Saturday, February 19, 2011

2 kidneys versus 100,000 lives

This story about a kidney transplant mix-up in California is bound to get lots of coverage. It is these extraordinary cases that get public attention. I am sure it will lead to a whole new set of national rules designed to keep such a thing from happening.

Of course, such rules already exist, and it was likely a lapse in them that led to this result.

Nonetheless, we will "bolt on" a new set of requirements that, in themselves, will likely create the possibility for yet a new form of error to occur.

This kind of coverage and response is a spin-off from the "rule of rescue" that dominates decisions about medical treatment. We find the one-off, extreme case and devote excessive energy to solving it. In the meantime, we let go untreated the fact that tens of thousands of people are killed and maimed in hospitals every year.

Those numbers are constantly disputed by the profession. To this day, many doctors do not believe the Institute of Medicine's studies that documented the number of unnecessary deaths per year.

And you never hear anyone talking about this 2010 report by the Office of the Inspector General, which concluded:

An estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths, which projects to 15,000 patients in a single month.

As the IOM notes, “Between the health care we have and the care we could have lies not just a gap, but a chasm.”

There is an underlying belief on the part of policy makers and public and private payers that the focus on quality is best addressed through payment reform. Let me state as clearly as I possibly can: That is wrong. It is a classic example of the old expression: "When you have a hammer, everything looks like a nail." Changes in payment rate structures, penalties for "never events," and the like can cause some changes to occur. Their main political advantage is that they give the impression of action, and their major financial advantage is a shift in risk from government and private payers to health care providers.

But these are gross tools and will have unintended consequences. More importantly, they do not get to the heart of the problem, the manner in which work is organized in the highly complex environment of hospitals and physician practices. This is an environment in which ineffective work-arounds -- instead of front-line driven process redesign -- are the usual answer to obstacles in patient care.

They do not address the unmet education needs of doctors-in-training, training that is a throw-back to a cottage industry in which each person is expected to be an artist, relying on his or her creativity, intuition, and experience when taking care of a patient. The resulting lack of standardization -- the high degree of practice variation -- creates an environment that is inimical to process improvement based on scientific methods.

They do not address the documented advantages of engaging patients in the design and delivery of care, nor the power that such engagement brings to both doctors and patients.

Add to this the sociology of dehumanization in medical schools documented by Linda Pololi, and you have a stewpot of well-intentioned people destined to kill and maim others.

It is up to the medical profession, not the politicians or the insurance companies, to change this. First, though, they have to be willing to acknowledge that problems exist, that the current level of harm is not a statistically irreducible amount. The need to put aside the usual responses -- "the data are wrong" -- "our patients are sicker" -- "our care is the best in the country" -- and have the intellectual modesty to recognize that the real work has just begun.

To the extent the medical profession continues to abdicate responsibility, the more will step in politicians, regulators, and payers to do it for them. If you are a doctor and already feeling a lack of control over your professional life and your relationship with your patients, just wait.

I have previously quoted experts on this field, but the most cogent imperative remains the one provided by Ethel Merman:

Now what kind of an attitude is that, 'these things happen?' They only happen because this whole country is just full of people who, when these things happen, they just say 'these things happen,' and that's why they happen! We gotta have control of what happens to us."


Dale Ann Micalizzi said...

How true, Paul. Following my son's death, we met with the anesthesia group when the gossip (or should I say truth) surfaced ten days later that the event was caused by the anesthesia meds. The practice supervisor stated to us, "These things happen and you will never know what happened to Justin." The acting anesthesiologist was not allowed to speak other than saying, "I knew something was wrong when I heard the alarm." When we met with the resident, who actually did the ankle surgery, he stated, "Medicine is an imperfect science," AKA these things happen.

They acknowledged that things happen but did not acknowledge that these things were NOT OK and that they would do something to fix them. It was more like, these things happen so let it go-that's just the way it is. How wrong and sad. You many never know how many parents were given this answer and expected to accept it. It's not ok anymore...

Taking responsibility, learning from events and being careful don't cost anything or require new rules or laws.

Anonymous said...

Well Paul, in my 4 years of reading your blog as an M.D., you have converted me from my original intention to 'educate' you that these things do indeed happen and you shouldn't hold our profession accountable, all the way to my recent comment on your Feb. 17 post that patients should form organizations like the Freedom Riders and ACT UP in order to gain the rights and safety they deserve. Dale Ann's comment only drives it home further.

I have never been so glad to eat crow and say to my colleagues: this man is absolutely correct. We must lead. Please listen to him and, most important, let's get our professional societies and/or whomever it takes, to act. Stat.

nonlocal MD

Mary Ellen Mannix,MRPE said...

