Patient Safety and Health Care
Any group that believes itself to be objective isn't.
You cannot afford to have your well-being governed more by the beliefs of caregivers than knowledge of your own.
There is more than one thing that could be argued as being
the most important problem in health care, but one that no one in medicine talks
about is the psychology of care giving. Caregivers have a very strong need to
believe that they are doing good. Their need to believe that is stronger than
their need actually to do good. Evidence for that is the way information is
collected, and prevented from being collected, in medicine. You need to have knowledge of when that is a problem - because they don't. And they don't know that about themselves.
Belief rather than knowledge
Their systems are set up to collect information that supports
their beliefs. Their systems are not set up to create knowledge. This is explained from
other angles on this site (like the fact that in medicine you don't get punished for causing
problems [like being inebriated or acting out], you get punished for reporting
problems), but, for
starters, 93% of adverse events are not noted anywhere in any record (see Medical Reporting). It makes things look
much rosier than they are. It makes things appear to be in line with what
caregivers want to believe, rather than with the way things really are. In their
personal experience, adverse events, if they are recognized as such at all, are
regarded as rare anomalies, not indicators, and are not recorded or remembered.
I've never met anyone in medicine who would consider the
possibility that they might not be as objective as they like to believe they
are, that their self-interested group-think and herd behavior puts
filters on their eyes that cause them to interpret the evidence of their senses
in self-serving ways. And that patients die as a result.
If the beliefs that humans hold dear did not tend to be
justifications more than anything else, wouldn't they at least consider it?
Instead, they just don't believe it.
They just don't believe it
They don't believe the
studies that discover how many patients die unnecessarily in medicine. They
don't believe the studies that find how corrupt the records are. They don't
believe the claims of patients who seek treatment for iatrogenic injuries. It
leaves caregivers hopelessly out of touch with the downside of their treatments
and the desires of their patients. That makes them poor guides for patients
trying to find their way to health and safety.
Now Obama has decided that the solution is micromanaging them
from an even greater distance: more rules, more bureaucracy.
Franco tried that with the Spanish food industry and ended up with a nation
known for having the
worst food in the world, until Franco died. It's too bad Obama comes from the law and not business.
Even show business. Even the most basic show business of all - street performing.
Regulating Cost and Safety
Once upon a time in New York City there were street
performers. Sometimes you would stumble upon them in Greenwich Village late at
night attracting a small crowd for a performance on the sidewalk. Sometimes one would appear
on the grass in
Central Park. But the best place of all to see them was weekend afternoons in Washington Square Park.
People used to go there just for that. The performers there were within sight and earshot of
each other. They competed with each other trying to attract each other's
audiences. At the end of their shows they would pass a hat. If they were good
performers,
people were generous. If they were not, people were not. I saw some
brilliant performers there, some I never will forget.
I had heard that in Boston, in the Faneuil Hall Marketplace
area, they had street performers too. But in Boston the street performers were
regulated. They had to audition. They had to get permits. It was said that there
were no bad shows because the poor performers had been weeded out by a process
set up to regulate them.
The next time I was in Boston I went to see them. They were
the most tired, uninspired performers I ever have seen. Even kids
just working out their acts for the first time in New York had more life in
them. In Boston they dragged themselves through repetitions of acts they didn't
even listen to themselves, and then were rude if you left before they passed the
hat. In New York when the audience began leaving before the act was finished,
the performers knew it was their own fault and that they had to improve their acts. In Boston, they
didn't. They had been certified.
A performer in Boston accosted me when I turned to leave halfway
through his act. He said that he had performed for me and now I should pay. He
didn't even like his audience. He didn't feel he needed to give anything other
than his time, and that once he gave that, he was owed something. He was an
insult to street performers.
Think how long it has been since caregivers have had to
worry about having their pay depend on actually doing something for
patients. Your caregivers can grope you and infect you and put lies in your
record to make sure no one diagnoses the injuries they gave you, leaving you worse off than you
were before
you saw them,
and still believe they deserve to be paid and deserve to have good reputations.
They get certified by experts, not the community of patients.
Sometimes pages of rules and regulatory agencies populated by well meaning people kill inspiration, empathy and common sense. The people on
the frontline have their focus shifted away from serving the recipients and toward serving regulators and rules.
