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Notes 11

"The structure of evidence is not linear, like a mathematical proof, but ramifies like a crossword puzzle."
- Susan Haack



Wall of Silence

Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans
by Rosemary Gibson, Janardan P. Singh, Rosemary Gibson, Janardan Prasad Singh.

Links are to a page on this site with more about the book.





"A profession is not just a way of making money; it's a form of public trust . . . Medicine has for many decades now been betraying this public trust," says Dr. Howard Brody in his book Hooked. Ethics, the Medical Profession and the Pharmaceutical Industry published by Bowman & Littlefield.





The story was in the Cincinnati Enquirer on Wednesday, November 22, 2006. It was written by Eileen Kelley, a staff writer, and was called "Golden Rule is tarnished by robber."









Semmelweis Society, an organization set up to protect doctors (apparently specifically from the results of peer review), decries the "Health Care Quality Improvement Act's toleration of libel." It appears they don't want people to be able to criticize physicians without being sued for it.







Millenson ML. Demanding medical excellence: Doctors and accountability in the information age. Chicago: University of Chicago Press, 1997: 52–73.







Who is guilty?
If you did a study to determine how serious people in healthcare think various malfeasances and adverse events are, you would not learn the truth about how they behave in the real world. If you asked them which is worse, a doctor assaulting a patient or a patient assaulting a doctor, they might say that they believe that a doctor assaulting a patient is worse because some patients are mentally disturbed or confused or have other problems that cause them to be problems. But doctors are supposed to be sane and peaceful.

However, when not taking a survey, if confronted with a patient who says that a doctor assaulted him or her, everyone in medicine turns against the patient to protect the doctor without ever having a moment when they wonder if the doctor could be guilty. When a fictional example is presented to them, for the purposes of the survey they assume it to be true that a doctor has assaulted a patient. But in the real world, they don’t. They protect each other first and turn against the patients.

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Millenson 2
The Silence
by Michael L. Millenson
in Health Affairs, 22, no. 2 (2003): 103-112

The link leads to an abstract, but at the time of this writing the whole article could be accessed there

















The Semmelweis Society decries the Health Care Quality Improvement Act's toleration of libel.




Note to myself:
Where do I put the below? It was removed from  Wall of Silence page.

“This country has not taken seriously the alarms we sounded in 1999. . . Why?” asked Arthur Levin, director of the Center for Medical Consumers and an author of the 1999 report “To Err Is Human." It estimated that medical errors of all sorts led to as many as 98,000 deaths each year. He said that just about everyone in the health system was to blame.

“The key is having the will to make these changes,” according to said Charles B. Inlander, president of the People’s Medical Society, a consumer advocacy group, and an author of a more recent study called “Preventing Medication Errors.” He was speaking about reducing medication errors in particular when he spoke as though the problem were merely a lack of will.

According to Stephen G. Pauker, M.D. in the New England Journal of Medicine "the core problem in hospitals is the inability of the system and its managers to solicit and integrate the knowledge and experience of front-line workers (physicians, nurses, and support staff)," expressed as though it is merely a problem of getting the right management procedures to motivate healthcare workers.

The most misleading assumptions
are the ones that you don't even know you are making.
- Douglas Adams

The above assertions have a fairy tale as their underlying premise. They are based on assumptions that fly in the face of the most important facts known about the bad things that happen to patients in healthcare.

The underlying assumption is that it is possible for healthcare workers to be objective and honest reporters and enforcers of patient safety problems. There is no recognition of the conflict of interest between the needs and desires of healthcare workers and the safety of patients and how that makes it so that they never will be impartial reporters. There is no recognition of the prism through which healthcare providers see the world being at odds with the experience of patients and the statistics about patient safety. We are on a merry-go-round that spins around false assumptions when we need to be walking down the path.

Most of the problems that people have in medicine are not the results of crime committed against them in healthcare, but the mechanisms that allow crimes to be committed against them are the same ones that enable and cover up most of the problems that they do have. Systems that ignore crimes ignore the fundamental problems.

JCAHO found that when healthcare workers commit crimes against patients the least likely of all people to report those crimes is anyone working in healthcare. The significance of that is lost on the medical community and on patient safety advocates. We continue to have faith in them to be selfless and honest when they won't even report crimes. Intentional injuries, committed by healthcare professionals, the front-line workers, against patients, with virtually none of them helping the victimized patients, is the most important and most telling story in patient safety. But the discussion being had in patient safety is not about that. In an environment where they won't even report rape we are imagining that we can create a culture more friendly than Mr. Rogers neighborhood.

And none of the failures and refusals to report
are regarded as a wall of silence.

We are so careful about how we speak about healthcare workers that we have discussions that cannot lead to solutions because they are not about the real world. They dance around the issue so politely that they don't touch the fundamental problems. The rock bottom foundation of patient safety is criminal law. Conflicts of interest block its enforcement and maintain a the wall of silence around it. We speak of "the inability of the system and its managers" to encourage the changes even when Genene Jones is murdering children while her supervisor protects her and the only nurse who tries to report her gets fired for reporting. The system and its managers are the ones who fired her. The problem is not just a matter of management eliciting information from front-line workers. The entire system has interests and biases that are in conflict with the safety of patients, including management. Management engineers the wall of silence. And cases like Genene Jones are not even recognized as indicative of how management and the rest of medicine handles patient safety. They are dismissed as "one-offs."

Do you know what happens when a patient reports to hospital management that he/she was intentionally injured there? They sue the patient to shut the patient up. If the discussion has to be about how to elicit information, perhaps it should begin with discussing how to keep management from shutting up the only people reporting it.

The very least a patient should be able to expect when entering a healthcare system is to be kept safe from intentional harm. Failing that, there should be someplace that patient can go for help. At present there is no such place. The system cannot provide this safety in part because it refuses to form an accurate picture of the problem. Murderers do not report themselves. And their colleagues protect them to the end. If someone figures out how to change human behavior so that murderers report themselves, then there will be a point in discussing how to elicit information from the frontline workers. Until then, it's discussing a fairytale.







Whistleblower Charles Rosen, M.D. stated in a 7/25/2003 Street.com article that he wondered why no agency was intervening after he reported the source of the unusually high infectious rate at his facility. Instead he watched his hospital deliberately attempt to cover-up the problem for financial reasons.

Davis M. "Whistleblower Wants Tenet to Come Clean"
TheStreet.com 7/25/2003