Josie King Foundation

On February 22, 2001, eighteen-month old Josie King died unnecessarily in the hands of medicine. The Josie King Foundation was set up with a settlement from the hospital.

You have to be grateful for the superhuman effort of people trying to protect patients like the founders of this effort do. But they might not be looking in the right place for the answers. The experts contributing to their site are learned and articulate, but they are examples of why, year after year, improvements in patient safety are nominal at best, without those experts ever figuring that out.

For instance, the lawyers on their site say that the best place for injured patients to begin expressing concerns about care problems Reality Checkis with the doctors and nurses who were in charge of their care. For problems small enough to elicit a "Whoops. Sorry. Let me fix that" it might be reasonable advice, but for anything larger that is the top down perspective of people so focused on managing their careers and businesses that they are woefully out of touch with the realities of the people they are supposed to help. One normally may go to experts to ask how things work and to learn what the problems are in such fields, but this is a good picture of why, in medicine, that is like going to the queen who thinks she means well when she says, “Let them eat cake.”

People who think that going back to the caregivers who caused the problem is realistic advice for the average injured patient are so far removed from the realities of the barriers thwarting injured patients that I’m not sure any amount of explanation and reasoning could help them get a more accurate perspective. I suspect they would have to get raped in a hospital to find out what happens when patients return to those same caregivers for help afterwards.

How to Choose a Lawyer?

Like their advice about how many lawyers to interview before choosing one. Of the patients with legitimate grievances, only one in some thousands can get a lawyer. The question is not how to choose one. The question is what to do after you figure out that you cannot get one.

Most injured patients do not begin by seeking lawyers in the first place. They begin by seeking help. They are injured. Their first concern is getting diagnosis and treatment. When they cannot get that, they seek answers. When they cannot get those they seek justice. When they figure out that there is no agency or department to help patients with that and that the only avenue for that is court, then they call lawyers. But the conundrum they face at that point is not how to choose one. It is how to get one at all.

For the expert lawyers on this foundation's site to articulate the problem as being one of how to choose one from among the many truly is telling starving people to eat cake. It is the same perspective held throughout medicine with regard to patient safety.

Safety Advice from a Nurse

Like the nurse on the site who explains how to improve patient safety. Her points are not invalid. But they address only something like 3% of the problems in her own field. 97% of what patients need her to address is outside of what her blinders allow her to see. 

Her points, even if adopted across the nation, would not make a noticeable reduction in the thousands of patients who die unnecessarily each year and the many more who have their lives ruined unnecessarily, sometimes intentionally, because nurses don't see and don't address that which would prevent it. Indicative of their perspective is that not only do none of the people on the site acknowledge intentional harm, they issue an active denial of the possibility, “caregivers cannot be blamed when the system fails,” as though no caregivers sell unneeded products to make money, as though there is no lechery or jealousy in medicine, as though all people in medicine are saints without agendas that compete with the well-being of patients.

Every page I turn to on the site leaves me with the same thing to say. Medicine watches out for itself first and has its own political correctness to stifle awareness of that. In medicine it is politically incorrect to suggest that the fundamental problems and obstacles are anything other than innocent errors. Any suggestion that anyone in medicine might have a motivation other than the well-being of patients is not tolerated. Learned, experienced people assume themselves to be objectivity and selflessness and to assume the same for everyone else in medicine as they have discussions that have too much in common with the discussion, once considered legitimate, about how many angels will fit on the head of a pin. They are not quite that fanciful, but in terms of solving safety problems for 97% of patients, they are just as far removed from reality.

If It Were Doctors Dying

How differently would doctors would throw themselves at the problems if it were several hundred doctors dying unnecessarily every year instead of several hundred thousand patients (see Preventable Deaths)?

They are not saints. They are in denial about the extent to which medicine puts self-interest ahead of patient safety. 93% of adverse events go unreported not because medical professionals are honest and objective and selfless but because they are self-interested first and concerned about patients maybe fourth.

They claim to hold the safety of patients as their highest goal. Their most fervently held belief might be that they do, but they don't. They will go to meetings about patient safety. They will sign initiatives promising to promote patient safety. They will believe in their hearts that there is nothing more important to them than the safety of their patients. But there is a disconnect between what they believe and what is true.

All of the time and intelligence and experience on the Jose King Foundation's site focuses on points that show, more than anything else, how far removed people in medicine are from the real problems. They are the angels dancing on the head of a pin with no awareness of the pin, only of the head on which they dance, while below, out of their sight, patient after patient gets skewered. That will sound harsh to people in medicine. To millions of patients and their families, it merely is sadly accurate.

I am grateful to the founders of this foundation's effort for worrying about patient safety. I am grateful for all of the work and resources and concern and love and sacrifice they bring to it. I could not be more impressed with their devotion and the scale of their effort. I think, though, that they more or less have been duped by a culture and an unrecognized political correctness that maintains the status quo. Like the "failures of communication" that the experts on their site keep mentioning. Those are important and need to be worked on. They might prevent a few adverse events. But it is system-tweaking. It is addressing 3% of the problems, and not the fundamental ones.

They call for better communication

The extent to which better communication can be a two-edged sword is not something it is in their interest to understand. Better communication frequently is used in ways that are unfriendly to patients. Sometimes getting diagnosed and treated is possible only if failures of communication enable patients to get objective information from new healthcare providers who have not been influenced by the assumptions or prejudices formed by previous providers. That is part of what blacklisting is about. Especially if the patient was injured by previous health care providers who now have an active interest in protecting themselves by making sure that no one creates diagnoses that reveal the injuries. They actively work to prevent such records from being made. It is not by accident that 93% of adverse events are not reported and most of the rest are reported inaccurately. The culture in medicine is setup to protect itself first.

It is possible that some lives will be saved by the superhuman efforts of the founders of sites like this. I don’t mean to discredit them. It’s only that I get frustrated with living in a milieu in which there isn’t even recognition of the biggest problems. We are suffering and dying and being abused while being told how fewer than .1% of us should go about choosing lawyers.  What about the rest who just need help?