Thanks for converting some clinicians, Paul - like Dr. Nonlocal (thanks Doc for keeping an open mind).

The biggest untapped resource is the patients themselves and you did a wonderful job in exemplifying this by ending your piece with a quote from a nonclinican.

Patients have broad backgrounds and expertise in the very issues that the MDs are wrangling with - specifically communication and education.

Two years ago the WIHI program invited sociologist & educator Parker Palmer to share how his restorative approach to culture change and paradigm shifts can be successful. His point - systems are made up of the people within them. If the people don't change their behaviors, the system never will.

My baby died in this nearly ten years ago. The only way change is going to happen is if more people are engaged. Personally, I see the same names, faces, and stories told and retold in the patient safety cottage industry. But ironically, front line clinicians have never heard of them (like a practicing surgeon of 25 yrs who has worked in a Presidential Cabinet or the RN of 10 yrs or the newly graduated resident and CEO of a major hospital). It is time to go farther and demand more of these stories - both clinicians and patients - are shared.

As such, I shared your blog again in my post today (all month focusing on CHD issues for Heart month) at

e-Patient Dave said...

This turned into another post-length comment.

Here's the Feb 17 post to which nonlocal referred. (Paul, your post titles sometimes leave something to be desired - in a hurried world I had no idea about the focus of that post; "cost vs choice" could have been about anything.)

Here's the core of nonlocal's comment:

"I do not believe the patient will be given a stake in any future form of health care ... unless he demands it. ... I believe this struggle will proceed along the lines of civil rights or gay rights - it will take way longer than it should, rights will be wrested from a reluctant status quo, and progress will require organization, tenacity and, unfortunately a bit of a hard edge.

"Although the patient advocacy movement is taking shape, I have yet to see the emergence of the three elements listed above..."

Oddly, I too have recently been reflecting on the structure and stages of other movements: women's suffrage, civil rights, the antiwar movement of the Sixties, feminism, gay rights. I know the patient movement has reached a certain stage because two signal events happened in 2010 that I saw in the Sixies: ridiculous rumors about us started circulating, and divisions and rivalries started to emerge within the movement. Both are good signs.

Nonlocal says we need "organization, tenacity and a bit of a hard edge." Don Berwick spent 15 years applying the first two at IHI, developing and preaching methods that work; but to a large extent the industry's doctors, managers and executives are not adopting the improvements.

Perhaps the hard edge will arise only when we awaken to the searingly painful stories we heard in Orlando, at the IHI Patient Activist Summit, as person after person told of the horror of seeing their family members die or be maimed... bring those stories "out of the closet and into the streets."

The outrage is that the profession has largely failed to adopt improvements that are known to work. That is the outrage: how long can that go on before we start crying "Sin!"?

Yet just last week, in the patient activist group on Facebook, one of us said she was told years ago that we won't make progress if we upset the people in power. And I, one of the least radical (in the Sixties and now), replied that that hadn't gotten us far.

What will our slogan be, our actions? "Out of the closets and into the streets"? Bra burning? Will it come down to throwing rocks and occupying the president's office, as happened during our college years?

Will we see a day when a patient activist is shot?

jonmcrawford said...

Perhaps we could have virtual sit-ins, where instead of showing up, we book appointments with physicians who resist patient empowerment, clogging their books, and then don't show. Vote with their wallets, in essence.

Anonymous said...

There is a certain numbers game - a frequency-dependent feature to successful social movement. There are many, many informed patients and family members who access time, money and attention (thank you, e-Dave) for the many more who are left feeling that something about their or their family's care was just not right. That perhaps they should not have died that way. That perhaps the physician should have looked them in the eye when they told them, instead of away. And the bulk (according to the mountain of daily errors) that do not know how chaotic delivery is, how inefficient information flow is, and how heavily defended physician status is. Life is challenging enough, with inflexible jobs and family demands. If I questioned authority, what would that (difficult) effort buy?

How can the patient safety movement mobilize a public health movement? Poor policy, poor delivery, poor outcome anyone?

e-Patient Dave said...

Anon 6:06, do you know any specifics about the numbers involved in social movements? That's an example of what I've been trying to explore.

What we've been seeing in the Arab revolutions powered by Facebook and Twitter is that information has flowed more freely - people have seen quickly what's happening elsewhere and that they're not alone in their sentiment. My gut says this has such profound possibilities, but nothing's more fraught with hazard as an uninformed gut...

Thomas said...

Wondering if I can elicit a response from you and responders to this question:

Should every "procedure room" have protected (you won't find it on YouTube) video?

I believe there are many reasons to do this, but I'm concerned there will be a public outcry against the idea because of "privacy" issues.


Paul Levy said...

