Healthcare reform

“Honor Amongst Thieves” — A Perspective on the Access to Medicine Index

iStock_000004475255MediumEach year, the Access to Medicine Foundation publishes a hierarchical list of pharmaceutical companies ranked on their efforts to improve access to medicine in developing countries.”  See: http://www.accesstomedicineindex.org/ranking. Without wanting to diminish the good intention of this group, the index, from my cynical perspective, may denote little more than the level of “honor” amongst thieves.

Gilead — the Poster Child:

 While seemingly noble on the surface, one does not need to dig deeply to discover the degree to which these companies are vastly more concerned with quarterly returns to shareholders than altruistic actions that benefit global health. Take Gilead Science, for instance, and the company’s perceived, initial reluctance to discount Sovaldi – a breakthrough drug in the treatment of Hepatitis C. The undiscounted cost for a course of treatment is approximately $85,000. According to a June article in Forbes, “Sovaldi costs about $130 to manufacture, reinforcing how outrageous its pricing is.”

Yet, it was only after being cast as the poster-child for egregious profiteering that Gilead reassessed its stance on the cost and availability of Sovaldi. The organizations that spoke out about Gilead’s pricing were formidable, as evidenced by an article appearing in the April 11, 2014 edition of Bloomberg News stating: “The WHO yesterday called for ‘‘a concerted effort’’ by various stakeholders to lower the cost of the drug.”

Implicit in the WHO comments was a threat that generic versions could be produced independently of Gilead: “In addition to tiered pricing, voluntary and compulsory licensing, where generic-drug makers are given permission to produce more affordable versions of a medicine, can also help achieve affordability, the WHO said.”

Bowing to Pressure:

In response to increasing public pressure and the potential loss of control of their golden goose, Gilead slashed the costs of Sovaldi to selective countries, such as Egypt and India, where there are large populations of infected individuals that lack the resources to pay for the drug. Yet, they did little to address the drug’s unaffordability to the myriad of indigent patients in economically developed countries.

It’s worth noting that Gilead acquired the ability to manufacture Sovaldi through the purchase of Pharmasset at the cost of $11 billion. Amazingly, “Gilead is on pace to recoup the full cost of its $11 billion investment in just over one year. That is unprecedented,” according to the Forbes article.

Deanna Beasley, writing for Reuters, quoted Brendan Buck, a spokesperson for America’ Health Insurance Plans, as stating: “The blank check mindset we’ve seen from Gilead is a threat to our entire health care system, and we hope they will pursue more sustainable pricing in the future.” Gilead ranks fifth from the top (out of twenty) on the Access to Medicine list.

18/20 Companies Guility

It is unfair to single-out Gilead as the greedy one amongst pharmaceutical and biotech firms. As a recent New York Times article pointed out, “Eighteen of the 20 companies in the index have settled or been convicted of unethical marketing, unfair competition or bribery in the last two years.”

Again, I applaud the foundation’s efforts. Whether its list  is a noble attempt to improve transparency within the pharmaceutical industry and catalyst for greater altruism or simply lipstick on the pig, I will leave up to you…my reader.  

WHO IS PROTECTING US FROM BAD DOCTORS?

Caduceus Medical Symbol chromePhysician Self-Evaluations

It is extraordinarily difficult for a consumer to evaluate the clinical competency of a physician. If you don’t believe me, doctors will be the first ones to tell you so! According to researchers James and Hammond, “Only another physician has the necessary knowledge and experience to judge whether a professional colleague adequately discharged his or her fiduciary trust to a particular patient.”[i]

James goes on to state that doctors are so self-protective of their cultural status that “not only do physicians resist attempts of those outside the profession to inappropriately judge medical performance, they also insist on holding one another accountable for their performance within the profession of medicine.”[ii] Evidence suggests otherwise. Though they may “insist” on holding one another accountable, they do very little to honor it.

 Policing Their Own Ranks to Protect Patients from Dangerous Doctors

If James’s statement were true, the medical community bears a clear obligation to safeguard its patients’ well-being by policing its ranks. Poor clinical performers, impaired physicians, and unethical practitioners should succumb to peer scrutiny or dramatically change their ways.

Theoretically, there are three levels at which such scrutiny should apply: (1) the peer-review committee of a hospital—which granted hospital-based privileges to the physician in the first place—(2) a state board of healing arts—responsible for ensuring the practice of safe and ethical medicine within the state—and (3) the ethics or disciplinary-action committees of national medical associations.

Unfortunately, a tremendous barrier stands in the way of effective reporting of physicians’ malfeasance: the physicians’ code of silence. Much like the mafia’s omertà, it is an inviolate code of conduct inculcated into trainees early in their education. The message is simple: Don’t attack your colleagues, or you might find yourself ostracized.

If you think I’m exaggerating, listen to what two, nationally known physician-authors have to say on the topic, beginning with Dr. Marty Makary: “Doctors and nurses know of docs who are reckless, but it takes moving a mountain to do something about it. Not reporting incompetence among peers is part of medical culture and has been for centuries. Medicine is poorly policed. Getting fired takes an action so egregious or offensive to hospital administration that I have only seen it happen twice among all the hospitals in which I’ve worked and trained.”[iii]

Dr. Otis Brawley, Chief Medical Officer for the American Cancer Society, shares Dr. Makary’s sentiment. “I know doctors who are just plain bad. Why do they continue to practice without impediment? The answer is simple: because no one is looking over their shoulders, no one files a disciplinary complaint, no tribunal of peers punishes them unless they do something spectacularly awful.”[iv]

Peer Review: A Perfect Path to Burying Problems

When the level of suffering, injury, or unnecessary death inflicted by a colleague weighs too heavily on the conscience of some physicians, they can turn to peer review. The peer-review committee provides a venue for discussing and investigating allegations of inappropriate conduct by members of the medical staff. These allegations can run the gamut from violating standards of surgical appropriateness to boundary violations with patients.

