The Death Of The Autopsy And Its Implications For Public Health

Death_Rembrandt_autopsy_Harmensz_van_Rijn_painting.jpgAutopsies are a routine part of hospital deaths, right? Well, actually, no. Today autopsies are only performed in five percent of hospital deaths, down from over sixty percent 40 years ago.
As the incomparable philosopher/economist Robin Hanson notes at, would we let it slide if only five percent of airline crashes were investigated?
Hanson argues that hospitals don’t want autopsies to be performed because they reveal too many doctor errors. According to a 1998 article published in The Journal of the American Medical Association, autopsy results show that doctors misdiagnose the cause of death at least 40 percent of the time. Hanson asks, “Could there be any clearer evidence that docs care more about getting paid than about healing patients, yet the public can’t bring itself to imagine docs are that selfish?”
I wholeheartedly agree with Hanson that the medical profession is not seriously committed to studying and learning from its mistakes. If it were, it would follow the model of the aviation industry and adopt the same kind of safety principles that the aviation industry has implemented.
But I disagree with Hanson that the medical profession’s atavistic impulses for self-preservation are the reason we’ve seen this dropoff in autopsies. I think we don’t get autopsies because insurers don’t pay for them. Private insurers generally do not pay for them and Medicare never pays for them because, under Medicare regulations, a dead patient does not meet the statutory definition of a “beneficiary.”
If we paid for autopsies, we’d get them done.
Autopsies are terribly important. It was autopsies that first made doctors realize that smokers were dying of lung cancer.
So what should we be doing? A lot of libertarian-leaning commentators (including liberals like Matt Yglesias) have been urging us to relax or abolish professional licensure requires that jack up the prices of services from hair salons to dental hygience to medicine.
I think autopsies are a perfect candidate for a procedure we should allow non-licensed professionals to perform. After all, what’s the worst harm that you can do to the person being autopsied? Kill them?
Let’s start doing autopsies again. We can do them at low cost and obtain all the benefits for public health.

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A New Breed Of Medical Specialist: The Nocturnist

Nocturnist Medical Malpractice.pngIf you had asked me last week to define “nocturnist,” I would’ve guessed, “A musical composer who writes nocturnes. For example, Chopin or Debussey.”
But, as Kaiser Health News reports, a nocturnist is actually a member of a new medical specialty – a doctor who works exclusively nights at a hospital. You can think of a nocturnist as the nighttime counterpart of a hospitalist, that relatively new breed of doctor who practices exclusively at a hospital.
Hospitals are hiring nocturnists to reduce the nighttime incidence of medical malpractice. Nighttime can be an especially dangerous time for hospital patients: not only do hospitals tend to run a skeleton staff at night, but many of the doctors who are on duty (younger residents who work long hours) can be fatigued at nighttime.
The research data starkly illustrate how dangerous short staffs battling fatigue can be to patients. According to a 2008 study by the American Medical Association, hospital patients who suffer nighttime heart attacks are 50 to 70 percent less likely to survive than patients who have their heart attacks during the daytime, when medical staff are bright-eyed and bushy-tailed.
My guess is that hospitals’ use of nocturnists will reduce medical malpractice. Three months ago, we blogged about a new obstetric patient safety program that reduced medical malpractice by 99 percent in New York hospitals that participated. One of the main techniques that these New York obstetrics wards employed was the hiring of a “laborist,” an obstetrician who only worked nights and who was there to help the daytime obstetricians who might become fatigued during a labor that drags on for hours and hours.
We’ve also seen how minor fatigue — the typical fatigue that occurs over the course of an eight-hour daytime shift — can raise doctors’ risks of medical malpractice by twenty percent.
So let’s hear it for the nocturnists. And let’s hope they help the medical profession to cut back on the 100,000 deaths that occur annually due to medical malpractice.

