PUBLIC DECLARATION REGARDING

SCRIPPS CLINIC, GREEN HOSPITAL, LA JOLLA, CALIFORNIA

Laura Walther Nathanson M.D., F. A. A. P.

This Declaration arises from events that occurred at Scripps Clinic, Green Hospital, La Jolla, CA prior to the death of my husband, Charles (“Chuck”) Nathanson in June, 2003. 

No fewer than nine doctors in five Scripps Clinic departments were involved in fundamental lapses that led to a two-year delay in Chuck’s receiving an accurate diagnosis. By that time, his potentially curable cancer required such intensive chemotherapy and radiation, and such extensive surgery, that the treatment killed him. 

My worry is, and has been, that these lapses stemmed from policies at Scripps Clinic—not just from missteps of individual physicians. That is, that the Scripps Clinic Administration either mandates or condones practices that are below professional and/or community standards. I have every reason to believe that the same harmful policies that prevailed then remain in place, and that the same lapses repeat themselves over and over, placing the health and wellbeing of patients at unnecessary risk.

I have concluded that neither the Administration, the Departments, nor the individual physicians involved are willing or able to confront these below-standard practices. It is a sad commentary on the integrity of the institution that it has failed to take responsible steps to change these policies. 

The only possible solution, it seems to me, is for patients to take on the task of policy change themselves. If you are a patient at Scripps Clinic or Green Hospital, you must learn exactly what risks you run, and how to protect yourself and your loved ones. That is why I am including in this Declaration the names of individual doctors and links to the documents that support my concerns. 

My major concerns are with the following Scripps policies:

It is Scripps Clinic Department of Radiology policy for their specialists NOT to interpret abnormal chest x-rays and mammograms. Instead, they have instituted a policy called “MAFI.” Under this policy, radiologists merely code these abnormal studies with a “1”, which purportedly alerts the ordering (clinical) physician to the fact that the x-ray is in some way abnormal. 

Exactly what aspects are abnormal, what that implies, and how to evaluate further are all entirely the responsibility of the ordering physician—Internist, Pediatrician, Gynecologist, and so on. 

These non-radiologist physicians have neither the training nor the experience to perform as radiologists. Moreover, these physicians appear to be unaware that this responsibility has been placed upon them. 

The MAFI situation is documented here.

It is Scripps Clinic policy to require or to allow physicians to assume responsibilities for patient care in areas in which they have NO Board-Certified competence.  

Medical students and doctors-in-training are permitted to take on the sophisticated task of diagnosis without supervision: as shown here.

Specialists can be assigned to work outside their area of specialty. For instance, a specialist in diseases of the blood (Hematologist) can be assigned by the Oncology Department to diagnose and treat a patient with a solid tumor, despite having no specialist training in that area, as shown here.

Patients with rare and life-threatening diseases may not be referred to the centers most likely to save them, as shown here.

It is Scripps Clinic policy to allow physicians to fall back prematurely upon what is known as a “Diagnosis of Exclusion.” A Diagnosis of Exclusion is an unproven diagnosis – a fancy way of saying, “We really don’t know what is wrong with the patient.”  

Such a diagnosis ought to be reached only after serious possibilities, such as malignancy, actually have been excluded.  To make such a diagnosis WITHOUT EXCLUDING malignancy or other dire possibility is a betrayal of medical ethics, as well as a betrayal of the patient. This class of error may be particularly likely to occur when physicians assume responsibility for patient care in areas beyond their training and experience. 

See examples here.

This public declaration is a last resort following nearly five years of conflict with Scripps Clinic administrators, as illustrated here. At no time have they acknowledged that, as a physician myself, I have a serious and legitimate interest in making sure that the care patients receive meets at least the community standard for quality. As they stand now, these policies fall well below both the “Guidelines” of the Specialty Boards, and the standards of the larger San Diego Medical Community.

While individual Scripps Clinic physicians may practice at or above standard of care in these areas, they must do so on their own initiative, creating their own culture of quality care within the larger institution. 

