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

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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?

By in Healthcare reform, Medical Error, Physicians No Comments

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

By in Healthcare, Healthcare reform, Medical Error No Comments

 

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).]

How to Find the Right Physician for You and Your Family

By in Healthcare, Physicians No Comments

Trust MeIn your health-care journey, nothing exceeds the importance of finding the right physicians for you or your family — beginning with the all-important primary-care doctor. He or she will be your tour guide any time you embark on an adventure in the confusing realm of health care. The decisions you and your physician reach collaboratively will, at critical moments, touch your life in a profound way. So before you begin this search, you need to establish both the criteria that will optimize your chances of success and a process for applying those criteria to prospective physicians.

Two levels of discernment

The information you are seeking can be divided into two categories. The first contains the basics—does the physician accept your insurance plan? Are his or her hours convenient and accessible? Is he or she accepting new patients? This information can be quickly gleaned via a telephone conversation with the office staff.

Our second category contains more vital information and can only be gleaned through a rock-solid due-diligence process that combines Internet searches, speaking with friends or family, and, most importantly, interviewing your potential doctor. Why go to all the trouble? Because this is one of the most important decisions you will make.

So what exactly are you looking to discover? That depends on which characteristics are most important to you in a physician. If you are simply seeking a warm body with an MD, then the first category of information may suffice. If, however, you are more discerning and want a lifelong partner who will help you make astute decisions about your health, then roll up your sleeves and get ready to go to work. You want the kind of doctor that journalist David Bornstein described in the New York Times. “Great doctors,” Bornstein opined, “don’t just diagnose diseases, prescribe medications and treat patients; they bring the full spectrum of their human capabilities to the compassionate care of others.”[i]

10 criteria for evaluation

How do you identify a “great” doctor? There are ten criteria I believe you should consider when evaluating a physician. Before we get started, though, there is one very important caveat: It will be impossible to evaluate anyone across all the criteria due to the complexity of the task and the dearth of comparative information. Simply remember that each bit of information you gather adds important grist to the decision-making mill as you seek to identify the best physician for you.

No. 1: Education

Your physician has made a tremendous investment in his or her education. With few exceptions, they have completed four years of postgraduate study, followed by a residency in their chosen specialty (including family practice or internal medical medicine). Residencies range from three to eight years in duration. A family-practice residency requires three years, whereas a plastic-surgery residency requires approximately five years. Some physicians will then further subspecialize by completing one or more years in fellowship training.

Over the past century, America’s medical schools have worked arduously to standardize their curricula. Of the 141 accredited medical schools in the United States, all are members of the Association of American Medical Colleges, a not-for-profit association that seeks to elevate the standard of training across all educational facilities. Even so, there is still variation in training—particularly once a physician enters residency. This variation may account for a portion of the geographic variation documented in the Dartmouth Atlas.

Arguably, there is also a vast difference in the quality and rigor of education provided by different medical schools. Though the barriers to entry are high across the board, admission criteria nonetheless vary dramatically. Most of the top medical schools are aligned with prestigious universities, whose brands carry equal cachet—such as Harvard, Duke, Stanford, Johns Hopkins, or Penn.

U.S. News & World Report ranks the nation’s medical schools annually. For a fee, they will also provide a report showing two key criteria for admission: (1) the average MCAT scores (a standardized test that all applicants to medical school must take) and (2) average undergraduate grade-point averages. Top-ranked schools, such as Stanford, may accept as few as 3 percent of their applicants. The average undergraduate GPA for students admitted to Stanford or other comparable schools, such as Johns Hopkins, runs close to 3.8 on a 4.0 scale. MCAT scores are also exceedingly high at these schools.[ii]

State schools, by comparison, have slightly more lax standards. For example, in the latest data reported by U.S. News & World Report,the University of Texas Health Science Center at San Antonio, which ranked sixty-eighth, accepted 14.2 percent of applicants.[iii] Students’ average MCAT scores run approximately 20 percent lower than at Stanford, and the average undergraduate GPA is 3.57. Similar results can be seen across a plethora of other schools. Mind you, it is no easy feat to matriculate to such schools, but the criteria for admission, nonetheless, are less demanding than those found at the most academically elite medical schools.[iv]

Why some of the best physicians select state schools

It’s more than just class rank or MCAT scores that determines where students matriculate. Some of the best and brightest students cannot afford the cost of tuition at the academically elite institutions, nor do they wish to be saddled with debt as they graduate from medical school. Full-time tuition at Stanford runs more than $47,000 per year. Harvard approaches $50,000. The University of Texas is a “paltry” $14,500 for in-state students. Remember that great physicians emerge from each university. Even so, there is a difference in the academic milieus across the 141 medical schools.

