Bostonmagazine.com

The Silent Treatment
by Doug Most
Copyright February 2003.

Boston may be a medical mecca, but it's a reputation doctors and hospitals protect so fiercely  that they're keeping secret the mistakes they make. And what you don't know could hurt you.

The little boy was two years old, one of the 2,000 children admitted each year to Children's  Hospital for cardiac procedures. No surgery could completely heal him — he had been born  with one ventricle instead of two — but doctors hoped to make his weak heart strong so he  could one day play soccer without losing his breath in seconds.

It should have been a routine, if delicate, procedure, one that required placing a tiny tube of  mesh wiring called a stent inside one of his heart vessels to keep blood flowing through. But  the stent jarred loose and drifted into the boy's chest like a wayward satellite. The surgeons  quickly called in Dr. Jim Lock, chief of the hospital's cardiology unit.

"In the process of putting in the stent, it dislodged and moved away from the wall of the heart,"  Lock recalls while watching a grainy, black-and-white recording of the surgery a few days after  it happened in December. "It's not fatal, but it's not a good thing, either. It's floating around,  and it might lodge in another vessel and reduce the flow there." As soon as he scrubbed in, he  recognized the problem. "I helped them by putting in a second stent that captured the first  stent, repositioned it, and kept the blood flowing."

Afterward, with the boy recovering, the doctors Lock had assisted pulled him aside. "They asked  how I knew to do exactly that, and I told them it had happened to me," Lock says. "You have to  ruthlessly and publicly identify your mistakes so it won't happen in the future. If you just say  it was a difficult case, that that's why it happened, you'll never learn."

But statistics suggest, and leading experts confirm, that doctors and hospitals around Boston  — widely considered the medical capital of the world — are vastly underreporting their  mistakes to regulators and the public.

In 2001, Massachusetts hospitals reported 982 "serious incidents," or medical errors, to state  regulators, up from 636 five years earlier, but still an average of just three reports per day.  In New York state, by comparison, hospitals submitted nearly 30,000 reports, or 82 per day. In  fairness, that disparity is mostly due to the different ways the states define a medical error:  New York studies every little complication; Massachusetts, only major incidents. Still, even  New York is criticized for disclosing fewer medical errors than actually occur, and with a  population only three times that of Massachusetts, it is reporting more than 30 times as many.  One doctor who was a member of a Massachusetts oversight committee says statistics show there  should be 10 reports of medical errors per 100 hospital beds each year. In fact, hospitals in  this state are disclosing roughly three. Even when they are reported, one Harvard School of  Public Health professor says, many medical errors are barely investigated because of a lack of  resources.

Massachusetts hospitals also hardly ever discipline their doctors. Even though state officials  insist that high discipline numbers prove a hospital has high standards and strong performance  reviews, discipline figures remain shockingly low. In 2001, only 25 of 112 Massachusetts  hospitals took any action at all against any of their physicians. Beth Israel Deaconess,  Tufts-New England Medical Center, and the Lahey Clinic were among the 87 that did not  discipline a single doctor in 2001, while Massachusetts General, Children's Hospital, and  Newton-Wellesley Hospital all punished three or fewer.

"Either there are some remarkably good things happening here," says Nancy Achin Audesse,  director of the Massachusetts Board of Registration in Medicine and the chief state regulator  of doctors, "or hospitals are shirking their responsibility."

"When you've been going to see your doctor for so long, that's who you rely on." Bob Manuppelli  has to bite his lip when he says this. He's sitting in blue jeans and sneakers sipping wine in  a seafood restaurant on the Salem wharf near where he lives with his three kids. A machinist,  Manuppelli is 47 and has a goatee that's more salt than pepper. Almost 10 years have passed  since his wife, Barbara, died at age 42 of breast cancer, but it's been impossible for him to  move on. It was a decade spent fighting for answers that finally came last year when a jury  decided that his wife's doctor had misdiagnosed a lump in her breast — a lump that spread  into the cancer that killed her. The $7.1 million judgment was the largest malpractice award  of 2001.

"She felt a lump and had me feel it to verify it," he remembers of the day back in 1987. "It  felt like a mass. She went to her doctor [Dr. Joel Berman, a now-retired Salem gynecologist],  and he did the ultrasound and determined it was a blocked milk duct."

But did Berman simply miss the tumor because it was hard to spot, or did he bypass a more thorough  exam? Separating a medical error from an error in judgment is difficult.