In theory, peer review provides a fair and informed method for assessing the clinical or nonclinical behavior of a physician and the resulting potential for harm to patients. The proceedings are safeguarded against legal discovery—with the intent of promoting open, honest, and corrective dialogue.

Far from being effective, “such internal peer reviews are a little like the Russian parliament under Stalin,” finds Makary. “No matter how much discussion there is, the results seems foreordained . . . any doctors who might raise probing questions are well aware that they can pay a heavy price for challenging their peers.”[v] In those rare times when action is taken, the physician is often given the opportunity to simply resign their medical-staff privileges at a hospital or health system. By so doing, their misdeeds go unrecorded and they move across town to wreak havoc elsewhere.

I’ve seen physicians who fall asleep in the midst of complex surgeries, others who open up purportedly blocked arteries with multiple interventions—despite no discernible evidence of coronary disease. Some physicians knowingly inflict pain—either because they are sadistic or, more likely, because they don’t want to waste time waiting for the effects of anesthetic agents to kick in.

The most outrageous case I know of  involved a physician performing a circumcision on a two-year-old. The parents, waiting in a nearby room, heard their child screaming in pain. When later they asked the physician what had caused such a violent reaction in their child, he responded, “the injection of an anesthetic.” In reality, he provided the child with no anesthetic—after all, it was a simple, quick procedure. In my mind there is a fitting punishment for such behavior on the part of the physician . . . and it is no mere slap on the wrist.

Finally, there are those who are blind drunk when operating. Such behavior is tolerated day in and day out in American medicine. To do otherwise would be to break the code of silence.

There are physicians who hold themselves to a higher code—one that demands owning responsibility for their actions. One such physician, Dr. Peter Elias, writing in the New York Times’ Sunday Dialogue, offered this advice to his colleagues regarding medical error: “As a practicing family physician for thirty-six years, I have come to believe in the seven essential Rs of an apology: it should be Rapid (as in right away when the error is discovered), show true Remorse, Recognize explicitly the error, accept Responsibility, acknowledge the Repercussions for the patient, offer Restitution or repair, and close with a Repetition of the opening words: I’m sorry.”[vi]

State Medical Boards Receive an F for Failing to Protect Us

A second “safeguard” against dangerous physicians should be state medical boards, which oversee licensure and disciplinary action. But they are not, according to Alan Levine, who provides oversight of the medical boards on behalf of the United States. Inspector General Levine indicates that many of these boards serve the vested interest of physicians to a far greater extent than they serve the public good.[vii]

Though the accounts are anecdotal, I’ve heard many physicians suggest that these boards are partly populated by dangerous physicians. It’s a case of the fox guarding the hen house. If there’s bad news coming down the pike regarding a physician’s practice, a position on the board will ensure that the physician will be first to hear it and attempt to squelch it.

In a recent review of state medical boards conducted by the consumer advocacy group Public Citizen, only two states were given an A rating. The vast majority received a Fs. What was particularly disturbing was the variance seen among these boards. “The most recent three-year average state disciplinary rates (2009–2011) ranged from 1.33 serious actions per thousand physicians (South Carolina) to 6.79 actions per thousand physicians (Wyoming), a 5:1–fold difference in the rate of discipline between the best and worst state doctor disciplinary boards.”[viii]

Sidney Wolfe, MD, founder of Public Citizen, noted that there was no evidence to suggest that the rates of inappropriate behavior by physicians vary dramatically between states. Therefore, the variations observed by Public Citizen can only be attributable to the manner in which individual boards manage physician disciplinary issues. He goes on to state that “there is considerable evidence that most boards are underdisciplining physicians.”[ix]

Wolfe’s research concludes that the average serious disciplinary rate, for any cause, is only 3.06 per one thousand . . . or 0.3 percent. Yet we know that there are a tremendous number of impaired physicians wreaking havoc on patients every day—physicians who obviously go either undetected or unpunished.

As Dr. Marty Makary points out in his book, Unaccountable, “There are also grossly impaired physicians [and] doctors with horrible skills, hazardous judgment, [and] ulterior motives or who suffer from substance abuse or other problems that make them dangerous. Society ought to be able to deal with this better, not sweep it all under the rug.”[x]

Do such physicians represent the proverbial needle in the haystack and thus only affect an infinitesimally small portion of the population? Makary asks us to consider what it would look like if 2 percent of our doctors had a major impairment due to drugs, alcohol, or other causes. He then calculates that there would be twenty thousand impaired physicians in America treating up to ten million people per year.[xi]

That’s a lot of needles and haystacks.

