Full Table of Contents
_______________
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.
The Saint Theory
of Medicine
Why scientific studies, closed claim projects,
whistleblowers,
examining existing records, reorganizing administrations
and altering the way clinicians are paid are only patches.
A ship taking on water must be patched. It is not as though patches are not crucial. But when ships keep sinking because the shipping company earns more when they do. . . When ships keep sinking because it is not important to shipping companies to avoid storms or build ships that can survive them because sinking means more business. . . When passengers keep getting on ships that sink because there is no way for passengers to learn which companies keep sinking ships. When the solutions proposed imagine that none of this matters because saints are in charge. . .
The Saint Theory of Medicine is the basis for almost all the theories and proposals that are supposed to fix medicine. It comes in many colors and sizes, but in short it is the idea that saints can run everything without patients needing to know anything other than what they have been told to do and what they have been told to pay. Like passengers getting on ships with no information about how safe they are or how much the fare costs.
Consider the discovery of the importance of hand washing. When Semmelweis discovered that it saves lives, he was in charge of two maternity clinics. Comparing them enabled him to do a rudimentary clinical systems analysis. The first clinic had a high enough death rate that expectant mothers who had been assigned to it literally got on their knees pleading to be reassigned to the second clinic. When they were not, some women chose to give birth in the street. The "street births" had a higher survival rate than the women who gave birth in the clinic. It was safer to give birth in the street than in the clinic. Yet the clinicians, knowing that, continued to send patients to the most dangerous clinic.
Informed Patients
This is the way medicine always has taken care of patients. Most of the patients in the most dangerous clinic did not die. Some months as many as 30% did, but apparently that was a high enough success rate for the health care professionals who were not going there themselves. Today providers argue against allowing patients to know the success rates of providers and facilities saying that maybe the deadlier ones gets sicker patients. The problem with getting information from health care professionals is that they are not the ones who are dying. They are neither objective nor selfless. They are not saints. So they worry more about the reputation of the clinics or the caregivers and less about the survival of the patients.
Today we hear that most patients are happy with their health care. We hear this even though health care is the greatest source of accidental injury and death in the country and the greatest source of personal bankruptcy. It even is bankrupting the federal government. But most patients are happy with it, so apparently that is good enough for the people who earn their livings in medicine today too. Whether they do it by informing patients or not, they steer patients into the situations that cause all those deaths and bankruptcies. If they know the information that patients need to make cost-benefit choices that are safe and affordable, they are not telling it to patients. And they are not using it themselves to protect patients. This should raise questions about the worthiness of all the theories in which the people running medicine make medicine safe and affordable rather than enabling patients to seek that which is safe and affordable.
Making Medicine Safe for Patients
Semmelweis figured out that washing hands would bring down the death rate in the more dangerous maternity facility. In fact, two months after instituting handwashing, the death rate fell to zero - better than in the safer clinic. But sharing the discovery did not result in clinicians washing their hands. Just like the more recent discovery that checklists dramatically can reduce negative outcomes has not resulted in clinicians using those either. Their own well being is not effected. They don't die if they don't use the checklists or wash their hands. Scientific studies or the examination of closed case claims have little to do with whether caregivers implement what is learned from them.
It has been 160 years since hand washing was discovered to be important. Currently, according to the CDC, 99,000 people per year die from infections acquired in health care. For 99,000 to die from that, some millions must have made sick by it. For some millions to have been made sick, there must have been some hundreds of millions of unsafe acts. A lot of those unsafe acts were failures to wash hands. Many of the rest might have been more complicated acts, but still acts known to be unsafe. Another closed claims project determining that clinicians need to wash their hands will not ensure that they do. Closed claims projects or other scientific studies can determine what the clinical systems problems are, but they cannot motivate clinicians to implement the solutions well or at all. They also cannot motivate clinicians to figure out how to implement them for less than it costs to send a space shuttle to the moon.
Gouge
I know of a physician who bought a machine that is estimated to have cost $20,000. It is the size of a desktop computer printer. It emits a laser beam through a stylus that can be used to kill toenail fungus. He knew of a homeopathic healer (prescribes herbal remedies) who was starving. So he made a deal with her. He put the machine in her office and pays her $60 per hour to do the treatments. It takes two to three hours to treat a patient. Doing this work is what keeps her in business. So there is a reasonable amount of it.