In medicine the recipients of services are
prevented from knowing who the good performers are until its too late. And then
they are prevented from warning other patients (covered in detail on this site).
The performers do not need to compete
to attract patients because patients cannot figure out who is good or bad or
even figure out who is affordable. Caregivers get
paid even when all they do is mail in a poor excuse for performance, even when
they lash out at their audience, even in ways that ruin the lives of their
customers. And somehow these caregivers believe, and lead everyone else to
believe, that the problem is the suits brought by the people they injure. They
even regard the suits as being frivolous in a world where only a fraction of 1%
of patients with legitimate grievances can get a lawyer (see
Studdert). And yet they give patients no other way to respond and don't know
that.
How out of touch with your audience can you be?
Patient-friendly Rule
Here is how unfriendly and out of touch medicine is. Patients
cannot even find out about cost ahead of time, let alone quality or safety. How about taking
one small step toward addressing one part of the problem by passing a
rule that empowers patients in the simplest of those areas - a
rule that requires health care providers to quote on services when asked to? Did you ever call
a hospital and ask how much an MRI is going to cost only to be told that they
don't know? You can end up with a bill for thousands of dollars when someone
else could have done the job for hundreds. Patients cannot make intelligent
cost-benefit decisions without being able to shop around to get reliable
information about the costs (and quality, but one thing at a time).
Home remodeling contractors are required to give firm quotes
on work to be done. Why shouldn't medicine be required to as well? If a building contractor can
tell you how much it will cost to add three rooms onto your house, a health care
provider can tell you how much it will cost to provide a service he/she has done
a thousand times before.
After that why not get some insurance company to create a policy
that gives lower rates in exchange for accepting a sliding co-pay that rises
with costs, not punitively, only enough to make it
so that patients care about what things cost so that they will shop around?
It would be nice, someday, if we also could start keeping track of where care is better and
where care is worse, so that price is not the only information on which to base
decisions. But let's not reach for too much at once.
[People in medicine continually insist that it is impossible
for patients to evaluate safety and quality anyway. They are never going to
record the information that would make that possible. We are going to have to
get it from patients.]
Blinders
The well meaning people at the top never can be well meaning
enough to do the job that patients will do for themselves if given the
opportunity. The people at the top usually don't even understand how poor of a
job they are doing. In Boston, do you think the regulators understand how much better
street performers are when they don't have the life squeezed out of them? The
people in charge earn their livings by being in charge. Like most people,
they probably believe they are doing as good a job as can be expected. When did
a dictator ever not think that? Just like
the people running medicine right now with its outrageously high rates of
unnecessary death and injury and personal bankruptcy.
Did you see the study in the New England Medical Journal (Nov 2010) that
found no progress in safety in hospitals? Like that was news? Well, to people in
medicine it appears to have been news. I couldn't find anyone in medicine who
believes it. They do not
know that their safety initiatives are created by people whose first interest is
protecting providers. They do not know why patients need to know things like success rates and error rates. They have no idea
what happens to the patients they injure. They seldom even are aware of how many
patients they injure, personally or as a group. They have no idea what the worst
problems in medicine are. They have no clue why putting risk management in
charge of the oversight of patient safety defeats any initiative they produce.
They do not know that voluntary reporting means no reporting. Their belief in
themselves overwhelms any effort to recognize the problems in medicine, let
alone fix them. They tell me they don't believe such studies. They have seen
progress with their own eyes.
It's that same old problem. With their own eyes. As though
they are objective. As though their self-interested group-think and herd
behavior do not filter what they see with their own eyes in self-serving ways.
The lead author of
the study, Dr. Christopher P. Landrigan of Harvard Medical School, says that
voluntary reporting "vastly underestimates the frequency of errors and injuries
that occur." That there are people in medicine who do not already know
that (I can't find any who do) shows how self-serving the blinders and filters on their perceptions are.
We cannot rely on their good will to make us safe when we
cannot rely on their perceptions to be lucid. We cannot
educate them into it. We cannot regulate them into it. It has been tried and tried
and it hasn't worked. Just look at how the government tried with radiology (see
mammography).
Live and Die by the Audience
The only way things will improve is if
patients are able to learn where things have not improved and go somewhere else.
