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and making it briefer makes it sound harsher.
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Dr. Marty Makary says that medicine is full of good people, but that health care professionals absorb unwritten rules when they enter the profession. One of those rules is to overlook the mistakes of colleagues.
Already the list of problems with his thinking is getting too long to address in a short article. He himself doesn’t recognize the self interested myths he believes as a result of working in medicine.
His heart really is in the right place. But his perspective is not. He does tell us the story of how he first learned what a Hodad is. Hodad stands for “Hands of Death and Destruction.” It is a nickname sometimes given to the doctors who are recognized as being major sources of patient harm. He also makes us privy to the standard rationalizations employed in medicine, and by him, to avoid the personal consequences that would come from reporting a Hodad.
But he says that the solution is more transparency in medicine. That he imagines that such a heaven on earth could be created shows how he himself doesn’t recognize as myths much of what he believes as a result of being in medicine.
Outside of medicine, when laws are passed to protect citizens, are the laws and the enforcement mechanisms based on the idea that the community is full of good people who have only the best intentions? Or are they based on the fact that no matter where you go you will find people who cannot be trusted and so mechanisms are needed to protect us when they do things that are bad?
Any patient safety initiative that starts with the idea that medicine is full of good people starts with a faulty premise.
One of the facts to which thinking in medicine manages to remain immune is the fact of how little honest reporting there is in medicine when things go wrong. I’ve written about it enough elsewhere on this site. If you’ve not read those pages, glance at Medical Reporting.
93% of the time no record is made when bad things happen in medicine, and most of the other 7% of the time the record is inaccurate. Medicine is full of people who are bad when something causes them to worry about their careers, or the careers of their colleagues, or the reputations of their institutions. All of those good people in medicine have moments when they worry more about their careers (“being there for the next patient”) than about the current patient, or integrity, or obeying laws, or, in fact, being a good person. In those moments health care professionals behave like sociopaths. Mechanisms that address that are the foundation for making patients safe.
Where is transparency going to come from in a world of people who behave like criminals covering their tracks at the exact moments that are the most important ones to report if the goal is to keep patients safe?
If you were trying to bring transparency to the financial sector and said that we just need for bank robbers and embezzlers and such people to start creating honest records of what they do, you would be making as much sense as you are making when you ask the care giving community to be more transparent.
The fundamental problem for patient safety must be viewed as crimes committed against patients, not just because there is a crime rate in medicine. Patients do get groped and raped and murdered and operated on unnecessarily to make money and a long list of similarly unfriendly things. But also because even when the harm that was caused to a patient was well-meaning and accidental, the cover up that follows is not. And there always is a cover up. The cover up is a willful act of malice that is illegal and further damaging to the patient and the patient community. It happens nearly every time that something harms, or could have harmed, a patient. That is a lot of behaving badly.
The mechanisms necessary to address that are the fundamental ones necessary to address all other safety issues. In the moment when something has gone wrong and the loyal teams of the good people in medicine view the world through their self-serving lenses, they believe they are doing the best thing for the patient community when they behave like criminals covering their tracks.
Until mechanisms are erected to address that there will be no mechanisms that can make more than a superficial difference to safety in general, as the last couple of decades have proved.
What is the least a patient should be protected from in medicine? If it isn’t crime then we are not thinking about keeping patients safe. We are thinking about keeping health care professionals comfortable.
Currently there are no mechanisms in medicine to address crimes committed by caregivers against patients. The average caregiver’s response to that is “call the police,” which shows how out of touch they are with the world they create for patients. What are the police to do when faced with a community of caregivers who have created records that say no crime was committed and who themselves will not testify to the truth?
Ask a few patients who have been victims, and read other pages on this site (there are more than a few), if you don’t understand that there are no mechanisms in medicine to protect patients from crime.
If anyone in medicine really were concerned more about making patients safe than about making nice with the rest of the care giving community, the first people they would want to have be part of any patient safety discussion are patients who have been victimized by crimes committed by caregivers.
Instead, patient representatives are screened to make sure they are on the same page as health care professionals. It is not difficult to find patients who are. Most patients get most of their information about medicine from people in medicine and so believe in the same set of myths health care professionals believe.
Health care professionals say that when they get sick they are patients too so they understand, but a doctor is a patient like a member of the Royal Family in England is a citizen.
What doctor or nurse is going to grope or slap or rape another doctor or nurse? Other health care professionals could get someone to listen to their complaint. So it’s not going to happen. Health care professionals do not have to worry about the worst problems that patients have to worry about. They will be inclined to protect the groper or rapist (try saying that in a group of caregivers and witness the scoffing).
Dr. Robert J. Weil, a neurosurgeon at the Cleveland Clinic, said that although it might seem a good idea to inform patients of differences in outcomes among hospitals, there would be “a variety of hurdles.” And David I. Shalowitz, a bioethicist, said that expecting surgeons and hospitals to disclose information about other doctors and medical centers would create an untenable conflict of interest for them and should be avoided.
That shows that there is at least some recognition in the medical community of the fact that care givers are the wrong people to expect to make the problems in medicine transparent to patients. I just wish they would start standing up and saying that when the rest of the care giving community claims to be able to make patients safe because they understand and care. They never will understand. And when it counts, they don’t care. They define their victims as cranks with frivolous grievances and manipulate them out of even being able to get treatment for their injuries and don’t know that they do (see blacklisting).
Health care professionals always will be an elite who cannot share the interests of patients. They are not saints. We need to recognize that and start building safety initiatives based on the real world and not the myths that it makes medicine comfortable to believe.
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