Friday, February 13, 2009

Please suggest an answer

In the last sentence of the post below, I posed a question. Probably, readers thought it was a rhetorical one and therefore did not submit answers.

But please treat it as a real one on which I am soliciting comments, OK?

Here it is, with the preceding sentence:

"We are causing people to die who should not die. What would we call that if we saw it happening in other sectors of society?"

Sorry, but I think it is important to draw out this point. Think about companies in the following industries and fields -- automobile manufacturing, airlines, restaurants, pharmaceuticals, food processing, architecture, public transit, building construction. Please give your answer below and tell us why the same term should not be applied to hospitals.

40 comments:

Jason Yip said...

It would be called negligence (potentially criminal) if people generally agree that something could have been done to prevent the deaths and it's reasonable to expect the company to know about it.

Carol Romashko said...

Sadly, I think this would be manslaughter - no malice aforethough, not wilful, though worst cases may be careless and reckless. Back to the old analogy: "if 1 jumbo jet fell out of the air every day, don't you think someone would do something about it?"

Thank you for your honest post!

DZA said...

Have you never seen FIGHT CLUB? Tyler Durden's alter ego is a "Product Recall Specialist". It is his explicit job to do simple calculus on the economics of product safety versus predictably fatal defective industrial products. (in this case, autos). So I would call it an epiphenomenon of industrialized society, whereby perfect is the enemy of good enough. Anything less than acknowledgment of this modern day state strikes me as Pollyannish.

/first rule of hospital safety is you do not talk about hospitals being the most complex and dangerous human environments ever devised.

//running a modern med-surg unit makes NASA's job look like a cake walk...whatever that is.

the man from Utz said...

I guess that you are looking for Jason Yip's answer, perhaps the stronger "Murder!"

Paul, I speak as a patient who is likely to face admittance, and has a very feeble immune system. This is a terrifying subject to me personally, and I admire and am grateful for your insistence on it. Personally I go to some lengths to avoid being admitted for exactly this reason- though I must emphasize that I have never had a problem at Beth Israel. This by way of honoring the importance of the question.

Why the lack of response? I think that partly it is rooted in two complexities around the question. The first is that the other industries you cite just don't excite the vehemence in most people that they should. The second may be that the gap between good intentions failed on the one hand, and bad intentions perpetrated on the other may be too large for well meaning people jump.

It is very perplexing to sort out individual responsibility from corporate conventions, and the actions of one corporation from the environment that allows others to present the dangers as something the individual enters into by choice.

If that is the case then perhaps we can establish that being admitted to Hospital is not a matter of consumer choice and therefor the responsibility of the institution is greater.

Obviously you and your hospital understand this, and while I don't always have the choice of when, I do have the choice of where I may be admitted. For me that choice is very clear, the BI, and only the BI.

I gain great comfort from your persistence on this subject.

jgnat said...

I remember the reaction in a local engineering firm when a bridge collapsed in Quebec. Even though it wasn't their bridge, there was immediate professional wounding. Someone's calculations failed. Perhaps they were relying on those same faulty calculations in their own designs. Immediately they sought out the cause.

It would be a failure to dismiss the failure on the construction or materials. Professionalism demanded answers, to track down the source of the failure, no matter how obscure.

zfraile said...

It would be called the normal course of business. I have no doubt that 5 minutes on Google News would give me at least one current news story highlighting such an incident for every one of the industries you mention.

The only difference is the for-profit industries noted are more likely to have better legal and financial resources along with less of an assumed social conscience than a hospital.

To be more blunt, as CEO, you should really be more concerned about addressing these issues from a cost-savings or revenue enhancing perspective. That said, I applaud your determination to succeed on your own terms.

Keith said...

