The Saint Theory
The Saint Theory of Medicine is the basis for almost all the theories and proposals that are supposed to fix medicine. It comes in many colors and sizes, but in short it is the idea that saints can run everything without patients needing to know anything other than what they have been told to do and what they have been told to pay.
Inevitably every thought and every proposal about how to improve health care is based on the idea either of educating or screening or micromanaging or in some other way arranging for care givers to be saints. This is true of people both inside and outside of medicine. And it is an antiquated and unworkable premise.
Even Chamath Palihapitiya, a former Facebook executive and now the founder of the Venture Capitalist firm "Social+Capital Partnership," who says, “Every interaction in every area related to health is just so sh*tty. The software is crap, the services are crap, the people are crap. So there is a lot of value that people like us can add because you have a very different perspective on how the system should work.” (quoted at this link in Forbes)
Can you see how that is just another way of imaging things would be better if saints were in charge? That model has had the same problems since before the USA became a republic, one of which is that people are not saints. What is necessary is enabling patients to protect themselves from humans who are anything but saints and have tremendous power over them. What is naive to the point of being asinine is continuting to let people with tremendous power be the only source of information about themselves.
Does someone think they are going to make it transparent when they don't wash their hands so that others can protect themselves from them?
Not in the last 160 years
When Semmelweis discovered that washing hands saves lives, he was in charge of two maternity clinics. Comparing them enabled him to do a rudimentary clinical systems analysis. The first clinic had a such a high death rate that expectant mothers who had been assigned to it literally got on their knees pleading to be reassigned to the second clinic. When they were not, some women chose to give birth in the street. The "street births" had a higher survival rate than the women who gave birth in the clinic. It was safer to give birth in the street than in the clinic. Yet the clinicians, knowing that, continued to send patients to the most dangerous clinic.
That hasn't changed.
This is the way medicine always has taken care of patients. Most of the patients in the most dangerous clinic did not die. Some months as many as 30% did, but that was good enough for health care professionals who were not going there themselves. Today providers argue against allowing patients to know the success rates of providers and facilities saying that maybe the deadlier ones gets sicker patients. "Maybe" is good enough for them. They aren't the ones who are dying.
This is the one of the problems with getting information from health care professionals. They have a vested interest that competes with caring about the ones who are dying. Health care professionals do not even recognize that they worry about the reputations of clinics and caregivers more than about the survival of the patients.
Caregivers mistake their own self-interest and prejudice and habits and comforting myths for what is right for patients, as though whatever is good for caregivers must also be good for patients. They are humans with vested interests who are neither objective nor selfless. And they are not aware of this about themselves. When a judge or a juror would not be permitted to render judgment because of a conflict of interest, health care professionals are. They decide how and whether patients get to live. To earn a little money, physicians will prescribe disabling treatments that are profitable for themselves rather than refer patients to others who can cure the problem without creating disablements.
Where is awareness and analysis of the ways in which health care professionals think, the ways they rationalize, the ways in which they manage and massage their moral self-images? Where is awareness and talk and literature about their moral failings? Instead of the fruits that could come from that, they and we are buried in words about how medicine is full of good people for whom the well-being of patients is the highest priority. If it were, they would report what goes wrong instead of hiding it 98% of the time (see Medical Reporting and see Dr. Hodad).
In medicine selective memory is not just personal. It also is institutional. That is by design. They think that is a good thing. They don't even understand enough to know better than that. I know a patient safety advocate who was visiting a hospital when a surgeon wagged a finger in her face angrily demanding to know why we thought we had any business knowing about the things that go wrong. They truly don't get it. We are dying, getting disabled, and even getting victimized. When we do, 98% of the time there is no record of it. And they don't know why we need one. You see, they don't need it. It only is patients whose well-being depends on it.
Instead of setting up the world of medicine in a way that would keep patients safe in spite of the foibles of the humans earning their livings in it, medicine is set up in a way that assumes they are saints. They are not. They never will have the will or the ability even to tell patients what patients need to know to in order to seek health care that is safe and affordable, let alone deliver it to them.