In December 2001, a surgeon at Rhode Island Hospital in Providence opened up the wrong side of  a man's head because someone had placed a scan of the patient's brain backwards on an x-ray  viewing box. The reversed scan made it look as if the brain's left side was bleeding instead  of the right. After the surgeon drilled two holes in the left side of the skull and found no  bleeding, he repeated the procedure on the right side and drained the blood. The patient was  unharmed, but experts say the mistake could have been avoided easily if the staff had done  what hospitals across the country are now doing regularly: simply marked the surgical site  (in this case, the patient's skull) with a pen. For Rhode Island Hospital, the error came only  a year after another mix-up in which a surgeon operated on the wrong child, removing the tonsils  of a girl who was supposed to have eye surgery, an error hospitals now try to avoid by giving  every patient a wristband with their name that's checked presurgery.

Walking the hallways at Children's Hospital, Dr. Lock is unusually candid in talking about medical  errors. Later this year, in a step that could be unpopular with his colleagues, he plans to publish  stories of actual mishaps that occurred with patients in his department. "I hope it will liberate  others," he says, "to find strategies to deal with their complications."

Some change is already afoot. Massachusetts improved its ranking among states in disciplining  doctors in 2001 after dropping to 45th in 2000, but is still a below-average 27th. "A hospital  with a high number of doctors being disciplined is a good thing," says Audesse. In addition,  the Institute for Health Policy at Massachusetts General Hospital has started interviewing  discharged patients about problems they may have experienced while hospitalized. And the state  has begun using a $4.5 million federal grant to study its current reporting system and recommend  improvements. "One of the best ways to prevent medical errors is to get information to the  hospitals about what happened next door," says Nancy Ridley, the state's assistant public-health  commissioner.

The biggest challenge is finding a way to break the culture of silence in hospital corridors  that has long crippled efforts to cut medical errors, just as the blue wall of silence has stifled  police investigations. But the difference between the two silent treatments is that one protects  dirty cops and the other puts millions of patients at risk. A 1999 study estimated that as many  as 98,000 people nationwide die each year as a result of drug mix-ups, surgical gaffes, and  misdiagnoses. (A separate study released last month found that surgeons in Massachusetts had  left medical devices inside patients' bodies 61 times in the last 16 years.) Yet while 20 states  including Massachusetts require the reporting of medical errors, one authority questions how  strictly this is enforced. "None of them do a thorough investigation of what's reported and  report back to hospitals," says Dr. Lucian Leape, a professor at the Harvard School of Public  Health who is widely considered the godfather of the movement to reduce medical errors.  "Massachusetts did for a while, but now the majority of reports go into a drawer."

Boston-area hospitals have a mixed record of handling such mishaps. When a physician at Mount  Auburn Hospital last summer walked away from a patient during back surgery to deposit a check  in a bank, the hospital kept the embarrassing incident quiet from the patient for a month and  only admitted its gaffe publicly after being cited by the state. In contrast, when Boston  Globe health reporter Betsy Lehman died in 1994 of a chemotherapy overdose at Dana-Farber  Cancer Institute, the hospital confessed after learning the overdose caused her death and began  aggressively campaigning to improve patient safety nationwide. Yet even though Massachusetts has  been at the head of that charge to reduce errors, the debate about how best to catch and correct  them still rages, while evidence suggests that many mistakes that happen here are still going  unreported.

"The only thing wrong with the system is it has not adequately been supported financially by  the state," says Dr. Arnold "Bud" Relman, a Harvard Medical School professor, former editor of  the New England Journal of Medicine, and former chairman of the state's Patient Care Assessment  Committee. (The five physicians and two public members of the state medical board are paid $35  for each day they meet.) "There's inadequate staff and funds to rapidly respond to reports from  hospitals."

While Leape agrees the board could use more resources to investigate claims, the flaws are  inherent in the system, he says. "I like Bud, and Bud's a dear friend of mine," responds Leape,  "but he just doesn't get it. The system doesn't work well. People work around it."

To the patients who sit in their waiting rooms, strip down, lie on those cold metal tables,  and place their trust in the hands of the person in the white coat in front of them, the mere  suggestion that their doctors might make a mistake in diagnosing or treating them is inconceivable.  They say we're healthy, we run for the door. They say we're sick, we follow their prescription.  In Barbara Manuppelli's case, Berman had been her doctor for years, so when he assured her that  the lump in her breast was just a harmless cyst, why wouldn't she believe him?

