1. Doctors Are Human…So…Why Worry?
Introduction
Here we are in the 21st century with the marvels of potent antibiotics, ‘smart bomb’
chemotherapy able to seek out and kill cancer cells, sophisticated (and expensive!) imaging like
MRI, but we still have the human beings (aka doctors) wielding these modalities. Therein lays a
major challenge because doctors are human. Why worry? As a retired internist who spent 38
years in the medical field (30 of those years followed completion of training) I can assure you
there is plenty of cause for concern. But, before you jump to the conclusion that this treatise is
an indictment of American medicine, let me state categorically that American medicine is
wonderful…but imperfect as practiced by imperfect human beings one of whom is me. I hope
that what follows will motivate you to become actively involved in your own medical care and
health maintenance as well as that of your family members. No one should be more interested
in an individual’s health than that individual. It follows then that the individual needs to be an
involved advocate for his or her best health interests, and that individual needs to
communicate that personal concern for health to their caring medical providers in a way that
demonstrates such interest. The medical providers and the patient need to become ‘team
players’ whose driving focus is the health and wellbeing of the patient. The patient then is a key
participant in the team function ideally. Providers perceive readily whether a patient is involved
or not by witnessing their own efforts at improving personal health, and providers are
encouraged by those patients showing motivation toward adopting healthier lifestyles.
Providers should also be challenged by those patients manifesting more personal interest in
their health and hopefully such providers will themselves do a better job of trying to optimize
such patient’s health care.
My Family’s Revealing Tales
My own family exemplifies some of the pitfalls of American medicine, and I share this not
because it is unique but because it is typical of the practice of medicine…remember we
physicians are imperfect at best. Get used to it because it is reality. Beginning with my paternal

2. grandmother in 1928 medical misadventure has happened. She was subjected to surgery
allegedly to remove a nonfunctioning kidney that was causing some sort of health problem.
Remember that 1928 was nearly 30 years before dialysis became available. I was told by her
widower in the 1950’s that she died of surgery because doctors removed the wrong kidney,
leaving her with a single nonfunctioning kidney which was incompatible then with life. Fast
forward more than 50 years and my brother who was critically burned and miraculously
survived from amazing medical/surgical triumphs of critical care. Nevertheless he wound up
with a fused knee due to unrecognized lingering infection in pinned bone while the medical
teams were preoccupied with trying to keep him alive dealing with overwhelming injuries
elsewhere over his body. At one point when the critical care team decided that bilateral hand
amputation was called for (and my brother was still comatose) my father intervened and
refused to allow the proposed amputation. Those ‘hands’ (grossly deformed as they are)
operate chain saws and perform activities of daily living…a huge advantage over prosthetic
limbs. In the 1980’s my father underwent operative orthopedic biopsy of a bone growth on a
rib. Less than 2 hours postop he was discovered to be seizing, unresponsive and blue
progressing to cardiopulmonary arrest. During CPR a portable chest X-ray showed both lungs
totally collapsed and his arterial pH was 6.8 (generally thought incompatible with life especially
in a 65 year old). It was later discovered that the anesthesiologist had punctured both lungs
doing regional anesthetic blocks for the biopsy procedure but he had not requested a postop
chest X-ray or written any special caution postop orders before he left the hospital for a golf
game appointment. Other than permanent vocal cord malfunction from the urgent (and
lifesaving) CPR treatment with traumatic intubation of the trachea (windpipe) my father
showed no apparent long-term sequelae from this catastrophic anesthetic complication. A
simple postop chest X-ray done before he was transferred from the recovery room to the open
ward would almost certainly have shown the abnormal air collection developing around the
lungs and led to standard measures of intervention which would have prevented the
catastrophic events which followed. In 1998 my mother was diagnosed with depression in the
setting of losing my father to cancer 3 years earlier. While prolongation of the normal grieving
process well beyond a common 6 months is not unusual it is incumbent on the provider team to

