Injured patients who want to help and be heard,
click here.
Thomas Jefferson said that given the choice between
government without newspapers and newspapers without government, he would choose
newspapers.
In medicine we have government without newspapers. Patients
cannot find out what they need to know to make informed choices. No one in
medicine records or reports the information patients need to know the most. So
patients will have to do it.
Conflicts of Interest
They have a business incentive not to know
and to not let anyone else find out
Focusing on errors is focusing on symptoms. It is like trying to
cure small pox by focusing on skin lesions and putting ointment on them. We
cannot scrutinize every iota of medicine to root out every moment that presents
a danger and put in place some kind of mechanism to make it safer. We have to
make it so that it is in the interests of healthcare providers to make medicine
safe on their own. Currently it is not even in their interests to be aware of
whether their care is beneficial, let alone safe (see
MammoSite, for instance). The result is that it is not uncommon for them to
assume things must be effective and safe when no information has been gathered
to support that assumption.
Since the mid 1950s regular revelations about medical
treatment resulting in unnecessary death and injury have had almost no effect on
the practice of medicine (see Millenson 1).
Why does medicine not heal these problems even when they are pointed out? The
unacknowledged elephant in the room of patient safety is the fundamental
conflict of interest between providers and patients.
Medicine's looking out for Number One
would make patients Number Two
if looking out for colleagues wasn't already Number Two
They say that there never has been a democracy that has
experienced a serious famine. People look out for their own interests better than
elites ever will. But in medicine they believe, like elites have tended to
believe throughout history, that the people are not smart enough to be masters
of their own fate and are better off being take care of by the elite. So
patients have the equivalent of a famine every year - 320,000 of them dying
unnecessarily every year according to
a recent study.
According to the CDC, "In American hospitals alone,
healthcare-associated infections account for an estimated 1.7 million infections
and 99,000 associated deaths each year." That's just one slice of the pie of
unnecessary deaths. Given the nature of reporting in medicine and how hard it is
to find out about these things, it will not be surprising if the 320,000 figure
continues to climb.
Hospital infections
are the eighth-leading cause of death in the United States
according to the Centers for
Disease Control and Prevention (CDC).
If they were the
eighth-leading cause of death among doctors, how much harder would they work to
cure the problem? The medical profession keeps repeating, and
apparently believing, that the well-being of patients is their number one
concern. If it were, patient safety would not be an issue. Medicine would be
self cleansing. The motivation would exist to cure these problems. But it doesn't.
Patient safety is an issue because the healthcare industry
and its practitioners have goals and needs that are in conflict with the safety of patients.
Their need to
protect their reputations
Their loyalty to their colleagues
Their need to advance their careers
Their need to move on to the next patient
Their need to protect their staff
Their need to avoid liability
Their need to believe in themselves and their profession
The CDC projects that in the USA one of every twenty-two
patients will acquire an infection. In the Netherlands and Finland almost none
do because they fixed the problem. In the USA the infections are considered to
be an acceptable cost of doing business. And so they haven't solved it? And the
well being of patients is their first priority?
Humans find ways to believe that their self-interest is virtuous
In healthcare they do not recognize self-interests as
obstructions to safety. No one for whom safety is
the first priority would quietly allow Genene Jones to work somewhere
else in healthcare. Ditto for Michael Swango and
others who preyed on patients.
One of the mantras of medicine, a phrase often repeated and never questioned, is
"you have to protect yourself from lawsuits." With that phrase they
quietly rationalize behaviors and habits directly in opposition to the well
being and safety of patients.
Many of the things medicine does to protect itself from lawsuits
add to the many unnecessary patient deaths. Information is
hidden. Stories are squelched. That which needs to be announced and learned from
in order to protect patients, instead is covered up in order to protect health
care providers. In their world patient-deaths are acceptable costs, but
lawsuits are not.
Why is that line not repeated during discussions of these
issues? In their world patient-deaths are acceptable costs, but lawsuits are
not. Perhaps because
Being surrounded by others who share your perspective
is a
powerful reinforcement
Collectively agree on self-serving delusions that are bad for
patients, like the idea that they are objective.