You have to accept the premise that hospitals are actually "causing" people to die and perhaps beyond that, doing so willfully. Do you believe that BI was actually -causing- people to die before you began posting your infection rates, willfully or not? And do you expect hospitals to just say 'hey, my ICU causes people to die'?
I agree wholeheartedly, and I hope that the other area hospitals do as well, that every ICU can be more vigilant still, continually interrogate SOP's to reduce infections as your institution has done, and to approach and achieve a zero infection goal.
But to accomplish this, is it necessary to post one's numbers? And is it easier to do so after the institution has seen success with a program such as BI has?
It is important for someone to put this information out there to establish that the problem is real and can be fixed, and you are to be applauded for being the one to do so, but I don't see how everyone else posting their numbers helps them in any way and certainly not from a business perspective.

AnnB said...

As the mother of an immuno suppressed post transplant 5 year old, I have the same reaction as the man from Utz. I have some experience with central lines as we maintained a CVC line virtually without incident for almost 4 years. Unlike the other industries you mention, engagement with a hospital is predicated on the chance that the client, service interaction may result in death. We do not assume this when we buy a sandwich or hop on a bus. Perhaps this may explain our complacency.

Paul Levy said...

"Do you believe that BI was actually -causing- people to die before you began posting your infection rates" Yes.

"But to accomplish this, is it necessary to post one's numbers?" Yes, unless all parties involved in delivering care are aware of where you are relative to your goal, you do not get process improvement. That is a fundamental rule of process improvement.

Does it have to be posted for the world to see? Well, truthfully, once it post it broadly enough internally, it will be made public to the world anyway.

But, beyond that, the fact that everyone inside knows that any outside can see the data gives an extra impetus to succeed.

And to you final point, we have no indication whatseover that posting these numbers hurts us on the business side of things.

Anonymous said...

If you believe BI was "causing people to die", what consequences have there been for those who killed patients? Have you fired anyone? Have you called in OSHA to investigate why your workplace is so unsafe? Heck, did you call the cops?

I applaud what you are doing, Paul, and I do believe that transparency is essential. But your overheated rhetoric is just making you look like a hypocrite. If you really believe that your hospital is/was killing people, then the solutions should be much more drastic than mere transparency, and the consequences should be much more severe than a few shaming blog posts.

OMD said...

I have to say once, again that although I think dialogue, openness, and discussion are great, there is no real scientific evidence that reducing incidence of line infections in the way your hospital has saved lives. It does encourage hospitals to "redefine" what a line infection is in order to target an objective on the metric when you've really done nothing - but now they are good hospitals. Has the incidence of bacteremia actually changed in your instition - if not the line infection numbers are questionable. To say that BIDMC was killing people before and now is not stirs up emotions, but is lacking in fact.

I know that you might say that your not an expert in this area, if so then how can you be so sure about your statements of killing people, saving lives, etc?

Keith said...

Paul,
As usual, appreciate the frank answers.

Regarding "unless all parties involved in delivering care are aware of where you are relative to your goal, you do not get process improvement" I agree, and I would hope that this information is known and continually being worked on internally, my point was more toward posting it to the world (and even in a way internally that is not easily passed to the world).

Regarding "we have no indication whatseover that posting these numbers hurts us on the business side of things", I would expect that it would not hurt you in any way given the large reduction so far this year. My point was for the hospitals whose numbers are not as good as your's at present (or if your's increased for some reason), once posted, comparisons can be drawn between institutions (end up on the front page of the Globe) and then business issues have to be considered.

Again, thanks for the dialogue.

rockwoodfarm said...

When I climb into my automobile, board and aircraft or settle into a chair at a restaurant I have an expectation that my personal safety will not be violated by the intent of which ever party I am interacting with. If it is, that is negligence if I die it is manslaughter. But when I step into a hospital there is more at stake. I accept some greater measure of risk because the environment demands it. That said, the institution is responsible for minimizing risk to the greatest possible extent, if they do not their position is no different than any other entity.

Kris said...

As an HCA student, I listened to a guest speaker once in my undergrad quality class who was in charge of quality at her hospital. She said something that really made an impression on me and I think of it often: "What gets published...improves!" or something to that effect. I think BIDMC's publishing of infection rates is more than just "admirable"--it's critical to seeing improvement. The most important thing that it does is it creates accountability to entities outside of the organization. Another thing that is critical to BIDMC's improvements in this area is the level of commitment to quality from the TOP of the organization, including CEO AND board members. This creates a culture of quality throughout the organization.

