To date, “Adventures and Images” has been a travel blog, but in this installment, the nature of the adventure changes. Instead of a travel adventure, I’m taking readers on a walk through a hellacious episode from my past — one that happened in my professional capacity as a physician assistant and as a writer for a medical journal.
Like me, many people have recurring nightmares based on a fear (rational or irrational) or lack of self worth, whether conscious or not. My nightmare is always the same: I’m in college, enrolled in a class I loathe. I haven’t studied for the final exam, and I’m at the venue for the test, completely unprepared. Since 1970, the dreaded dream has occurred as often as several times a month.
It was a complete surprise when at the age of 80, my father told me he had been having the identical nightmare since he was 20! Could nightmares have a genetic pathway, or were we both such screw-ups in college that our youthful failings resulted in psychic trauma that plagued us for decades?
Fortunately, in the past year I can’t recall awakening with the dreaded apparition, but that doesn’t mean I no longer experience unpleasant dreams. On a recent summer’s eve, I awoke from another nightmare, and in this one I was told that in two weeks my 24 years at Kaiser Permanente would be over — I was being fired. My partner Lorn was speaking to a Kaiser R.N. I’d never met, and he told me about their conversation.
“It’s true,” he said. “In two weeks, you’ll be history. Clear your desk and get out.” I had hoped it was just a nasty rumor — that I’d be able to continue to work there until I retired. What would I do? I was terrified.
Of course, it was then that I woke up. It took me a few minutes to realize that what I had dreamt wasn’t real; that I had retired two and a half years ago; that I still worked a few days each month at Kaiser and that as far as I knew, no one planned to tell me to pack my bags.
Many will relate to this dream, but in my case, there was a time that this scenario came very close to reality. Kaiser Permanente is the largest health maintenance organization in the United States, with beginnings in the 1940s when Henry Kaiser searched for a way to provide medical care for thousands of workers building aqueducts in California. In 1997 the Northwest Region of Kaiser (Oregon and Washington) became the first Kaiser region to roll out an electronic medical record system, and its EMR called EpicCare was later leased to hundreds of health care corporations all over the United States.
Because of our excitement in the Northwest Kaiser Region over what we knew was likely to revolutionize the way health care is structured and delivered, in 1997 I decided to write a two part article for a national medical journal on the development and realization of our EMR — one of the first in the nation. The journal’s publisher, Medical Economics, was then probably the largest publisher of medical periodicals in North America. I wrote a regular column in one of their journals called “Notes from the Northwest,” where I told stories of interesting patient encounters and provided a behind the scenes look at the political and social world which clinicians called home.
I spent six months writing the two articles. I interviewed clinicians, patients and Kaiser administrators. Illustrations included “screen shots” from patients’ electronic charts. I took photographs of the medical record and sent them electronically to Medical Economics headquarters in New Jersey, with explicit instructions for the publisher to redact any personal information — names, addresses, phone numbers and medical record numbers.
At the end of the project, I excitedly waited for the hard copy journal to reach my desk at my office in Salem, Oregon. I was thrilled with anticipation of the prestige the article would bring Kaiser for its pioneering work, and I was proud to have participated in its creation.
The day finally arrived. There was the story on the cover, and as I turned the pages to the article’s beginning, I gasped when I saw the first illustration: a page from a patient’s chart with her name, medical record number, and 10 or more test results. I couldn’t believe my eyes. Although it had happened at least 4 months before, I explicitly remembered telling the journal’s editor to have his graphics department remove all personal information, but had I asked him verbally or was it in an e-mail? I frantically looked through six months of e-mails to the editor, and I came up completely blank.
To understand the depth and scope of this violation of patient confidentiality, I offer this perspective. I have seen physicians whose negligence results in a patient’s death who were defended in a courtroom by Kaiser attorneys, as well as provided counseling for the grief they must have suffered. Every clinician makes mistakes; some worse than others.
But to violate a patient’s confidentiality is a heinous and inexcusable error; it is well known by all employees that the offender is subject to immediate dismissal. I called the editor at Medical Economics to tell him about the gaff and asked if he remembered a conversation with me or an e-mail instructing him to redact all personal information before publication. He didn’t, but he promised to search his files and let me know if he came up with anything. He also assured me that if they had agreed to remove the information, they would take complete responsibility for any consequences, but I wasn’t really sure what that meant.
The next step was to phone my boss, a Kaiser Vice President who oversaw our development of the EMR. I was employed by his department as a trainer in advanced efficiencies for clinicians who used the system. After hearing the story, he instructed me to phone Kaiser’s legal department and explain what had happened.
I had a sense of disbelief that I was experiencing this scenario from hell — a nightmare I never thought I would face in my career. At that point, I was resigned to be fired and felt the punishment would be completely justified. I had made an extremely serious error by allowing a patient’s medical information out of the clinic without taking personal responsibility for removing all identifying data before sending it. That I trusted the largest medical publisher in the world to do so with its vast technical resources was naive and just plain wrong.
Later that day, I received a phone call from Kaiser’s medical director, Allan Weiland, M.D. I had met Dr. Weiland at social functions, but I doubt he knew me and we weren’t friends.After he identified himself, I was certain he was calling to fire me. I wasn’t angry; I was completely prepared for the outcome. The conversation went something like this. “Eric, this is Al Weiland. I’ve heard about the patient’s personal information in the magazine article you wrote. We need to do the right thing, and I want you to call her and tell her what happened. Show her the journal. Then call and report back to me.”
The next problem was that she wasn’t my patient; she was the patient of another physician who worked on my team. Dr. Weiland told me to have that doctor contact the patient, then get back to him by the end of the day. I told the physician and he seemed annoyed — not so much at me, but because he felt Dr. Weiland was making a big deal out of very little. I couldn’t have disagreed more. I told him to contact me as soon as he met with the patient so I could call Dr. Weiland as I had agreed.
At 4:30 I hadn’t heard from the physician, so I went to his office and asked him if he had done as Dr. Weiland asked. Still looking annoyed, he said he had — that the patient had no questions and didn’t want to see the article. I called Dr. Weiland and gave him the news. He said, “Eric, we’ve done the right thing and the matter is over.” I honestly can’t remember what I felt at that moment. Perhaps I cried. Perhaps I didn’t really believe it was over. It was much too long ago.
A few days later, I received a call from the magazine’s editor at Medical Economics. “Eric, I found the e-mail you sent, and your instructions to me were exactly as you said. I’ve already sent an overnight letter to you at Kaiser with our agreement to assume full responsibility for any legal or economic damages Kaiser or you might suffer as a result of the breach and error on our part. Please accept my heartfelt apologies. I know you must have been through hell in the past few days.”
I sent the letter to our attorneys and Dr. Weiland, but no one ever raised the matter with me again. Nevertheless, their silence failed to erase the shame I felt. Six months later, I was at a Christmas party sponsored by the department charged with clinician EMR training, and I cringed when I saw Dr. Weiland walk in. I made a point to move to the other side of the room. After a few minutes, I felt so uncomfortable that I started down the stairs to leave, but I heard someone call my name. The voice sounded uncannily familiar: it was Dr. Weiland’s. What could he possibly want?
After shaking my hand and smiling, he said there was a Kaiser physician who had recently retired on medical disability due to severe, chronic headaches. He knew my clinical expertise was as a headache specialist, and he asked me to offer her a second opinion. He knew how much she had been suffering.
It wasn’t until that evening that I felt I had been forgiven for my transgression, and I will forever be grateful that Dr. Weiland treated me with such kindness and had the integrity to handle a potential legal and publicity disaster with as much wisdom and grace.