A line they do repeat frequently is that "You have to be there for
the next patient" which means that each patient is expendable. It is the idea that making medicine more expensive would make it so that the community
of patients would end up getting less care. This translates into the idea that their profit is good
for patients. People always find ways to believe that their self-interest is
virtuous. That will never change. Perhaps what needs to be changed is what makes
profit in medicine. Perhaps we need to make it so that patients
have the information necessary to understand what is
not in their interest and make it unprofitable - like informed consumers do in
real markets.
One of the chief reasons medical errors are not reduced
is that they have not found a way to make a profit on safety
A designer and implementer of horse racetrack betting systems
once worked for a race track owned by the Mafia. Because of who his employers
were he said,
"You just didn't make mistakes." Designers and implementers and practitioners in
healthcare do not experience that kind of motivation. It's not their lives on
the line. Profit, career advancement and avoiding liability
are more important concerns for them than the safety of their patients.
Healthcare professionals have numerous incentives to cover up adverse events and
few to report them. That is devastating for the safety of patients. But they
have a system of rationalizations persuading themselves of the opposite.
A mantra in medicine is the repetition of the idea that the
safety of patients is their top priority, but there are so many pressures that rivet their attention
in ways that the safety of their patients never will. They will never
feel the pressure for safety that patients feel. The pressure to increase safety is not going to come from
healthcare and its practitioners.
It is going to have to come from patients. For patients to be able to bring that
pressure they need to be able to exert pressure on what healthcare does care
about. Healthcare professionals cannot achieve their own goals if they do not
have patients. So patients need to be able to decide which healthcare
professionals to support based on considerations like safety. Currently patients
do not have access to the information necessary to make purchasing choices based
on anything but ignorant faith. Consumer reports and the grapevine are of little
use for understanding an industry that refuses to collect the information needed
to understand and evaluate it.
The patient community needs access to information about
infection rates and success rates and such. How many adverse events occurred in
a certain hospital? No one is collecting that information at present. Medical practitioners say that admitting errors is
nothing new inside hospitals. They say that people discuss them all the time in
regular morbidity and mortality meetings. But what is discussed amounts to a
single digit percentage of the number of adverse events occurring. And no one
who commits a crime brings it up in a conference. Patient abuse is not reported.
Exploitation is not reported. Even innocent errors rarely are reported. And when
they are, patients are not allowed to know about it.
It is kept secret to encourage reporting. That might work in
a world where people were honest with themselves. But we live in a world where
tobacco executives found a way to believe that smoking neither is harmful nor
addictive. And we live in a world where doctors think they have to protect
themselves from lawsuits while patients think, "No. You have to protect
patients."
In medicine they believe that their highest concern is the
well-being of patients. As long as they believe that, they will continue to
imagine that healthcare workers will report enough if they are shielded from
consequences for reporting in spite of all evidence to the contrary.
Consumer Reports
In one hospital a doctor discovered that one-third of the doctors in his
hospital didn't remember if they had ordered their patients' urinary catheters
removed when they no longer were necessary, which was resulting in a lot of infections. So his
hospital instituted a procedure that automatically removed the catheter after a
few days. The rate of urinary tract infections plummeted. Were patients able to
determine what the rate of urinary tract infection was for that hospital before
it plummeted?
What about now? How does it compare to all the other hospitals? For how many
years did this situation exist in that one hospital without anyone bringing it
up in a morbidity and mortality meeting? Why isn't there a list of such things
for Consumer Reports to track so that consumers can bring pressure by avoiding
hospitals that don't take care of this and things like this?
Why didn't anyone in that hospital think to do something about this problem
before this doctor came along? More attention needs to be paid to how healthcare professionals think
in order to understand why medicine does not make patients more safe on its own. DNA analysis
illuminates the causes of disease. Computers refine MRI images. Robotics
facilitate operations performed inside the brain. But the
psychology
of the people at the center of all that is assumed to be good will and
objectivity and integrity and, above all, a concern for the well-being of
patients superseding all other concerns.
Mickey Mouse thinks more deeply than that. Sometimes people in medicine hate
their patients. Sometimes they care more about their wallets. Sometimes . . .