Just my observations...

Paul Levy said...

Dear anon 12;21,

Thanks for the lecture! There have been numerous studies demonstrating that thousands of people die in American hospitals as a result of preventable errors. BIDMC was just one of hundreds.

You don't solve that problem by firing people and calling regulatory authorities. You solve it by redesigning the way care is delivered.

Hospitals are full of well-intentioned peopel who want to cure disease. The paradox is that those same people cause harm, usually because the systems in which they work lead to harm.

You overstate my case by asserting that I say that transparency will solve the problem. If you read what is on this blog over many months, there is tons of material on process redesign and improvement, based on work done by IHI, Spear, James, and others.

But if a place tries to do all that work and is not honest in reporting progress, you undermine the efforts. Why? Because you fundamentally do not hold yourself accountable.

By the way, thanks for the lesson in not using overheated rhetoric, too. I haven't been called a hypocrite in a long time. I sign my name to what I say and believe. Would you like to do the same?

Paul Levy said...

Keith,

Thanks, but there is no indication so far that consumer behavior is affected by posting of this kind of data. Maybe it should be, but so far no.

Paul Levy said...

Dear OMD,

I fear you are falling into a reductionist view of the world when you say, "There is no real scientific evidence that reducing incidence of line infections in the way your hospital has saved lives." Of course, we could do a case-control experiment and reach certain conclusions, but things don't work that way, do they?

Let's say that the "only" thing avoided by avoiding a CLI is a CLI. That would be good enough, right? Would you agree to that?

Would you also agree that there is SOME correlation between CLIs generally and mortality? I hope so.

Maybe you don't feel it is right to draw a 1-to-1 correlation between the experience of a specific period and specific cases of avoided deaths, but I hope you would agree that -- directionally -- reducing CLIs is likely to save some lives.

By the way, there was no change in methodology in counting CLIs.

Thanks for your coments.

Paul Levy said...

Thanks, Kris! It sounds like your lecturer and I have been trained by the same people.

Paul Levy said...

A general thought, looking at these comments so far: Doctors write in complaining about the data or overstatement. Members of the public write in saying they expect a higher standard of care.

Dear Doctors,

"They" have more votes, and if we don't all get our act together and help build public confidence and trust, the regulatory requirements you see today will pale in comparison with those that come down the pike in the future. And we all know they will be crude and ineffective.

Carl said...

Paul,

You asked about other industries. Well there is always peanut butter...or banking. What responsibility do these industries have for the harm placed on their customers? This is really an apples and oranges comparison. Hospitals are different, we all know that. Striving to improve a process is commendable; however, posting shortfalls is not a motivator to improvement. What role should leadership play in the culture of improving the process? You have celebrated many of the accomplishments of your organization and have shown that these improvements result in better care. There needs to be a well thought out strategy to improve this process and transparency may not be it. What about putting the focus back on the hospitals that are successful? Instead of others sharing the central line infection rates, why doesn’t a great organization share how it has reduced that rate. Not at a seminar or in a paper. What stops all hospitals for posting their process improvements in a blog or on the wall for everyone to see?

Anonymous said...

Well, once again I tried to keep my mouth shut as these arguments keep going nowhere, but Paul, your comment of 2:48 sent me over the edge. What makes you think the medical profession should take the lead in publishing these statistics, when the statistics occur in hospitals, which are overwhelmingly controlled by non-M.D. administrators, who in turn control what statistics are published? Just simply go to whatever hospital CEO organization that exists, and get a rule passed that these statistics must be published - even by medical department if necessary - and then just do it - nationally! You will see the physicians come around in no time. (There IS good evidence that individual or group feedback comparing a doctor's performance to that of his/her peers does influence their behavior.)
Although your intentions are good, it is the CEO's here that call the shots to produce the data you are asking for. It's not Boston's physicians' fault if Partners is ignoring you.

nonlocal MD

Carol Romashko said...

Zfraile said, "To be more blunt, as CEO, you should really be more concerned about addressing these issues from a cost-savings or revenue enhancing perspective."

