many accomplishments of Joan Rivers, I suspect that they read a great deal about her recent death, secondary to a “simple” procedure. Whenever a well-known personality dies, especially under such circumstances, it generates news stories and magazine articles for many months. From the medical perspective, the obvious question is why Ms. Rivers died.
Needless to say, the lawyers have already become involved both from the side of the Rivers’ estate and from the side of the physicians who were treating her. In the professional literature, a number of physicians have already spoken up about the incident. This morning, I read a blog post that was written by a physician and which attempted to summarize the event and offer some explanation. At the moment, there is no clear identified reason for her death, even after autopsy. I have no doubt that this case will linger in the courts for a very long time.
I purposely am not going to identify the source of the blog, because I found it to be a pathetic apologetic attempt to explain away Ms. Rivers death. At one point, the author just stops short of blaming patients when procedures go awry. There is a clear attempt by the author to find an excuse for any error that may have occurred. I personally find the entire blog post to be insulting to me as a physician.
Let us start with one critical point: doctors are humans who have completed a number of years of didactic study, followed by an apprenticeship. Most doctors themselves are not researchers; they are effectively only purveyors of medical information and no more. In other words, when the surgeon says to you that you need an operation, that is based on what the surgeon was taught, learned by observing other surgeons, learned by performing surgeries under the guidance of senior physicians and to some extent, read about in various medical journals. When a new procedure comes along [like the near replacement of open surgery with laparoscopic surgery], the surgeons need to retrain. Once again, they must learn by observing and then doing under observation and concurrently reading about the new technology.
What this all means is that errors will happen. Humans are incapable of perfection. Even if a doctor is correct in his or her diagnoses and treatments 99.9% of the time, one in 1000 patients will suffer from this doctor’s human error. The question remains if the doctor did everything humanly possible to avert such an error.
In a medical environment, this basically means following standardized procedures and guidelines. There should be checklists for every step of the management of the patient. There should be regular reviews of practices. There should be regular consultation with other colleagues to be sure that the best treatment has been provided. I cannot speak for every doctor in the world, but in my own experience, I have seen countless examples of physicians of all types not following these basic rules. In the past, I have spoken of the tremendous value of handwashing by physicians, and yet in study after study, less than a third of physicians wash their hands before each patient. I think this says it all.
What I found most disturbing was the use of the term “VIP syndrome”. The meaning of this term is that physicians may react to celebrities differently than they would a noncelebrity. The idea is that in the attempt to impress the VIP, the physician forgets to follow through on proper procedure and ends up doing more harm than good.
I have heard the term “VIP syndrome” used so often in the last few weeks, that I suspect that some people think that this is a medical condition that affects doctors. It makes it sound as if any physician would have succumbed to this syndrome and thus made mistakes in the handling of the celebrity, leading to the tragic outcome. By using this term, there is a very subtle but obvious attempt to minimize the responsibility of the physician. “He was overwhelmed”, “he was overtaken by anxiety”, “in his attempt to achieve perfection, he effectively flew into the sun with wings made of wax”. I suspect that these phrases, or ones similar to them, will be used in the defense of the doctor who treated Ms. Rivers.
There is no such thing as “VIP syndrome”. Doctors can become anxious or distracted for any number of reasons, such as physical exhaustion, stress, being overloaded by a large number of simultaneous cases and so on. One obvious reason for distraction would be treating a member of your own family. That is actually why it is strongly recommended that a physician not be his or her own family’s doctor.
The point is that if a doctor knows that he or she is being distracted, or there is a significant chance of becoming distracted, then that same doctor must just say no. The doctor must say “no, I cannot treat you”, “no, it is best to transfer you to another doctor”, or while looking in the mirror “no, do not allow yourself to become distracted”. In any case, if “VIP syndrome” is a real condition and more so, is very common, then perhaps only certain doctors should be allowed to treat such VIPs. Which doctors? Perhaps the doctor who has never heard of the celebrity. Or perhaps a doctor who is so professional, that he or she is truly unaffected by the syndrome.
As always, I will suggest a technological solution to this issue. And it will be the same solution that I have suggested many times in previous blog posts. Basically, the treatment for VIP syndrome is to either eliminate the human component of the treatment or to institute safeguards that humans cannot bypass.
For example, you could design an anesthesia table that will not allow anesthesia gases to flow, until a computerized checklist is filled out. You could design smart syringes that have a lock on them that will only be released by the computer after the checklist is filled out. When doing laparoscopic surgery, you could lock down the video feed until the appropriate checklists are digitally filled out. In other words, you would empower the computer to babysit all of the experienced professionals about to perform a procedure.
The assumption would always be that something has been forgotten or done incorrectly. And in each case, the physician would need to indicate on some type of checklist, that everything in fact has been done and done correctly. With such an approach, you actually do stand a chance of achieving 100% of human capability. If the patient dies even after everything has been done under computer supervision, then at least you know that you truly did your best. And by the way, it is a small but significant comfort to a family when they hear that everything possible was done for their family member. Under computer supervision, this would not be a lie.
What about physician autonomy? What if there are special cases? What if the program for the computer has a bug? These are all valid questions. But the ultimate question is – are patients safer when the physicians are supervised by a computer, versus the physicians being free to act as they see fit. The answer is clear.
As to physician autonomy – I personally do not believe in it. If there is a guideline for treating a patient, that guideline must be followed. And if the physician decides to treat a patient against the recommendation of the guideline, that physician must be able to support this action by some form of evidence from the medical literature. A physician should not have the right to randomly choose a high blood pressure medication based on his or her own impression of the literature [assuming that the doctor even read the literature]. The physician should prescribe what is recommended by the guideline.
We do not have all the answers. There will be times when there are absolutely no guidelines. In such a case, one will have to rely on the personal opinion of the treating physician. In most cases, this opinion will have no inherent validity. The personal experience of any doctor is extremely limited to, perhaps, a few thousand patients over years of work. Unless the doctor is Dr. Spock (from Star Trek), the physician in question does not have the memory or the inherent mental analytical skills to extract statistics from his or her own personal medical experiences. On the other hand, if the doctor does have these skills as well as an eidetic memory, then he or she should leave medicine and work for the NSA.
The time of apologies and excuses is over. The public deserves better than made up syndromes to explain away very human and very preventable error. When doctors finally accept the fact that they need help, now more than ever, then there will be a glimmer of hope that patients will not needlessly die.
Thanks for listening