I would view that as a waste of resources and ineffectual. Not all harm shows up in the procedure rooms, first of all. Secondly, most harm is not the result of an explicit mechanical error. Third, the camera cannot see all things going on.

Paul Levy said...

Meanwhile, check over at The Health Care Blog for more debate about the numbers:

Anonymous said...

Thomas, I agree with Paul at first pass, but it makes me think about cockpit black boxes and voice recorders, and about the video cameras now in many police cars.
And yes, you'd really have to put it in patient rooms also to capture more errors, and then who would review it? Or perhaps it would just be available in case of a problem.

I'd have to agree that with the current financial stresses in hospitals, it would be difficult to justify unless the technology becomes an order of magnitude cheaper. But, I am interested in your enumeration of the 'many reasons' to do this?

nonlocal MD

third-gen feminist said...

e-Patient: You have such good things to say but you discredit yourself by rehashing the bra-burning myth as an emblem of women's rights. If you're advocating patient rights, please drop this or, in the vernacular, Snopes:

e-Patient Dave said...

Hi, third-gen - thanks for your addition, particularly the Snopes link.

I confess that I was only referring to my own personal experience. I find I constantly get in trouble if I cite things I only heard about, without saying where I got them.

Ms. Magazine's book "Decade of Women" taught me that bra burning was "an invention of the media." But as it happens, I talked with a radical woman who said she did participate in a bra-burning in Colorado ... in any case, that certainly became a symbol of the issues, and I knew many women who rejected the use of bras as discriminatory and unpleasant for them.

Anyway - do you have any great ideas for a highly adoptable symbol if the patient movement? As I say, I've been hungering.

Thanks for calling me out - I'm constantly looking for BS detectors.

e-Patient Dave said...

Re in-room videos: the whole conversation shifts if we start thinking about shared efforts to improve. I know that's not a trivial culture change, but please, let's start by imagining a world where we work together to improve.

One way that unfolds is if we respond together to errors by working together to figure out what went wrong, how, and why. Cameras and other types of monitors could help, but only in a world where people don't fear "punishment" for ordinary variations.

Anonymous said...


I was thinking of the video cameras more along the lines of a data collection device similar to the airplane recorders, not as a method to "catch" people. However, as I mentioned I am not convinced how much good they would be in this setting. Something to brainstorm about certainly, however. One must think of the questions first before we can ask them.

As to bra-burning, all I can say is, : ((:


Anonymous said...

Symbols. A simple graphic of a person sitting in a waiting room chair with head folded down into hands. A repose of deep loss. The bold demanding text above: ASK WHY.

Thomas said...


Thanks for the come-back on VIDEO...
I see video as the foundation of the next generation of the medical record. Dictations: done for you by smart software built into the video system. Documentation for Credentialing of all professionals in the room. Insurance fraud protection. Loss prevention. Drug diversion protection. Monitoring of equipment/drug stations etc during down hours when maintenance/housekeeping/technical crews clean and replace. Ongoing analysis of Compliance: submit a sampling of clips involving your personnel over the year to Joint Commission and tell them to stay home: do Compliance monitoring year-round rather than for 2 months before the JC visit.

Look at YouTube: not the acting, but the medium. The medium is so data laden that we can't handle it all right now: but we will develop the technology to use the images wisely.

Look at the eMR now. It's garbage.

Go to "my" hospital and pull up a "chart": here's a current picture of the pt. His wife. Their kids. The gall bladder in the path lab. click on it. Look at the cancer in the gall bladder. click on it. jump to the latest treatments for adenocarcinoma. Watch a clip of the laparoscopic procedure. Watch the anesthesia folks perform the intubation. Video images bring life to a completely dead document.

Every procedure should be recorded. We record so much banal BS now, can't we get around to saving something potentially useful.

Imagine the "pace" of legal settlements in the video era (hey- I can hope).

How much does a big hospital spend on liability insurance? What if the carrier will give you a huge discount if you record?

And on...

Thomas said...




Anonymous said...

Wow, Thomas; that is the kind of creative imagination our industry needs! Unfortunately as of yet we can't even figure out how to get the patient's existing (however inadequate) medical record from one provider to another in real time, so we are far from your goals. But certainly something to consider incorporating into future efforts.


Anonymous said...

Thomas if you're still there, I just discovered an interesting use of video - to debrief medical students following a simulated "event" in a "procedure room" (the example given was a cardiac arrest). 5 cameras recorded everything including the 'patient's' monitor information. I quote:

"When students see themselves on video, they have a much better understanding of who they are and what they appear to be. Sometimes there's an uncomfortable disconnect between the two."


Thomas said...


your med students:

tip o' the iceberg!

keep it going.