The physician charges patients $1,200 every time he prescribes it. In a matter of months the machine will have paid for itself and he will be making $1,000 every time he prescribes it. Scientific studies say that the treatment is successful half the time. They don't say how successful this homeopathic healer is at using it. There are no scientific studies telling patients if someone half an hour away is doing the same thing for one fourth the money with triple the success rate. There are no scientific studies motivating patients to care what it costs either. The patients with toenail fungus go where they are told and pay what they are told and imagine that some saint somewhere is making sure that the success rate and the costs are what they should be. They also imagine that their primary care physician cares enough about their well being not to gouge them financially.
80% of Medicine
80% of medicine is maintenance, not emergency care. There is time to make informed cost-benefit decisions for 80% of health care. Unfortunately, there is no opportunity to do so. Patients being screened for cancer cannot know whether the radiologist examining their x-rays ever recognizes cancer in an x-ray. No one monitors that.
That was studied once. It was found that there are radiologists who cannot recognize cancer in an x-ray. The government tried to fix that. They wanted to test and rate radiologists. But government is political and medicine is powerful. The effort devolved into the government regulating the equipment that radiologists use. The inept radiologists are still enjoying long and lucrative careers getting paid for doing something they are incapable of doing. They have degrees. They have training. They have good social skills. They talk a good talk. They just don't do a good job. Patients are told to go to them and pay whatever the insurance company can be persuaded to pay. If the patients don't have insurance, often they are told to pay more than the insurance company would have had to pay. And they do that, patient after patient, year after year, with no benefit to anyone but the radiologist.
Closed Claims Projects
For something like a closed claim project to address that, lots of patients would have to suffer and file claims in order for there to be claims that have been closed. And that would have to happen for every radiologist in the country. Efforts like the ASA Closed Claims Project really only are about systems improvement. That is vital. That can saves lives. That can reduce the extent to which injuries and lawsuits add to the increasing cost of medicine. But that cannot evaluate whether your clinician is competent or even safe. That cannot watch every nook and cranny of medicine so that patients don't have to.
There are no closed claims to study for the toenail laser operator. People who pay too much and don't get healed do not file claims. They don't know they paid too much. They don't know that they have been sent to someone who heals only a fifth of her patients. Her patients did not become disabled. They did not die. There are no claims. The patients merely continue to live with toenail fungus, possibly trying a drug treatment next, or a repeat attempt with the laser, but without learning that there is a more successful operator in town, and without future patients learning anything about the less successful one.
It doesn't have to be this way. The patient community does not have to pay exorbitant prices for bad medicine. Currently there is no downward pressure on the laser operator's price or upward pressure on her quality. There have been attempts to have every corner of medicine scrutinized and run from above, like with the radiologists, but those efforts are pale compared to what happens when patients know success rates and prices and make decisions about where or whether to get treatment. Sometimes it is better to limp than to get treatment.
Eating Cabbage
If a centralized planner were to tell a citizen of the USA that it had been looked into and decided that it is too expensive or too dangerous to provide treatment for that limp, it would be a severe violation of what this country is about. It also would be the Soviet style of management that resulted in the joke "What is 200 yards long and eats cabbage . . . A Russian meat line." The Closed Claims Project is vital for how it helps people in the system understand how to clean up systems, but it will not ensure that all clinicians are competent enough to do it, or whether the competent ones bother to do it regularly. Or whether they do it in an affordable way. It is not what will solve medicine's being dangerous and expensive. As David Goldhill said in his article in the Atlantic, only consumers can be the ultimate guarantors of good service, reasonable prices, and sensible trade-offs.
Patients cannot be that without the information necessary to make informed cost-benefit decisions. That kind of information is not produced by closed claim projects and scientific studies. To be informed requires knowing the success rate of individual clinicians and facilities. The women assigned to the dangerous clinic 160 years ago did not have knowledge of any clinical systems analyses. They did not understand what the problems were. They understood only the success rates. Too many people were dying in the first facility. They didn't have to know anything about medicine. But they did have to know success rates. Patients cannot make informed cost-benefit decisions without knowing success rates. Neither can doctors, but none of them do.
Motivating Safety and Efficiency
Under the right circumstances, that toenail laser treatment could cost $150 from an operator with a high success rate. Scientific studies and efforts like the Closed Case Claims project produce nothing that motivates clinicians to figure out how to compete at that price. They might reduce the number of expensive litigations resulting from toenail laser accidents. They might produce safe practices guidelines. But they do not motivate operators to be safe. They do not motivate operators to be more efficient and less expensive. When patients pay whatever they are told to pay without regard for what they are getting, there is no reason to become more efficient or less expensive. There isn't even much motivation to become safer. However, there is a strong motivation to keep anyone from finding out when they are inept and/or expensive. There is a strong motivation to silence claims and hide results. And doing so makes it so that no one knows success rates.