Otherwise, all the commitment and all the regulation and all the education of
all the people in medicine comes to little. Anytime something goes wrong "you
can't let one patient ruin your whole career" rationalizes the cover-up and the
continuation of the practices that caused the problem in the first place. Not
until patients stop coming will it matter enough to caregivers to make patients safe.
For patients to know enough to stop coming to where it isn't
safe requires gathering
information that no one in medicine will report. The negative information is so
ubiquitously covered up that providers don't know it themselves. We will
have to get the information elsewhere because they will never give it to us.
The study by Landrigan in the New England Journal of
Medicine also found that about 18 percent of patients in
hospitals were harmed by medical care. That means there is
almost a one in five chance of getting harmed if you enter a
hospital. If you enter a hospital 5 or 6 times in your life,
there is a 100% chance of getting unnecessarily harmed.
The study also found that 2.4% of the time the harm was
great enough to cause or contribute to a patient's death.
This is how well patients are taken care of in the current
system. And now Obama wants to add a truckload of rules and
regulators into the mix. Franco Already
Tried That
This is what happened to food in Spain under Franco.
Franco mandated industrial methods intended to feed the
population cheaply (like what Obama is trying to do in
health care for patients). The result was Spain becoming
known for having the worst food in the world. When Franco
died, inspired chefs broke free and now Spain is spoken of
as possibly having the best food in the world.
Franco’s goal was to feed the entire population cheaply. He
governed the food industry instead of letting artisans
govern themselves. Artisans can govern themselves when the
recipients of services are capable of deciding where to go
and how much to pay based on honest appraisals of cost and
quality. Medicine destroys the information necessary to make
such appraisals. Obama thinks Franco style regulation can
fix that. What can fix that is honest information. Obama is
going to get none of that. Without it, his results will be
worse than Franco’s. At least under Franco there was enough
food, even if it was bad food. Under Obama, there is going
to be rationing in addition to bad care (which quality
problem will continue
to be unrecognized by the health care industry).
Description is Prescription
The health care industry does not appreciate the scale of the downside of
the
care they dispense. They do not know of how often they injure patients.
They don't know what they do to patients after they injure them. They are not just unaware, they are in denial.
For ten years I have been writing that the path they are on
is nothing short of silly. Their faith in themselves will keep it that way
forever - absolutely forever - as long as they are the source of all the
information and authority. They
don't know that. They don't even know what they don't know. They are not even
aware of how and what they think. Fortunately, they don't have to for the rest
of us to climb out of this mess in spite of them, as I explain on this site.
There is always news causing us to hang our heads in
discouragement
about the way they think in medicine.
More such news causing us despair is the fact that health care
providers keep operating as though patients have no right to
question or understand their own health care (see DNA for
example). Concerning the refusal to report
infection rates in hospitals, Gwen Borlaug of the Wisconsin Department of Health
Services said, "Because they're not reported doesn't mean that good efforts to
prevent them aren't going on." She said that there's no evidence that
publicizing infection rates reduces infections (in fact,
there is) and said, "We don't want to tie up
resources in simply reporting when it's not an issue in a particular hospital."
(November 2010)
And how are patients to know when it is an issue in a
particular hospital? Is Ms. Borlanug aware that error rates in cardiac patients
improved when fatality rates began being reported in certain hospitals?
One of the most crucial functions of media in a democracy is
keeping citizens informed about those with power over them, but Ms Borlang says,
"No." Well, who doesn't in medicine?
Ms. Borlaug has said that patients can go to hell if they
think they have any need or any right to know that which would enable them make
safe choices. She has said that the saints in medicine will do
that behind closed doors for them and patients will like it. She has faith that
safety can improve, even though it hasn't in the last decade, merely on the good
will of providers. She, like nearly everyone else in medicine, learns nothing
from studies like the one in the November 2010 New England Journal of Medicine
that finds no improvement in safety in a decade. It is
difficult not to express dismay and frustration over the fact that everyone listens to public health professionals as though they are
objective, selfless saints with both feet on the ground rather than
self-interested humans with vested interests mired in group-think and herd
behavior.
She doesn't want to tie up resources enabling patients to
become informed about their own safety in the environment that causes more
accidental death and injury than all others combined.
Sigh.
