Conflicts of Interest
It is in their interest not to know
and not to let anyone else find out
That is a big problem
How much are we in denial of the fundamental problems when books and papers and conferences have as their subject words like Transparency without major attention paid to the fact that providing it violates the interests of the people who are supposed to provide it? It really is time to face that goodwill and selflessness never have and never will be enough to solve the problems with the conflicts of interest in medicine.
The fundamental conflicts of interest have nothing to do with physician-owned distributorships, kick backs and such like, as bad as those are. But at least in those instances there are people who recognize the problem. With the more fundamental conflicts we cannot even get discussions going.
One's Well Being
A designer and implementer of horse race track betting systems once worked for a race track owned by the Mafia. Because of who his employers were he said, "You just didn't make mistakes." Designers and implementers and practitioners in health care do not experience that kind of motivation. It's not their lives on the line. Health care professionals have numerous incentives to cover up problems for patient harm and few to report them. That is devastating for the safety of patients. But they have a system of rationalizations persuading themselves of the opposite.
Their Culture's Conflict of Interest
Doctors know that other doctors will ostracize them if they diagnose injuries that are consistent with something like the abuse a patient claims to have endured at the hands of another doctor. They also know that no one will ostracize them for not diagnosing them. As long as that is the end of the story, patients will not be safe. Doctors will never care about the damage their colleagues do to patients as much as they care about their own careers.
It must be the case that patients can learn about such situations so that the patient community can do the ostracizing. Medicine has had centuries to take care of this itself. That is long enough to understand that they never will.
Currently medicine dissects system failures with the idea that no person within the system could be the problem. It assumes that the problems only are in communication, rigid hierarchies, absences of redundancies and other systemic flaws, but never the operators within the system. The assumption is that no one in medicine ever intentionally injures a patient. The assumption is that criminal law is irrelevant in health care because all the people in medicine mean well and deserve to be protected. The examples used as models for increasing safety are ones like airplane crashes, disasters in which the pilots have as great an interest in the outcome as do the passengers. But doctors do not go down with the plane. Instead doctors and nurses have an incentive to keep anyone from finding out about their equivalent of plane crashes. They don't even report them 93% of the time (see Medical Reporting). What we don't have good statistics on yet is the frequency with which they manage to persuade themselves that there wasn't a crash, and if there was it wasn't their fault.
"Those of us who work in hospitals have really become inured
to the frequency of errors, large and small."
- Dr. Robert Wachter
Pilots in airplanes do not drop injured passengers off in remote locations and then make sure that no other pilots pick them up in order to hide problems that the pilot caused. Victims of iatrogenic injuries do suffer that treatment from health care professionals (see blacklisting). The agendas and motivations and interests of pilots are the opposite of those of health care providers.
Do airlines have risk management departments that threaten passengers with lawsuits if they talk about what happened to them on the airplane? Do flight attendants learn not to ask passengers if they are all right because that could be used in court? Do pilots lobby the government to limit their liabilities so that they have an even lower stake in the outcomes they produce?
According to the Agency for Healthcare Research and Quality (AHRQ) root cause analysis (RCA) is one of the most widely used approaches to improving patient safety, but few data exist to support its effectiveness (at this link). When something is not effective, there is not much data to show that it is, because it is not. Lack of evidence to support the idea that something is effective is what tells you that it isn't.
RCA can help find out more about the 7% of the problems that get reported, but 93% are off screen. Medicine will pat itself on the back about how much better it understands the 7% and believe that they are seeing the whole picture. Just as they imagine that state medical boards take care of all of the problems they are supposed to (see OSMB). These things distract attention from the lionshare of the problems.
RCA is a method being promoted to increase patient safety because of how it works in aviation where it is possible to get honest information about what went wrong. In medicine 93% of the time you cannot get that. If you want to gauge how naive and out of touch someone in medicine is, find out how useful they think that the RCA of the airline industry would be in medicine.
Sometimes the system's success is the problem
It's not only the failures that cause problems for the patient community. Systems are successful when they protect the interests of providers even when those interests are contrary to the interests of patients.
Health care providers never will be as interested in safety as patients are. They never will be the ones to solve larger patient safety issues. They won't even report the problems let alone solve them. That's why the safety of patients is the issue that it is in the first place.
The Well-being of Patients
Sometimes health care professionals hate their patients. Sometimes they care more about their wallets. Sometimes . . . Why make a list? They may say and believe that the well-being of patients is at the top of their list, but the fact that they say that and believe that is one of the problems. That disconnect between what is true and what they believe costs patients their lives.
In 2002, the economists Steven Levitt and Chad Syberson did a study showing that houses owned by real-estate agents stay on the market longer and sell at significantly higher prices than do the houses they sell for their clients. The agents do better for themselves than they do worse for their clients. Whenever authority is delegated to someone else to act in your interest, that is a problem (click here for medical examples).
Currently patients are expected to take it on faith that everyone in medicine is good and competent. The fact that patients have no other choice is unacceptable. It is unacceptable for the well-being of patients to depend more on the beliefs and interests of health care professionals than on knowledge of their own.
Currently in the medical community you hear talk of the explosion of information available about medicine now. Can you find data on the success rate of your physician? Or of treatments or facilities? It is not possible to make an informed cost-benefit analysis without knowing the odds of failure. The fact that the medical community does not understand this shows how self-interested their perspective is.
Medicine is no place for blind faith
The patient community needs information that reveals who and what is safe and affordable. The medical community has interests that compete with patients having that and so never can be objective sources for it. Someday med students need to be educated on the extent to which they never will be objective and selfless. Even after that, patients still will need to go to other sources get information about health care that is objective (like, for instance, Community Patient Agencies).