Synopsis of Site
in which are included almost no links to the
corroborating materials that can be found in the
Table of Contents
I'm going to write a shorter synopsis eventually. It probably
will begin by saying that focusing on errors is like focusing on curing small
pox by looking for skin lesions. That is too shallow. We cannot scrutinize every
iota of medicine to root out everything that presents a danger and put in place
some kind of mechanism to prevent human error. We have to make it so that it is
in the interests of those providing care to need to care more about safety.
Errors are not the root problem. They are a symptom of the root problems.
Focusing on them misses the point. But I haven't written that short synopsis
yet. Below is the long one, and unfortunately, it's kind of old news to many of
us.
Sorry about that
It is old news that
195,000 people die unnecessarily each year in medicine. The number, of course, is not about the inability of healthcare to cure people. It is about UNNECESSARY deaths - like someone seeking attention
for sunburn ending up dead because of negligence or error or abuse. According to some estimates, the American medical system is the leading cause of death and injury in the United States.
Unfortunately, the number of intentional injuries are alarming as well. People who live in safe suburbs might be more likely to become victims of crimes in hospitals than anyplace else they go. I, unfortunately,
found out why.
Belief in Medicine
and how it fuels the problem
I was in Columbus, Ohio waiting for the beginning of the meeting of the board of directors of the Ohio State Medical Board, a group of MDs in expensive suits passing the time. I sat silently listening as they said that “There is no silence in medicine. No one working in healthcare would fail to report problems. The
consequences for patient safety would be too great.”
I have a photo taken in China of the Wall in a forested area where the tops of the trees rise around it to about the height of shrubs. If you didn't know better, you could think it was a photo of the Great Sidewalk of China. Whether you are looking down at something from above or up at something from below, has everything to do with what you see.
Healthcare professionals don't see their silence as the wall their patients do.
Another time I met with the head of investigations for the Ohio State Medical Board, a large man in a gray suit. He played football in high school then became a cop. Now he is the head of investigations. He told me that people in medicine are chatty about problems. He said that everyday they speak to healthcare workers who reveal problems. He
said that
there is no silence about problems in medicine. Shouldn’t facts external to one’s personal experience
have some influence on one’s view of the world?Like this fact from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). They did a study of crimes committed by healthcare workers against patients. In a recent given year, of the crimes reported, fewer than 1% were reported by healthcare workers.
Doctors, nurses, anesthesiologists and all the rest of the people working in healthcare are the least likely of all people to report crimes committed against patients. So in his job this chief of investigations might speak everyday to people who are reporting problems, but he’s speaking to fewer than 1% of the people with something to
report. How many fewer?When I had been trying to understand how, in my own personal experience, nurses could stand by and witness what was done to me without protecting me and without reporting it afterwards, that 1% number wasn’t available yet. The study had not been done. I had to do my own study to get an understanding it.
From the State of Ohio Board of Nursing I got the list of the 140,000 nurses in the state so that I could do a survey. I wanted to know what nurses report and how often they report it.
I chose 200 names randomly from the list. Among the questions on my survey were, “How long have you been a nurse” and “Have you ever filed a report with a state board or agency.” The 200 nurses collectively had 3000 years of nursing experience. In those 3000 years not one single nurse ever considered filing a report with a state board or
agency. I know they never considered it because that’s what I asked next. Frequently the response was “Why would I do that?”
The fewer than 1% number appears to be not 1 time in some hundreds but one in some thousands. A lot fewer than 1%.If you ask a nurse what the overarching goal or purpose of nursing is, usually you will be told that it is to advocate for patients. Nurses are the ones who watch out for us. That is what many of them are taught in nursing school. It is what they say and that is the way it feels when they are caring for us.
How to reconcile that with the numbers?
I telephoned Rose Mary Vosseler. She was a nurse at the Jones Memorial Hospital in Wellsville, New York. Wellsville is a rural village. The hospital is on North Main Street. Sounds like the setting for a Norman Rockwell painting of a nurse and a doctor, doesn’t it? But this doctor, Dr. Gary Ogden, was performing surgery while drinking the
equivalent of 20 shots a day. This had been going on for years. Everyone knew about it. The nurses had talked among themselves about it and decided not to say anything. Not only did everyone know about it. They discussed it. They arrived at a decision. They decided to remain silent.
Finally, a baby died. Rose Mary Vossler had grown up with an alcoholic father, so she had
a trigger point the other nurses did not share. She couldn't live with a baby dying because of a doctor’s alcoholism.
She didn't think it was her responsibility to say anything. . . a member of the profession that has as its goal advocating for patients, didn’t think it was her responsibility to say anything. One of her patients had died, but she didn’t think it was her responsibility to say anything.
However, to the appropriate person she said that she had smelled alcohol on the doctor’s breath. She had hoped to keep secret the fact that she reported it, but people figured out who reported it. The other nurses made it impossible for her to work. They wouldn’t listen to her. They wouldn’t talk to her. They wouldn’t work with her. Eventually she quit without
even having another job lined up. The nurses protected a drunk and banished one of their own for breaking the silence. Where only the silent survive,
there is an evolution that leaves a dangerous brew.After Nurse Vosseler and I had been on the phone for a while, I asked if she thought that there might be a white wall of silence in medicine. She told me that she had never thought about that before, but now that I mentioned it she said that she supposed there must be one or else Dr. Ogden couldn’t have continued this way for as long as
he did with everyone knowing about it but no one doing anything about it.
