In the JAMA July 14 issue, one of the major themes covered was research articles and commentary on the Physician Peer Review process and its effectiveness. The medical peer review is the process by which a committee of physicians examines the work of a peer and determines whether the physician under review has met the accepted standards of care in rendering medical services. This process is put in place specifically to assure physicians that their statements will remain confidential when commenting on the behaviors of their colleagues (many of whom are a physician’s primary referral sources).

An original research study titled “Physicians’ Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues” found that overall, “…physicians support the professional commitment to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority; however, when faced with these situations, many do not report.

The study reported in JAMA was a questionnaire-based study sent to a randomized group of 3500 physicians in the fields of family practice, internal medicine, pediatrics, anesthesiology, cardiology, general surgery and psychiatry (excluding certain physician specialties and hospitals).  Some of the results in the report suggest:

• 64% of the total physicians that responded to the survey completely agreed that physicians should report all impaired or incompetent colleagues.
• Women were more likely than men to agree with that statement.
• Graduates from US medical schools were also more likely to agree with that statement when compared with non-US medical schools.
• Physicians were more likely, in university or medical schools, to report all impaired or incompetent colleagues when compared to solo or 2-person practices (the least likely to report).
• Among the specialties, anesthesiologists and psychiatrists were the most likely to be prepared to deal with impaired or incompetent colleagues and pediatricians were the least likely to feel prepared to report.
• Physicians practicing in medical school and university settings were significantly more likely to report than those in other practice settings.

While 64% of physicians, overall, reported being prepared to deal with colleagues who were incompetent in their medical practice, only 17% of physicians reported having knowledge of an impaired or competent colleague in or around their practice. Among the 17% that had knowledge, the most frequently cited reason for not reporting was the belief that someone else was taking care of the problem, that nothing would happen as a result, or simply, fear of retribution.

The study has not accounted for every reason that a physician may not report fellow physicians. For example, it is entirely plausible that a physician with knowledge of an impaired or incompetent colleague did not have reliable and accurate information to allege such an incompetency on their peer. Notwithstanding such shortcoming to the published research, the suggestion is clear: there needs to be stronger external regulation in the medical profession to ensure that internal regulations are working as expected. A commentary in the JAMA issue suggests that reporting systems should be better maintained to protect confidentiality and raise confidences among the physician community that real action and investigation will be taken when reports are made.

Professionalism dictates that physicians and physicians groups work together to establish the highest level of care a patient can receive. Patients also have a duty to make informed and educated decisions about physician choice. So, when considering a particular physician or a method of treatment recommended by a health care professional, be your own advocate by:

• Be an active participant in the decision process
• Speak out – ask questions and insist on well explained answers
• Insist that health care professionals speak with you in non-medical language so you may fully understand them
• Investigate physician credentials and experience
• Insist on background information from your physician
• Insist on knowing the physician’s level of experience in performing a given procedure or in treating a particular disease
• Ask your physician for research and information to better and fully inform you before you make decisions
• Seek 2nd opinions for any recommendations involving serious surgery or treatment

A recent study by the University of California at San Diego demonstrates that fatal medication errors rose 10 percent in July at teaching hospitals in the United States. This “July Effect,” doesn’t seem to mean that hospital staffs are running amok, but that more medication errors seem to be the culprit in teaching hospitals. The study investigated more than 62 million U.S. death certificates between 1976 and 2006. Of those, 244,388 deaths were caused by medication errors in hospitals such as dispensing the wrong medications, overdoses, and accidents involving drugs or biological agents.

The researchers examined certificates of inpatients, outpatients, and those who died in the emergency department, in which medication error was recorded as the primary cause of death. Counties containing teaching hospitals experienced a 10 percent rise in fatal medication errors in July, whereas counties lacking teaching hospitals did not experience that spike.

“There is something going on in teaching hospitals in July, and the most common thing people think of is residents starting,” said David Phillips, lead author of the study and professor of sociology at the University of California at San Diego. Phillips said that they were careful to rule out medication deaths caused by unexpected allergic reactions and didn’t include medication deaths that happened outside of the hospital, which might be the fault of the patient.

