http://www.boston.com/dailyglobe2/23...crutiny+.shtml

Doctors' behavior gets new scrutiny


By Anne Barnard, Globe Staff, 8/18/2002

Beverly Grier describes herself as a ''mild-mannered associate professor,'' so she didn't complain until the second time in a row that her surgeon was more than two hours late for an appointment.


When she asked for an apology, Grier said, the reaction startled her: Dr. David Arndt started taking her X-rays down off the light board, told her he was ''not accustomed to being scolded by his patients,'' and threatened to end the appointment.

Grier, 52, practically begged him not to. ''I was frightened,'' she said. ''I couldn't help wondering if I needed surgery and he wasn't going to give it to me because he was mad.''

Long before he left an anesthetized patient on the operating table for 35 minutes while he took a paycheck to the bank, Arndt was becoming a test case for a nagging medical issue: how to react when doctors are rude, dismissive, or otherwise erratic in their dealings with patients.

Grier was too intimidated to report her concerns to anyone at the Harvard Vanguard physicians' group, but four other patients say they did complain about Arndt's upsetting behavior to doctors and administrative staff at Harvard Vanguard or at Mount Auburn Hospital in the past two years. In one case, according to the patient, Raymond LaVallee-Davidson, Arndt failed to show up for surgery at Mount Auburn, didn't call to explain until four days afterward, and later, was a no-show at a meeting he set up to apologize.

Taken together, those incidents - plus two brushes with the law not related to medicine - might have raised red flags about Arndt, who has blamed personal problems for several lapses, including the bank trip on July 10, which prompted the state to suspend his medical license. But until the incident last month, no one claims to have identified him as a problematic doctor, or at least not enough of a problem to keep him from carrying on a practice in spinal surgery.

And that's not unusual. Doctors are rarely disciplined or demoted for bad behavior in their interactions with patients, short of the most blatant cases, such as making sexual advances.

''If physicians were disciplined for being disrespectful, inconsiderate, and not on time, the medical offices of our nation would be empty,'' joked Dr. David Blumenthal, a researcher at Massachusetts General Hospital's Institute for Health Policy.

But there is an increasing consensus among medical researchers that poor doctor-patient interaction is not just a ''soft'' issue, but a threat to patient safety.

''If the patient feels intimidated and doesn't get to speak and share symptoms and their response to treatment, it's less likely that the right treatment will be provided,'' Blumenthal said. He supports a growing movement of employers and insurers that are working to develop uniform standards to measure doctors' interaction with patients - and want hospitals and health plans to take those measurements into account in credentialing and rewarding doctors.

There are many difficulties with that approach, however. Sometimes the most technically skilled doctors aren't the ones with the best bedside manner, and vice versa. Different patients can have widely differing views of the same doctor - as with Arndt, who was viewed as brilliant and personable by many patients. Traditionally, many doctors, particularly in surgery, resist being judged by any measures other than patient outcomes. And both inside and outside the medical world, difficult behavior from high-powered doctors is almost expected.

''There is a certain surgical arrogance - certainly not uniform among all surgeons - that is almost expected and sometimes even looked for,'' said Dr. Richard Croteau, a general surgeon and executive director for strategic initiatives at the Joint Commission for Accreditation of Healthcare Organizations, which regulates US hospitals.

For every patient who complained about Arndt, there is one who says he was warm, focused, and brilliant - one patient's relative even said he displayed ''the arrogance of excellence.'' But the ones who complained offer a window on how, short of a glaring medical mistake or ethical lapse, physican behavior can delay or mar treatment.

''Maybe if they had nipped [Arndt's insensitive behavior] in the bud back then, this surgery incident wouldn't have happened,'' Grier said.

It's unclear whether patient complaints resulted in employers trying to counsel or sanction Arndt. His lawyer, Claudia Hunter, has said that although his privileges at many area hospitals ended in recent years, in no case did he leave ''under a cloud.'' And officials at hospitals and the physician group where Arndt formerly worked declined to discuss details of the allegations against Arndt.

''The Harvard Vanguard physician group does not tolerate outlandish behavior by any of its staff, including physicians,'' said Peter Dreyfus, an administrator of Vanguard's Post Office Square office. ''Dr. Arndt resigned from his position [in September 2001]. I cannot discuss the context of his resignation.''

