“The initial orders were acceptable, though my choice of antibiotics might have been different. Her short course in the hospital was characterized by the nurse’s continued difficulty in reaching Polk for both routine and urgent matters. Polk discharged the patient prematurely, in only three days, and over the objection of the nurses and the family because she still had fever. Polk also failed to order follow-up x-rays.”
“We need to combine this record with MRN 190998, the readmission of the patient a week later in acute respiratory failure with a near whiteout on x-ray of both lungs because of the severity of the pneumonia. She barely made it, and may not have but for the heroic efforts of the pulmonary consultant, and nursing staff. I give both cases, nines on our scale. Any questions?”
Shaking the review sheets, Sharon complained, “If these cases don’t force you to a ten, Harvey, nothing will.”
Harvey ignored her comment and asked for other questions.
“Were there any notes by Joe suggesting he’d planned to see her soon for follow-up,” asked Brent Henry.
“Just a note saying that he planned routine follow-up, perfunctory. No details and no sign Joe appreciated the danger of discharging this patient home so soon,” Harvey said.
“The next case is MRN 190223 a thirty-seven-year-old accountant admitted with the diagnosis of fever and abdominal pain. Again, the H&P was impressive in size, but lacked much pertinent information. Joe ordered, what for the sake of kindness, I’ll call a complete workup. This poor guy, in the course of three days, had CT’s, ultrasonography, and tubes inserted into both ends of his digestive system. I’m surprised he survived. Polk eventually found a small ulcer on the back wall of his patient’s stomach.”
“When they called Joe on the fourth hospital day to report that the patient passed dark stools, he responded by altering the patients diet and reassuring the nurses who insisted his patient might be bleeding. Two days later, Joe ordered routine labs and discovered his patient’s hemoglobin decreased 50 percent from its admission value. He then ordered transfusion and refused all suggestions of GI follow-up or more aggressive treatment. Finally, when the nurses threatened to call the chief of medicine, Polk relented and asked Ken Peters to consult. This patient subsequently did well after aggressive treatment. I give this case a seven out of ten. Any questions?”
“What was he thinking?” Jim McDonald asked. “Were any of his progress notes relevant?”
“The notes were copious and mostly irrelevant,” Harvey said. “I’m speculating he thinks filling the chart with notes discharges his responsibilities.”
“Those were the biggies as far as I’m concerned,” Harvey said, shaking his head. “Review of the remainder of the charts given to me shows similar patterns of shoddy evaluation and treatment, and confrontation with the nurses. There were no significant adverse outcomes.”
“That raises an important issue for me,” I said. “I know we are looking primarily at how well a patient does, but shouldn’t we be looking at the process of caring for patients as well? Maybe this is too much tonight, but as it stands, we can look at a chart and see every variety of screw-up, and if the patient survives or is lucky enough to avoid a major complication, we do nothing.”
“You’re right Jack” Arnie said, “and we will need to deal with this but not tonight. Our cup already runneth over.”
“Let Alan present his cases, then we’ll take a break and begin a more general discussion,” said Arnie.
“I reviewed sixteen of Joe’s cases,” Alan Morris said, “and found major problems with three. The thirteen other cases, in my opinion, show similar problems to those noted by Harvey. Specifically, this includes sloppy work, inadequate availability, and conflict with nursing staff.”
He continued, “The first case is a seventy-eight-year-old female whom most of you knew well, Loretta Harrington, former Director of Volunteer Services at Brier Hospital. She had been in remarkably good health and Polk admitted her in early March with confusion and dehydration. Joe’s workup was unfocused. He ordered nearly every test in the lab syllabus. In my opinion, he had no idea about what happened to the patient or why. His treatment plan only made things worse.”