What is startling about the recent report on the “July Effect” is that doctors are well aware of the July troubles. “It doesn’t surprise me when you get new residents,” said Dr. David Orentlicher, a medical doctor and professor of law at Indiana University. “Residents are inexperienced, often sleep-deprived, working 36-hour shifts in many cases, and simply may need to learn the system at a new hospital,” added Dr. Orentlicher.

In recent years, doctors say that many teaching hospitals have offered better supervision of residents and new policies are being put into place to help prevent mistakes before they happen. Doctors are making sure residents are not sleep deprived when arriving to work. “There have been some improvements, but I think some of what this shows is the importance of having safeguards built into the system,” said Orentlicher.

Another study shows hospitals operate on the weekend with limited staffing or as some put it, “like they are a 7/11,” leading to an increase in deaths over the weekend in Intensive Care Units (ICU). The study demonstrates that on average, 8 percent of people admitted to ICU’s on weekends were more likely to die than people admitted during the week.

Dr. Paul E. Marik, a Norfolk, Virginia internist who helped conduct the study published in the journal, CHEST, says he sees reasons contributing to that should be very obvious:

• Low doctor- to- patient ratios.
• Difficulty obtaining necessary tests and therapies.
• Scant off -hour staffing.
• Other administrative problems.

New studies published in the 2008 Journal of the American Medical Association found that people who had heart attacks in the hospital during evenings and weekends were significantly less likely to survive than those who had heart attacks on weekdays. “Hospitals should operate on the same level during the day as at night and people should get the same level of care every day of the week,” said Dr. Marik.

The simplest way for patients to take care of themselves in a hospital is to ask questions and not be afraid to continue asking until you fully understand what you are being told. Don’t assume that a new doctor is familiar with your case; feel free to bring the new physician up-to-date. Verify that the doctors and nursing staff understand and confirm the medications they are giving to you and that they fully explain the purpose and the risks for each medication. Ask medical staff to satisfactorily explain to you what treatments are planned. By asking the hospital staff questions and insisting on full, understandable answers, can be the difference between a good or bad result.

Do not be afraid to go into a hospital in July, but don’t be afraid to ask questions and insist on answers, regardless of month or the day of the week it is. Remember, you are the “customer” and they are the “merchants”.

Regardless of our efforts to prevent injury and disease, inevitably we will require the services of a medical professional.  What is often overlooked is the important role of the patient in making sure the medical professional renders the very best of care.  This role is more important than we think.  For example, a 1999 study by the Institute of Medicine estimates that up to 98,000 people die in hospitals each year due to medical errors.  .  This exceeds the deaths from motor vehicle crashes, breast cancer and AIDS.

There was an excellent article on the CNN Health website advising patients to be proactive during a hospital stay to ensure that the very best care is received. The article suggests the following:

1.    Bring a list of the medications you are taking;
2.    Make sure the hospital gets your name right;
3.    Ask about every medication they give you;
4.    Make sure everyone washes their hands;
5.    If you think something’s wrong, don’t back down;

This is sage advice.  Many times, people admitted to a hospital feel helpless and confused and are hesitant to speak up when interacting with nurses and doctors.  We live in a culture that has for many years accepted the notion that what doctors say and do is not to be questioned.

Doctors are well regarded in our society, and for good reason. But let’s face it, no one knows your body and medical history like you do.  That is why it is very important to speak up when interacting with your medical providers.  One of the things that we see in our law practice is the failure of hospitals to properly document a patient’s medical history, which becomes very important in correlating medical events, management, lab & X-ray findings, etc. Like bad gossip, once a patient’s information is inaccurately recorded it ends up being passed on in that erroneous fashion, oftentimes taking on new twists and misinformation in the process. Fueling this problem is the transfer of data into computerized medical databases by non-medical personnel, like technicians and even I.T. staff, who are asked to take written patient questionnaires and type them into computer record systems. Thus, a good practice is to always ask to see what was recorded as your medical history in your medical chart before you leave a medical provider.

Even if a doctor or nurse responds defensively to questions or directions, a few awkward moments in a hospital room is a small price to pay for making sure you receive the very best of care.  The Joint Commission, which accredits hospitals, has embarked on an initiative to increase patient awareness and give patients more control over their medical care.  This initiative is called “Speak Up”.

The Joint Commission’s website provides excellent brochures in both English and Spanish that you can download free of charge. We encourage everyone, particularly patients, parents and caregivers to review these important materials. It just might end up saving your life or the life of someone you love.