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Notes Page 16

Healthcare VS Health Care
Some say that the single word refers to actions and the double word refers to systems. Let us please not burden our ourselves with having to think carefully about the distinction for two different usages within the same paragraph. There is almost no one arguing for us to.

Federal dollars favor two words in all things, like "Agency for Health Care Policy and Research" and the "Committee on the Quality of Health Care in America," and the "Health Care Reform Commission."

Linguists and grammarists say that adjectives are supposed to be separated from the nouns they modify, as in the words medical care, nursing home, and emergency room.

The style guides of most news organizations specify using two words just as they did for air plane, baby sitting, back bone, cell phone, child care, cross walk, earth quake, fire works, foot ball, life time, play thing, scape goat, voice mail and web site until they had to give in to how the rest of the world used those words.

Which is what is happening now. The private sector uses the single word. That is just people doing what works for them rather than what rules dictate. I predict a one word future.

However, the spell check in the program in which I am writing this changes the one word into two. And I don't want picky people to discredit me for not following a rule of grammar. So I am using two words until more programs and people feel that that going with the flow is going with one word.

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There was a time around the tenth century in Western culture when the link between culture and schools loosened. This freed thought and many existing literary genres took on new, clearly defined, individualities. Other new genres were introduced. Texts not originally included in the canan of the liturgy began to appear. The first verse masterpieces of medieval Latin literature appeared. There was an oupouring of significant prose. (The New Cambridge Medieval History: Volume 3, C.900-c.1024, Chapter 7)
Today medicine and patient safety need to have the thinking about them loosened from what is taught in schools so that better genres of thought may develop and spread. For instance, caregivers are not objective and when it counts put their own well-being ahead of their patients. Begin there and rethink what we are doing.


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Footnote for bullying_and_mobbing.htm
The information comes from Hutchinson, M., et al. (2010). Integrating individual, work group and organizational factors; testing a multidimensional model of bullying in the nursing workplace. Journal of Nursing Management, 18, 173-181

See also:
Lewis, M.A. (2006). Nurse bullying: organizational considerations in the maintenance and perpetration of health care bullying cultures. Journal of Nursing Management, 14, 52-58

Bartholomew, K. (2006). Ending nurse-to nurse Hostility: Why nurses eat their young and each other. Marblehead, MA 01945: HCPRO, Inc.
Available on Amazon.com at this link.

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Nancy Leveson, PhD - Safety (sunnyday.mit.edu)
Phone: (617) 258-0505
Office: 33-334
Email: leveson "at" mit.edu
The System Safety Research Lab is creating new approaches to system safety that handle increased levels of complexity and new technology. Our techniques are based on a new system-theoretic model of accidents (STAMP) that replaces the traditional chain-of-events model underlying most current accident investigation, prevention, and assessment procedures. The model includes software, organizations, management, human decision-making, and migration of systems over time to states of heightened risk. Several theses and dissertations as well as my new book that appeared in January 2012 demonstrate the application of the new tools to a variety of engineered systems. Looking for new worlds to conquer, we have been experimenting with the use of STAMP in non-engineering applications such as hospital safety, pharmaceutical safety, food safety, and financial.


STAMP Safety Pyramid
STAMP stands for "Systems-Theoretic Accident Modeling and Processes"


Systems can migrate over time into states in which those systems never should be. We should be thinking not just about hazards, but about how to avoid drifting into hazardous regions. To think about that there must be objective information about outcomes. In some fields there is almost none of that.


Viewing systems as interacting loops of control

STAMP Safety Pyramid

It says that "Operators continually test their models against reality." It also should say that they also test them for how they serve self interests. There needs to be appreciation for the extent to which operators adjust models to serve self interest. It tends to be assumed that operators define safety in ways similar to designers when, in fact, their goals, and their definitions, might be antithetical. It can be the case that all of the information about outcomes is recorded, or not recorded, by operators who have interests and definitions antithetical to those of the designers.