This is a typical level of self-awareness in healthcare. When asked if there is a wall of silence, her own does not cross her mind. She had said that the nurses had talked among themselves and decided to remain silent. It had been discussed. It had been agreed upon. When that is not recognized as a wall of silence, even by the kind of
person who would sacrifice her own career and her own social standing in a small community in order to protect patients, consider how far from consciousness it must be for everyone else in medicine.
She said another doctor in the hospital had the authority and the responsibility to do something but he said that he couldn’t because he was Ogden’s friend.
Whether it is the result of friendship or a meeting of the minds or just the habitual behavior of people used to deflecting liability and protecting each other, it is a wall. Yet I cannot find one person in healthcare who thinks it exists. They say there is no silence. They tell me that no one outside of their profession has a legitimate
viewpoint on this, particularly not patients. They tell me that only the professionals know what they are talking about. They walk down this path everyday. They can see it. It’s not a wall. It’s the path they walk on. Just ask them.
Just labeling it "Denial"
is oversimplifying
In the 1950's, the psychologist Solomon Asch did a series of laboratory experiments that showed that three out of four people will give an incorrect answer to a simple question after overhearing others give that incorrect answer. Recent research using MRI's shows which parts of the brain react to this. They are not lying. They see things differently based on what others
see. Seeing is believing what the group
suggests you should believe. These studies were done with groups of strangers from various walks of life. Imagine the outcome if the false answers were uttered by strangers who were members of the same profession, like a police officer among other police officers. Imagine how much stronger it would be if the
other officers were not strangers. Imagine if the participants in the study were members of a surgical team that works together everyday. That could make possible debacles like Dr. James Burt. After he fled to Florida to protect his assets, a nurse who had assisted him said that he dazzled them. They just didn't see.
Consider the fact that the president of the NSW branch of the
Australian Medical Association, Andrew Keegan, said "Simply being in the same
room doesn't mean you know what's going on."
Bellwether
How are we to get any sense of conditions in medicine when the people on the scene not only don't report the problems, but don't even recognize them? We need a bellwether by which to gauge what we cannot see by what we can.
What would be a good bellwether for patient safety? If you want to see how a system functions, look at how it handles its worst moment. In medicine
could there be a worse moment than caregivers murdering patients? As a bellwether for patient safety, let’s look at how healthcare handles violent crimes committed by healthcare workers against patients, crimes like murder - bodily harm in general. After all, criminal law
must be the rock bottom foundation of patient safety. If they aren’t even enforcing that, if they aren’t even protecting us from violent
crime, can we be expected to believe that they are protecting us from lesser dangers?
There are only two numbers you need to know to understand the entire landscape
of patient safety. They both have to do with crime and they both come from
JCAHO, the Joint Commission on Accreditation of Healthcare Organizations in the
USA.
In a recent given year, of the sentinel events in medicine, 4.1% were assault, rape and homicide. That is doctors, nurses and their colleagues committing these crimes against you
when you are in their care. How big of a problem this is is a subject for another another paper, but it is a big problem. So if it’s such a big problem, why don’t you
hear about it?
Because of a number I already told you. No one reports it. Healthcare workers are the least likely of all people to report crimes committed against patients, reporting them
way less than 1% of the time.
Who else is there to report it, other than the victims?Nobody has a set up like medicine for silencing victims, but that’s another paper too. The point is that we, the community, don’t get the information we need to develop the cultural vocabulary to discuss, understand and respond to crimes committed by healthcare
professionals against us (or to understand less sinister problems). Healthcare workers are humans. They experience lust, jealousy and rage just like anyone else. Wherever there are people, there are bad ones, and good ones having a bad day. In medicine, what is there to inhibit them when they are bad people or people who normally are good but who are having a bad day? Not enough. If they get angry while
driving a car, they have to worry that there might be witnesses, or that someone might retaliate or report them. Not in medicine. This is going to sound like hyperbole initially, but having the initials M.D. or R.N. after your name is like having 007 after your name. No one is going to report what you do. At least not to anyone who will do
anything. As examples of serial killers in medicine demonstrate, it is a license to kill.
Sounds like hyperbole, doesn’t it? Doctors murdering patients and no one reporting it? It doesn’t seem to make sense unless you've analyzed a few examples.
Remember Dr. Michael Swango? His colleagues nicknamed him double oh Swango, but they didn’t stop him from murdering his patients. When he made his own colleagues sick by poisoning them, that was going too far. Murdering patients they don’t report. But making your colleagues sick? They will report that. He got in a little trouble for that,
although not enough to get them to stop him from practicing medicine. Eventually, if you kill too
many patients, someone might stick out his or her neck and report it to a superior, but not to the police. And superiors do not enforce criminal law. If you work in medicine, no one is going to enforce criminal law. You do have a license to kill. If someone tried to kill you, and nearly succeeded, and you saw him, and other people saw him, and they recovered the weapon, wouldn’t you expect criminal law might come into play?