Class rank may be a hidden secret, but AOA membership is not

One secret you will probably never unlock is how your physician performed in medical school. As the old joke goes, What do you call someone who finished at the bottom of their class in medical school? “Doctor.” There is one indicator for excellent academic performance—membership in AOA. Each year, a small cadre of physicians who performed exceptionally well academically is invited to join an honorary society known as Alpha Omega Alpha (AOA). The society’s website states that “the top 25 percent of a medical-school class is eligible for nomination to the society, and up to 16 percent may be elected based on leadership, character, community service, and professionalism. Members may also be elected by chapters after demonstrating scholarly achievement and professional contributions and values during their careers in medicine. Distinguished professionals may also be elected to honorary membership.”[v] Just as Phi Beta Kappa connotes an important level of achievement, so, too, does AOA.

Where your physician did their medical training

Residency programs show similar variance in their exclusivity, though formal rankings are harder to come by. Two measures of such rankings are (1) the U.S. News & World Report rankings of teaching hospitals by department and (2) rankings based on the level of National Institutes of Health (NIH) research funding received by departments across the majority of medical schools. One Internet resource, ResidentPhysician, purports to provide rankings across seventeen medical departments among 123 academic medical centers.[vi] It should be noted, however, that the data listed may not be current.

Where your physician trained does make a difference. How much of a difference is impossible to quantify. What is easily measured, however, is the depth of your physician’s training. It is essential that you understand the level of generalized knowledge or specialized knowledge that your physician brings to the exam room via his or her formal education.

What defines an expert?

Since there are no official rules on holding oneself out to be a “specialist,” experts abound in medicine. A general surgeon, for example, who lacks formal fellowship training, may nonetheless proclaim that he or she is a breast surgeon simply by virtue of operating on such cases. An ENT may perform facial plastic-surgery procedures after only a short mentorship by a colleague. And a neurosurgeon may become an “expert” in deep-brain stimulation through a weekend course.

These physicians may be highly skilled and produce good outcomes, but there are factors not in their favor—beginning with the lack of formal, disciplined training, which also correlates with the number of cases performed in tandem with more experienced physicians before “flying solo.” Says physician Marty Makary, “After I graduated medical school and got my license based on a 70 percent-or-higher passing score on my board exam, I was literally licensed to do anything in medicine—perform brain surgery, prescribe chemotherapy, remove varicose veins, or do electric-shock therapy for psychiatric disorders. I can legally do anything. In fact, some varicose-vein-removal centers in the United States are run by former ob-gyn doctors and others by psychiatrists; they were doctors looking to do something different and took a weekend course to learn how to do it.”[vii]

Volume, volume, volume

You probably don’t want to be the third or fourth procedure a physician performs in their entire practice. Rather, you want to be their three- or four hundredth such case performed over the past few years. Furthermore, you want to know that your doctor has received impeccable training.

There’s nothing wrong with asking physicians about their education and level of training. Just bear in mind that it’s just one data point . . . and there are nine more to consider!

 

 

There are nine more important criteria for evaluating physicians. You can read about them in my recently released book: The Myths of Modern Medicine: The Alarming Truth About American Health Care. It is available at Amazon.com or from the publisher (Rowman & Littlefield).  Here is a link: http://www.amazon.com/The-Myths-Modern-Medicine-Alarming/dp/1442225955.


[i]DavidBornstein, “Medicine’s Search for Meaning,” New York Times Opinionator, September18, 2013, http://opinionator.blogs.nytimes.com/2013/09/18/medicines-search-for-meaning/.

[ii] “Best Grad Schools,” Special Issue, U.S. News & World Report 2014: D-95–D-105

[iii] Ibid.

[iv] Ibid.