Yikes! This CEO mentality is precisely what caused our economic mess today! To do so would be to adopt standards of "ethical blindness" and EVERY CEO should be very careful to not become ethically blind - not just those in healthcare. Reebok using child labor to manufacture shoes? Ethically blind. Walmart not giving employees health benefits until after 2 years employment? Ethically blind. AIG, Lehman, Immelt/GE and other CEOs' greed at the expense of shareholders? Ethically blind.

Thank you, Paul, for not being ethically blind.

Paul Levy said...

Nonlocal,

There is no such organization, or any one that has the authority you suggest. There are, however, professional associations of doctors of all kinds (surgeons, internal medicine, cardiology). These are all voluntary bodies, though. (By the way, I have heard great things about the cardiology association and its attempt to move that specialty along this path.)

In any event, whether a CEO is an MD or not, no CEO can take steps like this without the support of his or her clinical leadership.

I think the medical profession should take the lead because it is best able to publish the most meaningful statistics. In contrast, when they are ordered to do so by others (e.g., regulatory agencies, CMS) there are often (justifiable) complaints that the metrics chosen are not the most useful.

Paul Levy said...

Carl,

You ask: "What stops all hospitals from posting their process improvements in a blog or on the wall for everyone to see?" Answer: Noting at all. But unless they back it up with real numbers, it won't be very convincing.

You ask, too: "What responsibility do these (other) industries have for the harm placed on their customers?" Answer: A huge amount. Check the liability of construction companies and architects if buildings or bridges fail. Think about a restaurant's obligation to serve clean food. Think about an airline's obligation to make sure that (ahem!) check lists are followed. I'm not quite sure why you say that hospitals are so different.

Paul Levy said...

Carol,

Thank you for making that point!

Anthony Cirillo said...

Of course data can be manipulated. Take the case of Virtua Health in NJ that claims it has the most "best" doctors in the state of NJ. Cooper Hospital in Camden thinks otherwise and says that the ad agency for Virtua invented a study and skewed the numbers in their favor. Of course the bigger question is why are all of those dollars being spent on television advertising and litigation that has forced this issue to the state Supreme Court. Bottom line statistics can be suspect. Same argument for the recent Nursing Home Compare upgrade to their 5 Star System. What I don't see any where is outrage. I think people have thrown up their hands in helplessness. Thanks as always.

zfraile said...

I respectfully disagree, Carol. I was unabashed greed that got us into our current mess. Cost cutting and revenue enhancement alone are not bad things, it is the approach taken toward those goals that may lead to unethical action.

I am a firm believer in George Merck's point of view, which, essentially, is that if you do the right thing in business, profits will follow.

My point, which I think you and Paul both misunderstood, is that buy-in will occur at that level. I wholeheartedly agree with Paul's mission in pursuing this; to the extent that he can further his goals by disguising them as cost cutting / revenue enhancing goals, we will all be the better for it.

The bottom line is, in such a position of authority and responsibility, you need to make the most of it while you can. There will be plenty of time to claim the moral high ground later on...right now, just do what you must to move mountains. I am with you all the way.

david keefe, m.d. said...

The resounding support for error reduction in health care expressed above is stirring, but "murder" or "manslaugher" do not describe what goes on in hospitals today. The lack of intent behind most medical errors precludes a murder rap, and the tenuous link between provider behavior and adverse outcomes makes "manslaughter" a stetch.
"Opportunity to improve" fits best and moves the locus of responsibility off the individual and on to the system, where it belongs.
Even the term "preventable error" overstates the level of certainty we work with in medical care. Most adverse outcomes are relatively rare events whose prevention carries real financial and time costs to providers and hospitals. To the individual patient the value of error prevention is infinate and the cost irrelevant. Society, on the other hand, takes a different view- it can't even commit to providing any health coverage at all for 50 million Americans.
The term "preventable error" also overstates the level of certainty we have about what happens behind most medical mishaps. Typically we cannot prevent an adverse outcome, but rather lower the probability of it occuring.
John Maynard Keyes taught us that "probabilities are truths, but truths intermediate between truth and falsity". Taking a probabalistic approach over an evangelical one will better help us avoid medical misadventures.
Hence the need to measure frequencies.

