About malpraxis, with love

The title of this article for the Romanian Journal of Military Medicine, is inspired from the title of an American movie from 1967, ''To Sir with love'', starring Sidney Poitier in the lead role. Maybe some of you still remember it!... It is said that once, when school did not oscillate between ""variable concepts"" and ""palpable realities"", between protocols and procedures, a hydrogeology professor, in a practical work with his students, asked them if they knew the significance of the walnuts planted near the houses of the Romanian peasants. All the students were amazed by the question and kept silence. Nobody made any gesture. The professor knew that this would be the reaction of the students - because this was the answer to the following question: ""Why does the world need teachers?"" The professor answered the questions and taught the students, as much as a professor can teach, that ''a walnut needs plenty of water to grow and the roots of the walnut are very deep, and that is why houses that have walnut trees next to them will not have problems with dampness...'' This parable, as understood by our mind, aims on one hand to draw the reader’s attention to the fact that ""malpractice is defined as an improper or negligent treatment applied by a doctor to a patient, which causes the latter any kind of harm, in relation to the degree of damage of his physical and mental capacity"", according to DEX, and on the other hand to state that the ""WALNUT"" – that is, the Teacher, in the way he teaches his students will keep the ""house"" (i.e. the workplace) safe against possible future malpractice charges. And after all, malpractice can even be compared to dampness... for any professional organization. A superb allegory! I consider it a proper allegory and that is why I wanted to introduce it to you. I do not pretend to be an expert in the field of ""medical malpractice"" but being involved and exposed to it in my daily activities, I welcome some considerations on this topic, which I have found out from books, from the media, and also from journalistic practice. This article also wishes to draw attention of the medical community and to make it more aware of the responsibilities that we have when we dare to practice this noble profession. All of us – physicians, nurses, stretcher-bearers, technical staff – have civil liability (and here is the context of a possible allegation of medical malpractice), disciplinary liability (in the relationships we have as full members of our professional organizations) and criminal liability (most often as defendants, sometimes as investigated parties or as witnesses). I will present you several cases that have been the subject of disciplinary, civil and criminal investigations, all of them in the “urological filed”. Case 1 A 55-year-old patient is admitted in the Surgery Department for urgent mumps and blurred urine. Diagnosis at admission: ''Urinary infection. Prostate adenoma. Hematuria.” Diagnosis after three days since admission: ''Medium periurethral adenoma with urethral fistula microabs. Piohematuria. Urinary Infection."" Under antibiotic Gral (R) Prof DAN MISCHIANU Chief of Urology Clinic, Carol Davila University Central Emergency Military Hospital Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 6 treatment, the symptomatology improves and an open surgery is performed – with the patient's consent – practicing transvesical adenomectomy with favorable post-surgery progress. 14 days after surgery, the urinary incontinence at effort is detected, which subsequently worsens with the occurrence of episodes of urinary tract infection recorded on a posterior urethral stricture. Urethrotomy and TUR-P for remaining adenomatous tissue are performed within urological university department. The histopathological result revealed prosthetic adenocarcinoma microfocus and chronic urethritis. Unfortunately, the functional diagnosis is probative: High overall deficiency, Invalidity degree II. The patient's complaint was lodged against the surgery after which the patient was diagnosed with urinary incontinence that can only be cured by means of an artificial sphincter costing about 5,000 euros and retirement due to illness. The Superior Disciplinary Commission of the Romanian College of Physicians considered that the moment when surgery was performed and the surgical approach were inappropriate, therefore it decided to sanction the physician. [2] Case 2 The son of a patient lodges a complaint against his family physician for the unauthorized delay of the diagnosis of his father's renal carcinoma. The physician treated him for a year and six months for macroscopic hematuria and a so-called renal colic. After one year and 6 months, the patient is diagnosed with renal neoplasm, he goes through surgery and dies one year later. The Superior Discipline Commission analyzes the facts and notes the following: Hematuria is a diagnostic urgency and therefore its etiology needs to be confirmed as soon as possible by an urologist, the diagnosis of renal carcinoma is not the responsibility