3. consider other treatable causes and screen for same. On a Friday I (living 500 miles distant from
her) was told about her situation and her internist’s plan to have her seen by a specialist in
consultation set up for 2 weeks later. Though I was busily immersed in my own medical practice
activities something about the information I received that Friday made me uncomfortable. I
picked up the phone and called a former colleague in training who practiced in the town in
which my mother resided. I asked him if he would do me a favor and see my mother in
consultation sooner than already planned by her internist. He agreed to work her in that next
Monday, hospitalized her Tuesday because of blood findings of kidney failure with extreme
hyperkalemia (high blood potassium) and by Wednesday had a diagnosis of a rare autoimmune
disorder requiring potent drug therapy. She went on to live nearly 3 years despite the severity
of the condition and the toxicity of the lifesaving drug therapy required. Had she not seen that
consultant that Monday she would most certainly have been dead later that same week from
the high potassium level which causes cardiac arrest terminally. Finally I share the vignette of
my elderly father-in-law who developed dizzy spells at age 90. Neither he nor his wife of almost
70 years had stayed with the superb thorough internist who was our personal physician, but
rather wanted someone easy going who would abide by their wishes to shun preventive health
measures and let them use their own home remedies in preference to applying the strength of
modern medicine. When my wife shared what their newly chosen doctor was doing to
evaluate his dizzy symptoms I commented that ambulatory monitoring to detect important
cardiac arrhythmias was in my judgment more likely to be productive than the host of
neurologic testing chosen by his physician. Some weeks later we stopped by their home on our
way out of town for a planned week vacation just to make sure all was in order for their
comfort and safety while we were gone. We noted a bloodstained handkerchief which led to
eliciting a history of a fall during the night. Exam of his scalp showed a gash which clearly
required several sutures for repair. I loaded him in my loaded car to drive to the local ER for his
laceration repair. As I was driving he stated that he was beginning to feel like he had earlier that
night before he had passed out and hit his head. I reached over to feel his pulse with my right
hand as I kept my left hand on the steering wheel. The pulse was strong and regular but the
rate was exactly 28 beats per minute…typical of complete heart block which I had dealt with

4. numerous times in elderly patients during my medical career. Needless to say we aborted our
planned vacation trip and he got his permanent pacemaker (and laceration repair) which
eliminated his dizzy spells.
The Right Stuff
As I stated at the outset my vignettes, while unique in details, are typical of what the rest of you
can expect as you go through life dealing with health challenges ministered to by the imperfect
personages personified by we doctors. How can we prepare for such challenges or help prevent
these adverse outcomes? Using the case histories shared above I offer the following insights.
For my grandmother in 1928 I can only speculate since I have no medical records to
corroborate or refute my family’s version of why she died. But unfortunately well-meaning
physicians in modern times still mistakenly operate on the wrong side rarely. One of my own
patients, a nurse, was the unwitting victim of an orthopedist’s mistake operating on the wrong
leg with poor outcome. Tell your physician before a planned operation that you want him or
her to be sure to operate on the correct side. This might sound trite or condescending but it is
your body and no one should be more interested in your body’s well-being than you! For my
brother I bear some of the guilt for not being more involved at the time. I was a very busy
primary care doc partner in a clinic at the time and was 500 miles from his hospital. I managed
to fly up every 1-2 weeks on weekends for part of a day spent in the critical care unit with his
caregiver team. His injuries were beyond your wildest imagination…the consequence of being
trapped in a burning vehicle for 10 minutes cooking such that he had burns up to 5th degree (I’d
been in practice 6 years then and did not even know there were burns worse than 3rd degree)
over 40 % of his body. The pin placed in proximity to a knee was to stabilize broken bones while
more pressing issues bearing on his very survival were addressed elsewhere throughout his
body. I did not pay attention to that pin and its wellbeing during those early months of his
prolonged critical care. Would he have had a fused knee if I had been more observant and
shared my concern with the staff then about possible long-term infectious complications of that
pin used for leg fracture management? I think about that whenever he skis with me now. For
my father what if I had taken the day off and flown up to be present when he had his rib biopsy

5. 500 miles from where I lived? Would that anesthesiologist have been more compulsive about
his post-procedure orders and care? But this was common elective surgery with minimal risk
under normal circumstances so why worry? Had there been a second opinion sought and
rendered, and if so did that consulting orthopedist agree that biopsy done under rib block
regional anesthesia was a better choice than using short-term general anesthesia? I will never
know but I can tell you that sticking a needle in the chest (which I have done numerous times to
drain fluid from the chest cavity) always carries with it the risk of penetrating lung tissue and
deflating a lung. Performing a rib block involves instilling anesthetic in the region of the
intercostal nerve which lies just under the lower edge of a rib and outside the lining of the chest
cavity. I suspect this anesthesiologist learned the hard way on my father to ALWAYS ALWAYS in
the future get a postop chest X-ray just to make sure a lung was not inadvertently punctured
during rib blocks. What about the situation with my mother…isn’t it true that physicians are not
supposed to provide medical care to their own relatives because they can’t be objective or
whatever? Well had I stayed out of the loop and ignored that nudge that for some reason made
me uncomfortable with her medical care she would have died that week of unrecognized
hyperkalemia due to renal failure due to polyarteritis nodosa. She was forever grateful that I
‘meddled’ in her care then and I would do it again if it’s the right thing to do regardless of so-
called ethics dictated by medical practice organizations preaching non-involvement in relatives’
medical care. In my father-in-law’s case I should have been more proactive and sent a note with
my wife to her dad’s doctor appointment stating my opinion that a cardiac origin to his dizzy
spells must be screened for and recommending ambulatory monitoring. Now admittedly
arrhythmias don’t always happen when the patient is wearing the ambulatory monitor but that
is no excuse for not using available technology to try to screen for same. Devices whose
recording memory loop is activated by the patient pressing a button when symptoms occur are
a vast improvement over the older 24 or 48 hour “holter monitor”. His doctor might have
ignored my written suggestion or chosen not to follow it but at least I would have been able to
rest assured that I had done what I felt was right on behalf of his health needs.