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New Studies Say Missed Meds Cost Our Health Care System $250 Billion A Year, Potentially Fixable

Text-message.jpgWe all know that failing to take medicine as prescribed adds to the costs of our health care. For example, when someone fails to take a course of antibiotics to the end of the bottle and their infection flares back up, requiring another trip back to the doctor, that makes health care more expensive. And when someone forgets to take heart medication and has a heart attack, the costs of treating that heart attack are vastly greater than the cost of the bottle of pills that might have prevented it.
But just how much extra are we paying in health care costs because of people’s forgetfulness (and in some instances) and their willful failures to take medications as prescribed? According to two new studies (one by researchers at Harvard), failures to take prescribed medicines cost American health care $250 billion annually. (H/t USA Today). That’s an absolutely staggering number.
To give you some perspective on its size, last summer the journal Health Affairs published the most recent estimate of the annual cost of medical malpractice lawsuits. Its best guess was that medical malpractice lawsuits cost the health care system, directly and indirectly, $55 billion a year.
The cost of missed meds is five times as large as all of the costs of medical malpractice (including payouts to injured patients and malpractice insurance premiums), but you don’t hear people saying, “Hey, let’s do something about the problem of missed meds. We can save ourselves a fortune and, in the process, we won’t have to trample the rights of the people maimed, paralyzed and killed by medical malpractice.” Instead we hear the crusading tort reformers haranguing us that frivolous medical malpractice lawsuits are bankrupting the health care system (when all of the costs of medical malpractice, both direct and indirect, amount to less than two percent of health care spending).
If there’s any silver lining to learning that missed meds are costing us $250 billion annually, it’s that the problem has quick fixes. Studies show that when people get text message reminders to take their medications, they take them more reliably. Also, when patients are automatically enrolled in mail-order pharmacies, so that they don’t have to go to the pharmacy for their first script or for refills, many more patients take their meds.
I have an idea. Before we sacrifice the victims of medical malpractice on the altar of health care economy, why don’t we try text messages and see if that knocks down the cost of health care any?

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Atul Gawande’s Commencement Address To Harvard Medical

Pit Crew.jpg“We train, hire and pay doctors to be cowboys. But it’s pit crews people need.” – Dr. Atul Gawande
The commencement speaker who addressed this year’s graduating class at Harvard Medical should be a familiar figure to readers of this blog. It was one of the blog’s heroes – Dr. Atul Gawande – he of “checklist manifesto” and “health care cost conundrum” fame.
Although the tone of Dr. Gawande’s address was uplifting, it was not the typical commencement address larded with platitudes and bromides about life; instead Dr. Gawande delivered a clear clarion call to graduates about the future of medicine. Dr. Gawande stated that the task for this generation of doctors – the task which they must carry out if we are to improve health care and make it affordable – is to work together as members of pit crews work together, while applying data-driven best practices.
Dr. Gawande began his address which you can read here (h/t Cal Consumer Attorneys), by noting the explosion in the complexity of medicine in the last century, an explosion in knowledge and technology that outstripped the gains of all the past centuries of medicine combined.
In the 1930s, 40s and 50s, it was possible for doctors to tote around the whole of medical knowledge in their brains. Doctors were cowboys, lone wolfs, rather than collaborators. They didn’t need to know how to play nice or be part of a team because they didn’t need teammates; the sum total of the body of medical knowledge and treatment was at their fingertips, as it was so small.
But as medicine’s complexity has exploded, so too has the number of nurses, specialists and other health care patients involved in a patient’s care. In 1970, 2.5 nurses and doctors participated in the care of the average patient. By the 1990s, the number was more than 15.
As the number of moving parts in a patient’s care increases, the members of a patient’s health care team need to work together like a pit crew. Like pit crews, the members of a patient’s health care team should follow checklists – checklists that have been shown to reduce medical malpractice by forty-seven percent.
The principles doctors should follow in their checklists should be derived from data-driven research of best practices. As Dr. Gawande notes:

People in effective systems become interested in data. They put effort and resources into collecting them, refining them, understanding what they say about their performance.