Paul Levy said...

While of course there is some room around the term "preventable", David, I believe that your comment tends to understate the degree to which we know that many errors are truly preventable. Regarding the issue of central line infections, for example, we and many other places have shown how the consistent application of sensible protocols can help elminate this particular problem. This does not take very much in the way of extra cost or effort, and the avoided disease and death is certainly worthwhile.

I fear that your description is of the type that is often used to avoid such efforts -- not that you are advocating that. It applies the apparent use of statistical theory to overstate questions of specificity, while ignoring the very real results of process improvement approaches in the hospital setting.

You are so right that the issue is usually not the individual, but rather the system. But I do not think that takes the onus off those who are in charge of the system or those who work within it. Whether you call that an opportunity to improve or a failure to have already done so or negligence is in the eye of the beholder.

The fact that society hasn't yet figured out how to deal with the access issue is a red herring with regard to the extent that process improvement has or hasn't occurred. Indeed, to the extent that we could reduce harm in hospitals, it could free up resources for other purposes.

Anonymous said...

Once again, I think we are going in circles, but I believe Dr. Keefe is citing the valid point that not every adverse outcome is an error and not every "error" is necessarily preventable. Stirring up artificial outrage by overdefining any patient harm as due to error does nothing but lead to outcomes such as the commenter's 84 year old mother who won't go into a hospital even when needed - which could lead to a far more adverse outcome for her.
At the risk of repeating myself ad nauseum, Paul: I appreciate what you are trying to do but wish you would not overstate your case nor selectively accuse M.D's of trying to minimize the problem. This does not encourage the "backing of clinical leadership" which you say is so necessary for a CEO to achieve statistical transparency ( a statement which I question anyway). And spare me your old assertion that all the clinicians at your hospital already support you - obviously your outrage must not be meant for them.

nonlocal

Paul Levy said...

So, please describe again what you are offering as an explanation for failure to adopt harm prevention programs in so many hospitals?

Paul Levy said...

Regarding this: "not every adverse outcome is an error and not every "error" is necessarily preventable. Stirring up artificial outrage by overdefining any patient harm as due to error..." Now, you are doing what you accuse me of, i.e., overtsating things: I never, ever said every adverse event is an error, and I never, ever said every error is preventable. As I never, ever overdefined any patient harm as due to error.

I have said that there is much preventable harm, something supported over and over in the literature; that much is due to systemic problems rather than personal errors; that a good portion of such harm can be prevented by sound process improvement work; and that this work is dramatically enhanced by transparency.

Then, what seems to upset you the most is my suggestion that a failure to engage in such work is a really serious problem that would be called something more dramatic in other industries. And that I pointed out that very often, MDs respond to all this by saying, "Well, there is something wrong with the data."

Sorry, but these are ALL truisms.

e-Patient Dave said...

Okay, I’ve about had it with this attitude. Despite my great respect for the medical professionals who take their personal time to participate here, the time has come to say: KNOCK IT OFF.

Longest comment I've ever written but all this needs to be said.

SOLUTIONS TO PROCESS PROBLEMS EXIST. YOU ARE BEING BLIND, EVEN STUPID, TO DISREGARD THEM. AND IN SO DOING, YOU ARE LETTING ERRORS AND HARM CONTINUE TO HAPPEN.

Causing harm doesn’t mean it was intentional. But if you know a solution exists and you disregard it, you better think about the choice you’re making. And you hereby know solutions exist for preventing all kinds of simple human errors.

I’m going to be overly strong to try to wake people up, then revert to my more normal nice-nice.

Quit bitching about the data. Open your eyes and think about the STUPID mistakes that can be avoided by COMMON SENSE THINKING that doesn’t require a medical degree. (Sorry, folks, you may have been brilliantly trained about my kidneys but that doesn’t me you know squat about driving a dumptruck or designing a form. They’re different disciplines. Wake up!)

LIVES ARE AT STAKE. (Yes I’m shouting.)