Not in medicine. For instance, Rena Cooper, while a patient in a hospital, saw Dr. Swango injecting something into her IV. She had been a practical nurse for 19 years and knew that physicians do not administer injections. Nurses do that. After he had done it, he hurried out of the room. Her legs became paralyzed. Then she was unable to breathe. With no air she couldn’t cry for help.
She grabbed the rails of the hospital bed and shook them as violently as she could to get someone’s attention. Cooper's roommate, having seen the whole thing, and now seeing Cooper turning blue, screamed for help. That was heard. Help came running. They called a code and saved her life. It turns out that a nursing student had walked in on
Swango as he was poisoning Cooper. She was a witness. And the two patients were witnesses. The nurses already knew that Swango was poisoning patients. With this they would not stay silent any longer. So what did they do? Did they call the police? No. Did they file a report with the state medical board? No. They told a superior.
Boy, that’ll teach him.This is one thing on which you can get a unanimous opinion from people in medicine. They believe no one can police people in medicine except other people in medicine because no one else could
"understand." Let me tell you how the surgeon assigned to investigate this crime understood to handle protecting future
patients from Dr. Swango. He did not interview either of the residents who responded to the code, or any of the nurses who witnessed the events, or the orderly who discovered the syringe, or the victim’s roommate who had witnessed it, or any witnesses to any of the other suspicious patient deaths. He did not ask to see the syringe. No autopsies or physical tests
were ordered for any of the other apparent victims, nor were any experts in toxicology or anesthesia consulted for possible explanation of those deaths or of this victim’s paralysis. The surgeon felt that Swango must be innocent and the nurses’ “grapevine,” as he had put it, to blame for the rumors sweeping the hospital. So that was his
conclusion. Do you know about the studies that showed that generally colleagues within a profession believe that other colleagues are as skillful and knowledgeable and well-meaning as they themselves are? How rare would it be for someone in medicine to understand that someone else in medicine is not?
When the police finally did get involved, they could not find anyone with anything to report to them. Not even the nurses who
could not remain silent any longer. When journalists got involved, no one had anything to report to them either. How much more does one need to know about why the police are not enforcing criminal law in medicine? Well, there is more
to know about that,
but this page is only a synopsis. It got too hot in that hospital. Swango
was shuffled off to another hospital. When the heat became too intense in that one, he shuffled off to another. He is believed to be the most prolific serial killer the United States ever has known. No one in healthcare would stop him. He is truly a worst case scenario and healthcare handled
it but shuffling him off to where he could kill patients somewhere else.
Hyperpole
Nobody in medicine listens to me when I talk about these things. If I say something like “pediatrics might be the safest place for a pedophile,” I get accused of hyperbole, as though people who won’t stop serial killers will swing into action when the problems are smaller. In my experience, people in medicine all say that everyone they know certainly would report any harm done to any patient.
They take umbrage at the suggestion that someone might not.
"This cannot happen among the people I know."Remember that surgeon who carved his initials in his patient after delivering her baby? He carved his initials three inches high.
It is one of the rare instances about which we can talk because the surgeon signed his sin with his initials in front of witnesses who were not healthcare professionals. This happened in a delivery room. The patient’s mother and husband were there. So were the surgeon, a resident, two nurses, an anesthesiologist and an assistant. That is five healthcare
professionals and two relatives, watching the surgeon slice his initials three inches high into the patient’s abdomen.
Did anyone call security? Did anyone call the police? Did anyone report it to
the state medical board? Did anyone report it to the administration? Did anyone
tell the patient? They do not do those things in medicine. It is set up so that
they won’t.
A couple of days later the patient was concerned. She wanted to know why there was a parade of people coming in her room to look under her sheets. They wouldn’t tell her. Can you see the theme here? Can you feel the incredible inertia against reporting. That one percent number that I told you about. It’s not just that
they won’t fill out a form and file it with the proper authority. They won’t answer
questions asked by the police. They won’t answer the questions of state medical boards. They won’t even answer
the questions of the patient. Not even alone with her in her room when she just wants to know what is wrong. Not even an aside quietly whispered like, “You didn’t get this from me,
but . . .” They won’t even report it to the victim. Nothing to anyone on any level when things go wrong in medicine.
Poisonings. Knifings. No one calling the police. Do they think criminal law doesn’t apply to in medicine? Do they think they are above the law?
Above the Law
Dr. Gary Malakoff was vice president Cheney’s physician. He also was a drug addict who was prescribing drugs for himself under the name of a physician who was under his supervision.
It is both a criminal and a civil offense to prescribe controlled substances fraudulently. Malakoff had been abusing prescriptions for years. When caught, he lied, pretended to clean up his act and went on as before, and then repeated the process. He lost a few positions as a result. No one called the police. He was
allowed to continue practicing medicine. When asked to comment on that, his supervisors insisted that they had seen no evidence of his drug problems impairing his medical judgment.
