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Full Table of Contents
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Abbreviated
Table of Contents
Home Page
Patient Safety
Silence vs
Safety
Silenced
White wall
of Silence
Silencing
Conflict Of
Interest
Psychology of
Providers
Subjectivity
Blacklisting
Nurse survey
Loyalty
Mobbing and
bullying
Trust Us
Defensive
documenting
Report Rate
Risk
managemnt
SOAP
Management
Hospitals
Crime in
medicine
Sexual Abuse
Liability
Limitations
Free Speech
for Patients
Exploitation
OSMB Medical
Boards
Mammography
solutions
Medical errors
Medical Complaints
One number
Links
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.
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Notes 13
Profitable treatment ahead of good treatment
This footnote links to here to create options if the link to the source article
becomes dead. Here is the link:
http://www.nytimes.com/2009/01/06/health/06seco.html?_r=1
If the link no longer works, it is a New York Times article about physicians
recommending the care on which they can make money rather than the care that
would be best for the patient, even when that means unnecessarily putting the
patient on a colostomy bag for life.
The article was called:
It was written By DENISE GRADY and appeared in the New York Times on January 5,
2009.
In the article, a physician was going to do an inferior operation that was going
to put the patient on a colostomy bag for life rather than recommend her to a
another provider who could do a better operation that would not.
Dr. Robert J. Weil, a neurosurgeon at the Cleveland Clinic, said that although
it might seem a good idea to inform patients of differences in outcomes among
hospitals, there would be “a variety of hurdles.” And David I. Shalowitz, a
bioethicist, said that expecting surgeons and hospitals to disclose information
about other doctors and medical centers would create an untenable conflict of
interest for them and should be avoided.
Patients think that health care providers have the well-being of patients as
their highest priority. That is what medicine continually announces to them. But
it is not true.
For those who think this problem is being handled by sites like
www.hospitalcompare.hhs.gov and
www.hospitalinfection.org, see
this: hospital-compare.
Six years ago, a relative of mine found out that she had rectal cancer and would
need surgery, radiation and chemotherapy. She lives in a small town, and she
consulted a local surgeon at a community hospital.
He was pleasant and kind, and clearly explained her condition and the operation
he would perform. He was also painfully honest, and said that because the tumor
was large, he doubted that he would be able to save the sphincter muscles that
make bowel control possible. She would very likely need a colostomy, a procedure
to divert wastes out through an opening cut in the abdomen, and would have to
wear a colostomy bag for the rest of her life.
My relative thought it over. Being treated close to home had seemed so easy and
convenient, and she dreaded the thought of shopping around for doctors when she
was feeling sick, vulnerable and anxious. It was tempting to think that she
would receive first-rate treatment no matter where she went.
But she also recognized that this was a small hospital, and a surgeon who
probably spent more time fixing hernias and taking out gallbladders than he did
operating on cancer patients. She decided that she wanted a doctor who operated
on patients like her all the time, and that the two-hour trip to a cancer center
would be worth the trouble.
And so it was: she found a surgeon who specialized in rectal cancer, and today
she’s in good health, with no need for a bag. She might have done just as well
with the local surgeon, but we both doubt it.
An article published online in October in the journal PLoS Medicine really hit
home with me. Noting that the quality of cancer care is uneven, its authors
argued that as part of the informed-consent process, doctors have an ethical
obligation to tell patients if they are more likely to survive, be cured, live
longer or avoid complications by going to Hospital A instead of Hospital B. And
that obligation holds even if the doctor happens to work at Hospital B, and
revealing the truth might mean patients will take their business someplace else.
“It’s only fair,” said Dr. Leonidas G. Koniaris, an author of the article and a
cancer surgeon at the Miller School of Medicine at the University of Miami.
Studies have confirmed the common-sense notion that practice makes perfect, and
the medical profession has known for at least 30 years that how well people fare
after surgery often depends on where it was performed. For a given operation,
outcomes are generally best at “high volume” hospitals, which perform it often.
The difference between high- and low-volume centers is not just the surgeon’s
skill, but also the level of expertise in other areas that are crucial after
surgery, like nursing, intensive care, respiratory therapy and rehabilitation,
Dr. Koniaris said. The same principles apply to treating cancer.
But patients are not often told during the informed-consent process that the
results of cancer treatment can vary among hospitals, according to Dr. Koniaris
and his co-author, Nadine Housri, a medical student.
“I think it’s sort of starting to happen but hasn’t really become a dialogue
yet,” Dr. Koniaris said.
The strongest evidence that volume makes a difference comes from studies of
surgery for pancreatic and esophageal cancer, but Dr. Koniaris said the
experience of the surgeon and the whole medical team was important in any major
cancer surgery.
He was not surprised to hear about my relative. He was an author of a study
published in 2007 that found that people with rectal cancer survived longer and
were more likely to have operations that saved the sphincter at teaching
hospitals than at community ones — even though the university hospitals were
more likely to take on difficult cases with large tumors. Another study in which
he participated suggested that women with advanced breast cancer received more
comprehensive therapy and survived somewhat longer when treated at teaching
hospitals rather than at community ones.
