The story of Dr. Michael Swango is guaranteed to frighten the medical profession. Confronted with the facts of this case, those of us who work in hospitals are forced, at a minimum, to acknowledge that a determined and clever psychopath could harm our patients before being detected.
According to James Stewart, Michael Swango is a calculated killer who entered several medical training programs before anyone sounded an alarm at the terrorist in their midst. Journalist Stewart labels Swango's allegedly murderous course through American medicine "professional courtesy," which suggests that hospitals and doctors grant a kind of latitude to fellow physicians that in turn yields this situation. Is there a defect in the medical profession that allows a Swango to operate unchecked?
Stewart's article suggests that only a considerable defect in the medical profession's ability to screen for and eliminate deviants could account for Swango's ability to escape detection. At any rate, reading Stewart's article, it's easy to arrive at that conclusion. To more fully comprehend the facts requires an understanding of the nature and circumstances of the medical errors that occur in hospitals. Infrequently, bad things happen to patients even when excellent care is provided. Problems also occur when there are accidental deviations from the standard of care that cause significant harm, e.g., when a patient is administered a drug to which he is allergic. More alarming is when negligence is not accidental but occurs because the physician or nurse is impaired, e.g., under the influence of alcohol or drugs. Still worse, and fortunately quite rare, is the situation in which a physician or nurse intentionally harms patients.
True, hospitals have systems to deter errors and negligence. Over the last decade, continuous quality improvement processes, reviews by the Joint Commission on Accreditation of Healthcare Organizations and government regulators, as well as malpractice legislation, have improved the quality of patient care and overall medical outcomes. These processes for measuring outcomes should capture any significant variances from the standard of care. But a further complication occurs when a patient has the kind of critical illness that frequently results in death. A large hospital treating seriously ill patients with life-threatening illnesses may have at least one death every day. Quality of care reviews are rarely able to pinpoint the exact cause.
Suspicious behavior may be the only clue to hospital staffers that a killer could be in their midst. A medical setting provides many opportunities to disguise behavior that might appear very suspicious under the circumstances of a normal business. Therefore, it's not completely surprising that it was only at Swango's third medical training program that his supervisors dismissed him and warned other medical schools of his background.
Clearly, hospitals and medical schools need to cooperate more fully in sharing information about deviant and negligent physicians. But we should be careful not to expect immediate improvements in detection of Swango-like conduct. We must continue to improve the ways in which patient outcomes are measured and share that information with the public. These improvements represent an opportunity for greater public understanding of the variation in medical care that does exist in this country. For now, we need to rely on vigilant staff and courageous behavior to catch a Swango. All of us in hospitals are indebted to the few decisive individuals in New York and Illinois who stood up and identified Swango.