The operators who should record information about outcomes instead record end-action information in its place and pronounce everything safe and successful regardless of the actual outcome. The interests of the operators are best served by protecting themselves and the system that rewards them, not, say, the patients. To protect a self serving status quo there may be little honest honest reporting of safety problems. Systems appear to be safe even when they are not as operators adjust practices to suit themselves (see Cullen and Majors for instance).


In some systems keeping the system itself safe, since it rewards the operators, becomes what is habitually protected even at the expense of, say, the safety of the patients of those operators .


To measure how well a system works

they identify control actions that potentially are inadequate to maintain the safety of the system.


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Clinical trials skewed to meet goals of drug makers rather than heal patients?

This is the link to the article in Nature that found that results of landmark studies in cancer research got results that no one else could reproduce 88% of the time. It appears that to keep sources of funding open, researchers fudge results:





is the code number that says that the patient is feigning symptoms or disabilities.

Shouldn't there be a misdiagnosis code? Some say that misdagnosis is the most common problem harming patients. Shouldn't there be a way to make clear that a misdiagnosis was the problem when it is discovered that what was in the record prior to this point was only that? Especially when the cost is somethin glike F68.1?

And shouldn't there be a code for unfriendly practices? Unfriendly practices probably really are the most common harm caused to patients, unless you think that refusing treatment and creating false records isn't harmful and isn't unfriendly. The creation of false records is what happens nearly every time a patient is harmed so it happens quite frequently.

The refusal to treat iatrogenic injuries follows much, if not most, harm too. Shouldn't there be a code for that when it is discovered?

And shouldn't there be a code for blacklisting so that some health care professional who catches on and decides to do the right thing can bring an end to the conspiracy with a code that explains to others what the previous codes were about and try to get the medical community to help the injured patient?

A study done in a hospital some years ago discovered that fully a third of the deceased patients had been misdiagnosed. They had not been treated for the problems that killed them. Shouldn't there be a code for specific kinds of misdiagnoses so that awareness can grow about how many patients die as a result of specific misdiagnoses that repeatedly are being made?

Community Patient Agencies and State Patients Boards would need such codes for there to be a way to spread the word about dangerous practices.

If there's no code for it, it is very unlikely to be recorded in a way that would allow tabulation and an understanding of the extent of its presence in medicine. Maybe you can find an already existing code at this link that could telegraph something about any of the above, like they have found codes to spead the word about a patient who is a pain in the neck. For instance, what would be the code for "no one will treat these injuries because they are iatrogenic?" If you figure something out, Email me.














Doctors use a language that makes their knowledge seem to be beyond what mere mortals can understand, and it is Latin.


The name given to a problem limits what is thought about it.

The word "error" is neither general enough to refer to the range of issues harming patients unnecessarily nor narrow enough to enable identifying specific problems to address. It is a word that defeats identifying underlying problems and conceiving of solutions to them.

Awareness of the problems and discussion of the problems is shackled to a label that is laden with preconceptions that defeat thinking about solutions relevant to the problems. The Institute of Medicine, part of the National Academy of Sciences, has called the problems "the nation's epidemic." It is a disease that medicine itself has, but that is discussed as though the problem is only the occassional, accidental well-meaning slip-up.



From "Doctors Killed George Washington"

According to Catholic teaching, Saint Apollonia is the patron saint of dentists. Her claim to the job come because an angry mob yanked out her teeth one by one in 249 C.E when she refused to renounce Christianity.

Saint Harvey is the patron saint of optometrists, a little strange since he was blind from birth and was never credited with any eye-related miracles.

Pick your disease and the Catholic Church has a patron saint for it. Here are some: Saint Acacius (headaches), Saint Cathal (hernias), Saint Giles (lameness, insanity, sterility, and epilepsy), Saint Drogo ("gravel in the urine"), Saint George (syphilis), Saint Catherine of Alexandria (diseased tongues), Saint Lucy (eye diseases, dysentery, and "hemorrhages in general"), Saint Hilary of Poitiers ("backward children"), Saint Servatus ("leg diseases"), and Saint Benedict (fever, inflammation, kidney disease, and "temptations of the devil").




