IBlogdius

Foundations of Patient Safety

2005-01-17T13:54:00.000-08:00

I’m not sure if anyone would argue with me on this, but isn’t the rule of law the rock bottom foundation of patient safety? Consider a healthcare environment in which criminal law is not enforced, where crimes against patients are not reported or investigated, and where the victims of crimes cannot find anyone who will respond to their complaints. Could the state of patient safety be worse than that? If so, tell me how and I will begin the discussion there. For now, I will begin it with the assumption that keeping patients safe from crime in medicine is the foundation of patient safety.

Next consider this statistic from JCAHO. In a recent given year 4.1% of sentinel events in medicine were assault, rape and homicide. And the least likely people to report those crimes were healthcare workers. Indications are that they report such crimes at a rate that is one time in some thousands.

Unfortunately we don’t think in statistics. We think in stories. The thousands of crimes that are not reported are not stories that we hear. The one crime that is reported is. It skews perception making it appear as though reporting is routine.

Well, reporting some things is routine, just not reporting crimes. To refute the idea that there is a lack of reporting in medicine, recently Saint Nate cited the case of David Arndt, the surgeon who walked out of a surgery to deposit a check. That case does not refute the lack of reporting in medicine. For one thing, it was not a crime. The discussion was about crime (although I can see how that wasn’t clear). In the second place, Arndt’s behavior was something that routinely is reported. Whenever someone enters or exits an operating room, it is reported. If Arndt, instead, had groped the patient or punched the unconscious patient in the mouth, we would not have heard about it. That’s what the JCAHO statistic means.

I wanted to write a series of blogs backing this up. I wanted to cover the practices and routines preventing reporting, written state policy that advises not reporting, loyalty versus safety and how that creates silence at every level, examples more specifically relevant to this discussion, and what happens when patients report what has happened to them. But the more I learn about blogging, the more I think this isn't the appropriate forum for that. A website might be better for that. Blogs are so ephemeral. Commenting on the day's medical news is probably more appropriate for a blog.

However, the whole story is in that one JCAHO statistic anyway. There is a crime rate in medicine. The criminals almost never are reported. The medical profession brushes off discussion of this even though is the rock bottom foundation of patient safety.

2005009

Patch and Tinker

2005-01-13T03:12:00.000-08:00

To limit malpractice rewards for pain and suffering is to patch. To provide pharmaceutical benefits for the elderly is to tinker.

Medicine began as a fleet of canoes, practitioners who arrived in buggies to bleed patients, that slowly were lashed together to carry a titanic sized load. There are basic design problems with that. They won't be solved by patching and tinkering.

When medicine was horse drawn practitioners traveling to patients, the amount of the community's resources necessary to support medicine was a small percentage of what it is now. The amount of power that medicine had over the community also was small. If the founding fathers had been faced with it as being as large a component of the community as it is now, it would not have been left out of the constitution. It was discussed at the constitutional convention but was not included.

A few years after the constitutional convention, a fundamental change was made in the relationship between the people and politics. Our founding fathers saw that when people were sued merely for speaking about politics, the people could not have the public discussion necessary to check the government. If medicine had been as powerful as it is today, wouldn't they have fixed that for medicine just as they did for politics?

It would be a fundamental change in the relationship between medicine and the community. It has the potential to enable the community to learn enough about medicine to solve core problems. It also has the potential to motivate medicine to clean up its own act. A normal business responding to normal market pressures is intensely interested in following its customers to see how products work for them. For most of its products, medicine has no idea how its customers fair several years down the road.

Requiring them to has been tried and is like requiring children to mind. Putting medicine in a position to need to would be a fundamental shift. When both the medical community and the community at large have access to information that currently isn't even collected, we finally will be able to start talking about the problems. Just knowing that that information will become public will go a long way toward motivating medicine to clean up its act rather than simply screaming to protect it from having to pay for not having done so.

Punishing Persistent Wrongdoers

2005-01-10T14:56:00.000-08:00

The January 7, 2005 edition of Medical Economics says that we need to punish persistent wrongdoers in medicine.

Why does it have to be persistent? In medicine is it ok to do wrong as long as it is only once in a while?

We need to recognize what an information fortress medicine is. Medical personnel DO NOT report each other. They do not record wrongdoing. Loyalty is the overriding ethic of medicine, not law and not safety. Careers are not ended for venting by injuring a patient. They are ended for reporting it.

The result is that criminal law is not enforced in medicine except in the rarest of circumstances. What hope is there for improving patient safety when even laws are not enforced?