Why make a list? It would be a long list of things that are in conflict with the
well-being of patients. They may say and they may believe that the well-being of
patients is at the top of their list, but the fact that they say that and
believe that is one of the problems. Their disconnect between what is true and
what they believe costs patients their lives.
Opportunistic Behavior
In 2002, the economists Steven Levitt and Chad Syberson did a
study showing that houses owned by real-estate agents stay on the market longer
and sell at significantly higher prices than do the houses they sell for their
clients. The agents do better for themselves than they do for their clients.
Whenever authority is delegated to someone else to act in your interest, that is
a problem (click here for
medical examples). There needs to be accountability or oversight from consumers of healthcare,
or at least from their representatives. There cannot be that without reporting. But reporting is not in the interest of people in healthcare.
We cannot legislate motivations. We must recognize them and build systems that
account for them instead of reciting "We don't' believe people go to work to do
a bad job" as though all people in medicine are 100% selfless and that what is true of
realtors is not true of doctors and nurses. Currently patients are expected to take
it on faith that everyone in medicine is good and competent.
The assumption of most patient safety discussions and
initiatives is that among healthcare workers there is no avarice, lust,
jealousy, anger, etc., only the occasional well-meaning mistake. The assumption
is that the needs
of healthcare providers to earn livings and
advance careers never could cause any of them to be subjective and/or let
self interest influence their decisions about what to sell to patients. One even
hears it said that a healthcare professional would have no motivation to harm
his or her patient. In every other field in the world, even the Priesthood, it
is recognized that there are people with desires and agendas that are unfriendly
if not evil, but in medicine alone that is believed not to be so. The patient safety movement approaches
problems as though people in medicine all are saints who just need to have a few
systems tweaked.
Such a state of beliefs can be maintained only by routinely
and
unthinkingly denying statistics and the stories that patients tell. What we need
is a system that allows the patient community to tell its stories and collect
the statistics.
Egalitarian Ideology
People constantly size each other up. How they respond to
each other has a lot to do with how they perceive the way they rank in relation to each
other. Who is the most successful, the highest ranking, the smartest, the most
accomplished, the tallest, the most attractive, the most prestigious, etc.
Doctors and nurses are as susceptible to this as anyone else and just on that
basis can be more interested in helping some people and less interested in
helping others and sometimes even tempted to do something they should not do to
others.
Whether it is out of lust or competitiveness or anger or whatever, it is
unreasonable to leave healthcare set up as though no one in medicine experiences
such temptations and as though no patients need to be protected from them.
At one time in New York City, if you got tired of being
mugged and/or robbed and said, "Something has to be done," people would shoot
back with, "What do you suggest? A final solution?" In medicine they have
similar conversation-killing responses. In New York Giuliani came to office and
changed everything. Something was done. Things can be done. The conversation about what to do in
medicine needs
to be had. It is self-serving and obstructive for medicine to dismiss out of
hand suggestions about their motivations and questions about their innocence.
The reduction in
the number of accidental and intentional deaths in healthcare can never be as
large as it should as long as healthcare workers have so much power and patients
have so little. It's not just buying decisions that patients must be able to
make. There must be recourse for patients who are the victims of things like
unfriendly practices. Such recourse is more important even than knowledge of errors
and is the rock bottom foundation of patient safety. The least a patient should
be able to expect is not to be injured intentionally. If we do not even have
systems to respond to that, speaking about the rest is worrying about varnish on
rotten wood. But any discussion of unfriendly practices is dismissed out of
hand. There can be no meaningful recognition of the problem of conflicts of
interest in medicine as long as there is no willingness to recognize the worst
ones - unfriendly practices - and how the medical community protects and enables
them, including by refusing to let them be part of the patient safety discussion.
You cannot legislate or regulate or inculcate
good will, concern, and integrity
I wish someone in medicine and or patient safety would face
the fact that even the best people can be tempted to do
something evil, and that at those moments there
needs to be something to inhibit unfriendly behavior. Doctors do not
feel they can assault people in bars with impunity. They should not feel they
can in hospitals. Because if they feel they can, they will. We know that they
do. They have in the past and they
will in the future. The least, the absolute least, that a patient should be able
to expect in a hospital is to be protected from crime. Currently
patients are not. And the healthcare professionals who know about those crimes do not report them. That is outrageous.
