Spotlight Case

1. Spotlight Case The ECG is Not Normal

2. Source and Credits • This presentation is based on the June 2011AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Abigail Zuger, MD, Columbia University • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • State how frequently physicians care for family or relatives • Describe the risks associated with caring for family members or relatives • Appreciate some of the steps hospitals take to prevent identification errors

4. Case: ECG Not Normal (Submitted by a respected senior physician at an academic medical center.) “My healthy and active 13-year-old daughter had a syncopal attack—she just passed out. This was the first time she had ever been sick. Her blood pressure and pulse were normal right after the event and she recovered quickly. I was a bit shaken up and because I was not sure of the cause, I took her to see her pediatrician. The pediatrician felt it was probably dehydration (my daughter is an athlete), but wanted an electrocardiogram (ECG).”

5. Case: ECG Not Normal (2) “The ECG was performed, and as we were leaving the office I asked the front desk clerk for a copy of the ECG. I think the clerk recognized me as a physician on staff and handed it to me. As I walked away, my heart nearly stopped. The ECG was not normal. My daughter’s ECG was not normal. The rate was 44 beats per minute, and the tracing met criteria for left ventricular hypertrophy.”

6. Case: ECG Not Normal (3) “My mind raced, filled with the worst diseases I could imagine. Syncope combined with an abnormal ECG is never a good combination. I immediately paged a pediatric cardiologist colleague. He responded by phone that the heart rate was too low even for an athletic child and she should get an echocardiogram and Holter monitoring. I panicked even further and couldn’t get the terrifying vision of my daughter frail, sick, and dying in a hospital bed out of my head.”

7. Background: MDs Caring for Relatives • Physicians often provide medical care to close relatives • In fact, this practice may be the single most common ethical violation committed in medicine • Most advisory bodies warn against this practice

8. Background: MDs Caring for Relatives (2) • In the 19th century, British physician Sir Thomas Percival wrote that doctors should depend on their colleagues to care for sick relatives, because “solicitude obscures the judgment” • The modern American Medical Association (AMA) states “Physicians generally should not treat themselves or members of their immediate families” See Notes for references.

9. Treating Family is Common • A community hospital survey found 97% of respondents had provided a medical service for a family member • Mainly free drug samples and prescriptions • At another hospital, 74% of physicians reported treating their own children for minor acute illness • Most cited “convenience” as the major reason for their care, as well as confidence in their own diagnostic skills See Notes for references.

10. Inappropriate Care for Family Members • In one study, 1/3 of physicians had observed a colleague become “inappropriately involved” in a family member’s care • Mainly vetoing indicated procedures or demanding unnecessary care • In a small study of pediatricians, doctors’ children saw their doctor less often and frequently later than optimal See Notes for references.

11. Risks Associated with Caring for Family • There are multiple potential risks • Unlikely to perform a full, intimate physical exam • May not take a full social history, including sexual history or substance abuse • May try to spare a relative from a painful procedure • Can become too involved in a case and unable to step back when necessary See Notes for reference.

12. Case (cont.): ECG Not Normal “I called my daughter’s pediatrician to ask for referrals and another appointment to see her later that day, telling the front desk that I was both a physician and the parent. The pediatrician hadn’t seen the ECG but she approved the referral, and we were able to get an appointment for the echocardiogram the same day (likely due to my position on staff). After the test, we returned to see the pediatrician.”

13. Case (cont.): ECG Not Normal (2) “I breathed an incredible sigh of relief as the echocardiogram turned out normal. The pediatrician reexamined my daughter and found her heart, lungs, and complete examination normal. We decided not to proceed with the Holter monitoring, and to allow my daughter to play soccer the next day.”

14. Case (cont.): ECG Not Normal (3) “The following week, I stopped by to see the pediatric cardiologist with whom I had spoken and showed him the ECG. He read it and felt that the slow heart rate and the other changes were actually normal for a healthy athletic 13-year-old. I was now feeling much better about everything.”

15. Case (cont.): ECG Not Normal (4) “He scanned the tracing into the medical record and emailed me a PDF. I was speaking with my wife later in the day and she wanted to see the ECG, as she had not seen it yet (she is not a physician). I emailed her a copy and she called me a minute later. ‘This is not her ECG. It’s an ECG from some 24-year-old male.’ I opened the file and sure enough—it was the ECG I looked at, but it was not my daughter’s. It was not her ECG at all. It would have been obvious to me had I looked at the name and noticed it was wrong. All of this was a mistake.”

16. Parent-Turned-Doctor • Saw a test result that made little sense • Rather than think through the usual possibilities (e.g., lab error, wrong patient), he acted chaotically, driven by fear

17. Safety in the Digital Hospital • Technology can lead to different types of errors. • For example, paper charts can take on their own “personality” that can help in identification • Compare thick, dog-eared volumes to thin crisp charts • Hospitals have taken many steps to prevent these errors

18. Error Prevention • Scannable patient wristbands can reduce errors at the time of medication administration • In most hospitals, only the medical records department can provide patients with any portion of their record, including individual test results See Notes for reference.

19. When You Love Too Much • This case highlights risks associated with caring too much for a patient • Contradicts other tenets in Medicine including the maxim of Sir Francis Peabody, “the secret of the care of the patient is in caring for the patient” • Physicians must balance too little love with too much—a difficult balance See Notes for reference.

20. Take-Home Points • Becoming professionally involved in a family member’s medical care is risky • Taking short-cuts around a hospital’s established policies is risky • When confronting bad news, whether for a patient or a relative, first make sure of the facts