He broke laws. He lied about it. He got caught and continued to break laws and lie about it like an out-of-control addict would. But his medical judgment seemed fine so he was above the law? Mandatory reporting laws require reporting this. Federal law requires reporting this. The physicians and administrators who did
not report it were committing federal offenses by not reporting it. Is anybody going to enforce that law?
But if I talk about crime in medicine, if I say that a license to practice medicine is a license to kill, or that pediatrics might be the safest place for a pedophile, I get accused of hyperbole. Look at the bellwether. Look at someone who wasn’t just a pedophile. Look at someone who murdered children. Lots of children. Remember
Nurse Genene Jones? That’s what she did. When a committee was formed to look into that, they handled it by upgrading the level of nurse you had to be to work in her department, so that
by an administrative decision quietly she was eased her out to practice somewhere else. And she resumed killing children there, in the same way that Dr. Swango was shuffled
around, and Dr. Zarkin, the initial carver, was shuffled to another hospital.
Argue all you want about whether or not these things are rare in medicine.
What matters is that they are the bellwether. And that is how murder, even serial killing, is handled in medicine. Lesser crimes receive less of a response. We cannot be asked to believe that people who will not protect patients from serial killers will spring into
action to protect us from lesser dangers. And what’s the patient safety debate about? Well-meaning errors and protecting physicians from liability when they commit them -
liability limitations the practical effect of which is also to protect them when
they commit crimes even though they are not supposed to.
Our safety depends on honest reporting so that we can know
the landscape in medicine. But 4.1% of sentinel events in healthcare are assault, rape and homicide
and the perpetrators almost never are reported let alone brought to justice. And
no one even is talking about it.
The police and
the state medical board
I was such a booster of the police until I began to learn how they respond to crime in medicine. Among other things, the police tell victims that there is no point in filing the charges because there won't be
any witnesses because healthcare personnel always stick together. Police are very familiar with how tightly groups of colleagues stick together. If the victim persists through all the deflections of the police, sometimes they refer the victim to a state medical
agency, although they don't know which one and don't know
how to find out which one. When the victim figures out which state agency to call, state medical boards
accept the complaints and run them through their normal channels and then dismiss them. If a patient is so dedicated and
resourceful that he/she gathers overwhelming evidence so that it cannot be dismissed
so easily, state boards can spend years
giving victims the runaround before finally telling them that state medical boards are not charged with enforcing the laws governing crimes. You'd think that the people answering the phones there would know that and inform the victim of that during the first phone call. You'd think the police also would know that and not refer the victim
there in the first place. Once having been informed of that, you'd think the police would stop doing that, and that the people answering the phones at a particular state medical board would know the answer to that question next time. Could the true goal of all of these people be to get the victim to go away quietly?
OSMB
Even when the issue is not criminal, the medical board that I studied
the most, the Ohio State Medical Board (OSMB), does not discipline people in medicine on the basis of complaints from patients no matter what. They discipline healthcare workers for failing to maintain continuing education requirements or for getting convicted of a felony in another state or for getting
too many DUIs, but not for the things patients complain about. They have no choice but to suspend or revoke someone's license when the person shoots someone in Las Vegas. But if the investigation is up to the OSMB, somehow there never is enough evidence. Their disciplinary actions are public information. You can go through them and see this for yourself.
The Ohio State Medical Board is one of the most well funded and best organized state medical boards in the country, but it is run by the same physicians who used that board to lobby their state government for liability limitations to protect themselves and other physicians from patients. These are people who don't think of the word "lawsuit" without also
thinking of the word "frivolous." Would we expect them to think of the
word "complaints" without also assuming the word "frivolous?" They say that their mission is to protect patients, but the odds of a patient's complaint resulting in justice or discipline currently is zero. In the year I analyzed, I could not find a single instance of a patient's complaint turning into discipline. There is no political will to go after criminals in medicine, just as there used to be no will to go after priest pedophiles. Initiatives to reduce unnecessary patient deaths can have no effect when blindness to the dangers in medicine
is so great as to ignore how many of those deaths are
murders and what needs to be done about that. You've heard of the initiatives to reduce the penalties for reporting in medicine. When they won't even report serial killers, can it really be just a matter of reducing the penalties?
How about reducing the penalties for the victims who report so that we can hear from them and their loved ones? Currently they get sued if they say anything and the miscreants who ruined their lives get rich
by suing them if they warn any other patients. People in healthcare are amazingly successful at transferring guilt and blame to their
victims. All of their colleagues routinely rally to label victims as cranks and to discredit
the victims and question the sanity of the victims. Can you think of any victims of miscreants in medicine who have not been so labeled?
It's rare.
But those are not the only reasons why we so rarely hear from the victims of crimes or errors or abuses in medicine, or from their loved ones. Another of the reasons is that it they cannot find anyone to tell.
Need the police? Dial 911. Phone repair? 611. Oh, you're roaming? 811. Oh, you're deaf? 711. Non-emergency? 311. Travel information? 511. Need to report that your hospital is violating laws governing your care? Sorry, there is no one to call about that.