6. The Challenge for Physicians
Are you uneasy about American medicine yet or do you need more evidence than the foregoing
vignettes? Well relax…get used to it…and this kind of imperfection probably exists amongst
medical providers worldwide. “Why”, you ask asserting “but I thought physicians knew
everything and were perfect”. Stand in front of the mirror and ask yourself “is anyone perfect?”
Humanly speaking the simple straight forward answer should be apparent… “No!” But
physicians have increasingly been held to a standard of perfection that is unattainable in our
increasingly litigineous society. Medical malpractice insurance costs have prompted
conscientious talented physicians to eliminate some aspects of the field they were trained in
like obstetrical deliveries. The increasingly adversarial atmosphere surrounding the practicing
physician has been a major factor in driving physicians out of medicine and into other vocations
or early retirement. Significant depression and high suicide rates plague practicing physicians,
and these are a product of the stressful milieu in which physicians dwell and labor as imperfect
human beings. What a shame but reality is what it is and some things in life clearly are beyond
our control!
Hindsight Is 20/20
From the vignettes above you may have sensed some wrongdoing by some involved
physicians…be they areas of commission or acts of omission. Operating on the wrong side of
paired body structures is clearly an error of commission. Failing to recognize bone infection
until it has involved the knee joint to the point where knee fusion was the only reasonable
option was an act of omission. Penetrating the chest cavity bilaterally during attempted
intercostal regional block was an error of commission compounded by failure to get a follow-up
chest X-ray and write careful postop monitoring orders for possible respiratory distress
consequent to needle puncture of lung tissue…the latter were errors of omission. Failure to get
simple screening blood tests in the face of my mother’s spiraling apparent
depression/functional decline was an error of omission. Similarly ‘tunnel vision’ focus on my
father-in-law’s dizzy spells as likely of neurologic origin without considering possible cardiac
origin was an error of omission.

7. Physician Makeup Dissected
What is it in us physicians that lead us to commit errors of commission and errors of omission?
It is simply reality that although the legal system would seem to convey that doctors are
required to be perfect, we are in fact human beings with human frailties. Many of us are
obsessive compulsive perfectionist personality types…I included. That does not mean that we
are perfect but it does mean that many of us are our own worst critics. We seem to be so self-
critical that criticism levied from others is especially difficult to deal with. The adversarial legal
climate is one such potential outside source of criticism directed at our perceived quality of
practice. Medicare’s challenge of our submitted charge sheet for services rendered to a
Medicare-covered patient is another example of questioning our integrity by powers/agencies
beyond our control…an example of what many have come to refer to as the “hassle factor” in
medical practice. One of the areas of greatest difficulty is physician judgment in decision
making. There may be several correct actions to choose from but only one is the very best
choice, and we physicians are expected in our society to make the very best choice when it
comes to patient care actions and decisions. In reality we are human and we humans are not
always at our best in the application of judgment. We too have ‘off’ days. Sometimes personal
troubles (marriage, family, health, financial) crowd our minds. Sleep deprivation is no less
counterproductive to a practicing physician than it is to a commercial airline pilot. Both are
dealing with human lives in their care, but the pilot at least has several other sets of eyes and
ears in the cockpit to back him up whereas the physician is typically the ‘lone ranger’ in much of
medical practice decision making. None of my foregoing comments are intended to excuse
incompetence…they are designed to highlight the reality of our frailty. Did I personally ever

