More on the Conflict of Interest In Medicine

They aren't saints

Patient safety is an issue because the self-interests of the health care industry and its practitioners are in conflict with the safety of patients.

They haven't found a way to make a profit on safety, have they? There is a way, but they haven't arranged it and they never will. They don't need to. They are better off without it.

Democracy

They say that there never has been a democracy that has experienced a serious famine. In medicine there is no democracy (yet). So in medicine the number of people unnecessarily killed or disabled or bankrupted is the equivalent of having a famine everyday, but our health care professionals manage to imagine things are not that bad (see Psychology of Caregiving).

Consumer Reports

In one hospital a doctor discovered that one-third of the doctors in his hospital didn't remember if they had ordered their patients' urinary catheters removed when they no longer were necessary, which was resulting in a lot of infections. So his hospital instituted a procedure that automatically removed the catheter after a few days. The rate of urinary tract infections plummeted. Were future patients able to determine what the rate of urinary tract infection was for that hospital before it plummeted?

What about now? How does it compare to all the other hospitals? For how many years did this situation exist in that one hospital without anyone bringing it up in a meeting? Why isn't there a list of such things for Consumer Reports to track so that consumers can bring pressure by avoiding hospitals that don't take care of this and things like this?

Why didn't anyone in that hospital think to do something about this problem before this doctor came along? More attention needs to be paid to how health care professionals think in order to understand why medicine does not make patients more safe on its own. It is time to stop expecting them to.

DNA analysis illuminates the causes of disease. Computers refine MRI images. Robotics facilitate operations performed inside the brain. But the psychology of the people at the center of all that is assumed to be good will and objectivity and integrity and, above all, a concern for the well-being of patients superseding all other concerns. 

Mickey Mouse thinks more deeply than that

People constantly size each other up. How they respond to each other has a lot to do with how they perceive the way they rank in relation to each other. Who is the most successful, the highest ranking, the smartest, the most accomplished, the tallest, the most attractive, the most prestigious, etc. Doctors and nurses are as susceptible to this as anyone else and just on that basis alone can be more interested in helping some people and less interested in helping others and sometimes even tempted to do something they should not do to others.

Whether it is out of lust or competitiveness or anger or whatever, it is unreasonable to leave health care set up as though no one in medicine experiences such temptations and as though no patients need to be protected from them.

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It is a self-serving obstruction to safety for medicine to dismiss out of hand suggestions about their motivations and questions about their innocence.

There must be recourse for patients who are the victims of things like unfriendly practices. Such recourse is more important even than knowledge of errors and is the rock bottom foundation of patient safety. The least a patient should be able to expect is not to be injured intentionally. If we do not have systems to respond to that, speaking about the rest is speaking about varnish on rotten wood.

But any discussion of unfriendly practices is dismissed out of hand. There can be no meaningful recognition of the problem of conflicts of interest in medicine as long as there is no willingness to recognize the worst ones - unfriendly practices - and how the medical community protects and enables them, including by refusing to let them be part of the patient safety discussion.

You cannot legislate or regulate or inculcate
good will, concern, and integrity

I wish someone in medicine and/or patient safety would face the fact that even the best people can be tempted to do something evil, and that at those moments there needs to be something to inhibit unfriendly behavior. Doctors do not feel they can assault people in bars with impunity. They should not feel they can in hospitals. Because if they feel they can, they will. They have in the past and they will in the future.

The least, the absolute least, that a patient should be able to expect in medicine is to be protected from becoming victims of crimes committed by health care professionals. Currently patients cannot rely on that. And health care professionals don't even have that on their radar.

The health care professionals who witness or learn about crimes committed against patients do not report them. That is outrageous. That is not going to change with more forms to fill out and classes to take about patient safety. That is not going to be changed by peer review. That is going to change only by bringing to medicine a mechanism that no one in medicine wants.

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They don't even report crime.

The patient community must create mechanisms that gather the information necessary to make intelligent purchasing decisions about their health care, rather than being expected to have faith in health care professionals to be saints.

People gravitate to what is comfortable and lucrative. Safety does not line their pockets as long as patients are unable to make buying decisions based on information about it.

For instance, according to Joyce Dubow, associate director at AARP Public Policy Institute, in 1989 New York state started publishing the bypass surgery death rates for hospitals. Mortality dropped 40 percent in four years. The hospitals conducted internal reviews, hired new personnel and fired surgeons with high death rates.

Patients need to gather that kind of information about the thousands of other aspects of care not covered by that, and they also need to gather it about those same bypass surgery rates. There is more to know than the death rate, and ever that reporting did not come from disinterested parties.

Patients Need to Know

Mehmet Oz, a surgery professor at New York-Presbyterian Hospital/Columbia University Medical Center, said, "If we can get just 10% of people to be smart patients, it will change the system. People will know that sloppiness won't be tolerated. And it will drive quality." He is coauthor, along with the Cleveland Clinic's Michael Roizen and The Joint Commission, of the book You: The Smart Patient: An Insider's Handbook for Getting the Best Treatment.

There is a tacit recognition in that statement of the fact that it is not going to come from inside medicine. Patients need to be aware of more than how to pressure them to be attentive and less sloppy. If ten percent of patients were allowed to know the success rates of various places and parties in medicine, and the misdiagnosis rates, infection rates, crime rates, and other such information, and if they were allowed to talk about it without being sued, that could change medicine.

Earning Money on Indifference

According to Consumers Advancing Patient Safety 1.7 million people each year get hospital-acquired infections. That adds an estimated $27 billion to health care costs and, according to the Centers for Disease Control, kills nearly 100,000 of the people who get it. The fact that people in medicine resist reporting instances of that problem but shout about how much lawsuits drive up costs is another indication of where their interests really lie.

Paying for lawsuits concerns them. Getting paid for generating another $27 billion in health care costs does not. They resist collecting the data about it that patients need in order to make informed decisions about where to get treated.

Patients are not even Third on the list

Dr. Peter Pronovost saved the state more than $100 million and 1500 lives over an 18-month period by teaching doctors and nurses to use checklists for intensive care unit procedures. Andrea Seabrook talked to Dr. Provonost about it on National Public Radio. Atul Gawande, a surgeon, wrote about it in The New Yorker magazine. It is not as though it is a secret. Dr. Pronovost spoke about it before Congress and said that the program cost $350,000 to implement, but hospitals did not have a budget for that.

For saving thousands of lives they have no budget because they do not earn a profit on saving our lives. As much as they say that our well-being is their highest priority, it simply is not. Profit is one of their priorities that is higher. When saving our lives is not profitable they don't.

We could make a list of all the hospitals that do not implement Pronovost's plan and tell patients to avoid them so that to continue earning a profit they would have to implement the plan. But that would address only this one safety concern. It is a huge concern and needs to be addressed, but they will backslide the moment the pressure is taken off. And there are all those other patent safety problems that it is not profitable for them to fix. We need to make it so that their careers and their profits depend on the outcomes they produce for us.

We cannot scrutinize every iota of medicine to root out every moment that presents a danger and put in place some kind of mechanism to make it safer. We have to make it so that it is in the interests of health care providers to make medicine safe on their own. Currently it is not even in their interests to be aware of whether their care is beneficial, let alone safe (see MammoSite, for instance). The result is that it is not uncommon for them to assume things must be effective and safe when no information has been gathered to support that assumption.

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