Try it and see. Your hospital won't identify your caregivers? Try going to the
police or any other agency and see. What if you smell alcohol on your surgeon's breath? There should be a number well known enough to roll off the tongues of healthcare workers and patients. If you don't complain the next patient could get hurt. That's the chief purpose of complaints in medicine - to protect other patients. Since healthcare professionals almost never report problems or abuses,
it is especially important for patients to do it for each other. Almost never is not never. I do know of one instance of a healthcare worker reporting abuse. She reported it to the patient so the patient would understand
to escape. I was the patient. That's how I know about it. One angel did that for me.
But the provider who wanted to do an unnecessary procedure is still doing them.
And I cannot tell you who it is or how I know or I will get sued. Angel ReportingAbout ten years ago. I was in a dentist's chair. The dentist tapped a tooth and asked if it hurt. "No." He tapped harder. "No." He asked if it bothered me at night. "No." Sensitive to temperature? "No." Notice it when chewing? "No." Without my understanding it at the time, he had run down
the list of symptoms that would indicate that the tooth might be in trouble and all the answers were "No." He said it had fractures that concerned him and fed me information that eventually had me thinking I was lucky to have made it to where it could be fixed with a crown before it was too late. I asked if we were going to put a crown in
right now. He said that would have to be my
decision. All the information I had about it I got from him and the information
he gave me made it seem to be something that needed to be done immediately. So I
what I decided based on that information was to have him do it right then and
there. He turned away to prepare to put in
the crown. The dental hygienist leaned down and, being an angel, whispered in my ear, "Don't let him do it." It was a riveting moment. My caregiver was doing something wrong? It was unfathomable. I sat thinking about how to get out of this procedure without getting the dental hygienist in trouble.
After a pause I said that I suddenly remembered an appointment and we'd have to do this another time. I left and made an appointment with another dentist.
After the second dentist had finished examining me without finding anything needing attention, I asked if I had any need for a crown. He swung back toward me and said, "Is someone trying to sell you a crown?"
He was upset. He rechecked my teeth and wanted to know who was trying to sell me a crown. I told him, but he didn't seem to recognize the name and it doesn't appear that he reported it to anyone. I asked why a dentist would be trying to sell me something I didn't need. He smiled the way one smiles when a child innocently
has asked a question
that has an answer that reveals the darker realities of the adult world. He said
that crowns are very profitable for dentists. It was a scam.
Did I file a complaint? Did I step up to the plate to be an angel for the next patient? I didn't even stop going to that dentist. How could I be sure the next dentist wouldn't have some other gambit?
There is no information available on providers to enable patients to make such
choices intelligently. At least I was beginning to understand what to watch out for with this one. Better the devil you know than one you don't. Still, I knew I should complain, but would anyone believe me? What would I say? Who would I call? It was not the last time he tried to sell me something unnecessary during the next
ten years. In the last year, he made adjustments to my bite that were incorrect, although I didn't know that at the time. For months it was too painful to
chew anything harder than yogurt. His solution - crowns. I finally got a new dentist who, merely by filing, put everything back to normal. No new crowns. I should file a complaint, shouldn't I? He was trying to sell me crowns I didn't need again. It had been ten years and he was still selling people crowns they didn't need.
He still is doing that now. But I cannot tell you who he is or how I know
without causing problems for other people.
And this is the world in which it is thought that identifying
errors and adjusting systems will prevent the 195,00 unnecessary deaths each
year.
There are so many abuses in medicine. We need victims to report them, but did you ever try to figure out who to call and what to do once you've called them? Nearly everyone gives up. ObstaclesThe first time I was on the phone with my state government representative speaking about a patient safety issue, when he figured out what I was talking about, he went off on a rant, long and loud, about how
a certain hospital had murdered his uncle. I asked if he'd filed a complaint. "No."
Here I am, a person vocal enough and concerned enough to have created this website, and to have called my state government representative to persuade him of the need to attend to a patient safety issue. Here he is a politician who helps run the government that sanctions the agencies to which we are supposed to complain. And neither of us
complained. The way the process is set up that's what you can expect.Tomorrow if you were raped by your caregiver (it happens to both men and women), who would you call? Where would you start? If you start with the police, I've already told you what they will do. If you figure out to call the state medical board, they
will mail forms to you, tell you to collect documents, tell you to find the witnesses and get diagnosed and become your own investigator and counselor. And if all of that hasn't discouraged you enough, then they send you their conclusions. It appears that their conclusion will be that there isn't enough
evidence (I have not been able to get them to provide numbers that would help to determine if there are other excuses in some cases).
When there is enough evidence, they have been known to conclude that the healthcare worker being complained about has not "violated any provisions of law that this agency is charged with enforcing." It can take years for them to figure out that they are not charged with enforcing the laws violated. You know what provision of law they are charged with at
that point? The law that requires them to pass their investigation on to the agency that is charged with enforcing that, which is the police. Which very well might be where you started. But do you think they do that? Do you think they can be penalized for not doing that? Do you think there is anything you can do about it?
