Doctored

by Sandeep Jauhar

  * * *

  Those first few months at LIJ, I frequently assumed attending duties in the cardiac care unit. Most of my cases were straightforward, but a few required a subtle touch. Dick Perkins, a middle-aged construction executive, was admitted to the CCU one Saturday night after a prolonged bout of chest pain. Blood tests showed he had suffered a moderate heart attack, in which blood flow to the heart muscle is cut off by a coronary blockage. But when he was told he needed a coronary angiogram, he balked. “He doesn’t want any invasive procedures,” a bedraggled nurse explained when I arrived for rounds on Sunday morning.

  I had encountered such resistance many times. “I’ll talk to him,” I said. Patients are often anxious about cardiac catheterization, and a discussion of the risks and benefits usually allays their fears. But the nurse said Mr. Perkins had been ranting and uncooperative with blood draws and blood pressure checks. A psychiatrist, asked to assess decision-making ability, had deemed him incapacitated—he seemed to have paranoid delusions about his medical condition—and suggested forcibly treating him, if necessary.

  I walked into his room, hoping to avoid a showdown. He was standing with his back to me, talking on a cell phone. When he heard me, he hung up and turned around; he was an overweight man with a sallow, jowly face and a potbelly, wearing Dockers and a blue oxford cloth shirt. I extended my hand. “Hi, I’m Dr. Jauhar,” I said. “I’m the cardiologist on call for the weekend.”

  He eyed me suspiciously but reluctantly shook my hand. I asked him to sit down, but he remained standing, arms folded, with a fixed and fervent look.

  “You’ve had a heart attack,” I started off.

  “So you say,” he shot back.

  “Well, this is something I can say with confidence,” I replied, trying to project authority. “I’m told you’re a building expert. I know next to nothing about buildings, so anything you tell me I am likely to believe. Similarly, I think you should trust me if I tell you that you’ve had a heart attack. After all, I know how to identify heart attacks. It’s what I do.”

  I asked someone to pass me a printout of his test results. After I showed him the abnormal cardiac enzyme levels, he sneered and said: “Fine. So you think I had a heart attack.” Clearly, he still did not believe me.

  “The best treatment for a heart attack is angioplasty,” I said.

  “I don’t want it,” he said, his voice rising. “I told them I don’t want a stent.”

  “No one can force you to have it,” I said calmly. Angioplasty, in which tiny balloons and stents are used to relieve coronary blockages, wouldn’t work without his cooperation, and I wasn’t about to call in security guards to frog-march him to the catheterization lab. “But I think you should reconsider.”

  He glared at me and said he did not want to discuss the matter further.

  “Okay,” I said. “We’ll watch you for another twenty-four hours. If your condition remains stable, we’ll send you home.”

  “No, I’m leaving now.” He moved to gather his things.

  I watched him for a few moments. “You can’t leave,” I finally said.

  “Who says?”

  I wasn’t sure how to respond. “The psychiatrist,” I said tentatively.

  “Which psychiatrist?” he snarled. “The little faggot with the ponytail? The little frilly guy?”

  I immediately walked out to the nurses’ station and phoned Mr. Perkins’s son. He explained that his father had always been “strong-willed” and “done things just the way he wanted.” The behavior I was describing wasn’t so different from his norm.

  Now I felt even more conflicted. On the one hand, my patient clearly did not meet the standards for decision-making capacity. He did not understand his medical condition or its treatment options and the risks and benefits. If I let him sign out against medical advice and something happened to him (sudden death, another myocardial infarction), I would be liable. On the other hand, his intransigence was apparently just a part of who he was. As a doctor, I want to see my patients weigh risks and benefits in a careful, reasoned manner, use logic, have a clear sense of self, etc. In other words, I want them to think like me. But Perkins’s mind operated differently from mine, and not because he was sick. Shouldn’t I just allow him to be himself rather than insist on what I wanted him to be?