Some medical experts say complicated treatments like surgery for cancer or heart
problems should be regionalized — done strictly at specialized, high-volume
centers, not at centers that don’t perform the operations often enough to become
really good at them. But Dr. Koniaris and Ms. Housri suggested still another
option.
“We brought up the idea that maybe it should just be up to the patient,” Dr.
Koniaris said.
Studies have found that some people still prefer to be treated close to home
even if the risks are higher there. Maybe they shouldn’t be forced to travel,
especially if the difference is not large, Dr. Koniaris said.
Asked if he practiced what he preached, Dr. Koniaris said yes, that as a surgeon
he sometimes sent patients to other doctors, especially for pancreatic cancer
and liver tumors.
His article pointed out that in a few cases in the United States and Australia,
courts have ruled that doctors who had operated on people with poor results
should have informed the patients that more experienced surgeons were available.
PLoS Medicine framed the article by Dr. Koniaris and Ms. Housri as a debate,
with two other researchers taking different views. Dr. Robert J. Weil, a
neurosurgeon at the Cleveland Clinic, argued that although it might seem a good
idea to inform patients of differences in outcomes among hospitals, there would
be “a variety of hurdles.”
Which hospitals would be chosen for comparison? And as medicine advances and
changes, Dr. Weil asked, “is it possible to compare hospitals or even recent
time periods, especially when faced with disease courses that may extend over
years?” He also suggested that if hospitals were forced to give patients
comparative information, it might lead some to avoid difficult cases, to make
their numbers look better. And he pointed out that patients might have no idea
what to make of the information, because most people have a hard time gauging
risk or understanding that statistics apply to a population but don’t predict
the fate of an individual.
David I. Shalowitz, a bioethicist, said that expecting surgeons and hospitals
to disclose information about other doctors and medical centers would create an
untenable conflict of interest for them and should be avoided.
The question of what the doctor’s obligation is remains unresolved. People can
ask doctors for comparative information, but many patients would fear giving
offense. And judging by volume alone may have its pitfalls, because there are
bound to be some hospitals that do lots of operations badly and some that
perform few but do them well.
(For people who want to find out how a specific hospital performs in treating
certain illnesses and performing operations, the government Web site
www.hospitalcompare.hhs.gov provides information. In addition, some states
require that hospitals publish their infection rates; that information is at
www.hospitalinfection.org.)
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Michelle Long in Boise, ID
reviewing The Healing of America: A Global Quest for Better, Cheaper, and
Fairer Health Care by T. R. Reid on Amazon.com.
I am a nursing student. I returned to college after 20 years in hospitality and
project management in order to realize my dream of a career focused not on money
but on providing care to the most vulnerable. One disturbing pattern has cropped
up in my education- the emphasis (when studying the importance of avoiding
potentially life threatening errors) placed more on avoiding liability than on
the well-being of the patient (or "client" as we are now taught, in this
money-driven society). It also strikes me that I have never heard it suggested
that a health care professional should be painstaking in her work in order to
prevent avoidable errors that would bring dishonor to herself or her profession.
The focus is on avoiding "costly" errors.
The New England Journal of Medicine
Volume 355:2725-2732, December 28, 2006, Number 26
An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU
By Peter Pronovost, M.D., Ph.D., Dale Needham, M.D., Ph.D., Sean Berenholtz,
M.D., David Sinopoli, M.P.H., M.B.A., Haitao Chu, M.D., Ph.D., Sara Cosgrove,
M.D., Bryan Sexton, Ph.D., Robert Hyzy, M.D., Robert Welsh, M.D., Gary Roth,
M.D., Joseph Bander, M.D., John Kepros, M.D., and Christine Goeschel, R.N.,
M.P.A.
ABSTRACT
Background Catheter-related bloodstream infections occurring in the intensive
care unit (ICU) are common, costly, and potentially lethal.
80,000 patients per year get infected unnecessarily. A five-step checklist could
prevent all of it saving between 30,000 and 60,000 lives per year. But we cannot
get physicians to use the checklist. In the way people in that field approach
all problems, they are looking for a top-down way to persuade or incentivize
behavior that saves the lives of patients. That would be a weak fix, a narrow
thought, and the wrong approach. We need to put them in a position where their
careers depend on finding and fixing these problems themselves, even the ones we
don't know about yet.
BOOK:
"The Social Transformation of American Medicine" by Paul Starr, from the early
80s. Important history of how American medicine came to be provider driven
instead of patient driven.
AMA does not adjust for inflation
David Leonhardt in A System Breeding More Waste in The New York Times,
September 23, 2009, page B1.
Sites about medicine's attempts to change the legal environment in their own
favor:
http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=283068
physiciansfortortreform.org/ -
http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/litigation-center/case-summaries-topic/tort-reform.shtml
http://physiciansfortortreform.org/tortreform.html
http://www.politicsdaily.com/2009/10/12/tort-reform-could-save-health-care-54-billion-says-cbo/
http://healthcare.change.org/blog/view/whistleblowers_expose_hospitals_fleecing_the_publics_back
http://physiciansfortortreform.org/tortreform.html
http://www.instituteforlegalreform.com/?gclid=CKyyluGdgqACFVZS2godDEjgkw
http://www.healthreformscam.com/2009/09/09/thousands-of-doctors-sign-petition-on-health-care-reform/
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