2005007

Liability Limitations in Healthcare

2005-01-07T05:46:00.000-08:00

Another blogger, Curious JD, wrote, at:
http://www.rangelmd.com/2005/01/whom-do-you-trust.html
that "Unless you can show evidence that the jury system is completely failing on all counts (which would require you to argue that they should be finding MORE malpractice than they do). . ."

Harvard researcher Dr. David Studdert, in a 1999 study of 14,700 medical charts, found that of the patients who suffered negligent injury, 97% did not sue.

It is not hard to argue that they should be finding more malpractice than they do, but most of the people who would want to argue that cannot speak (see below).

An injured patient with a legitimate case almost never can get a lawyer. It's got to be a big-money, easy-win case not only because of how expensive it is to bring a case, but also because of how seldom medical malpractice cases are won. Each case has to have the potential to make up for all the loses. With liability limitations, injured patients with low salaries are rejected by lawyers, because income replacement is the lion share of what they can get.
This has the effect of making targets out of a class of people - all those below a certain income level.

One thing lost in this discussion is an awareness of physicians as people with flaws. If a senator or a med mal lawyer is the patient, you know how high the level of care will be. The reverse also is true. Patients who are viewed as powerless not only get less attention, but are the ones who become targets when a physician gets angry or lustful, or just feels like showing someone who is boss (dismissing this as too rare to worry about both ignores the statistics on the crime rate in medicine and is to say that it is ok for healthcare workers to commit crimes against patients, as long as they do it only rarely).

The first thing that happens when that victim tries to find treatment for the injuries, is that the victim is unable to find a physician who will diagnose the injuries. Physicians always ask a patient how he/she was injured. When a patient says the surgeon raped her, or whatever, it is guaranteed she will not get a diagnosis containing evidence of that crime.

When she goes to the police she is warned that she will be sued for filing the report and advised that there will be no witnesses (no matter who saw it) so there is no point in filing it.

When she telephones the state medical board, they say they will mail a form to her. She's got fresh wounds, possible fluids that could be evidence, and they are putting a form in the mail. When it arrives it requires her to do the investigation. The outcome of that investigation relies on the answer to the medical board's question: what physician verified that her injuries are a direct result of the surgery (they never say "the crime" or "the rape").

No physician can verify who committed a crime by looking at the injuries. So her case will be dismissed for lack of evidence (check that out - state medical boards, run by physicians, do not discipline other physicians on the basis of complaints from patients, but only for things like getting too many DUIs or failing to make child support payments). Medical board’s have processes that nearly always, if not always, result in the dismissal of the complaints of patients for lack of evidence.

So the patient has no where else to go but to a med mal lawyer. If she gets one, the lawyer will turn it into a civil suit. Lawyers cannot not bring criminal suits. County prosecutors bring criminal suits. But prosecutors respond only to investigations done by the police, and the police warn injured patients that if they file charges, they will be sued for more than their total lifetime earning potentials, and bankruptcy will not protect them from those judgements, and they probably will lose.

In all the discussion of liability limitations, there is no awareness of patients as victims of suits as well. There is no limitation on the amount for which patients can be sued just for speaking. We never hear their stories. Risk management departments at hospitals are experts at making sure patients are too frightened to speak, even to friends, even privately, about what has been done to them.

These are the patients who have the most primary information about how it is that there are so many lawsuits. They might be the ones we most need to hear from on this issue and they cannot speak. So the discussion is framed by physicians in terms that assume that patients are not well meaning (frivolous suits) while physicians are (errors).

Perhaps the problem of huge liability awards needs to be viewed from an angle other than top down in order to find solutions. Currently a license to practice medicine is a get-out-of-jail-free card. And the discussion is about how to make it a less expensive one.

Injured patients, when asked (which is seldom), often say that what they really want is a public accounting of what happened to them, usually in order to protect future patients. They get the opposite with nowhere to go but court.

Maybe we could make some progress if we recognized them as people with ruined lives and no where to go for help. These almost universally are patients who have no experience with suing anyone, but they are left with no other option. Part of the solution might be found in giving them some other option, rather than merely looking for ways to put a stronger lid on the pressure cooker. The complaint processes and self-policing currently existing in medicine don’t even reduce the rate of intentional injuries in medicine let alone give an outlet to victims of errors.

I doubt that liability limitations are the answer. I suspect that eventually there will be a backlash to them that physicians won't like. Maybe, as a token, it would help if we at least protected patients with the same liability limitations that protect physicians.

2005006

Do Patients Want Doctors to Decide for Them?

2005-01-05T19:48:00.000-08:00

Groups of humans contain people who become knowledgeable about different things. One person will read movie reviews and talk to friends who have been to movies to become knowledgable about entertainment choices. Another focuses on levies for school funding and education related issues. Another concentrates onkn zoning. Others will be inclined to assume policing functions. It is not necessary for each person to understand everything. The group figures it out.

