DC Medical Malpractice & Patient Safety Blog

A piece by a doctor in Salon.com puts the lie to claims from the medical industry that a dose of "tort reform" to curb medical malpractice lawsuits will lower medical costs and make for safer health care. Quite the opposite, as pediatrician Rahul K. Parikh, M.D. explains. Two short excerpts below from his article, which is worth reading in its entirety:

Their refrain [of the AMA leaders] is familiar to anybody following the healthcare reform debate. The only problem is that it's not true. There's nothing "sure or quick" about changing medical liability laws that will improve healthcare or its costs. Defensive medicine adds very little to healthcare's price tag, and rising malpractice premiums have had very little impact on access to care.

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Tort reformers neglect the fact that malpractice reform won't save one extra life. To make that difference, insurers, doctors and their lobbyists like the AMA need to find ways to improve patient safety. So for those who push tort reform as a panacea for a sick healthcare system, working to prevent injuries is a much more noble pursuit than writing up baseless arguments for the back pages of a newspaper [in this case, the Wall Street Journal].

The recent news about the two Northwest Airlines pilots whose licenses were revoked, less than a week after they let their plane wander 150 miles off course, raises the question: Where are the firing offenses in medicine?

The pilots injured no passengers, and the event didn't even qualify as a "near miss." But because they egregiously violated safety rules by working on their flight schedules on a laptop in the cockpit, the aviation authorities did not hesitate to pull their licenses.

In the medical industry, by contrast, it is well known that a doctor will lose his or her license for only flagrant patterns of drug or alcohol abuse or other criminal behavior, with a trail of dead and injured patients usually lasting years before the practitioner is finally put out of business.

Read my entire post on this in the Huffington Post here.

One of the HuffPost comments on my blog post raised the fair point about what should be firing offenses for attorneys. Here's what I said in response:

A firing offense for an attorney should be any conduct that is unethical or negligent and hurts a client. (That's a short and probably incomplete answer to a complicated question.)

In most states, the highest court of appeals of the state has power to revoke attorney licenses. Some do a better job than others. But unlike medicine, everything happens out in the open, for the public to observe.

For patient advocates like me, the frustrating part of the medical discipline system is its secrecy and unresponsiveness. I filed a formal licensing complaint about a Maryland plastic surgeon who put a healthy patient into a permanent coma with a gross overdose of local anesthetic; two years later, I received a one-paragraph response from the state board that he had received a "private reprimand." No details available, because, after all, it's "private."

In another recent case, I complained to the Florida nursing board about a nurse-midwife whose overuse of the uterine-stimulating drug oxytocin caused the uterus to rupture and the baby to suffer terrible cerebral palsy. More than a year later, I received a one-sentence reply that the board had "failed to find probable cause."

In the law world, comparable incidents would have received at least a detailed explanation of why the licensing body was or was not taking action. That's what we should demand of any professional disciplinary system that respects the public's right to know.

The current sorry state of medical discipline is one reason I warn readers of my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst," that patients need to go way beyond looking up medical licensing discipline to make sure they are picking the right doctor for themselves.

Most doctors have to take regular continuing education courses to maintain their medical licenses. But what if the courses have a hidden agenda -- promoting the drugs of a sponsoring manufacturer?

That hidden influence has occurred far too often for the comfort of patient safety advocates, who want prescribing doctors to receive fair, balanced and neutral advice in the important subject of what prescriptions to write for sick patients.

Now the group that gives the official seal of approval for continuing education courses is taking tentative steps to curb the drug industry's influence on these courses. The group is called the Accreditation Council for Continuing Medical Education (ACCME). Its approval is necessary for a doctor to get official credit for any course taken. The head of the ACCME, Dr. Murray Kopelow, told the New York Times he will:

First, make public in the next few weeks a list of the classes and educational companies that have already been found to have broken the rules against commercial bias. This list was previously secret. Apparently there are less than a dozen names on the list as of now.

