Decision-Making in Hospitals
Daily Observer
Felix
Gautier was paying a political call. He
had decided to run for a place on the board of directors and was actually
trying to solicit a vote from Lapius. According to his calculations, that would add
up to two votes, because if S.Q. Lapius agreed,
Gautier figured I would go along also.
But when I entered Lapius’ study bearing the
coffee urn, I hear Gautier say darling to Lapius. Flattery will get him nowhere, I thought.
“Do
you use those endearing terms with everybody just to get votes?” I asked dryly as I set the urn on the mosaic
tile table.
“Don’t
be facetious, Harry,” Lapius reprimanded
sharply. “Gautier and I were discussing
the Darling case. A crucial
point for anybody trying to become a member of the hospital board.”
It
came back to me. The Darling case,
around 1965, was a legal decision that held the hospital in part responsible
for the efficacy of its medical staff. A
young athlete named Darling had suffered a fracture during a football game and
was brought to the local hospital. The
leg was set properly and placed in a plaster cast, and within a few days
gangrene set in. Since this was hidden
by the cast, and since because of a sick neighbor in the room the source of the
odor was misinterpreted, and because the boy’s complaints of pain were ascribed
to the fracture, a series of macabre events unfolded which led eventually to
amputation of the leg. The doctor was
sued and settled his case out of court.
Then the hospital was sued and the resulting decision found the
institution liable on several counts, one of which involved the competence of
the attending physician.
“It
is conceivable that I might vote for you, Gautier,” Lapius
told the lawyer. “I can’t see how you
would be better or worse than any board member, not one of whom is medically
trained, but before I decide, I want to know your interpretation of the Darling
case.”
“Well,
of course, Simon, that demands some thought.
I can’t come up with a snap decision.”
“The
devil you can’t. You certainly can’t
hope to gain my confidence by pussyfooting about important issues. The question, Gautier, is just how much
authority can the hospital exert over the medical staff? Where do you stand?”
“Frankly,
Simon, the Darling decision forces the board to take certain responsibilities
whether we want them or not. If we are
to be blamed for the malfeasance of doctors, then we have to regulate the
quality of the doctor who joins the staff.”
“But
if a hospital decides to accept this responsibility, then it will find itself
liable in every case that now is limited to the physician. Much depends on how the bylaws are
written. I would hope that you would opt
for bylaws that separate the physician responsibilities from hospital
responsibilities.”
“I
see your point, Simon. I think you may
be right. But who then is to regulate
the doctors?”
“Everybody
is trying to regulate the doctors. The
real question is who is going to regulate the board of directors. Who is going to insure that the hospital is
properly administered? There is no legal
mechanism at present for overseeing the day to day functioning of the hospital. Doctors, after all, are regulated by
licensure, specialty board accreditation, the heavy onus of legal liability,
which you as a lawyer, my dear Gautier, certainly should be familiar with, and
lastly, and perhaps most important, in tradition in medicine that goes back
5000 years. Show me anything resembling
that set or restrictions or credentials in medicine for any member of the board
of directors.”
“But
doctors make mistakes, vital mistakes, sometimes legal mistakes.”
“Of course
we do. We are faced with crucial
decisions every day. Disease strikes
rapidly, and our therapeutic choices produce their own risks. We have to make delicate decisions and try to
effect a balance between risk and benefit in a given
case. What everyone, including you,
Felix, seems to forget, is that it is the disease that kills, not necessarily
therapeutic failure. Who is going to
decide that a doctor made the wrong choice when in fact no choice might have
been effective? The
board of directors?”
“What do
you suggest?”
Lapius packed his pipe and lit it thoughtfully before
rendering a reply. “I believe doctors
should be allowed to discipline themselves as they have done in the past. And I think that the board of directors
should be especially concerned with the ecology of the hospital. It should assure that all services are
prompt, efficient, disciplined and compassionate. That’s a big enough job without getting into
the practice of medicine.”
“But aren’t
you always writing that the doctors should police the board?” Gautier asked pointedly. “How do you rationalize that if you want a
separation of responsibilities between the hospital and the medical staff?”
“The doctor
can’t practice good medicine in a poor setting.
The health of his patient is paramount, and it is up to the hospital,
come hell or high costs to provide that ecology.”
“Most hospitals
haven’t that kind of money.”
“That’s not
my concern,” Lapius said flatly. “It is the board’s problem.”
“Your
position is prejudiced and biased in favor of the physician, Simon. Can’t you see that?” Gautier was irritated.
“Of course
I am prejudiced and biased,” Lapius said calmly
puffing his pipe. “I am not about to
yield perogatives in medical matters to newly arrived
lay people who somehow vault to positions of power in the medical
hierarchy. When board members have to
pass educational prerequisites, and pursue a course of study for their
credentials, then we can sit down and talk as equals.”
“Let’s get
back to the initial point, Lapius,” Gautier said
tartly, “Will you vote for me?”
“For what?”
Lapius asked blandly.