If Makary’s estimates sound absurdly high, consider the conclusions reached by researchers Eugene Boisaubin, MD, and Ruth Levine, MD, as published in the American Journal of Medical Sciences. “Approximately 15 percent of physicians,” they find, “will be impaired at some point in their careers.”[xii]That’s not to suggest that these physicians will, de facto, endanger their patients, but it certainly indicates a higher level of risk than might be suggested by the rate of disciplinary actions taken by state medical boards.

Caveat emptor to all patients: as Dr. Wolfe has demonstrated, “most states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner.”[xiii]

The Abdication of Responsibility by Professional Societies

The final level of protection from malevolent, incompetent, or impaired physicians resides in their professional associations—most prominently the AMA. The AMA’s Code of Ethics states that “a physician shall deal honestly with patients and colleagues and strive to expose those physicians deficient in character or competence or who engage in fraud or deception.”[xiv] The question becomes whether such standards are ever enforced. “After asking around,” Makary found, “it became clear that the only time that a doctors’ association would ever consider taking action against a doctor was if a state medical board had already done so.”[xv]

Professional societies exist not merely for the benefit of their members but to uphold the standards of the profession. Yet Otis Brawley, MD, questioned whether medicine even conforms to the definition of a profession. “A profession,” he notes, “is a group of people who police themselves and put the welfare of their clients above their own. In many respects, people within medicine have forgotten what the word profession means.”[xvi]

One can seek comfort in the belief that problematic physicians are few and far between, but the comfort will be short-lived. “An average American’s combined exposure to quality failure from providers’ underuse, overuse, and misuse of services is roughly 50 percent for preventive, acute, and chronic care services.”[xvii]

It’s Time to Step Up to the Plate: The Need for Physician-Defined Standards of Competency and Reporting Requirements

It is abundantly clear that there is a crying need to restore the fundamental trust between patients and physicians. A good starting point would be for the medical community to define criteria on which physicians’ performances would be evaluated, as well as the degree to which such information would be transparent to the public. Right now, “there is no agreed-upon definition of competence that encompasses all important domains of professional medical practice.”[xviii]

Doctors Epstein and Hundert, in an article published in JAMA, suggested a definition that, on the surface, appears quite cogent: “We propose that professional competence is the habitual and judicious use of communication, knowledge, technical skills, clinical reason, emotions, values, and reflection in daily practice for the benefit of the individual and community being served. Competence builds on a foundation of basic clinical skills, scientific knowledge, and moral development.”[xix]

The authors go on to discuss the importance of the following measures of competency:

  • Acquisition and use of knowledge
  • Integrative aspects of care: “It is defined by the ability to manage ambiguous problems, tolerate uncertainty, and make decisions with limited information.”[xx]
  • Building therapeutic relationships: “The quality of patient-physician relationship affects health and the recovery from illness, costs, and outcomes of chronic diseases by altering patients’ understanding of their illnesses and reduction patient anxiety.”[xxi]
  • Affective and moral dimensions: “Moral and affective domains of practice may be evaluated more accurately by patients and peers than by licensing bodies or superiors.”[xxii]

Epstein and Hundert also point out deficiencies in current methods for assessing competency: “Few assessments use measures such as participatory decision making that predict clinical outcomes in real practice. Few reliably assess clinical reasoning, system-based care, technology, and the patient-physician relationship.”[xxiii]</indent>

Finally, they point out, “Standardized test scores have been inversely correlated with empathy, responsibility, and tolerance.”[xxiv] Perhaps you should disregard what I said about MCAT scores.

In an interview in September 1997, I asked one of the physicians I revere the most how one finds a great doctor. Elisabeth Kübler-Ross, never shy of opinions, offered thoughts about why it is difficult to find a good doctor: “You have to be an A student. That eliminates 90 percent of the good people. Then you have to have lots of money—that eliminates the other few percent. That means it is pure coincidence if you get one good apple in the whole basket. Then you train them to cure, you don’t train them how to be physicians.”[xxv]

 

DISCOVER FAR MORE STARTLING FACTS ABOUT THE HEALTH CARE SYSTEM by reading:

The Myths of Modern Medicine: The Alarming Truth About American Health Care. It is available on Amazon.com or directly from the publisher, Rowman & Littlefield.



[i] James and Hammond, “The Challenge of Variation,” 1001.

[ii] Ibid., 1001.

[iii] Makary, Unaccountable: What Hospitals Won’t Tell You, 102.

[iv] Brawley, How We Do Harm, 125.

[v] Makary, Unaccountable: What Hospitals Won’t Tell You, 100.

[vi]Peter Elias, “Sunday Dialogue: Handling Medical Errors,” New York Times, October 18, 2013, http://www.nytimes.com/2013/10/20/opinion/sunday/sunday-dialogue-handling-medical-errors.html.

[vii] Makary, Unaccountable: What Hospitals Won’t Tell You, 103–104.

[viii]Sidney M. Wolfe,Cynthia Williams, and Alex Zaslow, “Public Citizen’s Health Research Group Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2009–2011,” Public Citizen, last modified May 17, 2012,http://www.citizen.org/documents/2034.pdf.

[ix] Ibid.

[x] Makary, Unaccountable: What Hospitals Won’t Tell You, 97.

[xi] Ibid., 96.

[xii]E. V. Boisaubin and R. E. Levine,Identifying and Assisting the Impaired Physician,American Journal of Medical Sciences322, no. 1 (July 2001): 31–6,http://www.ncbi.nlm.nih.gov/pubmed/11465244.

