UPDATE: Read my disclaimer. Don’t run crying to my employer. They have nothing to do with this.
UPDATE2: This is a repost of an article that was deleted when I had my disk crash, sent to me by a reader. I don’t have the comments, and I apologize to the commenters whose thoughts I have lost.
UPDATE3: This is the second of three articles.
The first installment is here.
The third installment is here.
The fourth installment is here.
The fifth installment is here.
The sixth installment is here.
In the last episode (Part 1), I discussed the medical issues behind the Martin Anderson case. Now, Dr. Siebert has been chosen as the sacrificial lamb for Florida’s racial politics. The establishment and media-friendly experts decided to ignore a decade or two of medical research and opine that Mr. Anderson had died of speculative causes. Now it’s time for the kill.
The Attorney General, and soon to be elected Governor, Charlie Crist decided to make an example of Dr. Siebert. After all, who was this little guy who thought that practicing medicine was more important than getting him elected? It was, I suppose, a no-brainer. Pandering to racial special interests is always a win when it can be done at no cost except for ruining the life of some cog in the machine.
So, the NAACP and similar folk decided to gin up some complaints against Dr. Siebert, and they found some editing errors in an older report. Attorney General Crist told the Medical Examiner commission to review Dr. Siebert’s previous autopsies and find something to crucify him with. They had their marching orders, and they stepped forward to obey.
The problem, unfortunately for the Medical Examiner Commission, was that Dr. Siebert is an excellent pathologist. The Medical Examiner Commission, made up primarily of political appointees but headed by a forensic pathologist, reviewed just under 700 of Dr. Siebert’s reports. What they came up with was shocking. In a review of almost 700 previous cases, they could find no diagnostic errors. None. Zero. Nada. Zip. Remember this. No diagnostic errors.
That was certainly politically unacceptable. So they decided to crucify him on the basis of his proofreading. The critique claims that it compared Dr. Siebert’s reports to autopsy report guidelines promulgated by the National Association of Medical Examiners. In fact, no such autopsy report format guideline has been promulgated by NAME. NAME has recently promulgated standards for the performance of autopsies, and the State of Florida also has professional practice guidelines. However, these were not used. They were not used for a reason. The reason was that Dr. Siebert met the NAME standards and Florida practice guidelines.
As one colleague who reviewed the critique noted, the Florida guidelines state that toxicology is only required on victims of violent death over the age of 10 where collapse occurred less than 12 hours prior to death,, and provides a statute as a reference. Yet Dr. Siebert was called “negligent” because he did not order toxicology on obviously natural deaths. In other words, he was castigated as “negligent” because he followed the Florida practice guidelines, not because he failed to meet them. The same was true for almost all of the examples of “negligence.”
Instead, he was castigated for such things as the fact that some of his reports had distances typed with the number next to the unit, and some put in a space (e.g. “2cm” as opposed to “2 cm”). He was criticized for not personally performing ballistics studies on retrieved bullets, even though doing so would have been bad practice, not good practice. In general, it’s not a good idea for a forensic pathologist to opine about criminalistic specialty issues he or she isn’t trained in. Some forensic pathologists are trained in other things; I’m trained in bloodstain pattern analysis, for instance. However, I’m not a ballistics expert. It would not be a good idea for me to report all sorts of things about a bullet I retrieved from a body and then turn it over to an expert for “real” analysis. We might not get the same answer, and then we would be in the position of having to explain why.
The mistake that the press really loved was a report in which a normal testes were written as present in a woman. In fact, of course, that was a trivial cut-and-paste editing error that can happen in virtually all systems that use word processing. And, at the beginning of the inquisition, this use of templates was the big thing the Commission criticized him for. Dr. Stephen Nelson, the chairman of the commission, was appalled that Dr. Siebert may have used “templates” or standardized base reports, from which he generated his final reports. This was, according to the commission, gross negligence.
Most of the alleged negligence came from Siebert’s use of “canned” autopsy reports that describe victims in much the same manner, using the same terminology to detail conditions of organs and other body parts, the panel found. The commission said it appeared Siebert used a standard template for his reports, not adjusting them to individual cases.