When you study the data, you find that the most effective health care techniques are not the most expensive. And that fact means that we can afford health care without having to ration it. As Dr. Gawande notes:

The places that get the best results are not the most expensive places. Indeed, many are among the least expensive. This means there is hope–for if the best results required the highest costs, then rationing care would be the only choice. Instead, however, we can look to the top performers–the positive deviants–to understand how to provide what society most needs: better care at lower cost. And the pattern seems to be that the places that function most like a system are most successful.
By a system I mean that the diverse people actually work together to direct their specialized capabilities toward common goals for patients. They are coordinated by design. They are pit crews.

If, in twenty years time, you go to the hospital and the staff’s coordinated efforts resemble the coordinated efforts of a NASCAR pit crew more than a traditional hospital, chances are the care that you receive will be better. And cheaper.

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A Massachusetts Medical Malpractice Mystery

WelcomeToMassachusetts.jpgAccording to a May 16 article in the Boston Business Journal, despite the stellar reputation of many of Massachusetts’ hospitals, you don’t want to be a Medicare patient in a hospital here.
We have nearly a half-dozen medical schools in the Commonwealth, as well as some of the world’s best hospitals, but all of our medical wizardry and brain power appears to be lost on Medicare patients. When it comes to Medicare patients, Massachusetts hospitals’ rate of medical malpractice is two to three times the national average.
Some of the medical malpractice committed on Massachusetts Medicare patients is of the forehead slapping variety. For instance, between October 2008 and July 2010 more than fifteen Massachusetts medicare patients suffered complications after they were sewn up with surgical instruments still inside them. This type of retained surgical instrument medical malpractice is especially egregious as it can be readily avoided by using any manner of new technology, such as tagging surgical tools and sponges with RFID chips.
What is up with prevalence of medical malpractice among Medicare patients? It’s a Massachusetts medical malpractice mystery.

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Laser Spine Surgery Centers: Are They A Scam?

laser surgery ppc.jpgLaser spine surgery centers. You’ve probably seen their pay-per-click ads on google (they advertise a lot through pay-per-click). Do they offer a new, better kind of therapy or is it all snake oil?
According to a recent Bloomberg news story, the surgeries at laser spine surgery centers are more expensive and less safe than traditional spinal surgeries. “[Laser spine surgery] strikes me as somewhat of a scam,” says Jeffrey Arle, a Lahey Clinic neurosurgeon. Arle and other surgeons believe that laser surgery simply offers the same surgeries performed with a different modality, and at a substantial mark-up. Laser spine surgeries often cost twice what traditional spine surgeries cost.
All of this would be fine – it would merely be luxury-branded spinal surgery – if it weren’t for the fact that many laser spine surgeries are unnecessary and the incidence of medical malpractice in laser spinal surgeries so frighteningly high. The number of medical malpractice claims at laser surgery centers is several times the rate at other types of surgery centers.
And many claim that the kind of aggressive marketing of laser spine surgery centers that you see on the web carries over into the operating room – with the surgery being sold to people who don’t need it. At some laser surgery centers, so-called “patient coordinators” are offered bonuses and other incentives – such as trips to the Bahamas – based on the number of surgeries “booked or sold.”
If you’re considering laser spine surgery, maybe you should get a second opinion.

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Phoebe Prince And Medical Malpractice