[xiii] Wolfe, Williams, and Zaslow, “Public Citizen’s Health Research Group.”

[xiv] Lundberg, Severed Trust, 10.

[xv] Makary, Unaccountable: What Hospitals Won’t Tell You, 102.

[xvi] Otis Brawley, MD, chief medical and scientific officer of the American Cancer Society, in discussion with the author, August 16, 2013.

[xvii]Arnold Milstein and Nancy E. Adler, “Out of Sight, Out of Mind: Why Doesn’t Widespread Clinical Quality Failure Command Our Attention?Health Affairs22, no. 2 (2003): 119–27, http://www.ncbi.nlm.nih.gov/pubmed/12674415.

[xviii]Ronald M. Epstein and Edward M. Hundert, “Defining and Assessing Professional Competence,” Journal of the American Medical Association287, no. 2 (January 9, 2002): 226–35, doi:10.1001/jama.287.2.226.

[xix] Ibid., 226.

[xx] Ibid., 227.

[xxi] Ibid., 228.

[xxii] Ibid., 228.

[xxiii] Ibid., 230.

[xxiv] Ibid.

[xxv] Elisabeth Kübler-Ross, MD, author of On Death and Dying, in discussion with the author, September 4, 1997, Carefree, Ariz.

The Danger Lurking in American Hospitals

 

Underlying their glistening facades, hospitals are home to a grievous level of medical error.

Underlying their glistening facades, hospitals are home to a grievous level of medical error.

The following post is an excerpt from John Leifer’s recently published book, The Myths of Modern Medicine: The Alarming Truth About American Health Care, now available on Amazon.com

The Danger Lurking in America’s Hospitals

Perhaps the most startling revelation about hospitals is the degree to which they imperil patient safety. Allow me to share a few tales—including one that I personally witnessed.

Tragedy Strikes at One of America’s Finest Hospitals: Downing a Rising Star

Harvard-affiliated teaching hospitals symbolize the strength of American medicine.[i] Among these giants, one in particular stands out—Massachusetts General Hospital. It was here, in 1846, that the public witnessed the miracle of the first painless surgery performed under anesthesia.

There have been many firsts at Mass General—often bringing renewed promises of life where before there had been little hope for desperately ill patients. But like all hospitals, Mass General has witnessed its share of tragedies, including ones that were avoidable.

In the tough world of television production, there are also giants, and Trevor Nelson was well on his way to becoming one. Though only thirty-four years old, he had already made his mark in the industry as a producer of the award-winning program 60 Minutes. Though his job was demanding, he always found time for what was most precious—his family.

While on vacation with his wife, Maggie, and sons, George and Conrad, Nelson became ill. Though he tried to ignore it, he couldn’t shake the headache that accompanied his general sense of malaise, driving him to seek treatment at a local hospital. A short battery of test revealed little about Nelson’s condition, and he was discharged with medication. The medicine, however, proved to be of little help in ameliorating Nelson’s wracking headache. So, three days later, Trevor and Maggie drove to the Mass General’s ER.[ii]

With more than eighty-five thousand visits per year, Mass General’s ER bustles like a small city. The seasoned staff, who are accustomed to treating major trauma, not “mere” headaches, saw no reason for undue alarm. In fact, after a number of hours had passed, they suggested that Maggie return home to care for the boys. Reluctant to leave, Maggie finally acquiesced, accepting the staff’s promises that her husband would be fine.

But Trevor was not fine. Diagnosed with non-life-threatening viral meningitis, Nelson was admitted to the hospital. During the course of his visit, he was given a plethora of powerful drugs to alleviate his intractable headache—purportedly including more than twelve doses of narcotics in fifteen hours.[iii] Early the next morning, when nurses came to check on him, they discovered he had no vital signs. Though placed on life support, Trevor Nelson would never recover . . . and nor would his family from their epic loss. Was his death attributable to a fatal combination of drugs that suppressed the central nervous system, as the family alleges . . . and was thus avoidable? That question would be determined by a jury.

The Case of the Blazing Patient

There’s nothing esoteric about an electrocautery. The device has been a fixture of virtually all operating rooms for nearly a century. As its name implies, electrocautery can be used to stem the flow of blood during surgery through cauterization of tissues and blood vessels. It can also be used to make an incision. In most situations it is both safe and invaluable.

There are exceptions, however, as “Mary,” an eighteen-year-old patient undergoing emergency surgery for a ruptured appendix, was about to find out. As Mary was being prepared for surgery, her skin was treated first with iodine and then with an alcohol compound known as spirit. The initial incisions were made, and as the operation progressed, the surgeon began to cauterize the surgical site. Following is an account of what happened next.

As soon as the cautery was used, the cotton wound towels applied on the two sides of the incision caught fire due to a flame arising from the undersurface of the towel. It was extinguished using another sponge but not before producing deep dermal burns on two sides of the skin incision. The cautery was checked and found to be correctly installed. On careful examination, it was observed that the skin was still wet with the last coating of spirit, which was not dried up properly. The residual spirit film on the skin caught fire from the spark of the cautery leading to burns involving the lower part of the anterior abdominal wall. It took three weeks for the deep dermal burns to heal with residual scarring.[iv]

 A research study published in the May 2013 issue of Anesthesiology examined the cause of OR fires using insurance-claims data. The researchers determined that the electrocautery was the source of ignition 90 percent of the time.[v] The most frequent cause was the ignition of oxygen being administered to anesthetized patients, though “alcohol-containing prep solutions and volatile compounds were present in . . . 15 percent of OR fires during monitored anesthesia.”[vi]

The Tragedy of Multiple Deaths Due to a Single Avoidable Error

Heparin is an extremely potent drug used to thin a patient’s blood as a preventative for strokes and other adverse events. It is commonly used in neonatal intensive-care units (NICUs) to keep the IV lines open in premature babies. The drug can be lifesaving when properly administered and lethal when given in the wrong dose.