of the family doctor, therefore the applied sanction has remained in force. Case 3 This is a case distinct from the others due to a capital error. It involves a 74-year-old patient admitted in a Urology department and diagnosed with: prostate adenoma, complete urine retention, prostate litiation. Twenty-four hours after admission, the urologist intervenes and performs transvesic adenomyctomy. Immediate post-surgery progression is favorable with the subsequent occurrence of a third degree urinary incontinence. Two years after the surgery, the patient lodges a complaint against the doctor. The Territorial Discipline Committee ordered the action to be discontinued, but the patient filed an appeal with the Supreme Discipline Commission. The latter did not find any irregularities neither in terms of the technique used nor of the complication that has arisen, not even regarding the postsurgery treatment administered by the urologist, that is, Driptane. The lack of the informed consent from the patient's file was the only and actually the capital irregularity found, for which the physician was sanctioned. The medical deontology code in Romania is very clear: ""for any diagnostic or therapeutic medical intervention, the informed consent of the patient is necessary"". Moreover, the consent is given only after informing the patient about his/her diagnosis, prognosis, therapeutic alternatives, along with their risks and benefits. [2] Case 4 In the same spirit, there is also the case of a 39-year-old patient admitted in emergency with the diagnosis: right kidney colic. Two days after the admittance in hospital, surgery is performed: right pielolithotomy with internal drainage for calculus included in the right skin-ureteral junction and secondary uropionefrosis. The immediate post-operative progression was favorable up to the occurence of a cardio-respiratory stop during the first post-surgery night which was found to be irreversible. The cause of death was a massive pulmonary thromboembolism with probable causes either the lithotomy position, or more likely the presence of urinary sepsis. The Superior Discipline Commission decided to sanction the physician for the lack of informed consent, lack of anticoagulation therapy and poor post-surgery follow-up [2, 3] Case 5 The following is the case of a 54-year-old patient with a transient ischemic stroke, recently treated in a hospital from the country, where a Foley autostatic bladder ureter was mounted. From the patient’s personal history, we mention: type II diabetes, hypertension and ischemic heart disease. Approximately 8 (eight) days after urethro-bladder probe was mounted (according to the patient's report), physicians found the presence of an irreducible paraphimosis. Upon admission to the urology clinic, glandular necrosis, lack of local sensitivity, denuded penile body, penile scar tissue and necrosis, present at the base of the penis, free cutaneous mucous suture, skin remnants, cavernous body having an indurated appearance at palpation are found. The consultation of plastic and reparative surgery is entirely consistent with the urological clinical examination Vol. CXXII • No. 3/2019 • December • Romanian Journal of Military Medicine 7 performed. Figure 1: Preoperative aspect; the devitalization of the gland and the partially necrotic areas of the tegument can be seen Figure 2: Postoperative final aspect; ureteral bladder and definitive perineal urethrostoma A surgical intervention is performed, after the patient gave his written consent, consisting of the following: noncrectomy, lavage, double drainage both by the uretro - bladder probe and by suprapubic cistostomy. After limiting the infectious process, a new surgical intervention is performed consisting of definitive perineal urethrostomy and closure of the penile arch. Post-operative evolution is surgically favorable [4] The patient contacted the media, the criminal investigation organs, the territorial discipline commission, and is in charge of the Superior Discipline Commission. CONCLUSIONS We wanted to point out, against all inconsistencies, errors, mistakes and malpractice, which perhaps appear at first sight incriminating up to the contrary proof, that the presence during the professional training of a ''Teacher'' of a “Walnut'' absorbing all ''professional dampness'' is defining for the next years of professional maturity. In relation to all the exposed cases, some of them not so relevant anymore, others still ''incendiary'' on which the public opinion and the indigenous media keep a close eye, I believe this journalistic warning should give us all something to think about. The old Romanian saying teaches us: ""The good deed speaks for itself"", but here, in Romania, there is a new saying which has been quoted for about thirty years, in my opinion without any substantial background, which says: ""No good deed remains unpunished!"" However, I have the absolute conviction that although you have performed 10,000 perfect surgeries, if you make a mistake on your last day of surgical practice, that mistake will not be forgiven!