Phoebe Prince.jpgThe tragic case of Phoebe Prince, the Northampton, MA teenager bullied into committing suicide, earned national attention and shone a spotlight on schoolyard bullying. It led to criminal charges against the bullies and, last week, the last of the accused teens entered into a plea deal.
None of the teens will be going to jail and there is some public furor over that fact, with many claiming the teens’ sentences were too lenient. (Based on the news accounts that I have read, I have conflicted feelings; my immediate reactions to the appropriateness of the defendants’ sentences vary with respect to the individual defendants and their differing degrees of culpability. Even if some of the teens will escape without carrying a criminal conviction on their record, in this day and age of google footprints each one will, for better or worse, carry these charges with them for life. At any rate, focusing on the on the sentences meted out to the bullying teens neglects the aspect of the case that initially captivated the public: that it seemed almost everyone in town – from teachers to school administrators, parents of classmates and hallway bystanders – shared some degree of responsibility for Phoebe’s death – but, since this diffuse blameworthiness did not fit neatly within the rubric of any criminal offense or civil tort, a lot of wrongdoing will forever go unpunished. One’s heart breaks over what Phoebe’s mother has endured.)
What Phoebe’s case helped illuminate is how serious the problem of bullying can be. It’s not the case that, “Sticks and stones may break my bones”; schoolyard bullying can kill, which is what made the case so surprising to many. And now we have the name and know the face of someone it killed.
After writing my last blog post – on physician-nurse bullying – it occurred to me that bullying also kills in the grownup world of hospitals and emergency rooms, but this problem gets less attention. According to a 2004 study published by the Institute for Safe Medical Practices, seven percent of the nurses surveyed had, within the past twelve months, been involved in a medication error for which doctor intimidation of nurses was at least partly responsible. When seven percent of nurses have within the past twelve months been involved with a medication error attributable to physician bullying, it is a virtual certainty that deaths caused by physician bullying are among the 100,000 deaths caused by medical error each year. But unlike with school-age bullying and Phoebe Prince, most of us can’t name someone whose life was lost to medical bullying.
Phoebe Prince’s death spurred new anti-bullying legislation for which I think we should all be grateful. (It’s about time that we wake up to the reality of child-on-child abuse, the same way that, a generation ago, with the OJ Simpson case, we awakened to the reality of spousal and domestic partner abuse). But deaths caused by doctor-nurse bullying haven’t led to any reforms. Instead, we see states like Florid passing tort “reform” programs that further insulate doctors from the consequences of their actions.

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Physician Bullying: One Reason For Miscommunication Between Doctors And Nurses

bullying.jpegMy last blog post was on how breakdowns in communication between doctors and nurses are the main source of medical malpractice in the Emergency Room.
Why are their problems in doctor-nurse communications? The white paper mentioned in my last post lays the blame at the feet of technology: nurses input data into computer systems and doctors don’t check the database – everyone’s communicating virtually and no one is relaying information face-to-face.
But an even bigger reason why doctors and nurses sometimes don’t communicate well is the problem of physician bullying of nurses. Theresa Brown, author and oncology nurse, wrote about the phenomenon last week in a New York Times editorial entitled, “Physician, Heel Thyself.” As Brown writes, “while many hospitals have anti-bullying policies on the books, too few see it as a serious issue.”
MDs engage in a wide range of bullying behaviors. We can all readily call to mind the image of the narcissistic surgeon going into full melt-down mode and throwing a temper tantrum, but, as Brown writes:

“…the most damaging bullying is not flagrant and does not fit the stereotype of a surgeon having a tantrum in the operating room. It is passive, like not answering pages or phone calls, and tends toward the subtle: condescension rather than outright abuse, and aggressive or sarcastic remarks rather than straightforward insults.”

Physician bullying not only takes a psychological toll on nurses but also gravely endangers patient safety. As Brown writes:

“A 2004 survey by the Institute for Safe Medication Practices found that workplace bullying posed a critical problem for patient safety: rather than bring their questions about medication orders to a difficult doctor, almost half the health care personnel surveyed said they would rather keep silent. Furthermore, 7 percent of the respondents said that in the past year they had been involved in a medication error in which intimidation was at least partly responsible.”

Florida and other states want to reduce the costs of medical malpractice by instituting draconian “reforms” of medical malpractice law. It would probably be a lot cheaper, and patients better off, if hospitals simply worked to improve doctors’ civility toward nurses.