8. make errors of commission or omission? The answer to both is a resounding YES! Am I proud of
having made those errors? Of course not!! Were some of my patients injured as a result of my
errors? Yes. One of the most difficult things in medical practice was the need to be more than
one place at the same time which of course is humanly impossible but was expected as part of
clinical care responsibility. Did I get away with mistakes that never hurt the patient? Yes. One
example involved an elderly person a few weeks postop open heart surgery who had fluid
accumulation in the chest that needed to be drained. She was on blood thinners. The
procedure called thoracentesis was done in the sitting position using a large bore needle
through which a plastic catheter was threaded into the pooled fluid filling the chest cavity. After
infiltrating some local anesthetic I introduced the large bore needle into the chest cavity
returning serous (light yellow) colored chest fluid. Instead of advancing the catheter and
removing the needle I kept advancing the needle up to the hilt or about 2.5 inches. I then
realized as I was withdrawing fluid that the needle was waving dangerously close to the
pericardium surrounding the heart, and I promptly backed out the needle as I advanced the
catheter and completed the drainage procedure without complication. I have no explanation
for my breach of technique in that one thoracentesis out of perhaps 300 done in my career
except to admit that it was my human error of commission fortunately without complication.
Sobering Fallout of Physician Imperfection
How common are physician errors of omission or commission? The simple answer is that we
have no way of accurately answering that question, but they are probably much more common
than the frequency of plaintiff lawyer malpractice allegations would indicate. “To Err Is Human:

9. Building a Safer Health System” came out in late 1999 as the result of the “Quality of Health
Care in America” project. This effort was begun by the prestigious Institute of Medicine in 1998
to develop a strategy that would “result in a threshold improvement in quality over the next 10
years”. Fortunately a very large unknown number of errors produce no evidence of patient
injury, but credible estimates of medical errors with fatal outcomes range from 44,000 to as
high as 98,000. Placed in perspective more people die annually from medical errors than from
auto accidents, breast cancer or AIDS…clearly alarming and unacceptable statistics. More
recently the Health Grades Patient Safety in American Hospitals study found an average of
195,000 patients dying annually years 2000-2002 of potentially preventable in-hospital medical
errors. The Health Grades study finding of much higher mortality figures than the earlier
Institute of Medicine (IOM) study is certainly cause for concern, and the former may be more
accurate. The reason is that the IOM data extrapolated from just 3 states’ records while Health
Grades data was based on all 50 states’ records. A recent JAMA article reported nearly 225,000
deaths annually due to a wide variety of types of medical negligence. Notable was the figure of
106,000 dying annually from medication side effects alone. The foregoing are just mortality end
points, clearly easier to tally and identify than morbidity due to errors of omission or
commission. With all this increasingly common fallout of physician/health care provider errors
it is no wonder that more than 15 million lawsuits are filed each year.
Personal Testimony& Musings on the Problem
Unfortunately many such lawsuits are without merit or what has been termed “frivolous”. The
only time I was named in a malpractice action was 35 years ago when I was one of 4 physicians

10. named despite the fact that I was out of town until 3 days after the patient was admitted and
sustained in-hospital procedure injury from a diagnostic study ordered by another physician.
The reason I was named was that my name was all over the chart as I was the one responsible
for keeping him alive and stabilizing him until transfer several weeks later to a referral center
for further care. It was the policy of that notorious law firm to name everyone involved in the
patient’s care until nearly a year into the lawsuit when I was ‘let off’ by “summary judgment”.
My life was altered for nearly a year and unfairly so while at the same time the injured patient
deserved compensation from the physician involved in the procedure. There are no winners in
such a situation except for the plaintiff lawyer who typically is rewarded financially in
proportion to how high he/she sets their award goals. And for “pain and suffering” juries have
rendered judgment awards as high as $27 million dollars! An interesting finding in the Harvard
Medical Practice Study was that only one malpractice claim was filed for every eight negligent
medical injuries…thus most patients receiving negligent medical care are never compensated.
With all this unsettling data is it any wonder that we physicians have been coerced by an
adversarial system (plaintiff lawyers preying on physicians all of whom are imperfect) to
practice increasingly costly ‘defensive medicine’. Nobody has a good dollar handle on the added
cost of such ‘defensive medicine’ to the total US health care costs, but as one who lived within
that care provider plaintiff lawyer target zone for over 30 years I can assure you it is extremely
high…that is the utilization of diagnosis and treatment options solely to reduce the likelihood of
legal suit actions rather than solely to enhance the patient’s care. Given the adversarial
atmosphere fostered by imperfect human beings (doctors) making mistakes seized on by
plaintiff lawyers some of whom are piranha-like in their war on doctors, it is not surprising that