On September 16, 2006, tragedy struck the NICU at Indianapolis-based Methodist Hospital, part of the Clarian health system (now IU Health). It began with a silent but deadly error—when vials of heparin containing adult doses of the drug were delivered inadvertently to the NICU by an experienced pharmacy tech.[vii] With tens of thousands of prescriptions being filled each day by Clarian pharmacists, it simply slipped through the cracks. Though there were numerous times when the error might have been identified, no one caught it before the drugs were administered.

As a result, six babies received a dose of heparin that was one thousand times more powerful than prescribed.[viii] Three of the babies died. Three were injured. As a consultant to the organization, I witnessed this tragedy unfold, albeit at some distance. I saw the ensuing anguish that cascaded through the organization. Everyone was heart-broken, as, of course, were the families of those tiny children.

The children were gone, and there was nothing the team at Clarian could do to change that fact. But, much to the credit of Clarian’s administrative and physician leadership, they immediately went public with the painful truth behind the tragedy, promising that these tiny lives would not be sacrificed in vain. The team then devoted themselves to identifying and fixing the systemic breakdowns within their hospitals so that such tragedies would not be repeated.

A Mother Loses Her Precious Daughter

Desiree Wade was full of life. As a four-year-old girl, she dreamed of being a ballerina—dreams that helped shield her from the difficult reality of life in Harlem and brought joy into her life. When doctors suggested to her mother, Beverly, that Desiree needed a tonsillectomy, she assumed it was a minor operation with few risks. And she was right, in terms of statistical averages, but not in terms of the one outcome that mattered most to her—her precious daughter’s health.

Desiree began to show symptoms of a problem the day after what appeared to have been an unremarkable surgery. Seventy-two hours later, Desiree was hemorrhaging massive amounts of blood from her mouth, dying shortly thereafter in her mother’s arms.[ix] A beautiful life, a mother’s hopes and dreams, cut tragically short by a surgical complication arguably due to a poorly trained provider.

A Kidney Goes Missing

In August 2013, CNN broke a story regarding the University of Toledo Medical Center.[x] According to reporter John Bonifield, patient Sarah Fudzcz was hospitalized for a kidney transplant. Her brother, Paul, was a perfect match. So on August 10 of 2012, Paul underwent surgery to remove one of his kidneys so that it could be transplanted into his sister.

The surgery went swimmingly. Unfortunately, though, a nurse inadvertently threw the kidney away. Hard to believe? It really happened. Dr. Jeffrey Gold, chancellor and executive vice president for Health Affairs at the university, offered a profound apology. The matter is now in the courts.[xi]

These Cases Are Not Isolated Examples

As outlined in chapter 1, hospital-induced injuries, illness, and death are a major problem in the United States. The extent of health care’s dirty laundry was fully exposed in 2000, when the Institute of Medicine (IOM) published, To Err Is Human: Building a Safer Health Care System. Headlines across the nation proclaimed that medical errors were now one of the leading causes of death in our nation.

The report was groundbreaking. The fact that such sensational findings came out of a methodical study conducted by the IOM made it difficult to refute, though plenty of pundits tried. Most importantly, though, “the report called for a fundamental transformation in the delivery of health care, emphasizing the culpability of the entire medical system rather than individual physicians.”[xii]

This report was akin to Upton Sinclair’s 1906 book, The Jungle, which exposed the ills of the meat-packing industry, resulting in dramatic industry changes over time. Sinclair was a muckraking journalist. The IOM is a distinguished scientific body. If Sinclair could catalyze wholesale change across an industry, could not the IOM?

Despite the concussive effects of its initial publication, the IOM report does not appear to be having a dramatic impact on the safety of American hospitals. High rates of errors continue to plague our hospitals, based on the current research.

Hospital-induced errors were the key focus of To Err Is Human, but such errors are pervasive throughout the delivery system—from the physician’s office to the ambulatory surgery center. Just how pervasive are errors within our health-care system? A 2002 study revealed that “35 percent of physicians and 42 percent of the public reported errors in their own or a family member’s care.”[xiii]

According to Walshe and Shortell, hospitals have a long history of sweeping problems under the rug, thus preventing improvement in processes across the system. “It is striking,” they say, “that major failures are not usually brought to light by the systems for quality assurance or improvement that are now found in most health-care organization in developed countries.”[xiv]

Walshe and Shortell reinforce their point by citing a somewhat dated but glaring example of this issue. “At Vermillion County Hospital in Indiana, where Orville Lynn Majors worked in intensive care and murdered patients, there were twenty-four deaths in the intensive care unit (ICU) in 1991, twenty-five in 1992, thirty-one in 1993, and 101 in 1994, but the quality-management systems did not identify a problem.”[xv]

Despite incredible pressure on hospitals to clean up their act, mistakes are still happening at an alarming rate. The May 5, 2013, online edition of the St. Louis Post-Dispatch reported the case of a fifty-three-year-old paralegal named Regina Turner.