Unless they are patients. Patients cannot do that. Patients are a group who cannot gather the information necessary to do that. The data isn’t available to them. Much of it isn’t collected by anyone. Much of the rest is hidden. Even a patient’s primary care physician does not have access to it. Recommendations made by physicians are not based on the kind of information and analysis that patients would require for themselves if making the decisions.

I went to a surgeon who recommended that I allow him to operate. He said the surgery had an 87% success rate (as I recall). I went to a physician in a related field, whose income does not result from that particular surgery, who told me that the operation really has a success rate of less than 20%. Another surgeon in the field gave another high number. Another physician in a related field put the number lower than anyone else so far.

What were those numbers based on? Dr. Robert Califf, a professor of medicine at Duke, recently said, "If you are making a ton of money being reimbursed by Medicare, the last thing you want to do is put your treatment to a test." The same is true whether or not Medicare is the source of the money, and whether or not the amount is a ton.

Surgeons quoting their success rates are not tracking patients in a scientific way. There is nothing correcting for their biases. There is no objective information on which to base success rates. How are that surgeon's patients doing three years down the road? No one knows. Patients are left hoping for luck when they take the recommendation of whatever physician is advising them at the moment. And medicine interprets their resignation as their not wanting to make the decisions for themselves.

The self-interest and disintegrity that is the foundation of so many recommendations made by healthcare professionals, while believing themselves to be well-meaning, is felt by patients who are conscious that medical matters remain beyond their comprehension without their understanding why.

Do you know your misdiagnosis rate? Do you think I would be satisfied with the basis of your belief?

It’s time to gather and release the information that will allow patients to understand their healthcare and make decisions knowledgeably.

2005005

Jury Award Caps

2005-01-04T07:42:00.000-08:00

What do the patients get? There is no cap on the amount for which physicians can sue patients. The first response of healthcare to an injured patient is legal. Risk management departments make sure injured patients fear of the amount of money for which they can be sued for talking. A victim of sex abuse in a hospital is warned that his or her filing criminal charges can result in punitive damages that cannot be escaped through bankruptcy and that can equal far more than the lifetime earning power of the patient.

The physician who negligently or intentionally injures a patient is protected by caps. The patient who speaks about it is not. When I try to speak to injured patients, usually they are too afraid to speak, except about why they are afraid.

When physicians get caps, what do patients get? The freedom to speak is a necessity if we are to learn about what happens to patients in healthcare. A mutual cap would be better than nothing, but freedom from suits altogether for patients who speak would help to open up the grand hush hiding negative information in medicine.

2005004

Tying Performance to Payments in Medicine

2005-01-03T07:48:00.000-08:00

Medicare experts are making a valiant effort. Unfortunately it will have stifling consequences in the long run.

For treatments on which there is complete agreement about what to do, Medicare has begun tying cost of living payment increases to compliance in delivering expected care. This has motivated physicians to take better care of patients. Unfortunately, it likely will stifle thought and innovation in one of the smartest groups of people on earth.

One of the problems Medicare is trying to correct is the problem of caregivers not bothering to provide the care that they know they should. If Medicare tells them exactly what care to give, won’t that create the problem of many of them doing nothing other than what the forms demand that they do? Isn’t that cookie cutter medicine at its worst? To say nothing of how frustrating it will be for highly trained professionals to be managed as though they had neither the motivation nor the acumen to handle the most rudimentary aspects of their jobs?

Let competition in the marketplace exert some of the pressure to perform. Let firms like Consumer Reports have access to information to rate performance. Let patients talk about their care without threats of lawsuits silencing them. Let journalists and others see what patients are complaining about to state medical boards. Open medicine up so that there is enough information for the market place to function. Physicians who do not bother to give adequate care will begin to when patients have the means to see that and go elsewhere.

When customers with weak immune systems are deciding which restaurants to go to, they can call the health department to learn which restaurants have the cleanest kitchens. Those same customers cannot learn which hospitals have high infection rates. There are agencies that track the infection rates of hospitals, but patients are not allowed to know it.

Medicare’s tying payments to performance has its heart in the right place, but managed economies are tyrannies that do not perform well. Where would cuisine be if health departments told restaurants exactly what to serve? Where would it be if people were not allowed to write about and talk about it if they got food poisoning in a restaurant (patients are threatened with lawsuits everyday to shut them up about negative experiences in health care)?

