Publishing a case report as a Med student where an error caused the patient to die?

[sabertoothkitten]

If I saw a really really interesting case that honestly should be written up to educate others... but it involved a patient who died and the attending is super defensive about it... how would I go about writing a case report? The disease was very rare and the doctor made a reasonable choice that in retrospect definitely resulted in the patient dying. I want to write a case report so others know not to make the same mistake (and because its a very cool case and I would learn a lot writing it up). But the attending involved is super defensive about it and wouldn’t even let it be presented at grand rounds. I don’t need him to be involved (would get another attending in a different service to coauthor) and obviously won’t identify him and will deidentify the patient. But I’m assuming if i need the permission of the next of kin they might want to read it and it could potentially lead to a lawsuit? Maybe I’m over thinking it. I just don’t want to get backlash.

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[7331poas]

I feel like this would never fly at my institution. How can you write a case without the attending physician's blessing? Easy way to get on people's bad side. Also want to make sure that this case is truly novel and worth publishing etc.

 

[deleted50541]

Don't do this. Obviously we don't know the details, but if the attending of record wouldn't support a case report, then you're asking for trouble.

You don't know what may be going on in the background too. This patient's death may be under review by the hospital or a state agency. As a med student, it's also bit presumptuous to say what this attending did "definitely" resulted in the patient's death.

You could do a review article of this rare disease if it has not been published on much or needs an update. But stay away from this case.

 

[Lawpy]

This is way too much unnecessary risk for a measly case report. The attending is defensive for a reason. Don't burn bridges just to publish something to show mistakes were learned

 

[Matthew9Thirtyfive]

Let’s keep the responses professional please. A post was removed that contributed nothing but insulting OP.

 

[sloop]

It is indeed possible to write a case report without the involvement of the attending of record. I did this as a resident, but that was a case where the attending was simply disinterested rather than opposed and I consulted another faculty member.

That being said, this is probably not a good move for you, your hospital, or your attending.

There are many possible outcomes here, but let me just pose one:

You publish this case report and there is some sort of malpractice lawsuit. It doesn’t really matter that you “deidentified” the information in the publication. The attorney will learn all of the members of the team at the time, including your name. A good attorney will find out that there is a journal article you wrote around the same time that has similarities to the case. This is especially true because, presumably, you had the patient or the patient’s family sign a consent for you to write the report. Said attorney then deposes you or subpoenas your testimony. They ask you, under oath, if the case report was based on their client/client’s family member. You are forced to confirm this. The lawyer then will attempt to use your peer-reviewed article as evidence of malpractice.

This is just not worth it. You will likely piss your attending off and you could potentially be deposed or subpoenaed in a lawsuit over a case report.

 

[RunsOnCaffeine]

There are endless interesting cases out there, OP. I would find another one.

 

[mrbreakfast]

You will read very few case reports about cases like this (learning from a possible mistake) but most academic institutions have a forum for these exact cases, which is morbidity and mortality conference. You could prepare an M&M case presentation, which is still impressive (resume material) and which the attending may be more amenable to.

I would not proceed without the attending of record's approval. I wouldn't worry about a lawsuit as much as royally annoying an attending.

 

[ortnakas]

There is no way doing this case report ends well for you.

agree with @mrbreakfast that it sounds like great M&M material. Remember that M&Ms are (or are supposed to be) confidential, nonjudgmental and for education only.

It may be that this case is already a planned M&M. As others said, there may be medicolegal issues in the background you’re not privy to. Another attending’s first question is going to be “well why aren’t you writing it up with attending #1” and when they find out attending #1 doesn’t want it done, they’re not going to open that Pandora’s box (not that I expect a non-involved attending to have any interest anyway).

There will be other cool cases stay out of this one.

 

[GoSpursGo]

No way. If the attending of record doesn’t want to write up the case—Ie is legitimately opposed, not just disinterested—you can’t publish it in any reputable journal. If the attending was just disinterested then you could find someone else in the department to be your senior author, but nobody is going to touch this case when they find the attending doesn’t want it published.

As others have said, find another case.

 

[mvenus929]

In case it's not clear yet, stay far away from this. There's too much room for something to go wrong, either with the attending, the hospital, or you, and it's not worth it. Learn from the 'mistake' yourself, or discuss with the M&M committee to present there, which you can add as a line in your CV.

