Why Lucian Leape is indicative of the problem.
We praise Lucian Leape for having said:
- Medical injury is pervasive and substantial and in every possible venue, all sites, committed by all kinds of professionals, and with all types of treatment.
- Accountability in healthcare is weak to nonexistent at every level, national, state, local, and within hospitals. Government agencies lack the resources, and usually the power or the inclination to identify hazards or do anything about them, or to enforce safety rules in hospitals or other places.
- The unique structure of healthcare and the way we finance it not only does not provide incentives for safety, it provides serious disincentives for safety. Perversely they make more money when they injure patients - by billing for the additional services needed - the opposite of the way it operates in most industries.
- The physicians who we would think would be leading the movement, in general, in the majority, have been distinguished by their passivity.
Lucian Leape is the Harvard expert who was the first to warn us that impaired and/or incompetent doctors are allowed to keep practicing.
But, as the job of the novelist is to identify the problem, not to solve it, the same can be said of the researcher in his position. He finally got the community to see that there is a problem. Where he errs is in getting trapped in the expectations people have for those who point out problems. They expect those same people to understand more than that there is a problem. They expect them to understand not just that there is one, but also to understand why. And then, beyond that, to know how to solve it.
Leape tries. Unfortunately, his thoughts about solutions do not have the potential to make patients safer. In fact, they keep us mired in bad ideas that cannot work. Because he believes in the health care industry's snake oil. That is understandable because he used to be a surgeon. So he is one of them. Collectively they share a view of the world that is more subjective and self-interested than they recognize. They all believe in their own snake oil. And they don't know that about themselves.
We are grateful for Leape's IOM study that finally managed to get the medical community to admit that there is a problem - a risky and brave thing to do. To get them to admit that, he used their own records to show it.
Originally, we had thought that he used their records in order to be as conservative and diplomatic as possible in order to have as much credibility and acceptance as possible with the medical community. There was going to be so much resistance to the information about the degree to which they err that this was important. So when he used their records, we thought it was for that purpose and that surely he would be aware of how little negative information actually gets into their records (2% according to the 2010 report by the US Department of Health and Human Services).
It turns out that he isn't. He believes their records. And he believes in their snake oil.
The medical community has an agenda that governs what gets in the record. All of the information Leape has about medicine is based what people in healthcare are willing to record. Regarding sins and errors, that is little to none. The most important thing to know to make patients safe is what goes wrong, when, where and how often. That is the last thing that gets in their records. Leape, like virtually everyone else in medicine, apparently is not aware of that.
What they won't record
He has said, "When I go to a doctor, I should have somebody who I know is competent, who I know I can trust and who will put my interest first. Two of those three have nothing to do with science." The first could have something to do with science, but doesn't. The second two have nothing to do with reality. Dreaming that they ever did or ever could is folly to a large degree that it will keep the believer from ever understanding what the fundamental problem is, let alone solving. For patients to be able to trust doctors to put the patient's interests first would require mere humans to become saints (which I've written about in The Saint Theory of Medicine). Leape, just like the rest of the medical community, is out of touch with the degree to which their colleagues sell bad medicine to patients routinely.
Are they not aware of, for instance, how few oncologists would submit to the treatments they sell to their patients?
Such unawareness is why safety
does not improve
and costs keep spiraling up
Saints might be able to keep the interests of their patients ahead of their own, but there are not any of those in medicine. Especially when things go wrong. When things go wrong, as one injured patient recently wrote, "They smear your name and leave you for dead."
Ever meet a doctor who is conscious of that? Lucian Leape isn't either. He drinks the snake oil.
Where is awareness of the refusal of anyone in medicine to report most adverse events? (see Medical Reporting) Where is awareness of the ubiquity of covering up (see Blacklisting)? Where is awareness of the extent to which health care providers are just brokers with no skin in the game? Where is awareness of the extent to which having "somebody who I know is competent" is a function of getting objective epidemiological information on practitioners from sources outside of medicine because no unbiased information comes from inside of it (see Benjamin Rush for starters)? Patients cannot even find out ahead of time what treatment will cost, let alone whether the providers of it are safe and competent. It is not in their interest for patients to know any of those things, so patients are not allowed to.
That is where the first of those three things could have something to do with science, but doesn't. But at least it could. The other two are fairytales from lala land. Any patient who is lulled into the trap of relying on either of those two things is perpetuating the system in which patients blindly do what they are told and then pay what they are told. Unfortunately, patients have no other choice as long as information about caregivers comes only from caregivers.