The administrators and physicians involved in Chuck’s case and in my attempts to improve the standard of care at Scripps Clinic include:

Administrators:

Christopher Van Gorder, President/CEO, Scripps Health Care
Larry Harrison, Scripps Clinic CEO
Brent Eastman, M.D., Chief Medical Officer, Scripps Clinic
Robert Sarnoff, President, Scripps Clinic Medical Group
Frank Panarisi, Member of Scripps Healthcare Board
Barton H. Hegeler, Attorney at Low, representing Scripps Clinic

Physicians:

Vivian Terkel, M.D., Internist
Michael Lloyd, M.D., First year Resident in Internal Medicine (January, 2000)
Douglas Triffon, M.D., Cardiologist
Merri Mc Mahon, Cardiologist
Walter B. Goff, D. O., Radiologist
Jacqueline Chang, M.D., Pulmonologist
Max Elliott, M.D., Pathologist
Michael T. Hopkins, Fellow in Oncology
William Miller, M.D., Hematologist

As a final attempt, I wrote this letter on August 18, 2007, once again urging investigation and change. Two of the physicians responded:

Vivian Terkel, M.D., Internist, wrote this  to express her sympathy and to confirm my suspicion that it was indeed the MAFI system that  “prevented” the clinical physicians from recognizing the tumor on Chuck’s chest x-ray.  Apparently, none of them realized that the quality and content radiologist’s interpretation was far below standard, nor that the Scripps Clinic system requires the ordering physicians to interpret their own chest x-rays (and mammograms) once they are designated “Code 1.” At Chuck’s follow-up visit,  here, Dr. Terkel does not even mention a chest x-ray. Both in her chart notes and in her letter, she seems to be unaware that the most important job of Chuck’s physicians was to rule out malignancy. She only confesses to having “worried” about him, as if she had no professional responsibility.

Max Elliott, M.D, Pathologist, wrote this to inform me of his strong view that Chuck’s diagnosis of Malignant Thymoma was an error. Dr. Elliott insists that his own diagnosis of Cancer of Unknown Primary Site was in fact correct, and that both Vanderbilt Cancer Center and M.D. Anderson Cancer Center were not only wrong, but also would not make the same error today. He accuses me of not facing up to the truth. Here is my response, which I sent to all the administrators and physicians listed above. In this response, I point out that none of Chuck’s physicians, including Dr. Elliott, seemed to recognize that they were making a diagnosis of exclusion. Possibly for that reason, none of them considered—even to try to exclude—the most obvious and likely diagnosis.

These two letters worry me greatly, as they manifest a deep misunderstanding of the most basic concepts in medical practice.

On October 3, 2007, I received this hand-delivered letter from Mr. Henderson and Doctor Sarnoff, stating that the administrators had considered and rejected my assessments of, and my requests for, changes in Scripps Clinic Policy. 

Reluctantly, I have come to the conclusion that the Scripps bureaucracy is dysfunctional in ways that many bureaucracies are prone to be. Like the bureaucracies of the Red Cross, the Catholic Church, and FEMA (the government agency that mishandled the aftermath of the Katrina hurricane), they appear to care more about their own self-protection and keeping critics at bay than they do about carrying out their mission. 

Instead of welcoming constructive feedback, they develop great skill in stonewalling outsiders, thereby rejecting opportunities for the kinds of adaptability that keep institutions alive and vital. 

As a physician who has regarded her profession as a solemn obligation, I am saddened and demoralized to conclude that this well-regarded institution should have permitted itself to fall into a trap that does no credit to Scripps Clinic, to the medical profession or to the honor and integrity of all involved. 

I strongly urge that patients who receive care at Scripps Clinic keep these three policy hazards in mind both for yourself and for those you care about. At the very least, I advise:

• Talk with your physician about these issues. Print and take this document with you.
   

• Obtain a copy of your complete medical record, and identify the Board Certification status of the physicians caring for you. If a student or resident doctor has dictated your reports, make sure a Board Certified senior physician has read and critiqued the work. Ask.
   

• Make sure that reports of chest x-rays and mammograms are complete, especially if they bear a “Code 1” in the lower left hand corner. Make sure a Radiologist has signed them.
   

• If you have received a “Diagnosis of Exclusion” that carries with it the possibility of a serious condition, ask for a second opinion to make sure that everything has been excluded that ought to have been excluded.
   

• If you have received the diagnosis of a serious or rare condition, make sure that you are seeing the best specialist. Insist upon a referral to the best possible expert care for your problem, whether within Scripps Clinic or elsewhere. 
   

• If the patient is 21 or younger and either has a serious or rare condition or requires surgery or hospitalization, strongly consider transferring care to Children’s hospital.
   

• If you have an unusual cancer, or are in any way uncomfortable with your diagnosis or treatment, demand a consultation at a Cancer Center that has been designated as such by the National Cancer Institute.