 

[Dave1980]

If I saw a really really interesting case that honestly should be written up to educate others... but it involved a patient who died and the attending is super defensive about it... how would I go about writing a case report? The disease was very rare and the doctor made a reasonable choice that in retrospect definitely resulted in the patient dying. I want to write a case report so others know not to make the same mistake (and because its a very cool case and I would learn a lot writing it up). But the attending involved is super defensive about it and wouldn’t even let it be presented at grand rounds. I don’t need him to be involved (would get another attending in a different service to coauthor) and obviously won’t identify him and will deidentify the patient. But I’m assuming if i need the permission of the next of kin they might want to read it and it could potentially lead to a lawsuit? Maybe I’m over thinking it. I just don’t want to get backlash.

Just in case you needed one more person to tell you no...

terrible idea for numerous reasons. no other Attending would agree to write up a case that their colleague may have messed up. the fact that you are even considering writing it up concerns me. bad judgement and not professional. this isn't a middle school book report and any avoidable death in the hospital will get some degree of scrutiny without the med student trying to get a pub out of it.

your lack of professional courtesy to the attending who doesn't want to you publicize the case and as you said made a reasonable choice is scary.

i hope you can reflect on the comments and change your mindset

 

[FistLength]

Case reports are not really worth much in academia, hence the juice is not worth the squeeze. If your goal is truly educational, M&M is a good avenue.

 

[dienekes88]

If the attending is super defensive about it. Just move on.

 

[George Lincoln]

If I saw a really really interesting case that honestly should be written up to educate others... but it involved a patient who died and the attending is super defensive about it... how would I go about writing a case report? The disease was very rare and the doctor made a reasonable choice that in retrospect definitely resulted in the patient dying. I want to write a case report so others know not to make the same mistake (and because its a very cool case and I would learn a lot writing it up). But the attending involved is super defensive about it and wouldn’t even let it be presented at grand rounds. I don’t need him to be involved (would get another attending in a different service to coauthor) and obviously won’t identify him and will deidentify the patient. But I’m assuming if i need the permission of the next of kin they might want to read it and it could potentially lead to a lawsuit? Maybe I’m over thinking it. I just don’t want to get backlash.

The point of Grand Rounds and M&M's are to present cases like this. As a retired Program Director it seems to me that this Attending shouldn't be an Attending. We're not Gods so sometimes things don't go well, but learning from mistakes is important. As they say there are three kinds of people, those that learn from their mistakes, those that learn from the mistakes of others and those that never learn. You never want to be in the last group. As far as litigation, not sure how that information could get out as the patient presented is not identified. In my role as a defense expert for over 35 years, I've never lost a jury trial; so I have been involved in cases with bad outcomes, but bad outcomes don't mean negligence. We all have an expiration date, we just don't know the date. Personally I have had unique complications over the years and in fact on complication I had back in the 1980's ARDS secondary to Narcan, which is now well documented. I submitted that case for publication and it was rejected because the reviewers couldn't understand it. That being said you probably should submit the case for publication if you feel it can be a learning experience for others so that they can better rendered care to their patients; because ultimately that's what it is all about. Sounds corny, but when you take the long view it's the only thing. Always do the right thing no matter the consequences. You say it sounds good, but it's true. More than once I've had to stand up to heads of departments and chiefs of service and Hospital CEO's. In one instance I had a 16 year old ASA 1 patient in for a minor procedure and the after a nasal intubation I felt the chest and listened to the chest and the right side had no breath sounds and did not rise. The Chief of Anesthesia was in the room with another Anesthesia Attending, the Chief indicated that he say no problem and I should proceed and the attending said he Chief said it was fine, but would not commit. Well I extubated the patient and suctioned a large clot from the right main stem bronchus that had occluded it and the breath sounds then returned. Bottom line I had a 16 year old young lady that still had two healthy lungs and I had a pounding headache. Enough advise and experiences, you know what you need to do.

 

[Redpancreas]

It is indeed possible to write a case report without the involvement of the attending of record. I did this as a resident, but that was a case where the attending was simply disinterested rather than opposed and I consulted another faculty member.

That being said, this is probably not a good move for you, your hospital, or your attending.