Apparently, a neurosurgeon operating at St. Clare Health Center in Fenton, Missouri, operated on the wrong side of Ms. Turner’s brain. As a result, according to Ms. Turner’s attorney, the patient “now requires around-the-clock care and cannot speak intelligibly.”[xvi]

A less malignant but nonetheless damaging form of error is the system’s failure to provide the requisite services for its patients. The IOM published a subsequent book on quality and error, entitled Crossing the Quality Chasm. In it, Sarah Bleich concludes that “the average patient receives only 55 percent of the services that would benefit that individual,” according to an IOM Report in 2001.[xvii]

In the automotive industry, there are extensive warranties on the product you are purchasing in order to provide a safeguard. In health care, not only are there no warranties, but providers stand to profit from the very problems they create through poor quality delivery.

 



[i] “Mass General Hospital Ranked No. 1,” Harvard Medical School, July 17, 2012, http://hms.harvard.edu/news/mass-general-hospital-ranked-no-1-7-17-12.

[ii] Olivia Victoria Andrzejczak, “Lawsuit: TV Producer Pumped Full of Drugs,” Timesunion.com, August 9, 2009, https://secure.timesunion.com/AspStories/story.asp?storyID=829318&category=REGION.[AU: The URL you offer is restricted and so shouldn’t be used as a citation for your readers. Is the following story perchance the same text? http://www.timesunion.com/local/article/Dead-by-mistake-547833.php]YES

[iii] Olivia VictoriaAndrzejczak, “60 Minutes’ Ace’s Death Echoes of His Own Investigations,” Houston Chronicle, July 30, 2009, http://www.chron.com/news/article/60-Minutes-ace-s-death-echoes-his-own-1747718.php.

[iv] Sanjay Marwah and Sham Lal Singla, “Spirit-Induced Cautery Burns: An Unusual Iatrogenic Injury,” Internet Journal of Surgery 22, no. 2 (2010): 1, http://ispub.com/IJS/22/2/9414.

[v] Sonya P. Mehta, Sanjay M. Bhananker, Karen L. Posner, and Karen B. Domino, “Operating Room Fires: A Closed Claims Analysis,” Anesthesiology 118, no. 5: 1133-39, doi: 10.1097/ALN.0b013e31828afa7b.

[vi] Mehta et al., “Operating Room Fires,” 17[AU: Please provide page number.]

[vii] Theodore Kim and Tammy Webber, “Third Baby Dies after Error at Indiana Hospital,” USA Today, September 20, 2006, http://usatoday30.usatoday.com/news/nation/2006-09-20-baby-deaths_x.htm.

[viii] Ibid.

[ix] Laura A. Fahrenthold, “4-yr.-old Dies after Surgery,” New York Daily News, March 23, 1995, http://www.nydailynews.com/archives/news/4-yr-old-dies-surgery-article-1.688316.

[x] John Bonifield, “Ohio Family: Hospital ‘Botched’ Transplant, Threw Out Kidney,” CNN, August 30, 2013, http://www.cnn.com/2013/08/30/health/transplant-kidney-thrown-away/.

[xi] Susan Donaldson James, “Toledo Hospital Threw Out Donor Kidney, Now Denies Negligence,” ABCNews, August 29, 2013, http://abcnews.go.com/Health/toledo-hospital-threw-donor-kidney-now-denies-negligence/story?id=20110334.

[xii] Sara Bleich, “Medical Errors: Five Years after the IOM Report,” Commonwealth Fund, last modified July2005,http://www.commonwealthfund.org/usr_doc/830_bleich_errors.pdf.

[xiii] Ibid., 9.

[xiv] KiernanWalsheand Stephen M. Shortell, “When Things Go Wrong: How Health Care Organizations Deal with Major Failures,” Health Affairs23, no. 3 (May 2004): [AU: Please provide specific page number.]107, http://content.healthaffairs.org/content/23/3/103.full.

[xv] Ibid., [AU: Please provide page number.]107

[xvi] Jim Doyle, Blunders: Botched Brain Surgery Prompts Extensive Review at SSM Health Care,” St. Louis Post Dispatch,May 5, 2013,http://www.stltoday.com/business/local/botched-brain-surgery-prompts-extensive-review-at-ssm-health-care/article_df1f66b8-ba03-5ba1-8e93-ce0cc771f0a5.html.

[xvii] Bleich, “Medical Errors,” 9.[AU: Your citation is for Bleich, “Medical Errors: Five Years after the IOM Report,” but your paragraph text indicates it ought to be Committee on Quality of Health Care in America and Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century (Washington, D.C.: National Academy Press, 2001). Please reconcile the seeming discrepancy The source is an Issue Brief from The Commonwealt Foundation (pub #830) published July 2005. The author is Sara Bleich).]

What I Learned From the Death of My Parents

 

Jack & Shirley Leifer in Havana, Cuba -- 1946.

Jack & Shirley Leifer in Havana, Cuba — 1946.

Every family has its rituals, and one of ours was Sunday night dinner. It was a time to share news, to talk about our hopes or dreams, to simply relish time spent together. Sunday, May 20, 2001, was no exception. I went home after dinner, counting my blessings—so grateful to have my parents, despite their advancing ages.