That is no better than letting mortgage brokers make your borrowing decisions for you. Believing in mortgage brokers resulted in thousands of bankruptcies. Even during that debacle, more bankruptcies still resulted from medical bills because there is even more of that kind of graft in medicine. Doctors are just brokers with no skin in the game. And ones who provide even less information than mortgage brokers about the products they are selling. Their information is based on faith and the self-serving, subjective information provided to them by other caregivers who do not report most of what goes wrong.
Does a pedophile report him or herself in the record? Does an abusive nurse record her abuse? Does your primary care physician know if he/she is delivering you into the hands of someone with a poor success rate? No.
Lucian Leape's report called for a national error-reporting system, as well as private reporting systems through which providers could discuss mistakes and best practices for fixing them without fear. It is possible to imagine that that will fix the problem only if you don't understand what it is.
Do they think that with a change in culture criminals will report themselves? Or that there will be no more crimes? Where is awareness of the crime rate in medicine? Where is awareness of the need for justice when crimes are committed? Where is awareness of the fact that the worse the adverse event the more energetically the community covers it up (the WHOLE community)? Where is awareness of the fact that systems that do not address the worst abuses cannot address more subtle problems?
For someone in medicine to report someone else in medicine is a betrayal of the highest magnitude. You would have to re-code their DNA to change that. The betrayer loses the trust of everyone in the system. It is not possible to work without that trust. No policy enacted from above can preserve or recreate trust destroyed by betrayal. The betrayer's career is over (see loyalty). To suggest that changing their culture to one that is "without fear of punishment" and/or that is "a rich reporting culture" is to bring to the subject such a shallow understanding of human bonds as to be talking about a fairy tale.
The idea that the culture could be changed to make it so that looking out for number one was not important to them anymore is not just silly. It is ignorant. Even Stalin could not do that. The Soviets tried to change human nature for decades and finally gave up. Changing culture will not cause the people within it to become saints.
Leape recommended that hospitals develop cultures of safety, and work systematically to create standards to measure in-hospital injuries and hospital-acquired illnesses.
Who is going to report those?
That aside, why are we talking only about hospitals? Most care happens outside of hospitals. That is ignored by that recommendation. In addition, besides assumes an unrealistic level of saintliness from people within that system, it ignores that better information can be gotten from sources that do not have the vested interests of the people within that system. The person in charge of complaints, the person in charge of paper supplies, the clerk at the desk of the records department, all have a vested interest and a subjective view. It has been demonstrated that patients, when given the opportunity, provide more information and more accurate information than anyone in medicine (See Medical Reporting). I've never met anyone in medicine with a clear thought about how that can be. They dismiss it on the basis of how it wouldn't work if it were done in some way that wouldn't work.
They also are not in touch with how dedicated medicine is to silencing patients. Limiting liability and keeping reputations stellar is more important to them than the well being of patients.
There really is no excuse for continuing to believe in medicine's snake oil of "transparency" or "cultures of reporting" at this point. It is confusing human nature and culture. It is thinking like Karl Marx. It is thinking that we can get people to care more about the well being of others than about their own well being. It's great if there are those among us who do, but public policy cannot be founded on the philosopher-king formula. Especially when the need is not just for a few to run a government, but hundreds of thousands to be caregivers. We cannot expect to select only saints for entrance to nursing and medical school.
Leape more recently has written, "Creating a culture of respect is the essential first step in a health care organization’s journey to becoming a safe, high-reliability organization that provides a supportive and nurturing environment and a workplace that enables staff to engage wholeheartedly in their work."
It might be a first step in creating an environment that is safe, supportive and nurturing for those who work in medicine, but that does not necessarily have anything to do with making it safe for patients. It more likely makes it less safe. Being supportive and nurturing of each other requires being loyal members of the team that does not report, or even believe, what patients most need to know. When records are falsified, or not even made in the first place, and incompetent and even evil caregivers are believed to be otherwise by their loyal and respectful colleagues, patients are left in the dark and in danger.
I would like to hear Lucian Leape's answer to the question, "What is the least, the absolute least, that a patient should be able to expect in medicine?" In saying, "When I go to a doctor, I should have somebody who . . . will put my interest first" he is describing the best a patient can expect. That is the wrong end of the problem from which to begin. What is the least a patient should expect? We have to start there. We have to arrange for that first. Otherwise, we are doing the equivalent of arranging for better lawn care on the playground in response to the problem of dragon in the bushes eating children.
We are ignoring the biggest and most fundamental causes of problems for patient safety. And the only thing about them that is cultural is the denial and self-interest that erects barries even to recognition of what the fundamental problems are.