That is, at least, until other forensic pathologists pointed out that it was not only common practice, but was taught as good practice in many of the best programs. Why? Because it acts as a checklist and encourages consistency. I use a template when I perform autopsies, and read it as a script when I go through the case. I do so because as I go through each line, I am reminded to check each thing that is discussed. If the script says “The irides are [insert color],” then I remember to look at the eyes and fill in the blank “The irides are blue.” It’s important to have a systematic approach to doing things, usually in a stepwise, checklist manner. Otherwise, you tend to focus on the big stuff and forget to check the small stuff. If you get a case with a big shotgun wound to the face and spend all your time describing that, you might forget to look at the toenail of the little toe of the left foot. If you follow a script, you will be sure to cover it.
You sort of have the choice of errors you can make. You can use a template and occasionally have cut and paste errors. Or you can use a stream of consciousness technique and forget to do stuff. Frankly, the first kind of error is better. Cut and paste errors, by their nature, are usually obvious and silly (such as reporting normal ovaries in a man or testes in a female), easily corrected, and almost never have any diagnostic significance (because if there were something there that was unusual, then the template would not have been followed for that organ). In contrast, the errors of omission that come from free form approaches are often not noticed and are, in my observation of practice and review of many, many reports by other forensic pathologists, frequently diagnostically important.
Second, there is the issue of religion about practice techniques. I have no problem with people who don’t like using templates. I’m not surprised that some people find that it increases their error rates. It’s like keeping track of appointments. Everybody needs to do it, but everybody doesn’t need to do it exactly the same way. Some people use Day Planners; some people use PDAs, and some people have secretaries that follow them around and tell them where to go. De gustibus non est disputandum and all that.
I find templates profoundly useful for the reasons that I have mentioned, and the use of templates as checklists increases the quality of my work. As far as I know, there are no empiric studies showing that people who use templates have a higher error rate or lower quality of work by any meaningful metric. I certainly don’t know of any study that shows that the occasional cut and paste error associated with templates is any worse than the errors of omission I have seen in the reports of people who do not use them.
It is one thing to eschew templates in one’s own work. That’s great – and whatever habits, crutches, and tricks one uses to do better work are good to go. It’s another thing to generalize that into a fundamentally religious statement of how *everybody* should practice. It is another thing again speak in the royal terms of the “people of Florida” to make those religious pronouncements with the implication that the use of templates, per se, is generally recognized to be bad practice. To many of us the opposite is true. It is even worse to pretend that an obvious cut and paste error is something other than a simple cut and paste error in order to support that point.
In fact, Dr. Siebert denies using templates, and the accusation has not actually been proven. More important, there there was a reason for the cut-and-paste error that made the news. As Dr. Siebert could have told the Medical Examiner commision, had they deigned to allow a reply, this was a report that was generated while the office was recovering from hurricane. As Dr. Siebert wrote to me about this particular case:
The one I have no excuse for missing on proofreading was the mixed up genitalia. It occurred during hurricane Ivan. The office lost power and my transcriptionist was working with a laptop and rather than starting a new document, she attempted to transcribe over a previously opened document. I take full blame for missing it on proofreading and when it was pointed out by the family, I immediately apologized and amended it almost TWO YEARS AGO.[emphasis his]
This is why Dr. Nelson and Governor Crist decided to ruin his life?
But let’s continue with these “errors.” In this litany, many of the “errors” were contrived, most were trivial, a few were insignificant, and one or two tested the waters of “minor.” Most of the errors were criticisms of omissions of various details. What the reviewers failed to acknowledge is that Dr. Siebert often went to scenes, and his examination of the body at the scene was recorded separately than the autopsy report per se. Thus, for instance, he was “negligent” for not indicating such things as rigor mortis at autopsy; he did not because he recorded that at the scene the night before, when it was much more meaningful. Since the reviewers declined to review that information, and declined to allow Dr. Siebert to provide input, they called Dr. Siebert “negligent” for not including these later (and thus useless) findings. Dr. Siebert was not allowed to review the report before it was given to the press, and thus did not have a chance to address these glaring issues. And, of course, these issues were ignored by the press.
Even so, the reviewer was forced to admit:
“It is also fair to say that these errors had no influence or potential influence on the final opinion.”
This is the central issue – yet is not discussed in the Conclusion. It’s not a freaking “Oh, by the way.”