11. there is controversy whether and how to design tort reform. I will not try to flog that beaten
horse except to assert that 1) clear medical negligence with resulting injury/disease deserves to
be compensated fairly which implies 2) award caps on “pain and suffering” should be enacted
to rid us of the jackpot lottery approach fostered by current system, 3) frivolous lawsuits must
be discouraged and enacting “loser pays court and attorney fees” changes would be expected
to discourage meritless lawsuits and 4) plaintiff lawyers should be subject to censure for
naming physicians in a lawsuit action simply because those lawyers have not yet done their due
diligence to determine which physicians are uninvolved in committing medical negligence
before that lawyer draws up his ‘hit list’ of names specified in the suit filing.
Protective Action Steps for the Health Care Consumer
How can we strive to bridge the gap between expected physician perfection and reality? I
propose several actions some of which were already illustrated above. First when life-altering
therapy or diagnoses are raised by your physician retain the right to request a second opinion.
Make sure that second opinion is rendered by someone who is unrelated (i.e. not a partner in
practice) and who has no ‘kick-back’ arrangement (if you scratch my back I’ll scratch yours-type
coziness). In other words search for a situation where you are most likely to get the most
objective unbiased second opinion. Your medical insurer may or may not cover such second
opinion cost but don’t let that be a barrier to doing the right thing which is to get that second
opinion.
Second make sure you understand what your doctor is trying to tell you. If you don’t
understand stop the doctor in the middle of his or her speech and say so. A good physician
talking to a patient wants that patient to understand what is being communicated. We
physicians are prone to lapse into using verbiage common to us but foreign to non-medical
people, and we need to know from you when we are not making ourselves absolutely clear.
Sometimes taking a friend or relative with background in the health professions field with you

12. to sit in during an appointment is helpful in facilitating good understanding between the doctor
and the patient.
Third be honest with your doctor. So often patients desire to portray themselves to their
longtime doctor as doing just great as if saying so will build up the doctor’s sense of worth as
having worked wonders in enhancing the patient’s health through his or her efforts, prescribed
medicines or just plain good will. If you need to, take along your spouse or daughter or sibling
or trusted friend who can help you ‘tell it like it really is’ and not ‘sugar-coat’ your reported
state of well-being.
Fourth bring a written list of items to cover in your interaction with your doctor rather than
trying to rely on memory to cover all items important to you. Realize that your doctor may have
his or her ‘list’ of items important to cover in the scheduled visit requiring more time than
scheduled in order to cover both your list and their list adequately. This may require another
appointment to complete all.
Fifth become an active participant in your own health care. Remember it is your body and no
one should be more interested in the well-being of your own body than you personally. If your
doctor urges taking on healthier lifestyles do something about it! Educate yourself about why
he or she is advising such change, what the cost will be and what the anticipated benefits will
be. Remember your health care team is only as strong as its weakest link. Your doctor is not
God even if he or she seems to portray self as such. Knowledge is power but without
application it is like so much blowing in the wind. As a physician seeing my patients applying
what I suggested and seeing their quality of life improve was so rewarding. Furthermore that
tends to encourage a physician to strive even harder on the patient’s behalf. Yes…I know…treat
all patients equally or like you yourself would like to be treated. But the reality is we humans
thrive on success or positive results. We like to win. Sharing common goals and strivings with
other team members makes us feel good about ourselves and our efforts expended.
Sixth if you truly feel unable to communicate freely with your physician or feel uncomfortable
around your physician consider finding a new doctor. None of us are made to feel comfortable
sharing our deepest most personal thoughts and feelings with just any other human being. It

13. follows that some physician-patient combinations are just not the best for promoting best
patient health care. Recognize and accept this reality of human nature. Early in my practice
years I felt a sense of failure anytime a patient chose to transfer out of my practice to another
physician’s practice. Over time I learned the reality that we are all not necessarily made for one
another and came to accept such changes. Of course there were times when I learned to
change my approach to some patients to avoid offending or repelling them. It is true that we
can and should learn from our mistakes and doctors should not be exempt from that
responsibility.
Conclusion
So…why worry? Well I believe what I’ve shared provides insight into why you the patient should
be concerned when on the receiving end of medical care. Yet scripture in Philippians 4:6 reads
“Be anxious for nothing, but in everything by prayer and supplication, with thanksgiving, let
your requests be made known to God; and the peace of God, which surpasses all
understanding, will guard your hearts and minds through Christ Jesus.” Only Christ was perfect
in every way and through His death and resurrection our medical care provider sins of omission
and commission are forgiven even as the secular world holds us accountable. Together patients
and the physicians entrusted with their medical care can become a stronger team leading to
improved health care for all.
Ward B Buckingham,M.D.
wbbcab@comcast.net