“In brief, this is what happened: when the patient was admitted, she showed marked abnormalities of her chemistries because of dehydration and kidney failure. She’d been eating poorly at home so Joe had the family pushing high caloric liquid meals. He failed to stress the importance of drinking enough water while receiving these supplements. Accordingly, she became dehydrated. This made her mild kidney failure much worse. Rehydration with water and control of how they should have administered the supplements would have corrected these abnormalities. Joe did neither, in fact he continued the full strength supplements and tried incorrectly to rehydrate her with salt solution, eventually throwing her into congestive heart failure. She never recovered.”
Alan paused a moment, searching for the right words. “I know these chart reviews are supposed to be impassive, impersonal and strictly professional, but after reading this chart and talking with nurses, and seeing the outcome, it pisses me off that something like this could happen at Brier. Once the patient developed heart failure, Joe began treating her expectantly, and incorrectly, as if Loretta had no hope of survival. Polk’s conversations with the family, overheard by nurses at the bedside, were all directive in character, that is, mom was old and sick, and further treatment would be inappropriate, useless, and cruel. I give this case a ten, hell, I’d give it a twenty, if I could, both in terms of poor practice, but also about Polk’s deliberate and calculated misleading of the family into a wrong decision to terminate care. I’d say this would be a bury-our-mistakes case, except I don’t believe Joe thought he’d made any mistakes.”
An ominous stillness filled the room. Everyone verged on comment, but no one wanted to be first.
Sharon showed an uncharacteristic reserve. “How could behavior like this have been going on all this time while we were unaware?”
“Unaware,” Brian Daly said, “how could we be unaware? These cases have been coming here for years. The nurses have done everything but drawn us pictures. Suggesting we were unaware would be self-delusion on a grand scale. We knew, or should have known, and chose to do nothing. Patients and our staff have paid the price for tolerating this kind of behavior. God only knows the true cost.”
Arnie raised his hands in a stop gesture. “Let’s try to hold the more general discussion until Alan finishes his cases.”
“I know how many of you feel,” Alan said. “It upset me to review these charts. Each had me shaking my head, becoming more angry, more disappointed. We permitted this to happen.”
As there were no other questions, Alan continued.
“The next case is a thirty-three-year-old flight attendant admitted last May with a heart attack. Here the H&P reached the level of fantasy. Nurses’ notes and the cardiology consultation reflect a more accurate description of the events leading up to this young woman’s hospitalization.
“She was a health nut. Diet and exercise were an intrinsic part of her daily life. She noticed a decline in exercise tolerance about three or four months before admission and noted jaw and back pain that she attributed to stress. She reported her symptoms to Joe Polk who did a brief examination and reassured her. When her symptoms persisted, she returned to see Polk, this time insisting on an EKG, a cardiogram, that he read as normal. I’ll return to that in a moment.
“About a week before hospitalization, she began complaining of an irregular heartbeat and a sense of sudden fatigue while exercising. On the morning of admission, while on her way to work, she suddenly developed crushing chest pain radiating to the neck and back, and collapsed in the airport.
“Admitting EKG and blood tests were classical for a massive heart attack. As if things were not bad enough, Polk refused to follow the recommended Coronary Care Unit protocols for monitoring and treatment of a heart attack. He refused cardiology consultation, though her
heart rhythm problems were complex and well beyond his capabilities, until the nurses brought Warren into the case and he asked Sharon’s partner, Rick Adams, to see her in consultation. Review of the earlier office EKG revealed abnormalities; clear signs of insufficient blood flow to her heart muscle.”
Alan paused for a moment, and then continued, “The care this patient received is an outrage. This physician is obstinate and unwilling to take advice or seek assistance. None of this behavior is new, and I conclude they are intractable. Joe, to be sure, is not a stupid man, so what explains his cognitive failures here, misreading of the EKG and failure to appreciate highly suggestive symptoms of coronary artery disease. I don’t know the answer, but this is another case that rates a ten.”
“What does his office chart on this patient reveal about Joe’s thinking?” Edith Keller asked.
