THE RIVETING CASE involving a nurse on trial in a West Texas criminal court for filing a complaint against a doctor is, of course, about much more than the nurse's specific grievances. It's about all doctors and all nurses. It's about the widespread and demoralizing battles between them that are often fought on an uneven battleground. And it's about patient safety, which frequently becomes collateral damage.
The nurse, Anne Mitchell, had alleged in an anonymous letter to the Texas Medical Board that a doctor with whom she worked was practicing unsafe patient care. She cited several cases that were concerning enough to have earned the doctor an internal reprimand from hospital administration. She also claimed that he'd been encouraging patients to purchase an herbal supplement that he sold on the side.
After the Board notified the physician — Rolando G. Arafiles, Jr. — about the complaint, a dramatic series of unfortunate events unfolded on a very small town stage. First, the doctor complained about being picked on to the county sheriff — who, according to court documents, was his friend, a grateful patient, and a business associate in the doctor's herbal supplement dealings. That's gotta be worth a whole lotta loyalty points in anyone's book.
It did earn the sheriff's interest and involvement. According to court documents, he set out to find the person who submitted the anonymous — and supposedly confidential — complaint against the doctor. He traced and contacted the patients mentioned in the complaint, and, with his suspicion honed, obtained a warrant permitting him to search Mitchell's computer. There he found the source of the complaint letter that she had sent but declined to sign — for fear of losing her job.
Her fear was well-founded. In short order, Mitchell was fired from her hospital job and, subsequently, unable to find alternate employment. To make matters unbelievably worse, local prosecutors even filed a criminal suit against her. They accused her of "misuse of official information" — a third-degree felony charge that carries a Texas-size maximum penalty of 10 years in prison and a hefty fine.
As of Wednesday evening, closing arguments in the case are expected within days. Meanwhile, Dr. Arafiles continues to work. The Texas Medical Board, which is required to regulate state medical practice, has yet to complete a formal investigation of Mithchell's allegations. And court hearings have revealed that the hospital's internal reprimand to Arafiles for breaches of care had consisted of the administrator's telling him "not to do it again.'"
On a grand scale, the terrible irony is that Mitchell's attempt to improve patient safety may have backfired for patients in general. If you think nurses and other health care workers were fearful of reporting their concerns about endangered patient care before "... .
This alarm also was sounded in a harsh letter from the Texas Medical Board that reprimanded the District Attorney for conducting a criminal felony prosecution of the nurse. It charged that, by doing so, the DA had "potentially created a significant chilling effect on the cooperation of any other hospital personnel who might have been able to provide additional information needed by the Board" to complete its investigation of the doctor.
I am unable to assess the validity of the nurse's charges against the doctor. Ideally, that assessment would have taken place in a more timely fashion (which might have precluded this outrageously unnecessary trial), and by a hospital administration that contained something heavier than a verbal reprimand in its patient safety toolkit.
But I am confident in declaring that Mitchell had every right — indeed, she had a duty — to speak up when she believed that a doctor might be harming patients. She went through proper reporting channels — internally within her hospital, externally through the state board — which should have carried her concerns about patient safety through a fair and judicious appraisal. Instead, the system penalized her, and it failed patients.
Mitchell's story also fully embodies the concept of "moral distress" among health care workers. Broadly defined, moral distress occurs when a professional knows the morally right thing to do, but institutional structures, organizational cultures, or conflicts with co-workers create barriers that interfere with their ability to "do the right thing."
The erosive effects of moral distress on staff morale and retention are gaining increasing attention, particularly within the nursing profession. I spoke with Mileva Saulo Lewis, a nursing professor and educator at Samuel Merritt University in San Mateo, who notes that: "Moral distress has been identified as one reason that nurses choose to leave their jobs and occasionally to leave the profession." This is particularly concerning "in the face of a national registered nurse shortage, increasing demands upon a strained healthcare system, and demands of consumers for more effective and efficient high quality care."
She stresses that when coworkers appear to be placing patients in harm's way, nurses and other professionals should be able to ask critical questions without fearing retaliation or organizational inaction. Otherwise, "the price to them and ultimately to their patients is too high."
So, while this story is a tale about a heroic nurse in a small town with big justice issues, it is also a story about speaking truth to power. It's a disturbing reminder of the power imbalances among nurses, doctors, and hospital administrators that too often interfere with collaborative communication. And in the end, the story is all about patients — or at least it should be.
Kate Scannell is a Bay Area physician and syndicated columnist.