Let’s get this straight. Folk put 698 autopsies under a microscope in order to criticize things like the number of spaces between 2 and cm, and found no errors of diagnostic significance. A twenty-some-odd year history of dedicated public service and zero errors in diagnosis. This is what the ME Commission calls gross negligence. In fact, no active forensic pathologist in the world would do much better. In this act, the ME Commission has basically put its foot on the neck of every ME in Florida, since all would be found negligent in a similar inquisition.
In most discussions of errors, there is some sort of grading of the impact the “error” would have had on the final diagnosis. For instance, in articles describing the value autopsy findings when compared to antemortem clinical diagnosis, these are usually classified: 1) they did not affect the diagnosis, 2) they had a minor affect on diagnosis and clinical course 3) they would have had a major change in the diagnosis, clinical therapy, and course. There is a profound difference between missing a capped tooth in a drug overdose and missing a bullet wound in a shooting. Were that done in this report, the newspapers would have had a different spin, I suspect.
But then they could not have tried him in the press. And, of course, the purpose of all of this was Dr. Siebert’s personal destruction. The commission head, Dr. Nelson, did not have any qualms with trying him in the press. And, it was clear that this was not directed at helping a professional that needed a little direction and retraining, but instead at destroying Dr. Siebert’s career in the long term. As Dr. Nelson was quick to point out when the Commission recommended a draconian probation, he wanted Siebert broken.
‘Siebert’s punishment clearly disappointed the commission’s chairman, Dr. Stephen Nelson, who led the three-member probable-cause panel and therefore couldn’t vote Wednesday due to the commission’s rules.
‘’This sends the wrong message to the people of Florida. It says this is just a clerical error, it’s no big deal. It says that sloppy work is almost acceptable. It’s not,’’ Nelson said. “These are people’s lives and families we’re talking about with these autopsies, and we owe them the best service possible.’’
Though the probation ‘’doesn’t do a lot,’’ Nelson said, it will be a stain on Siebert’s record when coupled with the national press attention surrounding Martin’s death. “All of this will certainly be fodder for attorneys who want to challenge his work.’’
In other words, the important thing is to destroy the man. Fix it so he’ll never practice again. Mission accomplished, Dr. Nelson.
These guys wanted blood, and they didn’t care how they got it. And that damned “due process.” It sure gets in the way when you just want to hang a man and get it over with. Dr. Nelson complained to the press when Siebert said he wouldn’t roll over:
“It’s frustrating, but it’s due process and it’s what our state statutes provide,” said Dr. Nelson.
Dr. Siebert’s case is now under appeal, but it doesn’t really matter what the results are. His career is ruined. He’s damaged goods. In that respect, at least, Dr. Nelson is getting his wish. I sincerely hope that Governor Crist is enjoying the governor’s mansion. The doors shouldn’t squeak; he’s oiled them with the blood of Charlie Siebert’s career. The treatment of Dr. Siebert has been so egregious that the National Association of Medical Examiners took the unprecedented step of writing the Florida Medical Examiner Commission to offer its assistance in rectifying the situation. I doubt the ME Commission will take them up on it.
In fact, I know they won’t. A source has told me that when the letter was mentioned at the last ME Commission meeting, Dr. Nelson said that since Dr. Siebert has chosen to appeal, there was no reason to discuss or respond to the letter. He never read it into the record and did not allow any discussion by the other commission members.
One of the reasons that Dr. Siebert’s career is ruined is that he is a contract employee. Even if he is exonerated by the appeals judge, I doubt that he will have his contract renewed when it expires in June. Recently, David Bernstein at the Volokh Conspiracy opined in favor of making medical examiners private contractors instead of civil servants. The problem is exactly this kind of thing. The modern version of the civil service system in the US, as a federal institution, became important after the assassination of President Garfield, who was killed by a disgruntled supporter who wanted a private contract job. Historically, before that time, government jobs and contracts were essentially political plums and resulted in the spoils system. The civil service was created to avoid the corrupting influence of political pressure on private contractors for the awarding and continuation of jobs and contracts.
