It's hard to determine whether Children's, one of the world's top pediatric centers, has more such problems than other teaching hospitals. But hospital executives and other specialists say that the problems cited by the state Department of Public Health last week -- such as miscommunications among multiple specialists at a patient's bedside, or insufficient contact between supervisors and junior doctors providing frontline care -- also exist at other teaching hospitals.
Dr. Anthony Whittemore, chief medical officer of Brigham and Women's Hospital, said the crisis at Children's is sure to reverberate through the nation's teaching hospitals. He said the case shows it is time to change a culture in which residents get much less supervision in some specialties than in others, and a longstanding tradition of autonomy that has made some leaders reluctant to accept centralized rules.
Meanwhile, Whittemore said, Children's is trying to find out whether the deaths reflect a particularly serious problem at the facility: in hospital-wide systems, specific departments, or individuals.
"Tragedies occur in every institution. There seem to be three or four that occurred at Children's in a relatively short period of time." said Whittemore, a member of a committee named by Children's president Dr. James Mandell to help design improvements.
Five-year-old Matthew Siravo died May 11 after suffering an epileptic seizure while recovering from surgery at Children's. Three medical trainees from three different specialties -- intensive-care medicine, neurology, and neurosurgery -- were involved in his care but were unsure who was really in charge. No one ordered the aggressive treatment that is standard for such emergencies. A senior physician did not arrive until more than an hour into the seizure. The boy stopped breathing and died two days later.
Public health officials said the case illustrated the need for better communication and clearer lines of responsibility at teaching hospitals, which often tackle the most complex medical cases but face special challenges because of the miscommunications that can occur between different specialists or different layers in the medical hierarchy.
The problems have special resonance in Boston, which is a magnet for medical training, with thousands of residents, supervised by medical school professors, providing cutting-edge care at the teaching hospitals of Harvard, Tufts, and Boston universities. Hospitals have been buzzing with discussion of the Children's case.
The strength of teaching hospitals is that residents are there around the clock, while at community hospitals, patients may have to wait longer for a doctor to arrive, said Dr. Debra Weinstein, director of graduate medical education at Partners HealthCare, which includes both Brigham and Women's and Massachusetts General Hospital.
Still, she said, teaching hospitals have taken notice of the Children's case: "Any time there's an event of this nature at any of our institutions, it's healthy for all of us to look again at how we do things."
Physician training is a kind of apprenticeship where medical school graduates accept increasing responsibility and autonomy as they learn. Educators have long debated whether more supervision and teacher-trainee communication is needed for patient safety or whether that would rob residents of their chance to learn.
Now, some medical leaders say it is time for the pendulum to swing firmly toward supervision, particularly because medical care has become so much more complex.
"There's probably a cultural environment that encourages independent thinking and independent responsibility at too early a stage," he said. "Some trainees progress more quickly than others, and some teachers are more adept than others in assessing that progression."
"Some departments, at least in the past, have discouraged communication on the grounds that junior residents need to do as much and take as much responsibility as they can," said Dr. Paul Friedmann, senior vice president of Tufts University-affiliated Baystate Medical Center in Springfield. "It clearly doesn't work any more in 2003."
Friedmann, a former chairman of the national group that regulates medical training and a key player in the decision last year to limit residents' work weeks to 80 hours, said the next national push will be to increase and standardize supervision.
At Children's, too, internal surveys have shown wide variation from one specialty to another in the amount of contact between residents and senior doctors, according to data released in the hospital's correction plan. In one program, most trainees reported calling senior doctors after hours "frequently;" in another the majority said they call "infrequently."
"Our goal is to get a very strong unified response as we survey in the future," hospital spokeswoman Michelle Davis said yesterday.
Children's is also trying to improve communication among specialists. That is a challenge because specialties such as neurology and neurosurgery, or cardiology and cardiac surgery, sometimes compete to provide the primary care for the sickest patients, said Whittemore, a vascular surgeon.
Since the seizure case, Children's has weighed in on a hot battle over medical turf. From now on, intensive-care doctors will take charge of all patients in the intensive-care unit. Brigham and Women's has a similar policy, while at Massachusetts General, surgeons remain in charge of their patients even in intensive care.
Children's faces a period of important tests: In a series of inspections and reviews, it must defend its right to collect Medicaid payments and keep its hospital license.
Friedmann said the hospital could face reviews of its nationally famous residency programs, "if it can be shown that there has been a failure of supervision."
Dr. James Mandell said the responsibility falls squarely on him and other hospital leaders.
"We have great doctors and nurses who care deeply about patients," he told the Globe last week. "We failed them by not creating a system where they could do their best for this patient."
Whittemore said the committee at Children's would look at recent deaths "to derive the common denominators in the system errors and/or individual accountabilities and make whatever changes are necessary."
Some doctors say specialties like neurosurgery need a certain bold autonomy to do their jobs and can't be subjected to the same guidelines as other specialties.
`I don't buy it for a minute," Whittemore said.
Anne Barnard can be reached at email@example.com.
© Copyright 2003 Globe Newspaper Company.