  The situation resembled a famous medical ethics case I’d read about. In 1978, Mary Northern, a seventy-two-year-old woman in Tennessee, developed gangrene in both feet, requiring amputation. When she refused to have the surgery, doctors at Nashville General Hospital determined that she did not have decision-making capacity and filed a lawsuit for permission to amputate her legs. “Ms. Northern does not understand the severity or consequences of her disease process,” they wrote to the Department of Human Services in Nashville. “[She] does not appear to understand that failure to amputate the feet at this time would probably result in her death.”

  A psychiatrist concurred, stating that Ms. Northern was generally sane but was psychotic with respect to ideas concerning her gangrenous feet. “She tends to believe that her feet are black because of soot or dirt,” he wrote. “She does not believe her physicians about the serious infection.”

  Two judges from the Tennessee Supreme Court went to see Ms. Northern in the hospital. “They tell us that your feet are shriveling up like a dead person’s feet,” one of the judges told her.

  “No, no,” she replied, insisting she could get up and “walk all the way down to the shopping places.”

  The judge asked: “If the time comes that you have to choose between losing your feet and dying, would you rather just go ahead and die than lose your feet?”

  She replied: “It’s possible. It’s possible only if I—just forget it. I—you are making me sick talking.”

  Before he left, the judge asked her, “Did you ever read the Sermon on the Mount?”

  “Yes,” Ms. Northern replied.

  “You remember one thing the Good Lord said?”

  “What?”

  “If thy eye offend thee—”

  “Oh, yes, take the eye out.”

  “—cast it out. If thy hand offend you, cut it off. Now, if and when your feet begin to offend you, maybe, maybe, you will remember that little verse.”

  The court decided that Ms. Northern was incompetent to make a rational decision and should have her feet amputated against her wishes. “On the subjects of death and amputation of her feet, her comprehension is blocked, blinded, or dimmed to the extent that she is incapable of recognizing facts which would be obvious to a person of normal perception,” the opinion read. “If [she] would assume and exercise her rightful control over her own destiny by stating that she prefers death to the loss of her feet, her wish would be respected … But because of her inability or unwillingness to recognize the actual condition of her feet, she is incompetent to make a rational decision.” However, because of complications, the surgery was never performed. Several months later she died as a result of a clot from her gangrenous leg that migrated to a vital organ.

  That afternoon I discussed the Perkins case with a member of the hospital ethics committee. “If you say he has decision-making capacity, then you have to say that he has the right of self-determination, even if you don’t agree with him,” he told me. “If he lacks decision-making capacity, you first go to a surrogate. If the surrogate is unwilling to act in the patient’s best interest, then courts have said that you have to do what’s in your power to prevent the patient from hurting himself. So it all depends on whether you think he has decision-making capacity or not.”

  I believed Mr. Perkins lacked capacity because he was unable to acknowledge that he had a serious disease or to understand the risks, benefits, and alternatives of treatment. However, there was no need for drastic measures. When I threatened to call security to keep him from leaving, he backed down. Though still refusing nursing checks and cardiac monitoring, he remained in his room overnight.

  When I went to see him the fo
llowing morning, his demeanor had changed. He was making laps around the unit with an orderly, still refusing telemetry monitoring, blood draws, vital sign checks, and medications, but now he seemed quite pleasant and reasonable. He told me he understood that he had a heart problem but that he wanted to go home and follow up with a cardiologist as an outpatient.

  It appeared to me that he had recovered decision-making capacity, and after seeing him, the psychiatrist agreed. Though still at risk, my patient had every right to sign out against medical advice. That is exactly what he did later that day.

  * * *

  I learned to make hard decisions those first few months as an attending, but the learning curve was steep. The pressure could be overwhelming at times because mistakes often had huge consequences, and fear of malpractice—and the resulting lawsuit—were lurking just under the surface of most of my and my colleagues’ dealings with patients. One morning I got a call from the emergency room. A young man—an intern, in fact, who had been on rounds on the wards—had been admitted with chest pains. Could I come to evaluate him?

  The ER that morning was the usual mess of drunks, druggies, and demented old ladies pretending to read The New Yorker. There were the usual pressured announcements overhead (“Linda, stat to the trauma bay … Linda”). Stretchers were arranged like latticework in the corridors, and the air was suffused with stale body odor. Searching for my patient, I ran into Joe Ricci, a jovial cardiologist who practiced in Howard Beach. Ricci was always impeccably dressed and, unlike most private practice doctors, never looked as if he was in a hurry. “How are things?” he said pleasantly. “Getting used to the place?”