The Patients Like the Dragon
So we hear that most patients are happy with their health care. We hear this even though health care is the greatest source of accidental injury and death in the country and the greatest source of personal bankruptcy. It even is bankrupting the federal government. But they say that most patients are happy with it.
That is good enough for the people who earn their livings delivering it. Whether they do it by informing patients or not, they steer patients into the situations that cause all those unnecessary deaths and bankruptcies. It was in their interest to allow their world to become arranged in a way that prevents anyone from knowing the information that patients need to make cost-benefit choices that are safe and affordable. They cannot tell it to patients. And they cannot use it themselves to protect patients. Without that information, even saints could not run medicine in a way that would make it safe enough and affordable enough for patients. It was not in the interest of providers to make it safe and affordable so they didn't. And there is no awareness of that anywhere in medicine. They do not even know what happens to the patients they injure (covered elsewhere on this site). They frequently do not even admit to themselves when they have caused the injuries.
It is hard being a doctor. The pressures are great. The problems are complex. There are so many patients with so many needs and demands. That's part of the point. They are not always attentive enough. They are not always competent enough. They are not always moral enough. They are not always honest enough. Sometimes they even are evil. They are not saints. Medicine should not assume that they are. Patients should not have to be in a position that requires that caregivers be saints.
Making Medicine Safe for Patients
Semmelweis figured out that washing hands would bring down the death rate in the more dangerous maternity facility. In fact, two months after instituting hand washing, the death rate fell to zero - better than in the safer clinic. But sharing the discovery did not result in clinicians washing their hands. Just like the more recent discovery that checklists dramatically can reduce negative outcomes has not resulted in clinicians using those either. Their own well being is not effected. They don't die if they don't use the checklists or wash their hands. Scientific studies or the examination of closed case claims have little to do with whether caregivers implement what could be learned from them.
It has been 160 years since hand washing was discovered to be important. Currently, according to the CDC, 99,000 people per year die from infections acquired in health care. For 99,000 to die from that, some millions must have made sick by it. For some millions to have been made sick, there must have been some hundreds of millions of unsafe acts. A lot of those unsafe acts were failures to wash hands. Many of the rest might have been more complicated acts, but still acts known to be unsafe. Another closed claims project determining that clinicians need to wash their hands will not ensure that they do. Closed claims projects or other scientific studies can determine what the clinical systems problems are, but they cannot motivate clinicians to implement the solutions well or at all. They also cannot motivate clinicians to figure out how to implement them for less than it costs to send a space shuttle to the moon.
And sacrosanct in all this is the idea that the problem is the systems, not the people who won't wash their hands.
I know of a physician who bought a machine that is estimated to have cost $20,000. It is the size of a desktop computer printer. It emits a laser beam through a stylus that can be used to kill toenail fungus. He knew of a homeopathic healer (prescribes herbal remedies) who was starving. So he made a deal with her. He put the machine in her office and pays her $60 per hour to do the treatments. It takes two to three hours to treat a patient. Doing this work is what keeps her in business. So there is a reasonable amount of it.
The physician charges patients $1,200 every time he prescribes it. In a matter of months the machine will have paid for itself and he will be making $1,000 every time he prescribes it. Scientific studies say that the treatment is successful half the time. They don't say how successful this particular homeopathic healer is at using it. There are no scientific studies telling patients if someone half an hour away is doing the same thing for one fourth the money with triple the success rate. There are no scientific studies motivating patients to care what it costs either. The patients with toenail fungus go where they are told and pay what they are told and imagine that some saint somewhere is making sure that the success rate and the costs are what they should be. They also imagine that their primary care physician cares enough about their well being not to gouge them financially.
80% of Medicine
80% of medicine is maintenance, not emergency care. There is time to make informed cost-benefit decisions for 80% of health care. Unfortunately, there is no opportunity to do so. Patients being screened for cancer cannot know whether the radiologist examining their x-rays ever recognizes cancer in an x-ray. No one monitors that.