That is not going to change with more forms to fill and classes to take about
patient safety. That is not going to be
changed by peer review. That is going to change only by bringing to medicine a
mechanism that no one in medicine wants.
Doctors will never care about the damage their colleagues do
to patients as much as they care about their own careers (they have to be there
for the next patient, right?). And they never
will have the integrity and the objectivity to see when they abuse their own power and
damage their patients while rationalizing that they are doing good. This is the root
of why they never can make medicine safer for patients on their own.
Patients will have to seize the right at least to complain.
Currently doctors know that other doctors will ostracize them if they
find that a
patient's injuries are consistent with something like the abuse a patient claims to have
endured at the hands of another doctor. They also know that no one will ostracize them for not
taking care of the injured patient. As
long as that is the end of the story, patients will not be safe.
Blameless RCA
Root cause analysis (RCA) is
the chief method being promoted right now to increase patient safety. It
dissects system failures with the idea that no person within the system could be
the problem. It assumes that the only problems are in
communication, rigid hierarchies, absences of redundancies and other systemic
flaws, but never the operators within the system. The assumption is that criminal
law is irrelevant in healthcare because all the people in medicine mean well and
deserve to be protected. The examples used as models are of things like airplane
crashes, disasters in which the pilots had as great an interest in the outcome
as did the passengers. Not a thought
is given to how different the motivations are in medicine. Doctors do not die
when their patients die. When they ruin lives, they move on. What pilot would
kill passengers intentionally? I have a
list of doctors and nurses who have.
"Those of us who work in hospitals have really become inured
to the frequency of errors, large and small."
- Dr. Robert Wachter
Pilots in airplanes do not drop passengers off in remote
locations and then make sure that no other pilots pick them up. Victims of iatrogenic injuries do suffer that treatment from healthcare
professionals (see
blacklisting). When a
doctor asks how injuries were incurred and the patient describes an adverse
event in medicine, the doctor becomes the equivalent of a pilot making sure that
the passenger does not get to where he or she needs to go to survive. The agendas and
motivations and interests of pilots are not analogous to those of healthcare
providers in the fundamental ways that have resulted in patient safety being the
problem that it is.
Do airlines have risk management departments that threaten
passengers with suits if they talk about what happened to them on the airplane? Do airlines
teach their flight attendants not to ask passengers if they are all right? Do
pilots lobby the government to limit their liabilities so that they have an even
lower stake in the outcomes they produce?
It's not all the failures of systems. A fundamental part of
it is the success of systems that protect interests of providers that are contrary to the interests of patients.
Safety does not
get as much attention from healthcare professionals as limiting liabilities and protecting reputations
and advancing careers. They do not recognize this because they are not
objective. They don't report or fix problems because
their self-interest is not served by reporting the problems. Their self-interest
is served by not reporting. They are not on the plane that goes down.
It is great that they have initiatives to try
to build a culture of safety, but if that would work then communism would have
worked. Wasn't that the basis of communism - that they could build a culture in
which people would be as motivated to contribute to the common good as
capitalists are to get rich? They never will be as interested in safety as
patients are. They never will be the ones to solve larger patient safety issues.
They won't even report the problems let alone solve them. That's why safety is
an issue in the first place.
They don't even report crime.
The patient community must have access to the information
necessary to make intelligent purchasing decisions about their healthcare,
rather than being expected to have faith in healthcare professionals to be saints. And
patients must be encouraged to report what happens to them in medicine,
rather than discouraged as they are now. They are the only ones who report the
worst dangers in medicine. They are the ones on the plane. They should be
allowed to tell future passengers how the flight went - especially if it
crashed.
People gravitate to what is comfortable and lucrative. Safety
does not line their pockets as long as patients are unable to make buying
decisions based on information about it. For instance, in New York state, according to Joyce Dubow, associate director at AARP Public
Policy Institute, in 1989 New York state started publishing the bypass surgery
death rates for hospitals. Mortality dropped 40 percent in four years. The
hospitals conducted internal reviews, hired new personnel and fired surgeons
with high death rates. They protect their wallets with more fervor than they do
their patients. Patient safety initiatives that do not take that into account
will have limited success.
