Longform

Missed Diagnosis

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"I had told the attorney he could have every penny we won," says Woodard. "This was not about money."

George Frey says he vividly recalls the three-page letter the board sent to him about Liechti's case. "The board did a thorough job of entertaining and evaluating the son's concerns," says Frey, who explains that he cannot discuss the particulars of his patient's case. In the end, however, the board took no action against him. "It's a very formalized process," Frey notes, "in a very neutral, unbiased environment.

"When you look at things from the inside, it may be very different from what the family sees from the outside. They're grieving and may feel nothing was done," says Frey. "But when you're talking about a complex medical environment, you need to make sure the people reviewing it have the proper experience to make a reasonable assessment of what went on."

Last month Woodard read a newspaper article about Debra Malone, an intensive care nurse fighting the Colorado nursing board's dismissal of a complaint regarding her father. Sixty-eight-year-old Karl Shipman, a physician for more than thirty years, died from a staph infection in Presbyterian/St. Luke's hospital two months after surgery for a broken wrist ("Doctor's Orders," March 25). During the most critical night of his illness, Shipman had been treated by an inexperienced nurse and an unsupervised medical intern in the ICU. (The medical board could not discipline the intern because she does not hold a Colorado license; it is now considering to push for legislation that would require licensing of all medical interns and residents.)

Woodard was struck by the similarities between Shipman's case and his mother's. He contacted Malone, who has since gone through Liechti's medical records for the most pertinent information so that Woodard can focus and resubmit his complaint to the board.

There is no statute of limitations for complaints to the medical board, but if a case is dismissed, "there really isn't any appeal per se," Miller explains. "When I talk to individuals who are very unhappy, what I advise them to do is write back to the panel and try and specifically articulate what really has them concerned. Sometimes, quite honestly, we never satisfy the complainant. They may go to a legislator, to the director of our department, those sorts of things."

"Often," explains Sinclair, the state representative with concerns about Janet Laurel's case, "it is only the person who has the perseverance and the will who gets some modicum of justice."

There are no personal horrors greater than seeing a baby wither away before one's eyes, or watching a parent suffer needlessly, or finding oneself suddenly faced with the prospect of a preventable death in the prime of life. Modern medicine, filled with daily miracles, makes patients want to believe that a cure is always within reach, if only their doctors knew where to aim their grasp. But when medicine fails to heal, human nature drives many to find someone or something to blame.

"Medicine is an art, not a science," explains boardmember Aguilar. "We probably make more mistakes than we ever care to admit--not just doctors, but nurses or anyone [in the medical field]. People aren't machines. Yes, there are things that are errors, but making them does not mean someone is a bad doctor."

Although most patients and their families are simply too grief-stricken, too baffled or too exhausted to get to the bottom of a medical tragedy, a few are driven to find an answer.

Even after her complaint against her son's pediatrician was dismissed by the medical board, Sharon Randel got back on the phone to the attorney general's office--which has taken the "extraordinary" step of looking into the case again, says Ken Lane, spokesperson for the office.

"It seems that we had to work too hard," Randel says. "For parents of a sick child, we just had to work too hard."

Scott Woodard is resubmitting his complaint--but this time his letter will be more concise and medically explicit. "I just want to make sure this time around I do it with proper help," he says.

Having lost two battles with the board, Janet Laurel has now turned her attention to other struggles. In her pink-walled office, where she sips a cup of warm water to quell a persistent cough, she points to the pin on her dress--the figure of an angel, sculpted from Spanish moss and Hawaiian iauhala grass, and sold for $15 each to raise funds for a nonprofit organization she's founded to explore the common medical and environmental history of all breast cancer survivors. Laurel named her group the "Cherubim Foundation" after the second order of angels, known as the "seekers of knowledge"; once she's recruited boardmembers, she hopes to survey 100,000 breast cancer survivors through the mail and on the Internet and hire a statistician to sift through the findings.

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Gayle Worland