"She never questioned it," says Bob Manuppelli, who has never before spoken publicly about his  wife's case. "The weight of the world was off her shoulders." But when the mass didn't change,  she went to a different doctor and a biopsy (Berman had failed to do one a year and a half  earlier) found the cancer. "We got in the car, and she cried," Manuppelli says, choked up.  "She kept saying, 'What about my babies?'"

The cancer vanished and returned over the next five years before finally taking her vision, her  liver, and eventually her life on June 25, 1993. A full three years passed before Bob Manuppelli's  sorrow turned to anger. "A blocked milk duct?" he says now. "And 17 months later, it's cancer  in the same place? I just don't want that to happen to somebody else."

He told the story to Brookline attorney Kenneth Levine. Levine says two things — Barbara  Manuppelli's age and the delay in her diagnosis — told him this was more than a doctor's  judgment error. This, Levine says, was an avoidable mistake.

"A lot of these cases come from arrogance, not from incompetence," he says. Berman argued in  court that the lump he felt really was a cyst and that the tumor appearing in the same spot  months later was a coincidence. But Levine's case came together when one of his witnesses, Dr.  Darrell Smith, a Brigham and Women's Hospital radiologist, testified that the negative result  on the mammogram should not have stopped Berman from also sticking a needle into the lump to  confirm it was not a tumor. "I guess you'd say it was an empty victory," Manuppelli says. "My  wife's not here to enjoy it with me. I didn't care about the money. I wanted to see someone  answer for the mistake."

But who should pay?

Many believe one of the biggest flaws in Massachusetts is that hospitals are considered  charities. They are protected by a charitable immunity law, something that exists in only  9 of the 50 states. It means that no matter how much a hospital may be to blame for a mistake,  it can be forced to pay only a maximum of $20,000. The cap was created to protect the public  funds charities collect, but many say the law is outdated and needs to go because hospitals  will only begin serious change once there are serious consequences for their errors.

In the meantime, lawyers like Levine say the charitable immunity law is why they rarely sue  hospitals and instead go after the doctors. (In Manuppelli's case, the doctor had so little  insurance that the family had to settle for significantly less than what was awarded.) "Doctors  think we're the devils," Levine says. "We're not. If we take bad cases, we'll go out of business."

Of course, the broader question for Massachusetts, and all states, is finding a way to stop  hospitals, doctors, and state regulators from finger-pointing their way around a problem that  kills more people each year than automobile accidents.

Hospitals say they have to be protected by immunity or they'll go bankrupt fighting million-dollar  lawsuits. Doctors say they have to be protected or their malpractice insurance rates will skyrocket  even higher than they already have. And state regulators and experts say they suspect that both  hospitals and doctors are holding back information about errors.

"What's noteworthy about Massachusetts is they do track and trend data and pass it on to the  Massachusetts Coalition for the Prevention of Medical Errors," says Jill Rosenthal of the  National Academy for State Health Policy in Portland, Maine. "It's a good system." That coalition  represents government officials, providers, and patients, but Rosenthal adds that Massachusetts,  like every state, has one critical problem with tracking errors: "Clearly, there is underreporting,"  she says. "New York gets about 30,000 reports a year. Massachusetts gets around 900. And even  New York thinks it has underreporting."

Dr. Mary Anna Sullivan, a psychiatrist at the Lahey Clinic whose term as chair of the Patient  Care Assessment Committee expired last month, says, "There is not one doctor who has made a  mistake who doesn't lie awake thinking about it." But, she adds, hospitals are not helping  their doctors by underreporting those mistakes. "We expected 10 reports per 100 hospital beds  each year," she says. "We're getting zero to five reports on average."

In other words, the system seems to have at least some of the right pieces in place but cannot  effectively root out trouble because it's getting incomplete information.

"We find the vast majority are reporting," says Ridley of the health department. "That's not to  say we don't see incidents when a hospital failed to report what we think is reportable."

Under the current system, one state agency looks into specific actions of doctors, while a  second examines whether hospitals follow proper procedures.

The state Department of Public Health requires hospitals to report within 24 hours to seven days  "serious physical injury" and "other serious incidents" that affect patient health and safety.  The reports are available to the public (minus patient names), and the state works with hospitals  to spot trends and issue alerts to all hospitals on ways to avoid repeating a mistake.