There are many possible outcomes here, but let me just pose one:

You publish this case report and there is some sort of malpractice lawsuit. It doesn’t really matter that you “deidentified” the information in the publication. The attorney will learn all of the members of the team at the time, including your name. A good attorney will find out that there is a journal article you wrote around the same time that has similarities to the case. This is especially true because, presumably, you had the patient or the patient’s family sign a consent for you to write the report. Said attorney then deposes you or subpoenas your testimony. They ask you, under oath, if the case report was based on their client/client’s family member. You are forced to confirm this. The lawyer then will attempt to use your peer-reviewed article as evidence of malpractice.

This is just not worth it. You will likely piss your attending off and you could potentially be deposed or subpoenaed in a lawsuit over a case report.

Post like these are why I come to SDN.

 

[Dave1980]

The point of Grand Rounds and M&M's are to present cases like this. As a retired Program Director it seems to me that this Attending shouldn't be an Attending. We're not Gods so sometimes things don't go well, but learning from mistakes is important. As they say there are three kinds of people, those that learn from their mistakes, those that learn from the mistakes of others and those that never learn. You never want to be in the last group. As far as litigation, not sure how that information could get out as the patient presented is not identified. In my role as a defense expert for over 35 years, I've never lost a jury trial; so I have been involved in cases with bad outcomes, but bad outcomes don't mean negligence. We all have an expiration date, we just don't know the date. Personally I have had unique complications over the years and in fact on complication I had back in the 1980's ARDS secondary to Narcan, which is now well documented. I submitted that case for publication and it was rejected because the reviewers couldn't understand it. That being said you probably should submit the case for publication if you feel it can be a learning experience for others so that they can better rendered care to their patients; because ultimately that's what it is all about. Sounds corny, but when you take the long view it's the only thing. Always do the right thing no matter the consequences. You say it sounds good, but it's true. More than once I've had to stand up to heads of departments and chiefs of service and Hospital CEO's. In one instance I had a 16 year old ASA 1 patient in for a minor procedure and the after a nasal intubation I felt the chest and listened to the chest and the right side had no breath sounds and did not rise. The Chief of Anesthesia was in the room with another Anesthesia Attending, the Chief indicated that he say no problem and I should proceed and the attending said he Chief said it was fine, but would not commit. Well I extubated the patient and suctioned a large clot from the right main stem bronchus that had occluded it and the breath sounds then returned. Bottom line I had a 16 year old young lady that still had two healthy lungs and I had a pounding headache. Enough advise and experiences, you know what you need to do.

Why does it say you are a dentist?

 

[Dave1980]

As a retired Program Director it seems to me that this Attending shouldn't be an Attending.

Get over yourself. You have been a member for over 2 years and your first post is holier than thou garbage. also you may or may not be a dentist in which case sorry to say unless you are OMFS you are out of your league

 

[sloop]

As far as litigation, not sure how that information could get out as the patient presented is not identified.

How is this not clear from what I said earlier? To publish a case report, the author must have gotten the patient or their family to sign a consent. If there was later a lawsuit, this very well might be something the client mentions to the attorney during their consultation. “Not sure if it’s important, but the medical student asked us to sign a consent to write a case report.” From there, there are a number of ways that they could get the information. If it is published, they could find it themselves by searching for articles authored by the members of the team. It would not be unusual for attorneys to depose members of the treatment team. They could then establish, on the record, that the case report was based on their client or client’s family member. At the point that they know a case report was likely being published, they could also potentially subpoena the article and/or the manuscript.

Whether the article itself would be admissible might be questionable. It is technically hearsay but there are many hearsay exceptions and it could potentially qualify under several of them.

so I have been involved in cases with bad outcomes, but bad outcomes don't mean negligence.

This is true, but if the OP is correct that the course of action led to the patient’s death, that fact is one of the necessary elements for a negligence case. Assuming that a negligence case is brought, one of the defenses might be that the actions of the defendant were not the proximate cause of damages. If OP’s case report were to portray the attending’s actions as leading to the death of the patient, this could certainly bolster a malpractice claim because it implies that the attending’s actions were the proximate cause of potential damages. Of course, one would have to prove the other components of negligence (that there was a duty, that there was a breach of that duty/non-adherence to standard of care, and that there were provable damages), but the fact remains that it has significantly hampered an important defense.

Assuming that the case report could be admitted into evidence, there are many ways it could be used against the attending. It could be used to impeach the testimony of the attending. It could be used to impeach an expert. It could be referenced by a plaintiff’s expert in their report or testimony. So many ways this could be bad.