On Monday, a call from my mother changed my world. My father had slept-in, which despite being 86, was not his habit. When she went to rouse him, there was no response. He seemed to be breathing okay, but was completely unresponsive. That’s when I got the frantic call.

So began our final odyssey with my father…a trip that would take us into the deepest realms of the health care system.

Eight minutes after calling 911, EMS paramedics were on site preparing my father to be transported to a nearby Emergency Room. Upon arrival at the hospital, the frenetic pace of the first responders was replaced by long hours of waiting as my father slowly moved from the ER to the ICU. There, a team of specialists went to work seeking to identify the underlying cause of his condition.

My father remained in a coma throughout that week, during which time our family maintained a vigil at the ICU. The waiting room, our temporary home, was bathed in the green sterile glow of fluorescent lights. It was a spaced shared with other families in crisis. Its eerie quiet was punctuated only by breathless sobs as bad news was delivered to loved ones. Whenever possible, we escaped to be at my father’s bedside, though watching the life slowly ebb from this once strong man was so painful.

Toward the end of the week, the doctors informed us that an underlying blood disease had transformed into a fulminating type of leukemia, from which my father would not recover. We were told that the merciful thing to do would be to let him go. When I asked for more information upon which to make such a difficult decision, a female oncologist turned away from me and directed her response to my brother, a physician. She seemed annoyed that I would not blindly accept what had been recommended, and cloaked her response in impenetrable medical jargon.

I again asked a series of questions—including whether my father was aware of his surroundings. A different physician addressed me directly and provided assurance that my father had no awareness and promised that he would quietly pass when we removed life support. After a family conference, we agreed to take him off the respirator.

As my father’s lungs labored for breath, he raised his arms up over his head and let them drop. I shot a sharp look at the ICU physician, who said that it was nothing more than a muscular reaction. My father repeated this motion several times before giving up. It was no simple twitch…it was more of a plea not to give up. His instructions to us had always been “Do everything in your power to keep me alive.” He was a fighter with an indomitable spirit. I will always feel that we let him down.

I hugged him for a last time, told him how much I loved him and would miss him, and said goodbye. I promised my nearly atheistic father that he was in for a beautiful surprise at what lay ahead of him.

After we had said our collective goodbyes in the bustling ICU, my brother and I took my mother’s arms and walked her out. Her inseparable partner for 61 years was gone.

My brother and I feared that it would not be long before we lost our mother. Life without her soul-mate would simply be too much to endure. But thankfully, she proved us wrong and lived another six years.

My mother’s death could not have been more different and opened my eyes to what Dr. Ira Byock refers to as “dying well.”

As my mother approached her 88th birthday, it was clear that she was growing weary of life without my father, as well as contending with an increasingly list of infirmities. Due to a series of falls, my brother and I had arranged for caregivers to be in her home 24 hours a day. This, too, she tired of, but accepted as a condition of maintaining some level of independent living.

Despite the careful eyes of her caregivers, she nonetheless fell again; this time breaking her knee. She was briefly hospitalized, during which time she was evaluated by an orthopedic surgeon. After viewing her x-rays, he recommended an immediate operation to pin the broken bone.

I asked if he was aware of my mother’s staggeringly high blood pressure and poorly controlled diabetes. He said yes. I asked if these conditions would substantially increase the risk of surgery. He grudgingly said yes. Finally, I asked what would happen if we did nothing other than bed rest. He indicated it would probably take an additional two to three weeks for her bones to heal.

It was stunning to me that the surgeon was willing to trade off a couple of meager weeks of bed-rest for a significant risk of surgical complications or death. My mother and I agreed that it was time to leave the hospital and go home. I informed the orthopedic surgeon that there would be no operation.

I’m not sure exactly when it happened during my mother’s convalescence, but, at some point, she decided it was time to let go. The fight was over, and she was ready to join my father. So she simply stopped eating.

I sat on the edge of her bed and asked if she knew what she was doing. She told me that she had been graced with a glorious life, and it was time to say goodbye. Her knee was mending. That was not the issue. My mother had watched as more and more elements of her life lay beyond her control. Through a simple, passive action, she could regain control and direct the remaining course of her days on earth.

It would take many weeks for my mother to pass. We brought in hospice, which helped us maintain her comfort and manage any pain or anxiety. Though painful to anticipate her loss, we nonetheless managed to savor every moment with my mother.

In the last few weeks, she became very confused and fatigued. Lucid moments seemed to be forever gone. I knew that death was near as I arrived early one morning to check on her. I was prepared to see the progressive and inevitable decline that had marked each of the past few days. But instead, I found my mother sitting in bed fully awake. She said, “John, honey, come here, I want to talk with you.”

Something incredibly powerful and unexplainable was happening. My mother was completely lucid and focused. It was as though her age and infirmity had been momentarily erased. She spoke with exacting clarity—wanting to ensure that I took in every measure of love and wisdom being doled out.

She said, “Remember how much your father and I treasured you. Always carry our love with you. And know that we will be looking down upon you…we will always be with you.”

I told her I loved her and reassured her that she wasn’t going anywhere quite yet…it wasn’t her time. But my mother knew differently. She told me she had to rest. That was the last time I spoke with my mother. She would pass away the next evening with my wife and me at her side. I would hold her hand as her body took its final breath. There was a peace in life’s finality.