Look at the Emily’s Atrium blog, a current case in Boston, a 16 year old girl getting a heart transplant. In isolation post-transplant, the family noticed that anytime a door opened, there was a draft. Isolation?? Hmmm. Staff wouldn’t believe it! So the husband took to standing in the room with a strip of toilet paper, so staff could see “Look, it’s blowin’ in the wind.” How stupid is that?? Why don’t they have sensors to confirm that isolation is draft-free?? Why?

It took staff a day but they traced it a problem at the top of the building. And when they found it, says the blog, “the idiots, believe it or not, came and reversed the air flow WHILE WE WERE IN THE ROOM. So the dust in the ducts from 3 years of sick, isolated patients was blown in on us.”

Look: When something like this goes wrong in NASA, somebody dies – and it makes headlines. NASA has developed process solutions, and those solutions are freely available. It’s a DISGRACE that Emily’s life was put at risk because “It’s just too haaaaaard” to expect this industry to grow up and be responsible.

The previous week the ICU renumbered some rooms and forgot to tell people. Result: meds (and guests) being sent to the wrong (ICU!!) room. The IT guy came in and reset the room number on the monitor and rebooted it – whereupon it went into “demo” mode and demonstrated telling the nursing station her heart had stopped. In flies a team with cart and all… mother had to physically insert herself in front of daughter before staff heard “It’s in demo mode!”

And this is a good, famous hospital! (And not part of Partners, so don’t tell me I’m bashing Partners.)

Speaking of which, some people have the gall to suggest that I’m biased in favor of BID. B.S. and shut up. Here’s one of my gripes about BID: Two years ago, a week after my nephrectomy (at BID), I needed a urinalysis on a specific day, to be certain my remaining kidney was working right – because otherwise, I was going to need dialysis pronto. A friend drove me to the hospital and I produced the specimen. Two days later, not hearing any results, we investigated and learned they lost it. I put it in the two-way door they told me to, with no barcode or anything on the cup, and nobody ever saw it again. Incompetence! At BIDMC.

Similarly, my catheter had not been removed on the scheduled day. I was waiting, staff didn’t do it, I figured they knew something I didn’t. I was wrong; they screwed up. Why was there no automated system in place to make sure the scheduled thing happened?? Solutions for this have existed in industry for years! (It's trivial: you put the order in the system, and if you don't click "done," it pops up and reminds you!)

A third: a friend’s daughter had a neurological episode last year and came to BID. My friend is a very empowered patient advocate, having been through multi-year crises with three successive relatives. She quickly sensed that BID neuro staff was mumbling and fumbling and guessing about diagnosis. I hooked her up with BrainTalk, one of the patient-generated communities described in the e-patient white paper. (Founded, btw, by Dan Hoch of Partners.) Within 8 hours she had learned enough to go back and challenge the doctor’s diagnosis, ask challenging follow-on questions about the reason for the diagnosis, establish (with the docs’ agreement) that the diagnosis was wrong and in fact the prescribed treatment would almost certainly have done harm, perhaps permanent. The daughter was transferred to Mass General and is doing well.

Friday BID billing called me about several supposedly past-due co-pays, asking me if I know anything about them, because they don’t know whether I paid them. Can you imagine any company operating that way?

So don’t give me any crap about being biased toward Beth Israel Deaconess. As Paul says, the point here is that you improve care by improving process, and publishing your results helps. Quit changing the subject.

Speaking of which, Salesforce.com is a very successful “software in the cloud” customer database system (I use it in my day job). They openly publish their downtime statistics. Don’t you dare tell me healthcare is different from marketing systems! That’s changing the subject – we’re talking about how when you publish your results, accountability improves. A for-profit company like Salesforce would have every reason in the world to cover up outages or slowdowns, but they don’t, and they’ve been growing like crazy – and taking business away from installed-in-house systems like Oracle. (And, their system has become increasingly stable, because everyone sees mistakes, both inside the company and out in public.)

QUIT WHINING. SHUT UP. Grow up and take responsibility for the fact that solutions exist and you’re ignoring them.