Patients Need to Know
Mehmet Oz, a surgery professor at New York-Presbyterian
Hospital/Columbia University Medical Center, said, "If we can get just 10% of
people to be smart patients, it will change the system. People will know that
sloppiness won't be tolerated. And it will drive quality." He is co-author,
along with the Cleveland Clinic's Michael Roizen and The Joint Commission, of
the book You: The Smart Patient: An Insider's Handbook for Getting the Best
Treatment.
There is a tacit recognition in that statement of the fact
that it is not going to come from inside medicine. Patients need to be aware of
more than how to pressure them to be attentive and less sloppy. If ten percent
of patients were allowed to know the success rates of various places and parties
in medicine, and the misdiagnosis rates, infection rates, crime rates, and other
such information, and if they were allowed to talk about it without being sued,
that could change medicine.
People in medicine never will change it. Their interests are
in conflict with it. That's why patient safety is an issue.
Each year, 1.7 million people acquire healthcare-associated
infections in hospitals. 99,000 of them die. Treating healthcare-associated
infections costs an additional $26 billion every year
Earning Money on Indifference
According to Consumers Advancing Patient Safety 1.7 million
people each year get hospital-acquired infections. That adds an estimated $27
billion to healthcare costs and, according to the Centers for Disease Control,
kills nearly 100,000 of the people who get it. The fact that people in medicine
resist reporting instances of that problem but shout about how much lawsuits
drive up costs is another indication of where their interests really lie. Paying
for lawsuits concerns them. Getting paid for generating another $27 billion in
healthcare costs has not spurred lobbying for legislation to stop it on their
part, like it has spurred lobbying for liability limitations for themselves.
Instead, they resist
collecting the data about it that patients need in order to make
informed decisions about where to get treated. Knowing infections rates is
important for patients. Knowing crime rates in medicine is too. Victims should be allowed to
report these things because the people who cause them won't.
At least, finally, there is at least a little governmental recognition of the
fact that medicine is not motivated enough to protect the well being of patients. Medicare is going to stop paying for problems, like infections, that
are caused by healthcare. The underlying assumption is that perhaps healthcare
will stop unnecessarily infecting patients, and causing other injuries to
patients, when doing so hurts their bottom line. Making safety failures
unprofitable could be a start, but one waits to see how healthcare gets around
it.
Patients are not even Third on the list
Dr. Peter Pronovost saved the state more than $100 million
and 1500 lives over an 18-month period by teaching doctors and nurses to use
checklists for intensive care unit procedures. Andrea Seabrook talked to Dr.
Provonost about it on National Public Radio. Atul Gawande, a surgeon, wrote
about it in The New Yorker magazine. It is not as though it is a secret. Dr.
Pronovost spoke about it before Congress and said that the program cost $350,000
to implement, but hospitals did not have a budget for that.
For saving thousands of lives they have no budget because
they do not earn a profit on saving our lives. As much as they say that our
well-being is their highest priority, it simply is not. Profit is one of their
priorities that is higher. Saving out lives is not profitable so they don't.
We could make a list of all the hospitals that do no
implement Pronovost's plan and tell patients to avoid them so that to continue
earning a profit they would have to implement the plan. But that would address
only this one safety concern. It is a huge concern and needs to be addressed,
but they will backslide the moment we take the pressure off. And there are all
those other patent safety problems that it is not profitable for them to fix. We
need to make it so that their careers and their profits depend on the outcomes
they produce for us. One suggestion is to cull the information necessary for
Consumer Reports and other such organizations to analyze which places are the
safest.
And we didn't talk about the tyranny of the status quo
and how that is an interest on their part that is in conflict with
reducing unnecessary patient death and injury.
Another of their needs: to avoid letting the
current problem interfere with their helping many more patients in the
future - always thinking of the current problem as just another "one-off" without keeping track of how many times there are "one-offs."
If you want to say something about any of my
sites, my phone number is on almost every page. So is my
email address. There even
are Feedback Forms where you can communicate
anonymously. I am listening. I will be sensitive to what you say.