That was studied. It was found that there are radiologists who cannot recognize cancer in an x-ray. The government tried to fix that. They wanted to test and rate radiologists. But government is political and medicine is powerful. The effort devolved into the government regulating the equipment that radiologists use. The inept radiologists are still enjoying long and lucrative careers getting paid for doing something they are incapable of doing. They have degrees. They have training. They have good social skills. They talk a good talk. They just don't do a good job. Patients are told to go to them and pay whatever the insurance company can be persuaded to pay. If the patients don't have insurance, often they are told to pay more than the insurance company would have had to pay. And they do that, patient after patient, year after year, with no benefit to anyone but the radiologist.
This is the way radiologists want the world to be.
Closed Claims Projects
For something like a closed claim project to address that, lots of patients would have to suffer and file claims in order for there to be claims that have been closed. And that would have to happen for every radiologist in the country. Efforts like the ASA Closed Claims Project really only are about systems improvement. That is vital. That can saves lives. That can reduce the extent to which injuries and lawsuits add to the increasing cost of medicine. But that cannot evaluate whether your clinician is competent or even safe. That cannot watch every nook and cranny of medicine so that patients don't have to.
There are no closed claims to study for the toenail laser operator. People who pay too much and don't get healed do not file claims. They don't know they paid too much. They don't know that they have been sent to someone who heals only a fifth of her patients. Her patients did not become disabled. They did not die. There are no claims. The patients merely continue to live with toenail fungus, possibly trying a drug treatment next, or a repeat attempt with the laser, but without learning that there is a more successful operator in town, and without future patients learning anything about the less successful one.
It doesn't have to be this way. The patient community does not have to pay exorbitant prices for bad medicine. Currently there is no downward pressure on the laser operator's price or upward pressure on her quality. There have been attempts to have every corner of medicine scrutinized and run from above, like with the radiologists, but those efforts are pale compared to what happens when patients know success rates and prices and make decisions about where or whether to get treatment. Sometimes it is better to limp than to get treatment.
If a centralized planner were to tell a citizen of the USA that it had been looked into and decided that it is too expensive or too dangerous to provide treatment for that limp, it would be a severe violation of what this country is about. It also would be the Soviet style of management that resulted in the joke "What is 200 yards long and eats cabbage? . . . A Russian meat line." The Closed Claims Project is vital for how it helps people in the system understand how to clean up systems, but it will not ensure that clinicians are competent enough to do it, or whether the competent ones bother to do it regularly. Or whether they do it in an affordable way. It is not what will solve the problem of medicine's being unnecessarily dangerous and expensive. As David Goldhill said in his article in the Atlantic, only consumers can be the ultimate guarantors of good service, reasonable prices, and sensible trade-offs.
Patients cannot be that without the information necessary to make informed cost-benefit decisions. That kind of information is not produced by closed claim projects and scientific studies. To be informed requires knowing the success rate of individual clinicians and facilities. The women assigned to the dangerous clinic 160 years ago did not have knowledge of any clinical systems analyses. They did not understand what the problems were. They understood only the success rates. Too many people were dying in the first facility. They didn't have to know anything about medicine. But they did have to know success rates. Patients cannot make informed cost-benefit decisions without knowing success rates. Neither can doctors, but none of them will record the data that would enable it to be known.
Motivating Safety and Efficiency
Under the right circumstances, that toenail laser treatment could cost $150 from an operator with a high success rate. Scientific studies and efforts like the Closed Case Claims project produce nothing that motivates clinicians to figure out how to compete at that price. They might reduce the number of expensive litigations resulting from toenail laser accidents. They might produce safe practices guidelines. But they do not motivate operators to be safe. They do not motivate operators to be more efficient and less expensive. When patients pay whatever they are told to pay without regard for what they are getting, there is no reason to become more efficient or less expensive. There isn't even much motivation to become safer. However, there is a strong motivation to keep anyone from finding out when they are inept and/or expensive and/or evil. There is a strong motivation to silence claims and hide results. And doing so makes it so that no one knows success rates.