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Floyd E. Bloom, M.D. (President of the American Association for the Advancement of Science and chief of the neuropharmacology laboratory at the National Institute of Mental Health) has said that he would like healthcare to be regarded as something like a public utility.

The idea that at least certain aspects of healthcare should be public arises in various contexts, but it does keep arising. One way in which it needs to be public is simply in what we are allowed to know and to say about it.



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Physician-owned distributorships, or PODs, have proliferated. For instance, surgeons who dictate to their hospitals which devices to buy can become owners of distributorships for medical-device makers. This means that they not only earn a profit on every device sold, but they also tell the hospital which devices to buy. This elminates competitive cost-benefit analyses from being made. Instead of the least expensive device with the highest quality, patients get the device that puts the most money in the pocket of the surgeon, which easily can be the most expensive one without being better, or possibly being worse, than less expensive ones that are available.

Can a patient do a search and learn this about a specific surgeon? When there is someone on the side of patients discovering that kind of information and making it available to them, patients will be safer.

Hit your back button to return to where you were.


















Recent research shows that people often make mistakes because they are not considered part of the system. Is it possible to be considered part of the system when you never can be considered to be at fault for its failure?

STAMP (Systems Theoretic Accident Model and Process) is a model developed Nancy Leveson, Ph.D. in her book:
Engineering a Safer World (MIT Press, January 2012);
by MIT Professor Nancy Leveson




AMA's Specialty Society Relative Value Scale Update Committee
Three times a year the AMA summons the Specialty Society Relative Value Scale Update Committee (or RUC, pronounced “ruck”).  It’s job is to decide what Medicare should pay them and their colleagues for the medical procedures they perform. 

That's price-fixing. In any other industry it would be illegal—grounds for a federal investigation into antitrust abuse, at the least.

But this is health care where “price-fixing” not only is legal, it is sanctioned by the U.S. government.

Behind closed doors they divvy up one fifth of the nation's GDP and create the perverse financial incentives that dictate how our care givers behave. The committee is dominated by specialists, in whose self-interest it is to set reimbursement rates for specialty procedures higher than for general services. As a result there are “a hundred ways to bill for removing varicose veins, and only one way to bill for an intermediate office visit,” said one former RUC member. So, for instance, radiologists make twice what primary care physicians do in a year.

The Affordable Care Act doesn't address it because touching it would have created too strong of a backlash. It might have prevented getting the Act passed into legislation. However, fixing it is essential to fixing health care.


No one cares about AMA. They care about the RUC. By controlling the RUC, it controls much of the source code that our health care system uses to operate. Every single one of those roughly 9,000 medical services and procedures has its own five-digit code, known as current procedural terminology (CPT), and the AMA owns them all. Anyone—physicians, labs, hospitals, etc,—who wants to bill Medicare, Medicaid, or a private insurance company has to purchase either AMA books and products, or products from other software companies that pay AMA royalties and licensing fees to use the CPT codes.

Every time a new procedure comes along, a special committee at the AMA called the CPT Editorial Panel decides whether or not it needs to create a new CPT code for it. 

Nnumerous studies have found that the best-quality and lowest-cost health care in America can be found in systems where doctors are on salary and paid for keeping their patients well, not according to a fee-for-service system. Even with RUC still operating, this can be established by doctors who want to work that way, if only there is a way for patients to compare them and find safe, effective and affordable care, like with Community Patient Agencies to guide them.


See an article about it in the Washington Monthly, or read about it in Wikipedia.




750,000 physicians in USA according to The Federation of State Medical Boards. And only 1,905 of them lost their licenses in 2011, less than 1/2 of 1 percent.












Malum in se (the act is wrong in itself; it is inherently wrong and evil)