They say it's the system
That's the only thing anyone is allowed to say - that it is
the system. When speaking about or working on patient safety problems, it is
viewed as impermissible to suggest humans could be part of the problem. No discussion is
allowed unless it assumes that the people in medicine are saints, but that the system
might be putting some of those saints in positions that result in
small problems through no fault of their own. In light of that, can we talk about changing the
system to one that does not require that the people in it be vice and error free saints? Absolutely not. We can polish it around the edges and varnish it in
places, but not dare to suggest digging out the rot at the core.
I do talk about it. For instance, I talk about how and why
the people in it want to keep it the way it is no matter what the consequences
are for patients. I talk about how and what they think that enables them to feel
that way. They are shocked, dismissive and not infrequently outraged when it is explained to them
- not a recipe for improvement.
The only discussions anyone will have about medicine are ones
based on the Saint Theory.
It is approached from different directions, but in the end it is the assumption that medicine
can be run safely and affordably by Saints who look out for patients while
patients do only what they are told and then pay what they are told while
blindly hoping that the providers to which they have been sent are as safe and
as affordable as other providers. That is the foundation for Gwen Borlaug's
saying that they don't want to tie up resources with mere reporting. Apparently
she is unaware that awareness on the part of the consumers benefits consumers.
In medicine, on the occasions when it is
thought that patients should be allowed to know something, the information is supposed to come
from providers who don't recognize their own self-interested subjectivity or
even that they have conflicts of interest.
And that is why medicine is the most dangerous and expensive
place America - something else about which public health employees have little
awareness. We can't find any who even think it is important enough to
worry about.
And Yet Doctor Knows Best?
All of the discussions about how to fix health care assume that
all physicians are equally competent and equally well meaning and that patients don’t
need to know better. Does one orthopedic surgeon keep sending older women with
shoulder pain into surgery, with no success, while another recognizes what
frozen shoulder is and treats it with physical therapy and has a 100% success
rate? In the current system no one knows. No one even knows that the first
surgeon has no success. Whether it is public or private, for-profit or not-for-profit, surgeons create their own records and record that their operations are
perfect as a matter of routine. The first surgeon’s operations might have been
done correctly, but they never should be done at all and he/she continues to
earn a living doing them. If his/her operations cause an unnecessary decrease in function 40% of the time,
there is no record of that. Patients will continue to be sent to that
operator until that operator retires.
Having faith in medicine to be well meaning
is self destructive
Human beings find ways to believe in that which serves their
self interest. The first surgeon has no motivation to discover that which would
end that lucrative part of his/her career. When it is said that people in power
always lie, it should be added that they almost always find ways to believe
their own lies. Learning the truth is a matter of life and death for patients.
Not learning it is a good career move for caregivers. Caregivers never have and never will reveal to
patients that which enables patients to find safety and affordability (see
Medical Reporting) and they do not know that
about themselves. They even are oblivious as to why it is vitally important to
patients to have that information. For patients ever to get this lifesaving information - the options, the dangers, and the success rates
in medicine - patients will to have to gather the information
from other patients, because no one in medicine ever has or ever will report it honestly
(see
Medical Reporting). Fortunately, for the first time in
history, that is possible.
We were too naive to ignore their counsel
and now we have embraced their ignorance.
- Charles Bukowski
If patients were crowd-sourcing information about their
experiences in medicine, one of the kinds of information that patients
could record but that healthcare professionals do not would be the fact that
that first surgeon does operations that are of no value. For the first time there
would be data not only comparing the surgeons, but also comparing which physical
therapists do a better job healing frozen shoulder without surgery. Some physical therapy
firms create schedules that extract all the money the insurance company will pay
before treatment ends. Others require less time off work for the patient and
fewer expenses for the insurance company.
There even are doctors who believe that the way to heal
frozen shoulder is to freeze it, stop antagonizing it with physical therapy, and
wait for it to heal itself. It is not possible for patients to visit enough
doctors to stumble on all of these options, and then learn what happened
to other patients who tried them. Patients think that someone in medicine must
be keeping track of such information. No one is. To avoid unnecessary surgeries, to find out
what actually is working for other patients, and to make intelligent
cost-benefit decisions, patients are going to have to get the information
from other patients.
Their reputations are not worth more
than the lives of patients
Nothing in scientific studies or evidence based
 medicine
or best practices policies touches the fact that all providers are not equal and
that all providers are not worth what they charge.