The Board of Registration in Medicine, which oversees doctors, meanwhile, relies on secrecy.  Hospitals, HMOs, nursing homes, and other health facilities must investigate all unexpected  deaths and serious injuries, then report cases every quarter to the board, which itself  investigates the most serious incidents. But these reports are confidential, even from the  state health department, which is why doctors fearful of being disciplined or sued prefer  this system. The board does issue punishments, but not as many as some would like. In 715 of  846 cases in 2001, the board took no disciplinary action; letters of concern, warning, or advice  were issued in 201 cases. Critics say relying on hospitals and doctors to initially investigate  themselves allows them to determine what to report — and what not to report.

That's risky, Leape, the Harvard School of Public Health professor, wrote in the November issue  of the New England Journal of Medicine , because doctors, either out of shame, a fear  of being sued or disciplined, or anxiety about their reputations, rarely talk openly about  their errors. "The fundamental problem with physicians, especially surgeons," Leape says in an  interview, "is they can do no wrong. It clouds your judgment."

Asked if he'd ever made a mistake in 50 years of medicine, Leape pauses, then recalls a girl  who lay dying on his operating table when he was chief of pediatric surgery at New England  Medical Center. "She had blood in her stomach," he says, his forehead a crumpled road map of  creases. "Everything I'd read told me not to operate and try to find the source of the bleeding,  but to do a blood transfusion and wait." He knew that young patients often prove remarkably  resilient. So he didn't cut her open. He waited. And he lost her.

"In retrospect, I made the wrong decision, and she died," he says. "Physicians make decisions  all the time. I was 45 or 50. I'd seen it all. But there's a lot of arrogance out there."

That some doctors can be arrogant about their medical views is like saying some lawyers can be  opinionated about their clients. In fact, some would argue that a supremely confident doctor  is the best kind. But a study by the Harvard School of Public Health and Kaiser Family Foundation  suggests doctors can be more than arrogant, as Leape says. They can also be stubborn.

Interviews with more than 800 doctors found many resistant to changes that could help reduce  errors. For example, only one-third of the physicians considered reducing the strenuous hours  of young doctors to be an effective way to cut errors. Even fewer doctors thought computerizing  paper forms, such as drug prescriptions, instead of relying on messy handwritten notations, would  make much difference. Brigham and Women's was one of the first hospitals in the country to use  computers for prescriptions to prevent medication errors.

Some believe the model the healthcare system should follow is that of the Federal Aviation  Administration, which allows pilots to report errors and near collisions anonymously.

"That's not a particularly good idea," says Relman. "When hospitals work right, everybody  knows what everybody else is doing. A lot of what goes on is best judged by professionals.  We want to make things better and not hide things. The public has to be willing to trust that."

Cynthia Warren trusted Brigham and Women's Hospital. She remembers sitting outside Brigham and  Women's on a muggy summer day just before her 61-year-old mother's hysterectomy. "It was her  first surgery ever," says Warren, one of Laura Johnson's nine children. "We were talking about  family and the trip she had just taken." Warren recalls kissing her mother before she was wheeled  away. "It was the last time I saw her."

What began as a routine operation back in 1996 ended with a lawsuit against one of the hospital's  doctors and a nurse. The suit claimed two errors caused Johnson's death: First, that following  the surgery, Dr. John Fox removed Johnson's breathing tube prematurely, causing her throat to  become blocked; second, after a breathing tube was inserted in an emergency tracheostomy, nurse  Thomas Adams dislodged the tube while changing Johnson's bed sheets. She went into cardiac  arrest, and just 12 hours after she had walked into the hospital for her hysterectomy, Johnson,  of Jamaica Plain, was dead.

"That night when we went home, I was still in shock," Warren says. "We sat in her bedroom and  cried. We decided we would go straight back to Brigham and Women's and demand answers. We wanted  a full explanation of what went wrong."

When they weren't satisfied, they sued, and in November, after five days of testimony, the  doctor and nurse settled for $2.3 million.

Audesse says that if hospitals followed a simple formula that includes open communication between  doctors and patients, and analysis after a mistake, no matter how serious or benign, patients  would be better off — and so would doctors and the hospitals themselves. After the death  of Betsy Lehman, the state set up the Betsy Lehman Center for Patient Safety and Medical Error  Reduction to look for trends of unexpected outcomes and report its findings to hospitals and  the state legislature.

"Here's the truth. I'm sorry it happened. Here's what I've done to correct it and make sure it  never happens again," Audesse says when asked what she would like hospitals to say in response  to an error. "We need to move from a risk-management mindset to a patient safety system. It's  not easy."

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