Alan shook his head. “Joe initially refused to give us her records, saying we had no right to his private office chart. However, with a signed release of records form from the patient, and a won’t-take-no attitude, we eventually obtained the chart and the abnormal EKG, but not much else.”
“Last, but not least, is the third case,” Alan continued. “This case came to our attention via nursing administration who lodged a specific complaint against Polk, Medical Record Number 190201.”
“This case involved a forty-five-year-old man admitted in August with an abdomen swollen with fluid to the size of a full term pregnancy. It had reached the point where he could not breathe because of pressure of this fluid on his diaphragms. While in the review of this case I found many objectionable actions by Dr. Polk, I want to focus on the one that precipitated the referral.
“On August third, Polk performed an abdominal paracentesis. He left the procedure in the hands of an inexperienced nurse, departed from the hospital, and they could not reach him when his patient began to deteriorate. This enraged Mary Oakes that Polk could leave any nurse, especially a new graduate, in a dangerous situation or one for which she had no training or experience. While she tried in vain to reach Polk, the patient suddenly went into shock requiring a full-blown resuscitation and transfer to ICU. Fortunately, he survived. When Mary finally reached Joe Polk three hours later, he said, “I don’t know what you people are making such a big fuss about. Everything was fine when I left.
“Polk’s response stunned Mary. He totally failed to understand the consequences of his action on his patient and on this young nurse.”
“I give this case a ten,” Harvey said. “Any questions?”
“He left the hospital without telling anybody?” Jim Mc Donald asked.
“Not only did he leave, the ward couldn’t reach him for at least three hours,” Harvey said.
Arnie looked across the room. “I’m going to have Jack briefly present another case, and then we’ll take a break and open this meeting for general discussion.”
I began, “Warren asked me to see Helen Martin, twice. The nurses’ concerns about her care initiated each request. Their actions were more than justified. The first instance involved failure of Polk to consider the obvious diagnosis of primary peritonitis, and the second with his failure to recognize and aggressively treat her hepatic coma and active GI bleeding. Additionally, he administered toxic doses of Neomycin resulting in hearing loss and vestibular toxicity. The level of care in both these instances is far below any reasonable standard we should allow in this institution. Both cases rate tens.”
The realities presented may have been more than anyone could absorb in one sitting. For the first time anybody could recall, the committee members were speechless as they rose for their break.
Chapter Thirty
At the break, I took the opportunity to make a few phone calls to check on my sickest patients in ICU, especially Carrie Palmer. For the moment, everyone was stable.
Committee members stood in the hallway chatting quietly. Hushed discussion replaced the usual boisterous and cheerful atmosphere. The presentations had been sobering, and even those who were less committed to the QA process knew that this was serious business. When they re-entered the boardroom and returned to their positions around the table, their discomfort was obvious as they avoided eye contact.
Arnie looked slowly around the room making sure he had everyone’s attention, “We will hear from each of you, first on the cases and secondly on disciplinary recommendations to the Medical Executive Board. We need to approach this discussion methodically.
“Though we’ve uncovered problems with many cases reviewed, I’d like to confine our discussion to the seven problematic ones we heard tonight. We can discuss each in detail and try for consensus on the grading of each case or we can enter a more general discussion regarding this physician’s practice and what disciplinary action may be appropriate. Without objection, we’ll go on with the general discussion.”
Indicating to his left, Arnie said, “Let’s move around the room starting with you, Sharon.”
The group girded itself for one of Sharon’s trademark intemperate outbursts. She sat quietly for a moment considering her response and then began slowly, her voice so soft that listeners had to attend to each word. “I have strong feelings about this doctor and the cases we’ve heard. The number and the severity of practice problems we’ve seen show that our QA system is broken. Any one of these cases, in my opinion, would warrant immediate dismissal of Joseph Polk from the medical staff. So many cases over a prolonged period of time show that we’ve failed ourselves and our patients.”