Folk decided that how quickly one got one’s car tags, etc. (or the contract to provide them) should not depend on one’s political affiliation. Nor, I personally believe, should forensic diagnoses. The presence of an apolitical civil service with protections against both political influence and private corruption is a cornerstone of making a democracy work, and the English tradition of civil service is one of the big reasons that democracy is more successful in the anglosphere than anywhere else.
It is always easy to blame civil servants for everything that goes wrong in government. But in fact, my experience has been that most civil servants try very hard to do a good job under difficult circumstances. Most of the inefficiencies that I saw as a DoD civilian, for instance, had much more to do with legal requirements than any desire to do a good job. And much of that had to do with contracting requirements – that a contractor be a certain race, a certain gender, from a certain part of the country, etc. In Washington, DC, for instance, there are minority/women-owned companies whose sole purpose is to act as a conduit for what you really want. You want an Acme widget because it is better and cheaper? But you say that Acme is a large corporation or a corporation run by a white male? Then call XX company, a minority, woman-owned company, and tell them what you want and where to get it. They will buy it an sell it to you at a 20% markup, but at least you get what you want. I did it every year. But, of course, those kinds of inefficiencies are the fault of “civil servants,” not contractors.
The constraints that make civil servants seem unresponsive are most often constraints that are placed onto him or her, and not a function of being a civil servant. As contractors take on more civil service tasks, they become more like civil servants, with similar constraints. Government money comes with strings.
Even the efficiency argument made by privatization proponents doesn’t really hold up to inspection. Sure, it’s fun to stereotype government employees as lazy and entrenched. But in fact, private contractors have just as many problems.
While there are many examples of contractors who provide excellent service, virtually every large comparison of privatization versus civil service over multiple contractors has been at best a draw, and in general have favored the civil servant. That is why in the past 10 years, in spite of increasing prejudice towards privatization, the use of private contracting has decreased, not increased, and many jurisdictions are moving away from privatization. A long term study at Cornell from 1992 to 2002 found that while privatization grew during the first part of this period, during latter part manyjurisdictions began bringing back in services they contracted out:
Local government service delivery is a dynamic process. This year, for the first time, ICMA looked at the stability of alternative service delivery, asking governments if they had brought back in house services that they had previously contracted out.Of the 22% that reported bringing services back in house, the reasons cited were problems with unsatisfactory service (73%), problems with insufficient cost savings (51%), and an improvement in internal government efficiency (36%). These findings show that it was primarily poor performance by private deliverers themselves rather than problems with contract specification and monitoring (cited by fewer than 20% of governments) that prompted governments to bring services back in house. In other words, it is poor contractor services and not politics that underlies strong political support for bringing service delivery back in house.
Warner, M and Hefetz, A. “Pragmatism over Politics: Alternative Service Delivery in Local Government, 1992-2002. International City/County Management Association Municipal Year book 2004, pp 8-6.
The disasters associated with privatization are well known, including the privatization experiment of welfare services in Texas and the mixed record of privatization of prisons. The list is extensive.
But efficiency isn’t really the point. I assume that most people would rather have a Medical Examiner who made his or her diagnoses based on medical issues rather than political demands, even if he or she were a tad less efficient than a contractor who had his or her diagnoses dictated from the Governor’s mansion
And that independence is what the privatization folk are throwing away. While many M.E.s in Florida are public employees rather than private contractors, they do not get civil service protections. They get the worst of both worlds. While the Siebert lynching has been playing itself out, I have listened to two Florida M.E.s state privately to me that they were appalled by what was going on, but were afraid to say anything for fear of being targeted by the ME Commision. If the trivial errors found by the Commission are sufficient for the official finding of “negligence,” then *all* Medical Examiners in Florida (and for that matter in the world) are “negligent.” That’s one reason I’m bothering to write these two articles. The MEs in Florida are intimidated. There are no innocent in Florida, now, only the untargeted.
We are seeing in Florida how the use of private contractors with limited terms will result in the political corruption of a Medical Examiner’s office. Dr. Siebert, I am sure, will not have his contract renewed. And it will not be renewed a) because he is a contractor and does not have the protections of a civil servant and b) because of political influence on the Medical Examiner system. A similar political attack is being played out in Indianapolis.
The Florida ME system was, at one time, one of the best in the nation. This demand that Medical Examiners base their diagnoses on political considerations rather than medical ones or face professional and personal destruction will destroy the system.