I had once asked Elisabeth Kübler-Ross, “What happens at the moment we die?” She responded, “It’s like a cocoon. When a butterfly is ready, the cocoon opens up and out comes a butterfly.”

That’s how I choose to remember my mother’s passing—like a cocoon opening to let a beautiful butterfly soar.

I witnessed two parents die under very different circumstances: one confined to an ICU and tethered to a ventilator; the other lying peacefully on a bed at home surrounded by loved ones. The experiences could not have been more different, and the lessons learned will stay with me forever.

Death Is Not the Enemy

Whether it is driven by cultural narcissism or some unique feature of our genetic make-up, most Americans are undeniably unaccepting of the inevitability of death. George Lundberg put it succinctly: “Let’s face it, no one wants to die but everyone must. Despite this overwhelming reality, we continue to chase the illusion of life everlasting.”[i]

This lack of understanding and avoidance of the reality of death come at a price. Without discussion, our fears, hopes, and final wishes go unattended. As Otis Brawley, MD, observed: “We cannot accept that death will come, and thus we cannot make a plan, talk reasonably about it, work our way to understanding, to the basic part of our humanity.”[ii]

Yet, as Lundberg and others have pointed out, death is not the enemy: “The real enemies of medicine are premature death, disease, disability, pain, human suffering.” [iii] Kübler-Ross would add “peace and dignity” to the list of enemies: “We would think that our great emancipation, our knowledge of science and of man, has given us better ways and means to prepare ourselves and our families for this inevitable happening. Instead the days are gone when a man was allowed to die in peace and dignity in his own house.”[iv]

The Road Less Traveled

Two roads diverged in a wood, and I—

I took the one less traveled by,

And that has made all the difference.[v]

Nowhere do Frost’s words ring more true than when facing end-of-life decisions. One path, if pursued to the end, leads to a medicalized death. Along the way, every tool, technology, and trade-craft is used by physicians to preserve life. It often begins in the ER and ends in the ICU, as it did with my father.

 

RECOMMENDED READING:  

After You Hear It’s Cancer: A Guide to Surviving the Difficult Journey Ahead. It is available at:

http://www.amazon.com/After-You-Hear-Its-Cancer/dp/1442246251/ref=sr_1_3?ie=UTF8&qid=1423064996&sr=8-3&keywords=john+leifer#

The Myths of Modern Medicine: The Alarming Truth About American Health Care.   It is available at:

http://www.amazon.com/The-Myths-Modern-Medicine-Alarming/dp/1442225955



[i] Lundberg, Severed Trust, 221.

[ii] Brawley, How We Do Harm, 122.

[iii] Lundberg, Severed Trust, 231.

[iv]ElisabethKübler-Ross, On Death and Dying (New York: Macmillan Publishing, 1969), 7.

[v] Robert Frost, “The Road Not Taken,” http://www.poetryfoundation.org/poem/173536.

The End of Blind Faith and the Beginning of Transformational Change in Health Care

myths.final.inddThe Painful Truth:

The American health care system is terminally ill. It is astonishingly expensive, remarkably variable in quality, and incapable of stemming the rising tide of chronic illness in our population.

Yet, the majority of Americans believe it is the best system in the world and cling to the belief that, far from ailing, it delivers care superior to those of countries across the globe.

The system has obliged us by providing an elaborate set of myths about American health care that significantly shape our beliefs  These myths keep us blissfully ignorant about the true quality, safety, and value of the care we receive. This ignorance has a price: it leads us to draw erroneous conclusions about our conditions, fail to properly evaluate potential treatment options, and rarely question our providers’ competency.

This book is based on the premise that consumer empowerment begins with an understanding of the true state of the health care system. Such knowledge not only increases the consumer’s ability to receive appropriate care, but also to take effective action to change the system. Armed with the correct information, consumers can make smart decisions for their health and the health of their families, as well as coalesce into social action groups.

The 10 Myths

The book identifies ten myths that must be debunked to achieve a true appreciation for the condition of our system. It also provides, where appropriate, specific steps that every consumer can take to optimize the quality, value, and effectiveness of the care they and their family receive. The Epilogue provides a preliminary roadmap to social action—changes that should be called for by consumers, and how, by coming together in organized structures, such changes are possible.

Throughout the book, the reader is reminded of his or her stewardship responsibility for their own health. Perhaps the most important lesson to be gleaned is the degree to which we can avoid encounters with the health care system by judiciously making smart decisions about our health.

If we are to heal the American health care system, we must understand how our false beliefs impair our ability to get efficient, effective, and safe care. Only then can we exercise stewardship responsibility for our own health. If patients understand how these myths influence their care, they might make better choices about their care, get more value from the system, and enjoy improved health and well-being. And, if we all use the system differently, the process of reshaping the system would begin to happen more naturally. We, as patients, can drive the reform of the system.

ACA is a Red Herring

The Affordable Care Act has made health care reform one of the most hotly contested topics in America, but it does not address the core problems in our system. Meaningful health care reform isn’t likely to happen as a result of legislative edicts from Washington. There is simply too much avarice and greed vying for its bounty. Reform will only happen when you as a patient, fully empowered with information, begin to assert your rights.

 

ARE YOU READY TO READ MORE?  Please order your copy of The Myths of Modern Medicine today:

http://www.amazon.com/The-Myths-Modern-Medicine-Alarming/dp/1442225955