Information about health care needs to be collected and revealed so that the marketplace can function to remedy these ills. It is not necessary that every patient grow to understand enough to manage his/her own care. Every taxpayer does not understand his/her taxes, but the marketplace invented H&R Block and a host of other means to help them. The same will happen with medicine if it ever is opened up so that the necessary information can be collected and disseminated. Currently, even primary care physicians cannot learn the infection rates of hospitals or any number of other kinds of information patients would want to have known by someone guiding their care. Patients themselves need to have access to this information so that enough of them can become experts in their own care to help guide this marketplace.

As it is now, minimum standards of care simply are not bothered with by caregivers who respond by demanding legislation limiting malpractice exposure to further insulate themselves from the marketplace.

* * * *

Here is a link to hospital ratings created by Medicare:
www.cms.hhs.gov/quality/hosital/
A meager amount of information is available there and requires the good will of the hospital to get it. In spite of that, according to the New York Times (12/25/04 front page), hospitals viewing that link often are in shock to discover they have been forgetting treatments that can make the difference between life and death.

They never will be adequate overseers of their own performance. Patients cannot be expected to believe that government agencies will oversee it either. Patients need the means to oversee it themselves.

2005003

Feedback Structures in Medicine

2005-01-02T08:22:00.000-08:00

"Doctors are unaware of their shortfalls and are rewarded no matter how well they do." - New York Times, December 25, 2004

Regulation cannot solve a problem like this. We need openness. We need sunlight. Market forces cannot operate when they don't have information.

The surgeon, who was the head of his department at the hospital, was earning his living by repeatedly performing the same, outdated surgery on one patient after the next. Once those patients have had the procedure, there is no way to go back to determine if the procedure was necessary. No one will be able to make that determination after the fact, and no other physician would criticize a colleagues care in that way.

He, as most physicians, wanted me to have faith in him. I’m not a standard patient. I needed knowledge and understanding and finally removed myself from his care and searched for patients with the same problem who had gotten successful results elsewhere. That lead to a surgeon who congratulated me on not letting the previous physician operate. All I needed was physical therapy.

It was so disturbing to know that my previous surgeon was wasting so much time and money and exposing patients with my condition to unnecessary surgeries that I tried to call his office to tell him what I'd learned. The nurses would not pass that information on to him. I tried to make an appointment, which I would have to pay for out of my own pocket, but the nurses would not let me make the appointment. They said, "You cannot tell him that because, see, he's a doctor."

One might have thought that his being a doctor was exactly why he should learn about this. There was no reasonable way for me to get the information to him.

When he had been trying to schedule me for surgery, he had explained to me that after this procedure I would need a maintenance procedure every few years (this was orthopedics). I do not need to point out the conflict here between a procedure that is expensive and invasive and provides an ongoing income stream to the surgeon versus simply sending patients to a physical therapist that do nothing to enrich surgeons.

We cannot count on physicians to be saints. Adequate feedback structures do not exist. One of them needs to be market forces, at least to some extent. Market forces cannot exist without information.

Currently the general public is denied access to basic information about medicine, like infection rates at hospitals. Other similar data is not even collected. People like the orthopedic surgeon above are not scrutinized in a way that solves this problem. They are insulated, protected and rewarded, most of the time, no matter what happens to their patients (paranoia about “frivolous” malpractice suits notwithstanding – fewer than 3% of legitimate claims ever find an attorney – so most of the times that damage is done they are rewarded).

All these points will be expanded in future blogs. I’m trying to keep these bite sized.

2005002

Coaxing Health Care to Care for Health

2005-01-01T17:25:00.000-08:00

On Christmas Day the New York Times ran an article under the banner on the front page called "Program Coaxes Hospitals to Seek Treatments Under Their Noses." I have a few things to say about points raised in the article. Today I'll touch on one.

The article points out that medicine is one of those very strange parts of the economy where the producers/providers get paid no matter what quality of service is provided.

There are a number of things I'd like to say about that single issue. For instance, where else in the economy do you call their office to ask if they can provide a specific service and be told that the only way to find out is to make an appointment and, after traveling to their city, waiting for an hour and a half, and paying $170 USD, learn within 40 seconds that the good doctor does not have that expertise?

The system of referrals that is supposed to deliver us to appropriate care, without their office personal even knowing what their bosses do, has too many holes in it and requires way to many trips to physicians referring to physicians referring to physicians hoping to end with someone knowing the correct one for the problem.

Medicine should operate more like the rest of the economy. Patients should be able to make phone calls, become educated by speaking to people who are educated, and find their way to the correct expertise without having paid for half a dozen unnecessary appointments.

That is not the main problem with providers being paid regardless of whether or not they actually do anything for the consumer/patient, but I'm trying not to write tombs longer than can be read, and written, in a casual sitting. I'll return to the issue another day.

2005001