Sorry, but LIVES ARE AT STAKE, and many solutions are available. What will it take to get that into your (highly educated!) skulls? What will it take before you wake up and say “I will do anything I can to reduce the risk of harm”?

e-Patient Dave said...

btw, as I was writing that, @Gfry (founder of ACOR) told me @SciAm had just tweeted from AAAS 09: "Benner quotes Stephen Jay Gould's panda's thumb: The strongest evidence for evolution is when the system is not behaving optimally."

david keefe, m.d. said...

Paul's clear, strong voice on harm prevention is Bobby Kennedyesque, "some ask why, I ask why not..", and therefore plays a crucial role in ingniting the debate. Change starts with a vision burning brightly.
But then the messy business of execution ensues. As pointed out above, our debate on harm prevention has become circular. We can only hope that it can become spiral, towards the vision, with engagement through fora such as this blog.
Process improvement bumps up against too many core values held by physicians, as they are currently trained- autonomy, authority, control, self interest, perfectionism.
Physicians are not selected nor advanced for ability to understand systems, nor to serve as change agents. Physician leaders are the most vested in the status quo.
Executing Paul's vision will require a change in the DNA of physicians. Medical students should be selected for ability to work in and understand teams, introduced to process improvement on day 1 of medical school, and required to perform a process improvement project during clinical clerkships. Before they graduate, residents and fellows should present a process improvement project.

Lachlan Forrow, MD, FACP said...

I've said this kind of thing before -- patience isn't a virtue when preventable deaths are occuring, and I haven't seen anyone dispute that that is happening. I suspect there was little else that Barry Goldwater said that I agree with, but his comment in accepting the 1964 Republican nomination seems relevant: "...extremism in the defense of liberty is no vice! And let me remind you also that moderation in the pursuit of justice is no virtue!"

Whether the intensity of Paul's comments generates backlash resistance that slows progress is a legitimate question, but I would like people who suggest that is true to provide examples of situations where expressed urgency or outrage about errors in hospital slowed progress (we can then learn from those). And a serious answer to Paul's criticsm about the medical profession resisting change is not just to deny it, but to point out counterexamples that show how fast we're pushing for change. I wish I could point to more (Rick Shannon, for example, an old friend from college, wouldn't get cited thousands of times if there were thousands of others doing what he did!).

Lachlan Forrow, MD
Director, Ethics Programs
BIDMC

Anonymous said...

I am struck by how often you urge physicians to consider doing this because otherwise government will start enacting regulations to make this happen.

I think that getting government to enact such regulations is clearly the most efficient way of creating this social change, the most equitable, and (not incidentally) the one that is most likely to be amenable to pressure from physicians' groups, as compared to insurers or employer groups creating the pressure. And since government is the biggest payor, it makes sense that government should set the terms. If we have a democratically elected government, than at least there is that degree of public accountability as opposed to only optional accountability which is what voluntary measures require.

So, why not lobby for more Medicare involvement in quality assurance? Wouldn't that be more efficient as a way of getting this done?

Lonnie Fuller said...

Sir,
I mistakenly posted my comment to the original article. I would appreciate your thoughts.

Eric said...

While I agree with the general gist of Dave's long and impassioned comment, I feel there's one thing worth calling out: "I will do anything I can to reduce the risk of harm”, while an admirable ideal, is not a reasonable practicality. There comes a point of diminishing returns, where the effort put in is not worth the miniscule risk reduction. This is true in any area of public safety - eg, we overengineer bridges, but no matter how much, it is always possible to overengineer them more; we have to draw the line somewhere. Human life is important, but if any risk of death becomes a trump card, we will bankrupt our lives, wallets, and future trying to achieve the impossible of "zero risk".

That being said, I don't think we're anywhere near that point with hospitals (or the health care system in general). The room for improvement is substantive, and the costs measured more in mental adjustment than dollars. Thank you, Paul, for carrying the torch on this one.

e-Patient Dave said...

Well said, Eric. I accept your adjustment. Perhaps I could have been more precise with words like "leave no stone unturned," "consider all kinds of options," etc.

I'm grateful for Lachlan's learned perspective, too.