I've just finished reviewing another maddening deposition. This one is from an academician trained in Connecticut at a school that rhymes with “fail.” Although he happens to be a plaintiff witness, that side of the aisle has no monopoly on such ivory-towered experts. In this testimony, the “expert” claimed emphatically that there were no acceptable obstacles to getting specialty consultations, MRI, MRA, carotid doppler, and CT angiogram 24/7/365 anywhere in the country, including the small-town community hospital in question. Of course his experience practicing emergency medicine in such a community was nil, or he would not have made such a rash, ridiculous statement.
Another expert in the same case, also an academician, claimed that the emergency physician at the same community hospital “should have called the stroke team,” and he would have gotten all the high-tech aid he could have wanted. Mind you, this is in a hospital lucky to have anything beyond the most basic specialty backup. In both cases, these guys were as serious as a heart attack. Subsequent questioning confirmed that this was not a misquote. They were really that far out of touch that they believed what they said.
Both had sterling academic credentials, a fact that I'm afraid would impress some jurors. Neither had a clue about the standard of care at the community hospital about which they were testifying.
I'm afraid that many of our most decorated academics, most of whom have never set foot in a hospital without residents and 24-hour availability of a pediatric otolaryngologist, are being used as “emergency medicine experts” in cases from an environment as foreign to them as a developing nation. And not only is their testimony being used to indict the average EP who is out there practicing in the real-life hospitals that treat the vast majority of Americans, their reach can extend way beyond review and opinions in a given case when their book chapters and other academic writings are quoted.
Much of the literature is full of statements that are absurd to the average practicing EP. Textbooks that state “every female with abdominal pain needs a pelvic exam,” and “every male with abdominal pain requires a scrotal and rectal exam” are two of my favorites. Try that out in the suburbs or rural America, and see how long you last.
Fact is, the vast majority of emergency patients (and all kind of patients, for that matter) do not present to gilded university hospitals with Professor Emergency Physician, his posse of house staff and students, and his extensive list of publications. In fact, with necessarily much less actual clinical time than his counterpart out in “the real world,” Professor EP is likely to be less of a diagnostician than his country cousin. It's a fact of life that none of us is great at everything. A great lecturer is seldom a great bench researcher is seldom a great administrator is seldom a great clinician is seldom a great author. Any of us who can claim two of the above is an outright star. (I'm certainly not in that class.) Yet are we to use his pronouncements as standard of care? I think not.
It is extremely important that experts on either side of a medical malpractice case be an expert with years of practice in an environment similar to the one where the alleged wrong was committed. Same region, same hospital type, similar payor mix.
Anyone who tries to argue that there is a single standard of care in every ED in America is by definition naïve. Huge diversity exists out there, by region, by hospital type, and by payor mix. It is incumbent on us to coach our legal eagles to expose those witnesses who are ill-suited. We'd best call our textbook authors on those same absolutes that don't translate to reality, or they may come back to bite us later.
To our academics of the highest stations, don't get fooled by everyone's praises that you are God's gift to emergency medicine. We are grateful for your many achievements, but a measure of humility is due. The actual clinical practice of emergency medicine has improved dramatically with the experience of large numbers of patients treated, and when you are lecturing, researching, writing, and administering, you necessarily are not seeing patients. As your spouses can attest, you put on your pants one leg at a time like the rest of us. Heck, you might even be the last one I want to look up and see hovering over me when I need a good clinician.
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Dr. Hossfeld is an assistant professor of emergency medicine at the University of Illinois-Chicago. He is a past president of the Illinois College of Emergency Physicians, and has been involved in the legal side of emergency medicine for more than 25 years. A collection of his columns is available on the EMN web site: http://bit.ly/GHossfeld.
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