For medicine to become safe and affordable, it must be the case that patients have the information necessary to know whether or not it is safe. It must be possible for entities like Consumer Reports to do epidemiological studies of individual clinicians and note when eleven 14-year-old girls complained of being groped by a certain clinician, without the girls who posted it on facebook getting sued, and without Consumer Reports getting sued for reporting how many did. Closed case studies do not improve the fact that sex predators in medicine abuse patients for decades before there are enough patients finally to force someone to pay attention. Waiting for the closed cases requires amassing an unacceptable number of victims to study. Even then, it does not put every doctor and hospital in the country in a position in which staying in business requires competing with people who are safer and cheaper.
Patients today do not know the success rates of almost anything or anyone in medicine. So 160 years after Semmelweis, clinicians still do not wash their hands often enough let alone take enough more complicated precautions to reduce infections.
The FDA shuts down an entire industry if a hamburger is found to contain E. Coli. But they do not tell consumers what and where to eat and how much to pay for it. If they did hamburgers would cost $300 and it would require lawsuits to respond to a bad cook, rather than consumers being able to tell the cook is bad and just stop going there. The FDA helps reduce the frequency of fatalities, but even if it were run by saints it could not motivate chefs to create food that is affordable and good.
If you want your hamburger to look like healthcare, put the FDA in charge of choosing what you eat and how much you pay for it. If you want medicine to look more like the way you eat, start arranging for patients to provide to each other the information that no one in healthcare will. No one in health care will warn patients when one doctor in a facility has a high death rate. No one keeps track of that. They don't know themselves. But other patients can. This has been studied. It has been demonstrated that when given the opportunity patients report more information and more accurate information than anyone in health care (click here for the study).
It is difficult to persuade people of how few adverse events get reported in medicine, but understanding that is essential for fixing medicine. See the most recent report from Health and Human Services:
Surviving Single Digit Reporting
The foundation for making medicine safer and more affordable is patients having the information necessary to make informed cost-benefit decisions so they can avoid paying $1200 for a laser treatment from someone with a poor success rate. So they can avoid paying $2,500 for an MRI they can get around the corner for $300. So they can avoid dangerous facilities. So they can avoid getting butchered by an inept physician no one in medicine will report. So they can put clinicians in the position of losing business if they have poor success rates from not washing their hands.
Scientific studies, closed claim projects, examinations of existing records, reorganizing administrations and altering the way clinicians are paid might offer patches for problems, but will not alter the fundamental issues. All of those patches require saints to understand and implement them. If health care professionals were saints they would put the interests of patients ahead of their own by recording 100% of adverse events, like airplane pilots do (because if the problem isn't fixed pilots go down with the plane). And they would figure out how to charge $150 for laser toenail treatment.
Think how valuable that would be to the patient community. The recording of adverse events would empower patients to protect themselves when clinicians turn out not to be saints. Lowering prices to 12% of current charges would end personal bankruptcies and make it affordable to extend coverage universally. But they are not saints. They don't do that. They charge $1200 for a $150 treatment whenever they can. So patients will have to do what is necessary to collect and disseminate the life-saving information themselves. Having that will put downward pressure on prices. Without having that information health care will continue to bankrupt and kill more people than anything else.
Within the patient community exists the information necessary to determine which radiologists have good batting averages and which don't. And which take too long and cost too much. With that information, patients can make choices that put inept radiologists out of business and cause the rest to figure out how to be efficient enough to be affordable.
All of the studies and projects set up to run medicine better for patients are vital, but never will do for patients what patients can do for themselves. Patients must be in the information driver seat. There are projects that could help them get there, but no one is talking about them. All anyone is talking about is what is being done at Mayo, or at the Closed Claims Project, that will make it so that saints can run medicine for patients with patients left in the position of doing what they are told and paying what they are told.
That's the model that got us where we are now.
What we need is for patients to know about the dangers and be in a position to care about the price.
Scientific studies, closed claim projects, whistleblowers, examining existing records, reorganizing administrations and altering the way clinicians are paid are only patches, and they are patches that don't necessarily make things better. If they are put in place by inept caregivers, another facility without any of these patches could be the safer choice.
When patients can learn success rates and go where it is safe and affordable, medicine will figure out its problems on its own - when patients have the real facts.