For medicine to become safe and affordable, it must be the
case that patients have the information necessary to know whether or not it is
safe.
It must be possible for entities
like
Consumer Reports to do epidemiological studies of individual clinicians and
note when eleven 14-year-old girls complained of being groped by a certain
clinician, without the girls who posted it on facebook getting sued, and without
Consumer Reports getting sued for reporting how many did. Closed case
studies do not improve the fact that sex predators in medicine abuse patients
for decades before there are enough patients finally to force someone to pay
attention. Waiting for the closed cases requires amassing an unacceptable number
of victims to study. Even then, it does not put every doctor and hospital in the
country in a position in which staying in business requires competing with
people who are safer and cheaper.
Patients today do not know the success rates of almost anything or anyone in medicine. So 160 years after Semmelweis, clinicians still do not wash their hands often enough let alone take enough more complicated precautions to reduce infections.
$300 Hamburger?
The FDA shuts down an entire industry if a hamburger is found to contain E. Coli. But they do not tell consumers what and where to eat and how much to pay for it. If they did hamburgers would cost $300 and it would require lawsuits to respond to a bad cook, rather than consumers being able to tell the cook is bad and just stop going there. The FDA helps reduce the frequency of fatalities, but even if it were run by saints it could not motivate chefs to create food that is affordable and good.
If you want your hamburger to look like healthcare, put the FDA in charge of choosing what you eat and how much you pay for it. If you want medicine to look more like the way you eat, start arranging for patients to provide to each other the information that no one in healthcare will. No one in health care will warn patients when one doctor in a facility has a high death rate. No one keeps track of that. They don't know themselves. But other patients can. This has been studied. It has been demonstrated that when given the opportunity patients report more information and more accurate information than anyone in health care (click here for the study).
It is difficult to persuade people of how few adverse events get reported in medicine, but understanding that is essential for fixing medicine. See the most recent report from Health and Human Services: reviewed hospitals did not generate incident reports for 93% of adverse events. The 7% of the time when they did generate reports, the information was inaccurate 63% of the time. Which means clinicians are willing to report accurate information about adverse events 2% of the time. This is not the first time this fact has been found. This is not the first time that information has been made available. Yet know one working in medicine knows about it. And adverse events are the most important thing to know. Especially for patients. Those are the strikes. Batting averages cannot be determined without knowing about strikes. Patients with no information about success rates are being asked to believe that all people in medicine are saints.
Surviving Single Digit Reporting
The foundation for making medicine safer and more affordable is patients having the information necessary to make informed cost-benefit decisions so they can avoid paying $1200 for a laser treatment from someone with a poor success rate. So they can avoid paying $2,500 for an MRI they can get around the corner for $300. So they can avoid dangerous facilities. So they can avoid getting butchered by an inept physician no one in medicine will report. So they can put clinicians in the position of losing business if they have poor success rates from not washing their hands.
Scientific studies, closed claim projects, examinations of existing records, reorganizing administrations and altering the way clinicians are paid might offer patches for problems, but will not alter the fundamental issues. All of those patches require saints to understand and implement them. If health care professionals were saints they would put the interests of patients ahead of their own by recording 100% of adverse events, like airplane pilots do (because if the problem isn't fixed pilots go down with the plane). And they would figure out how to charge $150 for laser toenail treatment.
Think how valuable that would be to the patient community. The recording of adverse events would empower patients to protect themselves when clinicians turn out not to be saints. Lowering prices to 12% of current charges would end personal bankruptcies and make it affordable to extend coverage universally. But they are not saints. They don't do that. They charge $1200 for a $150 treatment whenever they can. So patients will have to do what is necessary to collect and disseminate the life-saving information themselves. Having that will put downward pressure on prices. Without having that information health care will continue to bankrupt and kill more people than anything else.
Within the patient community exists the information necessary to determine which radiologists have good batting averages and which don't. And which take too long and cost too much. With that information, patients can make choices that put inept radiologists out of business and cause the rest to figure out how to be efficient enough to be affordable.
All of the studies and projects set up to run medicine better for patients are vital, but never will do for patients what patients can do for themselves. Patients must be in the information driver seat. There are projects that could help them get there, but no one is talking about them. All anyone is talking about is what is being done at Mayo, or at the Closed Claims Project, that will make it so that saints can run medicine for patients with patients left in the position of doing what they are told and paying what they are told.
That's the model that got us where we are now.
What we need is for patients to know about the dangers and be in a position to care about the price.