  I said I was. In fact, I was quite enjoying my work and was finally starting to feel confident. Ricci brought up a mutual patient. “Sarah Brenner is doing very well,” he said. “I guess those drugs you’re pushing really do something.” I laughed. “By the way,” he said conspiratorially, “did you see the article in the Times about how doctors should work on Sundays? Ridiculous, isn’t it? They think we’re selling shoes.”

  When I found the intern, Zahid Talwar, he was sitting on the side of a gurney, legs dangling, looking bored. He was about thirty years old, a Pakistani man with a long face and a white coat who straightened up respectfully when I arrived. I introduced myself and asked him about the chest pain. It had started after dinner the night before and had lasted about ten minutes. He had slept comfortably, but the pain recurred while he was walking to the bus stop that morning, persisting for almost an hour. It was a dense pressure in the center of his chest. To be on the safe side, he had decided to leave rounds and come to the ER.

  His blood tests were normal, as was his first electrocardiogram. He had none of the traditional risk factors for heart disease, such as diabetes, hypertension, or a regular smoking habit. I suspected he was suffering from acute pericarditis, a usually benign inflammation of the membrane around the heart often treated with over-the-counter anti-inflammatory drugs. Characteristic of pericarditis, the pain worsened when he took a deep breath. I told him that if blood tests in six hours were normal, we would send him home. I joked there were easier ways to get out of internship duty.

  Later that morning I got a call from an ER physician informing me that my patient’s pain had resolved completely after he had taken ibuprofen, further confirming the diagnosis of pericarditis. For a moment I considered sending him home right then, but I decided to wait until the next set of blood tests was complete.

  Just before leaving the hospital that evening, I ran into a physician’s assistant. He told me that Zahid’s subsequent blood tests showed evidence of minor cardiac muscle damage. This took me by surprise. Pericarditis usually does not result in abnormal cardiac enzyme levels. I quickly explained that the problem was probably myopericarditis, in which inflammation of the surrounding membrane can partially involve the heart muscle. He asked me if the young doctor should have a cardiac catheterization to rule out coronary blockages. It was late; I told him that any workup could wait until morning. I assured him that a thirty-year-old with no risk factors did not have coronary artery disease. I instructed him to draw more enzymes and to order an echocardiogram and call me at home if there were problems.

  Zahid had chest pains through the night. Doctors who were called to see him attributed them to myopericarditis, the diagnosis I had written in the chart. At 2:00 a.m. he asked for more ibuprofen. “I told them, if it’s pericarditis, give me more medication,” he told me later. “Means, do whatever it takes to make the pain go away.”

  When I saw him in the morning, the pain had subsided. However, further blood tests showed evidence of continuing heart muscle injury, and an EKG showed nonspecific abnormalities. Though I still doubted that he had coronary disease, I sent him to the cardiac catheterization lab for an angiogram.

  I received a call from Rajiv about an hour later, asking me to come over to the lab. When I arrived, the angiogram was playing on a computer screen. It showed a complete blockage of the left anterior descending artery, the so-called widow-maker lesion. The artery looked like a lobster tail, unnaturally terminating after several centimeters. X-rays showed severe dysfunction of the entire anterior portion of the left ventricle. My patient had been having a full-blown heart attack, in which blood flow to the front part of his heart had entirely ceased, damaging the muscle, for more than twenty-four hours.

  Nurses were spinning in swivel chairs, impatiently waiting for Rajiv to start the stent procedure. I sat down on a stool, feeling weak. Even the beeping in the control room sounded like an admonition. Rajiv was wearing a lead apron, standing over my patient, who was lying on a narrow operating table behind X-ray-opaque glass. Rajiv stared at me for a few seconds, as if trying to gauge my reaction. “Arm the dye injector, please,” he called out to a nurse.

  “Done,” she replied.

  “Give me ten cc’s of dye for twenty seconds.”