The very first step in making informed cost-benefit decisions about health
care is choosing providers based on more than rumors about beside manner.
Health care professionals continue say that the
way to choose a surgeon, or other caregiver, is to talk to friends and see who
they like. That first surgeon might be the most charming person with the best
bedside manner on earth, but his/her treatments for frozen shoulder are
unnecessary, if not injurious,
and expensive. The patients of that surgeon currently have no way to discover
that. They only can live with the consequences of being kept ignorant.
Since no one in medicine will record the information that would
enable patients to avoid dangers (see
Medical Reporting), we need to plug patients in to helping
each other by recording information on the internet where everyone has
access to it. Otherwise, now and forever, we will do what we are told and pay
what we are told no matter how much it costs and no matter whether it is of any
value or not. That is why costs will spiral upward forever while safety does not
improve if medicine continues to operate on the Saint
Theory as it currently does.
Cost Comparison
There finally are a few websites that are trying to
tackle the cost part of the issue. PricDoc.com, OutOfPocket.com and HealthcareBlueBook.com
take various approaches to trying to enable access to at least a little
information about how much things cost. But still it is buying blind. The woman
with pain in her shoulder might have been able to shop for a cheaper surgery
(one woman reported getting a $2,500 MRI for $300 after shopping around - I have
done that myself), but
she could not have learned which surgeons, including hers, have no idea how
to heal frozen shoulder. She could not even learn that surgery is the wrong treatment for it. She
should have been able to do a search on shoulder surgeons and read a wealth of
data collected from patients.
We need patients to be able to blog and twitter and Facebook
about whatever happens to them in medicine without fearing repercussions, so
that Google, or whomever, can make it available in a search. When enough of that
is online, motivated patients will gather it and make sense of it in various
ways. One fledgling attempt to do this can be seen at PatientsLikeMe.com, the
founder of which says, "When you need help, privacy is a terrible thing."
Angie's List has a fledgling attempt at working on the problem. Think what
Consumer Reports could do.
The surgeon who operates on shoulder problems without improving them
should be known. The surgeon who sends patients to physical therapy and heals
them should be as well. It should be possible to read about the patients who have been
down these roads already so that the next patient can skip the
surgery and go to the less
expensive physical therapist who heals that problem faster. When that is where
the business goes, other providers will learn how to do it faster and cheaper in
order to win patients back.
Without access to that kind of information, patients cannot
make the kind of informed cost-benefit decisions that drive quality up and drive
cost down. Instead, they will continue to be hapless pawns with no choice but to
do what they are told and pay what they are told while costs escalate and
quality does not.
Patients never will get this kind of information from their
caregivers because their caregivers are not saints. Medicine should stop being
organized as though they were.
It depends on which report you read. Some find a 0% report
rate. Others find a 7% report rate. Others find numbers in between, like the
Department of Health and Humans Services did in their 2010 report: 2%. What is important is how small the
percentages are. This might be the most important fact in health care (other
than, perhaps, the crime rate) and it is ignored by everyone in health care (as
is the crime rate). Click the link to see the studies and journal articles
behind it. If their first priority really were the well being of patients, they
would report and measure these errors and sins and inefficiencies in medicine. But they are not saints. And it is not in their
own interest. So they don't.
"What you measure effects what you do.
If you don't
measure the right thing, you don't do the right thing."
- Josephe E. Stiglitz,
Nobel Prize winning economist.
Patients need to know about adverse events in
order to drive down cost and drive up quality in medicine. Patients who don't
know about them are like base ball
team captains trying to
pick batters when the batters keep their own records and record only 2% of their strikes. They
all look stellar under those circumstances. But they aren't. And if you don't
know which aren't, you can't win.
There is little truth in medicine about what is wrong. There
is almost no justice. Both are essential. Neither ever have or ever will come from the
providers. Adverse events are the last thing anyone in medicine will record or
report and that is not acknowledged in any
of the proposals or reforms or discussions in medicine about how to fix the
problems. Fortunately, there is something
patients can do about it.
Errors are the symptom, not the problem
Right now the whole health care debate is provider-centric.
All of it assumes that well-meaning people at the top will protect the patients
who are hapless children with no ability to make intelligent decisions (which
will continue to be true as long as
they are kept in the dark about things like success rates and crime rates in medicine). It is how governments operated before democracy - as though the masses
are helpless idiots.