[v]Alpha Omega Alpha Honor Medical Society, last modified 2013, http://www.alphaomegaalpha.org/.

[vi] “The Official Rankings of 17 Medical Departments for their Resident Physician,” last modified 1999,http://www.residentphysician.com/.

[vii]Marty Makary, Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care(New York: Bloomsbury Press, 2012), 111.

 

 

Why You Should Care About the Lack of Transparency in Health Care

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Prying Open the Doors Concealing Health Care's Secrets

Prying Open the Doors Concealing Health Care’s Secrets

The following is an excerpt from my new book: The Myths of Modern Medicine: The Alarming Truth About American Health Care (Rowman & Littlefield Publisher, released on 9/16/14)

Talking the Talk, but Not Walking the Walk

Health-care organizations bandy about the term transparency—using it to suggest an air of openness and disclosure about their performance and cost data. They have made repeated pledges to be more transparent. Unfortunately, they have been painfully slow in making good on their promises, causing the Institute of Medicine to observe that “a serious commitment to transparency means that we will strive to provide consumers with a comprehensive price and cost analysis, including effectiveness, adverse events, administration, and the impact of individual references relative to convenience and access.”[i] Apparently this prestigious scientific body agrees that providers are not taking transparency seriously. The absence of data is not merely a sin of omission. The health-care industry has done a magnificent job of methodically shielding us from this vital information on which we could make value-based decisions regarding our health care. The providers simply don’t want us to have the data: “A Commonwealth Fund National Survey of Physicians and Quality Care revealed that 69 percent of physicians were opposed to sharing quality-of-care data with the public. Forty percent of these physicians would not even allow their patients to be privy to such information.”[ii] It’s not just the doctors. Hospital executives want to be certain that any type of damaging information never appears on your radar screen. The 2003 Commonwealth Fund International Health Policy Survey of Hospital Executives revealed that hospital CEOs in the United States were significantly more opposed to public disclosure of medical-error rates, hospital-acquired-infection rates, patient-satisfaction ratings, and average waiting times than CEOs in four economically advanced countries.[iii] Data behind Closed Doors Although you may not be able to access it, hospitals are nonetheless amassing a wealth of data on key quality variables. Federal mandates are partly responsible, though progressive hospitals interested in quality improvement are collecting data proactively. Some of the most important and potentially powerful data in terms of providing a window into the meaningful differences in quality between providers includes:

  • iatrogenic events
  • expected versus experienced mortality rates
  • sentinel events (in which the life of the patient has been threatened)
  • surgical-infection rates
  • unscheduled returns to the operating room
  • readmission rates (which are now becoming publicly available) and
  • punitive actions or sanctions imposed on physicians by their peers.

Don’t be put off by the unfamiliarity of the terms. Though you may need some assistance with translation, you’ll quickly grasp the significance of the measure. Take iatrogenic events for example, which, in plain English, translates into a hospital-acquired illness or injury. Why do we care about something as esoteric sounding as “iatrogenic events”? We care because, by definition, an iatrogenic event is avoidable. Furthermore, it adds unnecessary costs and can even result in death or serious impairment. Imagine going to the hospital for a simple outpatient plastic-surgical procedure and having your surgeon accidentally ignite the oxygen you are breathing with an inadequately grounded electric cautery. It happened at one of my hospitals. Iatrogenic events are not rare occurrences. Rather, they are daily events within the life of the American hospital. We generally only hear about them when they are egregious in nature, such as the amputation of the wrong limb, the overdosing of a patient, or the rapid spread of infection through a hospital. The media pay far less attention to the rate of falls in a given hospital, though such commonplace accidents can permanently impair an elderly patient who suffers a resulting hip fracture. This paternalistic attitude and the resulting lack of information divulged to the public stymies market dynamics. Regardless of who is paying the health-care bill, U.S. health care will never achieve true greatness without addressing the issue of transparency.

 

TO READ MORE ABOUT THIS VITALLY IMPORTANT TOPIC, please see The Myths of Modern Medicine: The Alarming Truth About American Health Care — Available at Amazon.com

[i] Yong, Saunders, and Olsen, eds., “Transparency of Cost.”
[ii] Ibid.
[iii] Collins and Davis, “Transparency in Health Care.”
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