Playing Around with Slides
Posted on 20. Oct, 2009 in Case Reports
Case Synopsis
Background
Dr. Green was board-certified in anatomic pathology, and in 1992 established a lab with his wife. His lab was responsible for screening pap smears and other tests for about ten doctors in his area. From 1993 to 1999, he was the medical director of his lab. Dr. Green also worked concurrently as a medical examiner for Klamath County in Oregon performing autopsies.
Back Sliding
At his lab, Dr. Green reviewed many slides for screening pap smears. For some reason or another, suspicions mounted against Dr. Green and his findings. An investigation was launched by the Board of Medical Examiners—initiating an independent review by Oregon Health & Science University (OHSU) of 100 consecutive pap smears performed by Dr. Green’s lab. The slides collected were between January to February 1998.
What OHSU found was interesting. Of the 100 slides, 97 were suitable for review. Of the 97 slides, Dr. Green only read two of them as abnormal. These two slides were found to be normal by OHSU. Of the remaining slides that were read as normal by Dr. Green, OHSU disagreed and found 4 of them significantly abnormal.
One of these slides was of major contention. Dr. Green stated that the slide was an “unsatisfactory sample due to there being excessive blood.” OHSU reviewers, however, found the slide to actually be a satisfactory sample. This slide showed abnormal cells suspicious for cancer.
An expert from OHSU testified that Dr. Green had breached the standard of care especially in the case of the reported unsatisfactory sample. The expert went on to say that there are very clear cut standards for reporting abnormal cells and that Dr. Green’s assumption that the slide in question was an unsatisfactory sample was not only “shocking” but a clear-cut violation. In this case, Dr. Green testified that he called the doctor and told him of the potential for cancer but that he had not documented this conversation. Dr. Green said that no harm was done anyway because a mass was found during the pap smear and the patient was able to receive timely treatment.
More Back Sliding
Another independent review of 598 more slides screened by Dr. Green from February 1999 to August 1999 was performed and it was found that a large number of them were understained. (In order for slides to be viewable under a microscope, they must go through a staining process to make the various parts of the cells visible.) The reviewer recommended that 204 of these tests (34% of the slides) be redone due to bad staining. Dr. Green explained that he felt he could compensate for the bad staining by increasing the power of the microscope and turning down the condenser. The expert from OHSU stated that this method is not standard procedure in cytopathology and cannot be used to compensate for badly stained slides.
Letting it Slide
Also working as the medical examiner for Klamath County in Oregon, Dr. Green performed autopsies. In five of these cases, the mishandling of them almost slid right by:
Adam
Adam was a victim of a car accident. On examining Adam for the actual cause of death, Dr. Green looked in the mouth and declared that he must have died from a heart attack. For reasons unknown to other medical experts, Dr. Green believed that tongue biting always happens when there is head, neck, or spinal cord injuries—and because Adam’s tongue was normal, he must have died from a heart attack. The actual cause of was a combination of chest injury and heart attack.
Sally
Sally’s family wanted a second opinion because they weren’t quite sure about how she died. They asked Dr. Green to examine her. As his customary routine, Dr. Green looked in the mouth, found that Sally had bitten her tongue, and reported that she died from neck injury. A subsequent autopsy by the State Medical Examiner showed no neck injury whatsoever and that Sally died from bleeding to death from a rupture of her aorta.
Bobby
Bobby was a newborn infant. Although Dr. Green’s conclusion was correct in this case (he was smothered to death), a review of this case found that an incomplete autopsy had been performed by Dr. Green. He did not remove the organs from the body and examine the tissue under a microscope. In a homicide case, it is important to do a complete autopsy.
George
George was a child victim of a car accident. Dr. Green’s conclusion was also correct in this case, George had died from a broken neck. However, Dr. Green once again did not conduct a complete examination by failing to examine the area internally, but instead relied on a CT scan. Dr. Green said that he did this to respect the Native American traditions of the family. In a public safety case such as this, a complete examination is performed regardless of the family’s preference.
Sharon
Sharon was an elderly female. In his autopsy report, Dr. Green indicated that she had a normal uterus, fallopian tubes, and ovaries. Sharon had a total abdominal hysterectomy years before. An incredible oversight to say the least.
Case Outcome
Dr. Green’s licensed was revoked. However, because he was cooperative during the investigation and showed that he was willing to be retrained, the license revocation was stayed (meaning he was allowed to keep his license). Dr. Green was placed on probation for 5 years with stipulations, including fines, re-education, oversight, and periodic review of his work.
Analysis by Florence
I think this case all about the physician’s incompetency. I don’t detect any signs of ill-will or greed, but rather he can be summed up as “lazy”.
He seemed to be bright, but refused to follow proper procedure. As a physician, standard protocol is very important, no matter what you are doing. The small details matter so much when
performing tests that could potentially save a woman’s life. This doctor failed to perform the correct test so many times! All those women will have to spend more time and money to redo the botched pap smears!
Also, not performing autopsies correctly simply puts the family of the deceased through unnecessary waiting and frustration. They depend on the medical examiner to do his job according to the book. So many times, doctors go beyond the call of duty just out of good will or protecting themselves from lawsuits. This doctor went the other way, and that is very sad. At least in the end he was willing to be educated.
| Score |
|---|
| 5 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 2 | 4 | 8 | 5 | 6 |
Response by Marc
Lazy or not is hard for me to say. It is possible he was swamped and was rushed. From my quick calculations, he read about 100 pap smear slides a month while at the same time working as a medical examiner. Reading the actual case files, Dr. Green argued that it was not a big deal to be wrong on a few pap smear readings. He appeared pretty emphatic with his reasoning that women are to get pap smears yearly, which means he has chance after chance to get the right diagnosis. Obviously most of us wouldn’t agree with his viewpoint, but what I think is the issue is that Dr. Green has forgotten his skill and ability. Thinking that bad staining can be compensated by manipulating the microscope and believing that biting of the tongue was the telltale sign for head injury points to an out of date doctor. He might have been great and passed board certification, but that doesn’t mean he’d stay good forever.
| Score |
|---|
| 4.6 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 3 | 4 | 7 | 4 | 5 |
Response by Lyssa
How did this doctor pass all his tests, become board certified, and end up being so lazy and just plain bad? Time after time he had excuses as to why he didn’t follow proper procedure. His mistakes and laziness cost his company and the government lots of money, as others had to go back and correct what he had done. Not only was he inept, what he did was also unethical. He is lucky that what he did didn’t apparently cause any physical harm.
| Score |
|---|
| 6.2 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 3 | 5 | 9 | 6 | 8 |
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