We don't have a complaint process. We have a process that stymies patients and shuffles them around until they give up. Complaints filed by patients do not result in discipline.Most errors and crimes go unreported and uncounted. No one learns from them. Nothing improves. How many lives could be saved,
how many abuses prevented, if we knew about them. Who do you call if the problem is with a pharmacist? Or a nurse? Or an anesthesiologist? Or a dentist? And how likely are you to persist in trying to figure it out while you are bleeding and in pain and the number you call is answered by a machine with a long phone matrix at the end of
which you can leave a message if you want them to call back? And then a day later when someone finally
returns your call, they
are of no help. When you smell alcohol on your surgeon's breath, or when you've just had your life ruined by a lecher with a medical degree, currently there is no number to call that is of any help. This leaves patients with no recourse other than to call
a lawyer. Did you ever try to call a lawyer when you were the victim of a crime. Lawyers don't indict criminals. They defend them. To pursue a criminal you have to call the police. And the police are useless for investigating crimes in medicine. Victims cannot even get them to allow them to file charges. So victims end up
reducing the charge to something not criminal in order to get a lawyer. But unless you have a big-money, easy-win case, you are not going to get a lawyer. Only
3% of legitimate grievances get a lawyer. That's LEGITIMATE, not frivolous, grievances. The vast majority give up without even trying to get a lawyer. They want help, not a court battle. So we never hear from them. We need to hear from them.
There needs to be a phone number, one phone number for all complaints about healthcare. One single phone number answered by someone who can explain which agency, which department, which person, and whatever else you need to know to respond to what has been done to you, or who can at least tell you when there is no
appropriate number to call.
After that there needs to be oversight of the agencies with which the complaints are filed. Not the vested-interest boards of MDs we have now. Putting some injured patients in positions of authority would be a good start. It is not going to change anything if all we do is get information, in the form of complaints, to agencies who will not share it with anyone and who have a history of
not acting on the information. The general public must have access to information in order for the public to be able to understand how to run its healthcare. But for now, at least getting a number to call would be a start. The information contained in complaints needs to be collected. No one else is reporting it.
Doctors and nurses do not report it. There is no other source for the information. And without it we cannot manage our healthcare
intelligently.
Information Fortress Without Signs
In an old Kurosawa movie a Samurai at a fork in the road has inadequate information about which way to go. I think there isn't even a road sign, so he tosses his sword in the air. When it lands, the direction it points is the direction he goes.
As he walks, a dog coming the other way carries in its mouth a human hand. That’s as good as a road sign. If a person were coming the other way complaining about what happened to him back down that road that would be a sign too. The Autoclub did a survey once that found that the biggest complaint drivers had was poorly marked roads, signs that either were bad or nonexistent. Information is crucial to our well being. Without it how do we know which way to go?
And what do we do when someone doesn’t want us to know?
I was reading a package of cheese and crackers. A few decades ago there were no ingredients listed. It was believed that food manufacturers had no desire to harm customers so customers didn’t need to know. They fought to keep us from knowing. Laws had to be passed. On this package of cheese and crackers it says,
“Made on equipment that also processes peanuts.” That’s life and death information for someone. Ingredients are a sign that helps us know which way to go. What signs does the
healthcare industry let us see when we’re trying to make informed choices about our
healthcare? If we do find something out, can we tell the people coming the other way along the road?
If a restaurant gives you food poisoning you can tell people. Gossip, the banter of the bazaar, people looking out for other people, is fundamental to living safely and intelligently. It is just not smart blindly to trust an entire industry no matter what their motivations are thought to be.
If you are buying a weed whacker, look in consumer reports. They have engineering specs, the results of tests, and they have surveys of previous purchasers of the product. What do they know about hospitals and surgeons? Restaurants you can find out about. The health department tells the roach counts of kitchens. Some suburban newspapers publish that. You can telephone the health department to ask the roach-count of the lunchroom at the school your child attends. You can learn the ingredients of the food your child eats at that school. You can learn its
nutritional breakdown.
What if your child needs an operation? What can you learn about the surgeon who is going to cut your child open, or the hospital where that will be done? Can you learn the infection rate? There are agencies that track that. Can you call them to find out what it is? No. They are not allowed
to tell you. You are not allowed to know it.
How do we pick surgeons and hospitals without that kind of information? A physician makes a recommendation. But what information is available to that physician? Not the infection rate. Not the misdiagnosis rate. Not the success rate. Not the results of autopsies either.In a study of autopsies in one hospital about a third of the patients
who had died had been misdiagnosed. Comparing rates of misdiagnosis would be extremely valuable when comparing hospitals or surgeons. It also could help a hospital or surgeon clean up its act. But records like that can create
liabilities and they cost money so they don’t do autopsies much anymore.
Autopsies might be the single greatest learning tool medicine ever has had. So much can be learned from them to protect patients, but they don’t do them much anymore. No one knows the rate of misdiagnosis for the surgeon or the hospital to which you are being sent. They are not learning from mistakes because they don't know when they
make mistakes.
How do they know
whether they are going to work to do a bad job?There isn’t reliable information on the success rate either. The success rate might be the most important thing you’d want to know. What percentage of people have had their lives improved by this operation, and what percentage would have been better off if they hadn’t had it done?