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Emergency Room Medical Malpractice: What We Have Here Is Failure To Communicate

failure to communicate.jpgAs the Harvard philosopher George Santayana famously remarked, “Those who cannot remember the past are condemned to repeat it.” Now Crico/RMF, the insurance company which provides medical malpractice coverage for Harvard-affiliated hospitals, is attempting to learn from past medical mistakes to avoid repeating them.
The results are a white paper on emergency room medical malpractice entitled, “Optimizing Physician-Nurse Communication in the Emergency Department: Strategies For Minimizing Diagnosis-related Errors.” (H/t WSJ Health Blog).
Its findings? Breakdowns in communications between ER docs and ER nurses are the main source of avoidable medical errors in the ER.
To give you a flavor of the types of errors that we are talking about, the report cites an 18-year old who showed up in the ER with fever, chills and mottled skin. The nurse noted the mottled skin – a symptom of a dangerous blood infection – but the doctor never learned of the mottled skin, leading him to discharge the patient with Tylenol, only for the patient to die subsequently of shock and sepsis caused by the blood infection.
If improving communication between doctors and nurses is the key to avoiding medical malpractice in the Emergency Room, it seems to me that medicine should, once again, be borrowing a page from aviation safety methods – such as the “first name rule” – that aviation industry implemented to improve communications between pilots and the rest of the crew. But the Crico/RMF white paper doesn’t float any proposals derived from the principles of aviation safety.
Instead, it talks about “Team Training/Simulation” and professional development for nurses, among other things.
If medicine were willing to learn from the aviation industry, I might feel as comfortable in the ER as I do flying on a 747.

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The (Supposedly) Quaint Notion Of Professionalism And Its Place In The Health Care Debate

working togeather.gifA couple of weeks ago, Nobel Prize-winning New York Times columnist Paul Krugman posted a blog entitled, “Patients Are Not Consumers,” in response to continually hearing both sides in the health care debate apply the erroneous label of “consumers” to medical patients.
Krugman wrote that medical care cannot be reduced to a commercial transaction. Medical ethics forbids doctors from treating the doctor-patient relationship as a commercial relationship.
Of course, a lot of us seem to have forgotten that fact or to be ignorant of the requirements of professional ethics that limit doctors’ conduct. As Krugman writes:

The idea that all this can be reduced to money — that doctors are just people selling services to consumers of health care — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.

Krugman’s blog post came in for ridicule in some quarters. Indeed, some liberal types, like Matt Yglesias, think that medical care involves transactions that are, for all intents and purposes, commercial.
Nowadays we seem to only be able to view non-social interactions between people, whether doctor and patient or lawyer and client, through the lens of profit and loss.
The proponents of such a world view seem to think that they are simply embracing a form of realism – they are describing the world as it actually works. But, that’s not the case.
Doctors, like lawyers, by and large behave in accordance with a higher code than the almighty dollar. If they don’t, they can lose their licenses to practice law or medicine.
People, like political pundits, who work outside regulated professions sometimes fail to grasp the difference between a professional’s relationship to his or her clients or patients and the relationships between people in a typical business transaction. The two types of transactions are vastly different and different rules apply. Imagine you’re a corporation and you don’t pay your lawyer. Your lawyer can’t simply decide not to file a motion for you because he has not gotten paid; a lawyer has a professional duty not to drop the ball for the client despite the non-payment. But fail to pay your dry cleaner and see what happens.
If you’re a home builder and you walk away from a job, you may get sued and, if the job winds up costing more, you may have to pay in damages the difference between your contract price and what the job ended up costing to complete. But you will still be able to practice your trade, to build homes for other people.
If you’re a doctor, on the other hand, and you walk out of the operating room in the midst of an operation, you’re very likely to lose your license to practice, regardless of whether another surgeon is able to come in and complete the surgery without any injury to the patient.
These rules of professional ethics govern doctors and lawyers in their day-to-day conduct; witness the recent kerfuffle over King & Spaulding’s decision to withdraw from defending the Defense of Marriage Act before the Supreme Court.
The people in the health care debate who believe the relationship between doctor and patient is a purely commercial one may consider themselves cold-blooded realists, but so long as they don’t understand the ethical duties that doctors owe their patients, doctors’ behavior will always remain mystifying, as it will defy their economic models that presume doctors should act as self-interested value-maximizing characters in providing health care.
Instead of running down and mocking the notion that a relationship could have any ideal higher than the profit motive, we should be celebrating such high ideals and helping them to flourish.

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