The greatest innovation machine that ever existed is markets.
Markets can exist only where consumers can make intelligent cost-benefit
analyses. In medicine
currently consumers cannot obtain the information necessary to be intelligent. The
health care industry wants it that way. For instance, during the health
care debates in Washington, lobbyists worked to get measures enacted to prevent
studies from being done that measure cost effectiveness in medicine. That is
wanting medicine to be expensive and wanting patients to be stupid and wanting all the
power in their own hands at the expense of patients.
Intelligent Consumers
The average consumer spends 12 hours on line doing research before
buying a camera. How much time would they would spend
researching the surgeons who were going to cut them open if as much information
were available on that? In ten minutes on line the patient has learned all that
can be learned about a surgeon, which is virtually nothing. There is nothing
about the surgeon's success rate (no one keeps track of that) or infection rate
or any similar information. You can learn more about a hairdryer you might buy than about the hospital where you are going to be
cut open or the surgeon who is going to do the cutting.
As long as no one is collecting information on adverse
events, all of the initiatives to fix health care are going to fall short.
Hundreds of thousands of patients will continue to die unnecessarily every year. Millions
more will continue to be injured unnecessarily. Costs will continue to rise. And
there won't even be a thought about finally, for the first time in history,
addressing the crime rate in medicine.
Crime against patients is the most fundamental problem for
patient safety and not only is it never mentioned in patient safety discussions
and other healthcare debates, but we defy you to find people in medicine who
even will acknowledge that there is one.
Fortunately, there is a solution
It finally has been demonstrated that when given the opportunity, patients are more frequent and
more accurate reporters of events in medicine than anyone in medicine. When
asked, patients report three times as many confirmable adverse events as health care professionals
(footnoted
here). Unfortunately, patients are prevented from sharing such information.
Not only is there no place for them to share it, they can get sued if they do. And
they can get blacklisted for it. It is
baffling to us how little awareness there is of the extent to which reporting of
adverse events by patients is not only discouraged but stopped.
Ever try to get your caregivers to write in the
record that your injuries resulted from bad care or malfeasance on the part of
someone else in medicine? You can't. They won't. There is no one you
can tell. You can't even become a statistic. The people who need to know the most are other
patients, but they are the last people who ever will know. Or rather, the second
to last. People in medicine would be the last as they are so deeply entrenched
in a culture of denial.
Every Try To Research a Surgeon?
Consider the surgeon who, among other surgeries, performs one that improves the condition of patients only one third of the
time. The other two thirds of the time it makes them worse. The surgeon doesn't see it
that way. Most of the patients of the surgeon's other surgeries improve. And the poor
success rate of this one surgery is believed to be no one's fault. It is assumed
he/she happened to get sicker patients than surgeons with better success rates, if he/she notices the negative trend at all. When
patients come back to him/her in worse shape afterwards, he/she says it is
because of the original problem, not the surgery. The record the surgeon creates always says that
his/her surgeries are perfect with no complications. The operating room staff and
the hospital believe it. The surgeon believes it too. There is no record and no
recognition of the bad outcomes and no awareness of the surgeon's extremely poor success
rate.
Patients think someone in medicine is on top of this. No one
is. They think there are agencies tracking this. There are not. When the rare
study is done, it uses the records created by the surgeons to see how things are going.
What is known is only that which is reported by surgeons who have a subjective,
self-serving view of the world that results in only 2% of problems and injuries
being reported. Their view of the world is that their track record is stellar
and they are saints. Patients cannot learn better in order to protect themselves. There is no
objective record from which to become educated. Medicine keeps
saying that it is "buyer beware" and advising patients to become informed, but
how? Beware of
what? There is no useful information of which to be aware. They make sure that
there isn't.
When the mission is in the disinterest of the people in
charge,
the mission does not get accomplished, and the physical and economic
well being of patients
is not in the interest of health care professionals. So they will never give us
the information we need to protect ourselves from them. We will have to get it
ourselves.
Next Page
Relying on a central board to make decisions for all of us turns us
into metrics in an aggregate. The fact that your health is failing
because of something that is not common will be unlikely to compute or
get treated. That already is the case frequently, which is a major
failing of the current system. Why would we want a system to makes more
failures?
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