Caveat Emptor

When Michael Hurewitz died at Mount Sinai Hospital last January, three days after donating part of his liver to his critically ill brother, Adam, the case made headlines. Blame was plentiful, and allegations of misconduct were leveled against the surgeon who failed to examine Hurewitz after the grueling operation, the doctor who approved his consumption of a lobster dinner even though his chart specified clear liquids (there was speculation of tainted shellfish when the autopsy indicated a bacterial infection), and the doctor who failed to take timely action when Hurewitz complained of nausea and began vomiting the blood that ultimately drowned him.

“Care was not optimal,” Mount Sinai’s then-president Barry Freedman conceded, and the state health commission concurred, fining the hospital and temporarily shuttering the live-donor transplant service. The state mandated new procedures and safeguards, and the unit is scheduled to reopen soon.

It’s true that under the best circumstances, and even with the most experienced staff and most attentive care, transplants are a risky business. But patients checking in for procedures far less dicey than a liver resectioning also have reason for concern. And a smart patient will want to be alert – even at a first-rate institution – to ways to prevent becoming a malpractice victim.

A recent study by the Washington, D.C.–based Institute of Medicine concluded that as many as 98,000 Americans die each year as a result of medical errors. In fact, the report says, more people die annually from such mistakes than from motor-vehicle accidents, breast cancer, or AIDS.

The temptation, of course, when things go wrong is to focus on the usual suspects: overzealous bean counters who order cost cuts, overextended medical personnel, and public enemy No. 1, managed care, which has decimated most hospitals’ unacknowledged fail-safe system. No longer are there what one doctor calls “staff redundancies” to catch problems like those on Mount Sinai’s transplant unit: the extra pair of eyes to check the chart, the non-sleep-deprived staff member who instinctively shadows the resident at the end of a tour of duty.

Well, not so fast with the witch hunt, says Michael Rothman, senior program officer at the Princeton, New Jersey–based Robert Wood Johnson Foundation. “You can’t blame HMOs,” he insists. “You can’t blame managed care, you can’t blame nursing cutbacks. Health care has always had quality problems.” Rothman sees the problem as systemic. Despite remarkable advances, medical care is uneven, and there’s always the chance that “you’ll get care that can’t possibly help you, you won’t get care that science knows can help you, or you’ll be injured or harmed by the care you receive.”

So how do you avoid being harmed even when you’ve entrusted yourself to one of the country’s premier hospitals and staffs? How do you make sure your X-rays aren’t flip-flopped on the O.R. light board, leading surgeons to operate on the wrong side of your brain, remove the wrong kidney, replace the wrong hip? How can you keep from getting the wrong medicine or the wrong dosage? How do you protect against a bad drug interaction?

“Assume that nothing is right,” Rothman cautions. “You really need to be on the lookout to make sure you get safe care.”

This could mean anything from refusing to be touched by health-care practitioners who don’t first wash their hands (“Infection is a really big problem, so this is important,” says Kathryn McDavitt, director of nursing practice at Mount Sinai) to, as one doctor puts it, “negotiating your way through the medical-center bureaucracy.”

“People should know there’s a hierarchy,” says Stephen Baum, chairman of internal medicine at Beth Israel. At a teaching hospital, there are generally five levels to that hierarchy: med students, first-year residents, senior residents, attending physicians, and consultants, and they should be so described on their identification badges. “Ask for an introduction,” says Baum. “If they have no hair on their heads and have a gray beard, like me, it may be fairly obvious, but otherwise ask.”

Ask a lot, but ask nicely, since that thing your mother told you about catching more flies with honey than with vinegar is absolutely true. “The simple rules of life work here,” says Robert Ascheim, an internist-cardiologist at New York–Presbyterian Hospital. “Patients who are obnoxious get treated less well.” Ask the practitioner who just came into your room to define her role in your treatment. If she’s a resident, ask, “Have you discussed this with the attending physician. Does he agree that this should be happening to me?” Ask the nurses and doctors whether they’re aware of your drug allergies and current prescriptions. If you’re moved to a different unit or ward, make sure the new floor staff has your pill protocol as well.

“Ask the surgeon, ‘What are you going to be doing?’ ” says Ascheim. “If he says, ‘I’m removing your kidney,’ ask which kidney, to make sure everyone’s clear.” And certainly get a second opinion if you question the set course of treatment. Several years ago, a friend woke up with intense abdominal pain that seemed to localize in what the doctors call “the lower right quadrant” – appendix alert. His doctor sent him to the emergency room, where he was examined, diagnosed with appendicitis, moved onto a gurney, and sedated for surgery. That’s when his mother-in-law showed up and insisted on a consultation with the head of surgery, who strode in, took one quick poke, announced, “It’s not appendicitis,” and walked away – leaving him to recover from a stomach virus but not an unnecessary operation.

“I learned a lesson I will never forget,”he says. “You have to be your own advocate.” (Or at least arrange to have the right mother-in-law.)

But while “be your own advocate” is perfectly fine advice, it’s often directed at those least able to follow it. Pre-surgery, patients are frightened and uncertain, perhaps in pain. You may not feel equal to the task of reciting your vitamin regimen, your medications (both prescription and over-the-counter), and your allergies to every doctor who happens by. Post-surgery, you’re often woozy, disoriented, and in pain, not in ideal shape to question the contents of the IV bag. One option is to deputize a family member or a detail-oriented friend. And you, or your deputy, should cultivate sympathetic staff members.

“It’s like anything else in the world,” says internist-oncologist Bernard Kruger. “Look around and make friends with a couple of people on the floor, and you know they’ll look out for you. Find a nurse or nurse’s aide and charm them a little bit. Bringing in a couple of dozen Krispy Kremes and handing them out to the staff never hurts.”

If you have the means, you might want to consider hiring a private duty nurse, particularly for the night immediately following surgery. But, say several doctors, paying the extra freight for a room in a VIP unit buys you little beyond better food. “It’s fine if there’s nothing further that can be done for you,” says one doctor, “but otherwise … “

Several years ago, a well-off 30-year-old divorcée who went to New York Hospital for a mastectomy decided to stay in the so-called Shah’s Pavilion. A few days after the surgery, a nurse showed up with a purple pill. “What’s this for?” asked the woman. “It’s your medicine.” “But yesterday you gave me a green pill.” A quick, nervous shuffling of papers, then an embarrassed “Uh-oh, you’re right. I’ll be right back with it.”

“You’re definitely not guaranteed better care in that part of a hospital,” says Baum. “We call it ‘terminal importance.’ If you reach a certain level of fame or importance, often medical care that might be given to others isn’t given to you because the staff might not want to invade your space or bother you.”

“If you’re having an elective procedure, you don’t want to get operated on at the end of the week, because not everyone is available on the weekend,” says an internist affiliated with a city hospital. “Stay out of the hospital in late June and early July, because the first-year interns start then.” Yes, those freshly minted med-school grads are backed up and supervised, “but,” says the internist, “even the supervisors are new in their roles.”

Of course, you often have no choice about the timing of the hospitalization. You’re sick, maybe you’ve been injured. But if you can’t control the timing, you can, in some instances, control the terms. Consider the fortyish woman who, on a snowy day a few winters ago, took a nasty spill in front of a Chinese restaurant. The owner called 911 and the woman was ferried to the E.R. at Roosevelt – where she lay in pain on a gurney for several hours, ignored by the staff. Finally, in desperation, she got someone to roll her to the pay phone. She called the police, explaining that someone was being held hostage at the hospital. Within minutes, the cops showed up. The woman was treated immediately. “Well,” says one doctor, “it is very important for a patient to speak up.”

Caveat Emptor