Harvey Ross came next. “On a personal basis, I’m having great difficulty with these cases and this doctor. While I agree with Sharon, the facts trouble me. I’ve known Joe Polk for twenty-five years and I respect him as a colleague and ardent supporter of the hospital and medical community. I reviewed these charts in detail and frankly, I don’t recognize Joe Polk as the doctor responsible for all this dreadful behavior. I’m certain that this was not happening during his entire tenure. Is it possible that this physician is somehow impaired? Maybe it’s drugs, alcohol, early Alzheimer’s, or a psych problem. I can’t excuse what he’s done, but there may be mitigating circumstances.”
Phil Banks with measured tones began, “No one hearing what we’ve heard tonight could fail to be troubled, but we’ve only heard one side. Joe’s offensive behavior with the nursing staff has not won him accolades. We must consider the possibility of bias in some of these reports. We can’t condone his dysfunctional relationship with nurses, but that alone doesn’t justify severe disciplinary action as some have suggested.”
Several looks of disbelief followed these last comments.
“You have to be kidding…,” Sharon began, but Arnie promptly intervened, “Put a lid on it, Sharon, we’ll open this for full discussion after everyone has had a say.”
Several members made brief comments supportive of the concerns already expressed.
When her turn came, Edith Keller, in a hesitant, but determined voice, said, “I can’t get over the terrifying thought these practices have been going on in this community and in this hospital for some time, and we did nothing. That I may have participated in enabling these actions fills me with shame and self-doubt. I, for one, will not tolerate this behavior for one second more.”
After a long pause, Alan Morris and then Jack Mc Donald expressed their agreement with most of what they heard. They dismissed the idea that bias played any significant part in the concerns expressed by the nurses.
I’d been mentally rehearsing my comments throughout the discussion. Each time my thoughts changed a bit so when my turn came, I had no choice but to abandon any planned statement and speak my mind.
I took a sip of ice water for my dry mouth. “Like many of you, I come from a tradition that not only permits criticism of physicians’ practice, but virtually demands it. I’m new here and frankly did not know how this approach would fly in a private community hospital. No new doc, especially a consultant, wants to make enemies in a place where he’s seeking accept
ance, but I don’t see how I can ignore what we’ve seen here. Helen Martin might be dead if it hadn’t been for Warren’s intervention. As it stands, she may have sustained permanent hearing loss through the misuse of Neomycin. Dr. Polk has exhausted any right to practice medicine in this community or anywhere else.”
Several more members briefly agreed.
Jim Mc Donald, next around the table, began, “I agree with everything said thus far tonight, but I’m willing to consider that Joe is somehow impaired. He’s always been a hard ass, smarter than anyone else, and never asking for help, but I never got the impression he didn’t care about the welfare of his patients. These cases undeniably expose gross failure in practice and total indifference to the people who trusted him.”
The rotation returned to Arnie Roth who went on, “Impaired or not, I hear a consensus that we cannot permit Joe Polk to practice at this institution. Logically, there are only two ways to go. We can suspend his privileges and proceed with permanently removing him from the medical staff or second, we can continue severe practice restrictions requiring a consultant on all his cases and referring him to the Committee for the Welfare of Physicians, where they can explore the issue of impairment. This investigation might prove interesting.”
Arnie glanced around the room. “I’ll open the floor for discussion,”
Harvey began. “Throwing Joe off the staff might be the most emotionally satisfying approach to fix this situation, but I’m not sure it’s the best way. We can fulfill our responsibilities to protect patients by imposing severe practice limitations and retain ultimate action until we clarify things.”
Joe Banks immediately added, “Loss of all hospital privileges is too extreme for my taste. First, we owe something to Joe. Second, he may be getting a bad rap from the nurses, and third, if the guy’s impaired, don’t we owe it to him and maybe to ourselves in the future, to deal constructively with his problems?”
First, Do No Harm (Brier Hospital Series Book 1) Page 19