Ron Stegall, a health care administrative worker from Boston, said that when he complained to the Harvard Vanguard staff about Arndt's chronic lateness, they told him that was part of the package with a ''gifted'' surgeon.

''I was told this is standard operating practice for him. He's always an hour and a half to two hours late,'' Stegall said. ''I should be happy that I'm seeing him, sort of a celebrity type mentality. I was fuming. He told me that his car was in the garage and had been in an accident.'' He decided to go to another surgeon.

Carol Hughes said Arndt's unavailability and disorganization complicated her adult daughter's medical care for a back condition. Records were not forwarded to other physicians, prescriptions could not be filled, painful and allegedly unnecessary tests were done, she said. Finally, Vanguard's chief of orthopedics apologized to her, she said, and provided another surgeon whom she found satisfactory.

Deborah Addis got the impression that Arndt felt she was ''wasting his time'' because he didn't think she needed surgery. Then, she said, he offhandedly suggested that she had multiple sclerosis, a debilitating neurological condition that can lead to paralysis. She was terrified for weeks, until another surgeon said there was no evidence of that and diagnosed her with a back problem that was cured.

Raymond LaVallee-Davidson suffered life-threatening complications under one surgery with Arndt, at New England Baptist Hospital. He was scheduled for follow-up surgery in August 2001 at Mount Auburn. He was about to be anesthetized when he said he had some questions for Arndt and wanted to wait for him. Five hours later, Arndt had not arrived. Days later, according to the patient's domestic partner, Bruce LaVallee-Davidson, Arndt called to say he had overslept.

''That just didn't cut it,'' Bruce LaVallee-Davidson said. ''The only excuse that would have been good enough was if he was in a car accident and unable to get to the phone.''

He said Arndt later promised to meet them at their doctor's office in Skowhegan, Maine, but called four hours late, saying he had car trouble. He finally arrived at a rescheduled meeting, also late.

''It really destroys your faith in the medical profession,'' said Bruce LaVallee-Davidson, who with his partner is planning a lawsuit against Arndt.

''That was a red flag,'' said Michael O'Connell, a vice president at Mount Auburn, referring to the LaVallee-Davidson incident. ''But the question is, if someone has personal problems should that stop them from being a physician? That's something we need to look at both here and around the state.''

Mount Auburn officials say they also did not know about another potential red flag: Arndt's brushes with the law. In 1998, Arndt agreed to pay $30,000 to a man he allegedly assaulted in Provincetown and, in the same year, he pleaded guilty to a federal misdemeanor for trying to help his domestic partner illegally get a US passport.

Criminal charges aside, cases such as Arndt's fall into a gray area: The state Board of Registration in Medicine requires doctors to report colleagues to hospital administrators if they believe that ''disruptive behavior'' is putting patients at risk, just as they must report drug or alcohol problems. But it's hard to define when behavior crosses that line, and people in any profession find it hard to intervene in colleagues' personal behavior.

When doctors get complaints about their colleagues from patients, they are likely to react by referring fewer patients to that person - not by reporting the information to supervisors, said Dr. Tom Delbanco, former chief of internal medicine at Beth Israel Deaconess Medical Center.

''Every field protects the brethren. It's the nature of institutions,'' he said. ''But it's not good for patients.''

What is needed, he said, is a standardized mechanism for patients to give feedback - anonymously if necessary - on doctors' communication and other interpersonal skills. ''There's very little way for patients to feel safe enough and brave enough to give feedback to doctors.''

Tufts Health Plan is the only one in the Northeast to publish patient satisfaction data on physicians' groups. And it is the only one in Boston that privately sends similar feedback to individual doctors, rating them on accessibility, communication, and other interpersonal skills.

Getting his Tufts report card was hard, said Blumenthal, the Mass. General doctor. ''I wanted to be in the top 1 percentile and I wasn't.'' But it helped him ''look harder at whether you are as friendly and as open and as interested as you ought to be,'' he said.

Most doctors would welcome the feedback, Delbanco said. ''Some doctors do get better.''

Anne Barnard can be reached at abarnard@globe.com

This story ran on page A1 of the Boston Globe on 8/18/2002.
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