My dad got a back operation. He had a herniated disk. After the operation he’d lost at least half of the use of his right arm. The surgeon said that he sees that all the time and it is because of the injury not the operation. My dad had had that back problem for several years without it effecting his arm. On the way into the operation
room he could sign his name on the forms. On the way out he could not. Where is this recorded? The surgeon creates the record of the operation and he says it was successful with no complications. And he sees this all the time (and, being a normal patient, my father never thought to complain, let alone sue, and didn't.)
The government has attempted to address the issue of success rates before. One time they went after the mammography industry. Studies in North Carolina and New Hampshire found that some clinics miss 40% of tumors. In New York a radiologist in the Bronx was found to have missed 25 tumors while finding only 7 in two years. No one knows how
the rest of the clinics in America are doing. No one keeps track.
The federal government was alarmed by these studies and wanted to weed out doctors whose track records at discovering cancer were worse than bad luck. Doctors and their allies derailed it. Even the doctors who analyze the mammograms have no idea what their
own success rate is. Your family doctor does not know
which of them to send you to when they themselves
do not know
how they are doing.There is so much record keeping in medicine. It creates the appearance of there being enough accurate and detailed information to protect patients. Speak to anyone in medicine about the inadequacy of reporting and the inadequacy of information available about problems in medicine and they will balk and recite the volumes of data
kept on each and every patient. But if the surgeon is drunk while operating, where is that recorded? What if you yourself discover that the surgeon was drunk while operating on your child? Can you add that to the banter of the bazaar? When they commit crimes against us they are protected by liability limitations in
many states (the letter of the law says they are not but, as I mentioned above, it is almost impossible to file a suit alleging a crime, so charges are reduced to get a lawyer and then liability limitations apply).
So the right of patients to sue them is limited, but their right to sue patients
is not. There is no limit on the amount they can get by suing patients merely
for speaking. Assault, rape and homicide occur in medicine everyday and we never are allowed to hear from the victims. We never are allowed to learn how these things happen
and why the perpetrators are not stopped from doing it again. By whatever mechanism possible, patients need to gain the freedom to speak. The next time a bill is passed limiting the liabilities of healthcare workers, it also should limit the liabilities of patients. It should reduce the liabilities of patients to one
dollar. Even then, risk management departments will be able to bankrupt patients just through the costs of defending suits over a dollar. When patients end up signing settlement agreements those contain gag orders anyway. But at least a few will pay the cost and speak. The need to hear from the victims of negligence and abuse in medicine is so important to the safety of the community, that healthcare workers are going to have to develop thicker skins and live with the fact that patients are going to talk about them.
It is necessary for patient safety. At present healthcare workers have all the knowledge and all the power and are amazingly successful at transferring guilt and blame to their victims.
In the face of the tens of thousands of unnecessary deaths occurring in medicine each year, it is not acceptable to keep secret the reasons for that and the accounts of that as told by the victims and the families of the victims. There is no other source for that information. Currently, we are not allowed to discuss things like the inappropriate behavior of surgeons or nurses. If we do
discuss it, their risk management departments descend with restraining orders and lawsuits. It’s as though you learned there were peanuts in a food product but would be sued if you told anyone.
Healthcare is one of the most powerful lobbies in Washington. We spend 15 percent of our gross domestic product on healthcare. Healthcare expenditures are a third of the budget in some states. Healthcare has so much control and influence over us,
it is too powerful and too important for it to be reasonable for it to continue to
let it hide behind closed doors preventing us from discussing our experiences with it. Since we are not allowed the means to overcome our own ignorance, when choosing a surgeon we are forced to have faith in the recommendations of family doctors who also don’t know the infection rate, the misdiagnosis rate, the success rate, the sobriety rate, or even the crime rate
of the providers being recommended. Or even the litigation rate. How often does
a specific hospital sue patients to shut them up so that you don’t find out what happened there?
Usually all they have to do is rattle sabers at patients and that is enough to silence them without actually filing the suits, so it would be hard to count.
Things need to be arranged so that you can tell people if the surgeon is drunk. Do you want to be operated on by people who are afraid of having anyone find out how they are doing, or even what they are doing?
Fixing this is going to take legislation.Getting the legislation will require an electorate refusing any longer to put up with being denied information. At important moments
healthcare can be the most dangerous and devastating force you ever will experience. Who you allow to cut you open and reach inside of you can change your life
forever. Yet the way things are now you can get more relevant information about a hot dog vending cart in a park than you can about the hospital where you will be operated on. You can get more relevant information about a hair dryer you might buy than about the surgeon who is going to cut you open.
The Department of Health and Human Services in the USA
finally is establishing as site that compares hospitals, but they can compare
only information that is reported. And they don't tell the kinds of stories that
enable people to think.
Societies need stories about their past
in order to organize the presentThe reputations and feelings
of providers are not more important than our lives. Laws have to be changed or created to allow patients to speak
and tell their stories without the fear of lawsuits.
Even with that, they won't be releasing, or even collecting,
some of the information the commonwealth needs to discuss to understand its healthcare. But at least
patients who experience something will be able to communicate it to the rest of us.
