A new normal?
Dr. Horowitz, who wrote of his experience in The Washington Post, said it reflects a persistent, systemic problem in health care: the inability to address medical errors and correct them. In the article, he addressed a phenomenon called the “the normalization of deviance.” Diane Vaughn wrote about this phenomenon in a 1997 book about the Space Shuttle disaster. Multiple flaws were noted in previous shuttle launches but then rationalized and “normalized” when they didn’t cause a disaster – until they ultimately did.
“That’s relevant to my situation,” Dr. Horowitz said. “The spine supervisor at this hospital excused the consultant by saying, ‘he did the exam to the best of his ability.’ Further, the response to my complaints came from hospital representatives rather than physicians, meaning that the ‘normalization’ was institutional, and it was willing to accept his poor performance without sanctions.”
He imagines that he could not be the only case handled poorly by this hospital or that particular consultant. “He could have done the same thing to another patient who didn’t have my medical knowledge,” added Dr. Horowitz.
In her book, Ms. Vaughan noted that whistleblower activity is sometimes the only device that reveals normalization of deviance.
Dr. Horowitz sees himself as a whistleblower for these types of mistakes. “The question is, how do we deal with medical errors even in sophisticated patients who see these errors, and how do you manage this in the average patient? I don’t want to see this type of medical care rendered for any patient, hence my attempt to make this situation public.”
A teachable moment lost?
Commenting on this case, Alan Rapoport, MD, said, “[it]illustrates inadequate physician evaluation in the ED, poor communication from the examining doctor about abnormal lab and MRI findings, unwillingness to call in consultants to properly evaluate the situation, and no recognition of the need to admit the patient.”
Dr. Rapoport is the editor in chief of Neurology Reviews and a clinical professor of neurology at UCLA in Los Angeles. He is a past president of the International Headache Society.
He noted that the patient is in his late 70s and needed to fly across the country to arrive at home. “Months later, when this situation was explained to the hospital via the mail, they totally failed to recognize their inadequacies and apologize for their mistakes. They were probably concerned about being sued, but I believe that their actions increased their chances of a lawsuit,” Dr. Rapoport said.
“When a teaching remedy was offered by the patient to the hospital so the doctors involved could learn from the experience, the hospital was not interested. The only party that learned from this unfortunate episode was the patient, not the doctors, or the ER, or the hospital administration,” Dr. Rapoport said.
He continued, “It is scary to think that an excellent hospital would act in this manner and refuse to learn from their mistakes. The California medical board was notified and did not investigate. It is not too late for the hospital to apologize, communicate their shortcomings, and fix the problem at multiple levels in the hospital.”
Dr. Rapoport consulted Morris Levin, MD, a professor of neurology and director of the Headache Program at UCSF, to ask what he thought, theoretically, about how a hospital should respond when they make a mistake and how much they should divulge. Dr. Levin is involved in Medical Ethics and often lectures about it at conferences.
Dr. Levin said, “When medical errors are made, to me, it is ethically sound to identify them and ‘fess up.’ There has always been reluctance to do so because of fears of lawsuits, but it turns out that when institutions do disclose errors, their liability costs actually go down.” Dr. Levin cited the University of Michigan, which tried a full disclosure policy as an experiment. “It led to reduced costs, not to mention a boost in patient satisfaction,” Dr. Levin noted.
He continued, “I think patients want and deserve to know the truth. I also believe they understand that medical errors can and will happen. It is my observation that patients have several key concerns: 1) how the error(s) happened, 2) how the error affected their health and what can be done to restore them to optimal health, and 3) what the institution is going to do to prevent this kind of error from happening to others.”
Dr. Rapoport concurs with Dr. Levin. “I am glad Dr. Horowitz has fully recovered and at least he has learned from the experience. I do not think the hospital and doctors did,” Dr. Rapoport said.
This article was updated 11/12/20.