Josie King Foundation
You have to be grateful for the superhuman effort of people
trying to protect patients like founders of this effort. But they might not
be looking in the right place for the answers. The experts contributing to their site are learned and articulate, but they
are examples of why, year after year, improvements in patient safety are nominal
at best.
For instance, the lawyers on their site say that the best place for injured patients to begin
expressing concerns about care problems is with the doctors and nurses who were
in charge of their care. For problems small enough to elicit a "Whoops. Sorry.
Let me fix that" it might be good advice, but for anything larger it is the top down perspective of people managing
careers and businesses without the perspective of the people they are supposed
to help. I know one normally goes to experts to ask how things work and to learn
what the problems are in such fields, but this is a good picture of why, in
medicine, that is like going to the queen who thinks she means well when she
says, “Let them eat cake.”
Someone who thinks that going back to the caregivers who caused the problem is
realistic advice for the average injured patient is so far removed from the
realities of the barriers thwarting injured patients that I’m not sure any
amount of explanation and reasoning could help them get a more accurate
perspective. I suspect they would have to get raped in a hospital to find out
what happens when patients return to their caregivers for help after adverse
events.
Like their advice about how many lawyers to interview before choosing one.
Only
3% of injured patients can get a lawyer. The question for 97% of them is not how
to choose one. Most patients do not begin by seeking lawyers in the first place.
They begin by seeking help. When they cannot get that, they seek answers. When
they cannot get that they seek justice. When they figure out that the only
avenue for that leads through the courts, then they call lawyers. But the
conundrum they face then is not how to choose which lawyer. It is
how to get one at all. 97% of patients
with legitimate grievances can call every lawyer in the phone book without
getting one. For the expert lawyers on this foundation's site to articulate the
problem as being one of how to choose one from among the many truly is telling starving people how
to choose cake. It is the same perspective held in medicine with regard to patient safety
as a whole.
Like the nurse on the site who explains how to improve patient safety. Her
points are not invalid. But they address only something like 3% of the problems
in her own field.
97% of what patients need her to address is outside of what her blinders allow
her to see.
Her points would not make a noticeable reduction
in the thousands of patients who die unnecessarily each year and the many more who have their lives ruined unnecessarily, sometimes
intentionally because nurses don't see and don't address that which would
prevent it. Indicative of their perspective is that not only do none of the people on the site acknowledge intentional harm,
they issue an active denial of the possibility, “caregivers cannot be blamed
when the system fails,” as though no caregivers sell unneeded products to make
money, as though there is no lechery or jealousy in medicine, as though all
people in medicine are saints without agendas that compete with the
well-being of patients.
Every page I turn to on the site leaves me with the same thing to say. Medicine
watches out for itself first and has its own political correctness to aid that.
In medicine it is politically incorrect to suggest that
the fundamental problems and obstacles are anything other than innocent errors.
Any suggestion that anyone in medicine might have a motivation other than
pursuing the well-being of patients is not tolerated. Learned, experienced
people assume objectivity and selflessness on their own parts and on the parts
of everyone else in medicine as they have discussions that have too much in
common with the old discussion about how many angels will fit on the head of a
pin. They are not quite that fanciful, but in terms of solving safety problems
for 97% of patients, they are just as far removed.
How differently would doctors would throw themselves at the
problems if it were two hundred doctors dying unnecessarily every year
instead of two hundred thousand patients? They are not saints. They are in
denial about the extent to which medicine puts self-interest ahead of patient safety.
98.5% of adverse events go unreported not because
medical professionals are honest
and objective and selfless. They claim to hold the safety of patients as their highest
goal. Their most fervently held belief might be that they do, but they don't.
They will go to meetings about patient safety. They will sign initiatives
promising to promote patient safety. They will believe in their hearts that
there is nothing more important to them than the safety of their patients. But there is a
disconnect between what they believe and what is true.
All the time and intelligence and experience on the
Jose King Foundation's site focuses on points that
show, more than anything else, how far removed from the real problems
people in medicine are. They are the angels dancing on the head of a pin with no
awareness of the pin, only of the head on which they dance, while below,
out of their sight, patient after patient gets skewered. That will sound harsh to
people in medicine. To
millions of patients and their families, it merely is sadly accurate.
I am grateful to the founders of this foundation's effort for worrying about patient safety.
I am grateful for all of the work and resources and concern and love and
sacrifice they bring to it. I could not be more impressed with their devotion
and the scale of their effort. I think, though, that they more or less have been
duped by a culture and an unrecognized political correctness that maintains the
status quo. Like the failures of communication that the experts on their site keep mentioning.
Those are important, very important, and need to be worked on. I am sure that
will prevent adverse events. But it still is system-tweaking. It is addressing 3% of the problems, and not the truly fundamental ones.
Better communication often is a two-edged sword.
Better communication frequently is used in ways that are unfriendly to
patients. Sometimes getting diagnosed and treated is possible only if failures
of communication enable patients to get objective information from new
healthcare providers who have not been influenced by the assumptions or prejudices formed
by previous providers. That is part of what blacklisting is about. Especially if the patient unnecessarily was injured by
previous healthcare providers who as a result now have an active interest in protecting
themselves by making sure that no one creates diagnoses that reveal the
injuries. It is not by accident that 98.5% of adverse events go unreported. The
culture in medicine is setup to protect itself first.
I’m sure lives will be saved by the superhuman efforts of the founders of sites
like this. I don’t mean to discredit them. It’s only that I get frustrated with
living in a milieu in which there isn’t even recognition of the biggest
problems. We are suffering and dying and being abused while being told how 3% of
us can find lawyers. What if we just need help?
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