Liability Limitations
It probably is illegal for state legislatures to separate out a certain group for special privileges by putting limits on the amount of damages for which they can be liable. At the time of this writing, the State Supreme Court of Wisconsin has declared their state's cap on medical malpractice awards for non-economic damages
to be unconstitutional. But the web site of the White House calls for liability limitations for doctors. This in spite of all of the work that has been done to point out that malpractice suits contribute only about one half of one percent to the cost of healthcare. We don't tend to understand doctors as people harboring self-serving
self-deceptions at our expense, but all of their hollering about medical malpractice suits being such an overwhelming problem is one example of that. Our rights are abridged in response to their paranoia. I bring it up here because it is another way in which patients are being silenced.
Another way healthcare manages to silence its victims is through settlements, both pre and post-trial. Silence is worth a lot to them. It drives up the cost of resolving disputes and, when they purchase the silence, prevents the community from getting information crucial to its ability to understand and govern its healthcare.
The silence also removes a strong inhibition against acting out on the part of healthcare workers. If they had to worry that their victims might speak, it could reduce the rate at which healthcare workers abuse patients. To address these issues, why not pass a law that says that access to information about healthcare is so crucial to the public’s wellbeing that a patient’s right to speak about it cannot be abridged by signing documents requiring silence. The law should make it illegal to ask anyone
in healthcare, workers or patients, to remain silent about anything
concerning healthcare, especially who did what and when. Any suit brought against a person, especially a patient, for revealing information should be considered harassment. It should be illegal to include silencing clauses in contracts and settlement agreements.
Instead of legislating a limit on liability claims,
might we not be better off prohibiting gag orders? If there is going to be legislation limiting liabilities, what do the patients get in exchange for losing the right to sue? Since that is what liability limits mean for many patients, why not add on provisions that create sunshine and communication? Why not redefine medicine as being public, so that we can
speak about it without being sued for defamation? We won't sue them if they won't sue us. Injured patients everywhere are warned not to speak. Defamation suits are just another gag order. We need to eliminate both gag orders and defamation suits. If we had those two provisions, then the next time a patient became a victim of assault, rape and/or homicide in medicine, we might hear about it. We might even begin to hear about problems that are not crimes.
And then if there were a phone number that patients and healthcare workers knew was the number to call, and knew that they should call it . . . And then if there were anyone in charge who actually was interested in enforcing criminal law in medicine, we might have reached square one in patient safety. Then we might make
some progress on the 195,000 unnecessary deaths and the many times more unnecessarily
injured, too often intentionally, that result every year because of current conditions in healthcare. RetroactiveThe bills need to be retroactive, otherwise we will
have to wait for thousands of new crimes to be committed against patients so that those new crimes can inform us. We should be able to learn from the crimes already committed so that we can prevent future crimes. Also, having the bill be retroactive will help signal that this is so important it always should have been
this way. There is going to be so much pressure for the courts and legislatures to water this down and undermine this, and so much reluctance on the part of the entire system to accept this change. Suits will be brought to attempt to establish precedents to undermine it. The effort is going to be tied up for years by suits brought by medical
interests.
Patient's cannot afford to defend them. We will hear nothing from patients for many years. However, if this bill were retroactive, we could start mining information that already exists. Currently, career predators in medicine not only get away with lives of crime, but too often get rich by suing their victims for complaining about it.
And the only thing we hear about are the poor doctors beleaguered with "frivolous" suits. Affront
How can patient safety improve when suggesting, to someone in medicine, that there are members of the profession who are bad is received as a cop would receive it if someone were aiming a gun at another cop? How can we reduce the rates of homicide and rape where no one will believe or report it and even receive
the accusation as an affront? The first and most important thing to do is to reduce crime in medicine. When systems are erected that finally improve that, then we have made the first step necessary to begin addressing all of the other safety problems in medicine. For all the areas in which medicine must be allowed to govern itself,
criminal law is not one of them. It is not for nothing that medicine has been called the profession that supports crime. There are doctors and nurses who will intentionally ruin or end the life of a healthy patient. Some people go to work to do a bad job. Instead of sloughing it off as being too rare to acknowledge,
it needs to be recognized as the bellwether for all of patient safety, and the measures necessary to discover and respond to it need to be recognized as the fundamental measures necessary for improving safety as a whole. Medical personnel may never have the humility to admit to the existence of crime in medicine in the first place, let
alone to accept the possibility that known colleagues could be guilty. Historically they have responded to the suggestion defensively and protected their colleagues. They are unscrupulous and/or unintentionally biased investigators. It cannot be left in their hands. This isn't figuring out what is wrong with
patients. This is figuring out what is wrong with doctors and nurses, what is wrong with their belief systems, with the culture in which they operate, with the way they always have done things. This is not something they are going to address gladly. Numerous studies over the last decade show that when people have
only one source for their information, no matter how unfounded or prejudiced it is, they tend to regard it as the truth. Currently we hear only the spin and the delusions of the providers. We need to hear from their victims. The issues (which
someday may be
linked to explanations):
1) Data sources are muzzled.
2)
Exterior enforcement systems lack will and requisite knowledge and
experience.
3)
Interior enforcement systems are inclined to protect rather than manage.
"It is difficult to get a man to understand something
when his salary depends upon his not understanding it."
-Upton Sinclair, novelist and reformer (1878-1968)
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