Lucian Leape
Why Lucian Leape is the problem.
The job of the novelist is to identify the problem, not to
solve it. That is the gift Leape gave to us. He finally got the community to see
that there is a problem. Where he errs is in getting trapped in the expectation
people have for identifiers of problems also to be solvers of problems. When a
novelist points out a problem, people can tend to
speak as though the novelist is a failure for not providing a solution. Just
identifying the problem should be recognized as a success.
Leape, though, talks about solutions.
Unfortunately, his thoughts about that do not have the potential to make patients
safer. In fact, they keep us mired in bad ideas that cannot work. Because he believes in their snake oil. That is understandable
because he used to be a surgeon. So he is one of them. Collectively they share a view of the world
that is more subjective and self-interested than they recognize. They believe in
their own snake oil. And they don't know that about themselves.
We are grateful for Leape's IOM study that finally
managed to get the medical community to admit there is a problem. To get them to
admit that, he used their own records to show it.
Originally, we had thought that he used their records in order to be as
conservative and diplomatic as possible in order to have as much credibility and
acceptance as
possible with the medical community. There was going to be so much
resistance to the information about how much they err that this was important.
So when he used their records, we thought
it was for that purpose and that surely he would be aware of how little negative
information actually gets into their records (2% according to
the 2010 report by the US Department of
Health and Human Services).
It turns out that he isn't. He believes their records. He
believes in their snake oil.
The medical community has an agenda that governs what gets in
the record. All of the information Leape has about medicine is based what
people in healthcare are willing to record. Regarding sins and
errors, that is very little. The most important thing to know to make patients
safe is what goes wrong, when, where and how often. That is the last thing
that gets in their records. Leape, like virtually everyone else in medicine,
apparently is not aware of that.
What they won't record
kills
patients.
He has said, "When I go to a doctor, I should have somebody
who I know is competent, who I know I can trust and who will put my interest
first. Two of those three have nothing to do with science." The first could have
something to do with science, but doesn't. The second two have nothing to do
with reality. Dreaming that that they do is folly. That would require humans to
be saints, which I've written about in The Saint
Theory of Medicine.
That is why safety does not improve
and costs keep spiraling up
Saints might be able to keep the interests of their patients
ahead of their own, but we don't have a lot of those. Especially when things go
wrong. When things go wrong, as one injured patient recently wrote, "They smear
your name and leave you for dead."
Ever meet a doctor who is conscious of that? Lucian Leape isn't either. He believes the snake oil.
Where is awareness of the refusal of anyone in medicine to
report most adverse events? (see Medical
Reporting) Where is awareness of the ubiquity of covering up (see
Blacklisting)?
Where is awareness of the extent to which health care providers are just brokers
with no skin in the game? Where is awareness of the extent to which having
"somebody who I know is competent" is a function of getting objective
epidemiological information on practitioners from sources outside of medicine
because no unbiased information comes from inside of it? (see
Benjamin Rush for starters)
That is where the first of those three things could have
something to do with science, but doesn't. But at least it could. The other two
are fairytales from lala land. Any patient who is lulled into the trap of
relying on either of those two things is perpetuating the system in which patients blindly
do what they are told and then pay what they are told. Unfortunately, patients
have no other choice as long as information about caregivers comes only from
caregivers.
That is letting mortgage brokers make your borrowing
decisions for you. Believing in mortgage brokers resulted in many thousands of
bankruptcies. Even with that, most bankruptcies still result from medical bills.
Because doctors are just brokers with no skin in the game, but doctors have even
worse information about the products they are selling. Their information is
based on faith and the self-serving, subjective information provided to them by
other caregivers who do not report most of what goes wrong.
Does a pedophile report him or herself in the record? Does an
abusive nurse record her abuse? Does your doctor know if he/she is delivering
you into the hands of someone who is a problem? No.
Lucian Leape's report called for a national error-reporting
system, as well as private reporting systems through which providers could
discuss mistakes and best practices for fixing them without fear. To think that
will work is to ignore the biggest problem for patient safety.
Do they think that with a change in culture criminals will
report themselves? Or that they will be no more crimes? Where is awareness of
the crime rate in medicine? Where is awareness of the need for justice when
crimes are committed? Where is awareness of the fact that the worse the adverse
event the more energetically the community covers it up? Where is awareness of
the fact that systems that do not address the worst abuses cannot address more
subtle problems?
For someone in medicine to report someone else in medicine is
a betrayal of the highest magnitude. You would have to re-code their DNA to
change that. The betrayer loses the trust of
everyone in the system. It is not possible to work without that trust. No policy enacted from above can preserve or recreate
trust destroyed by betrayal. The betrayer's career is over (see
loyalty). To suggest that changing their culture to one that is "without fear of punishment" and/or that is "a rich reporting culture" is to bring
to the subject such a shallow understanding of human bonds as to be talking
about a fairy tale.
The idea that if the culture is changed, looking out for
number one will not be important to them anymore is silly. That's what Stalin
tried to do. The Soviets tried to change human nature for decades and finally
gave up. Changing
culture will not cause the people within it to become saints.
Leape recommended that hospitals develop
cultures of safety, and work systematically to create standards to measure
in-hospital injuries and hospital-acquired illnesses.
Most care happens outside of
hospitals and that is ignored by that recommendation. For another thing, the
recommendation assumes an unrealistic level of saintliness
from people within that system. And it ignores that better information can be
gotten from sources that do not have the vested interests of the people within
that system. The person in charge of complaints, the person in charge of paper
supplies, the clerk at the desk of the records department, all have a vested
interest and a subjective view. It has been demonstrated that patients, when
given the opportunity, provide more information and more accurate information
than anyone in medicine. But medicine is dedicated to silencing patients.
Liability and stellar reputations are more important to them than the well being
of patients.
There really is no excuse for continuing to believe in
medicine's snake oil at
this point. It is confusing human nature and culture. It is thinking
like Karl Marx. It is thinking that we can get people to care more about the
well being of others than about their own well being. It's great if there are
those among us who do, but public policy cannot be founded on the philosopher-king formula. Especially when the need is not just for a few to run a
government, but hundreds of thousands to be caregivers. We cannot expect to
select only saints for entrance to nursing and medical school.
I would like to hear Lucian Leape's answer to the question,
"What is the least, the absolute least, that a patient should be able to expect
in medicine?" In saying, "When I go to a doctor, I should have somebody who
. . . will put my interest first" he is stating the most a patient can hope to expect. That is the
wrong end of the problem with which to begin. What is the least a patient should
expect? We have to start there. Otherwise, we are ignoring the biggest, most
fundamental problems. And they are not merely cultural.
I suspect that the answer he would give would be the answer that most physicians and nurses
would give, which is the problem.
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