Dr. Steven Horowitz is a retired neurologist from Maine and still teaches his specialty to future medical professionals at Tufts University School of Medicine. He is also a faculty member of the Maine Medical Center.
However, a 2018 visit to California to visit his daughter nearly led to a life-threatening medical mistake that could have cost the now-78-year-old physician his mobility and left the medical facility facing a medical malpractice lawsuit.
Bike ride leads to an ER visit
During his stay, Horowitz accepted a friend’s invitation for a 15-mile bike ride to enjoy the California countryside. While his friend cruised along using an e-bike, the physician tried to keep up using a bike that didn’t properly fit his frame.
Hours later, he developed numbness in his arms and neck pain that continued. Two days later, he went to an emergency department (ED) in a renowned hospital. Having the advantage of being a neurologist, he told the attending doctor he likely suffered from cervical spine disease with possible spinal cord and other conditions.
He asked the doctor to order an MRI scan and perform blood studies as he had suffered from a previous infection. He noted that the spinal consultant didn’t even use a reflex hammer during the examination and said he didn’t have or need one. Horowitz says that amounts to listening to the heart and lungs without a stethoscope.
The retired physician was in the ED for six hours without the doctor performing other basic tests that could have accurately diagnosed his condition. Despite not being informed that his blood test showed an increased white blood cell count, which is concerning, he was discharged and told to follow up with a spine surgeon later.
Doctor makes his own diagnosis after reviewing records
Horowitz was able to access his medical records when he returned to Maine two days later. He immediately recognized the magnitude of his situation and went to his hospital, where he underwent spine surgery and received strong antibiotics to counteract the infection.
If he had followed the California facility’s advice, Horowitz says he could have suffered catastrophic consequences – even becoming a quadriplegic, without the ability to move his legs and arms or even breathe on his own. Someone without his medical knowledge wouldn’t have been so lucky.
Hospital refuses chance to admit errors and learn from mistakes
As he recovered from his extensive treatment, Horowitz wrote several letters to the California facility detailing the lack of care he received. Hospital officials responded but refused to own up to the mistakes or apologize for the errors.
Horowitz even offered to discuss his case with the emergency and spine staff in light of his role as a teaching physician, noting it could have benefits for himself as well as the staff. The hospital ignored his offer.
The “normalization of deviance”
A landmark 1999 Institute of Medicine report said nearly 98,000 hospital deaths each year result from medical errors. Current estimates put that number as high as 251,000 per year. Medical errors are the third-leading cause of death in the U.S.
Horowitz says his incident highlights the phenomenon known as “the normalization of deviance.” It occurs when problems are identified but ignored or rationalized until a major disaster happens. He continued to reach out to the hospital, offering to do a presentation. The administrator responded, saying there was a chance that could happen once the statute of limitations passed for filing a lawsuit.
Horowitz replied, saying he didn’t want to sue the hospital, but help physicians learn from the experience. He said he would have certainly sued if he had not diagnosed his own condition correctly before more severe complications arose. He says it was an opportunity missed for all parties.