  “Coming up.”

  “Can I have a three-millimeter stent?”

  “You got it.”

  And then, before I knew it, he had inflated a balloon and deployed the stent, restoring blood flow down the coronary artery. “All right, I’m done,” he announced.

  Afterward, heat rose to my face as colleagues wandered in to inquire about what was going on. I said little, other than that my patient’s symptoms had mimicked pericarditis. But what I was thinking was, You bastard, how could you have missed it? I was well aware of the disturbing prevalence of heart disease in South Asians, whose risk is up to four times that of other ethnic groups. I knew that heart attacks in this population frequently occurred in men under forty years of age, who often don’t exhibit classic coronary risk factors. I knew all this, but somehow my mind had suffered a block. So much for the expertise I had claimed with Mr. Perkins.

  “Don’t beat yourself up,” a colleague said sympathetically. “Every doctor I know would have done the same thing.” Another told me that it was his policy to “cath” almost anyone who came to the ER complaining of chest pains. In his opinion, the risks posed by routine coronary angiograms were much less than that of a missed heart attack.

  Rajiv came out of the procedure room and took me aside. “It could have happened to anybody,” he said quietly, “but now don’t try to justify it.”

  I started to blame the on-call fellow, who’d gotten information during the night to diagnose the myocardial infarction, but Rajiv stopped me. “It’s not his ass on the line,” he said. “That’s the difference now.”

  “I’m not sure I did anything wrong,” I replied weakly. “Even Andrew said anyone could have—”

  “Andrew thinks you fucked up, all right,” Rajiv snapped. “He’s just being nice. Look, it happened. Just admit you fucked up and don’t talk about it.”

  I looked through the glass at my patient, being wheeled out of the lab.

  “People love it when shit happens to somebody,” Rajiv explained. “This morning I had a stent complication. The patient was coding on the table. I was th
inking, Fuck, the patient is going to die, I’m going to feel bad, I’ll have to talk to the family, lawsuit, paperwork, et cetera, et cetera, but the fellows loved it. It’s like NASCAR races: they go round and round in a fucking circle, big deal. But when there’s an accident, everyone gets excited.”

  What now? I knew I had to explain myself, but how much should I say? I had made errors before, but never one this big—and only a short while on the job, too. Should I just tell my patient the facts? Should I apologize?

  Most doctors are afraid to take responsibility for medical errors. We are acutely aware of the potential hazards—legal and professional—of taking ownership of a mistake. In surveys most doctors say medical errors should be reported, but a large number don’t report their own, especially minor ones that do not cause disability or death. “Apologies are a means of being polite if you are seven years old,” a doctor wrote on Sermo, the physician online community. “But when you are in medical practice, it has little role in patient care. An apology says, when the smoke clears, ‘I’m too inexperienced to be doing what I did.’ And, whether we like it or not, that is precisely what patients, their attorneys, and juries hear.”

  Another doctor wrote: “The whole ‘apologize and hope it goes away’ thing is such a phony myth perpetuated by ethics types who don’t have to worry about career ruin in the lawyer gang-bang that is U.S. health care.” And another wrote: “It’s like confessing an extramarital affair to your spouse. What do you expect to accomplish?”

  However, studies have shown that physicians’ apologies do not necessarily increase malpractice lawsuits. In fact, they might protect against litigation. In surveys patients say they desire acknowledgment of even minor errors. For both moderate and severe mistakes, patients are significantly more likely to sue if a physician does not disclose the error, a fact most doctors are unaware of.

  There has been a trend toward such apologies. Twenty-nine states have enacted legislation encouraging them, some even making physicians’ expressions of remorse inadmissible in court. It wasn’t always this way. Hospital legal departments routinely used to advise doctors never to admit responsibility for errors. During my internship orientation, a lawyer for the hospital said that at some point in our careers every one of us would likely be sued, and that we could even be sued during residency. She offered some advice: document your decision-making; document when a patient refuses treatment; never admit wrongdoing; never talk to an opposing attorney; and finally, be nice to your patients. Doctors who were nice to their patients were rarely sued, even in cases of egregious malpractice.