Second, consider further steps such as requiring the sponsor of a course found to be biased to send out corrective material to the doctors who took the course.

A doctor who is pushing for these and stronger reforms is Dr. Bernard Carroll, who filed a lengthy complaint about an online course on treatment of major depression, which he said was strongly biased by hiding bad information about the drugs of the sponsor, AstraZeneca.

The Times reported:

Dr. Carroll faulted the accrediting council for taking nine months to resolve the complaint, allowing the program to rerun and failing to notify doctors who had taken it. “They’re more interested in protecting the providers than watching what gets put out there as education,” Dr. Carroll said in an interview.

Here is Dr. Carroll's own blog posting on the subject.

The steps taken so far by the accrediting body are modest, but go in the right direction. Let's keep watching. As another industry critic, Dr. Bernard Lo, said, it's okay for the drug industry to support medical education. What's not okay is to create commercial bias in favor of one or another company's products.

Prostate surgery with a robot called "da Vinci" is often sold to patients as the latest and greatest technology and a way to get a better outcome. But on the key long-term complications -- urinary incontinence and erectile dysfunction -- the "minimally invasive" robotic surgery may be no better than traditional surgery, and may be worse if the operator is inexperienced.

A new study in the Journal of the American Medical Association criticizes the benefits of the "minimally invasive" surgery as oversold. The operation does cut the average time in the hospital from three days to two, but brings with it both more short-term complications plus more long-term injuries like impotence.

The lead author is Dr. Jim Hu of Brigham and Women's Hospital in Boston. "There has been rapid adoption of minimally invasive radical prostatectomy, however, outcomes have not been superior," Hu said.

Surgeons are trained to use the robot in a weekend course with the manufacturer. Dr. Hu said that a big part of the problem could be surgeons not getting enough experience with the device. He said he has now done more than 700 robotic prostate surgeries, but "it took several hundred cases before I thought I was doing really well in preserving erectile function and continence."

Articles about the new study can be found here and here

The new study brings home an issue that is discussed at length in Patrick Malone's book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst. Choosing the right surgeon is key to success, and patients need to ask about the surgeon's volume of cases exactly like theirs. For robotic prostate surgery, it's easy to find a surgeon with hundreds of cases. If that's an option, why would anyone settle for a surgeon who has only done a few dozen?

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State medical boards are important agencies that can take away a license from a doctor who is dangerous to patients because of drug addiction, ethical lapses or incompetence. Routinely, however, the boards turn out to be focused more on protecting wayward doctors than protecting the public from malpracticing doctors.

Here is how a new article in the Dallas Morning News opens:

Seven years ago, after a scathing series of stories in The Dallas Morning News, the Texas Medical Board promised to crack down on bad doctors. Patient endangerment would be dealt with severely. And sexual misconduct, one official said, would become "intolerable."

It hasn't turned out that way.

After its last meeting, in late August, the board announced decisions on four sex-related cases. Two involved doctors whom judges had already sentenced for crimes against children. Two involved psychiatrists found to have had affairs with adult patients – potentially sexual assault under Texas law, but they've not been charged.

The child abusers were allowed to go on practicing medicine, though not with kids. The other two are working without restrictions.

It's all part of a broader pattern of tolerance for misconduct, a News analysis shows. Others who kept their licenses after the August meeting include two doctors convicted of lucrative federal crimes that put patients in harm's way; a neurosurgeon who operated on the wrong body part four times; a cardiologist found to have performed dozens of invasive procedures with little or no cause; and at least seven physicians linked to a death.

In all, 131 doctors were disciplined at the meeting. Only two had their licenses revoked, and then only because they quit contesting the cases against them. A handful of others were suspended or surrendered their licenses rather than fight.

Readers are urged to look at the entire story.

This is depressingly familiar to patient safety advocates. Thirty years ago, I participated with a team of investigative reporters at the Miami Herald where we uncovered similar attitudes. (See discussion on my bio page.)

One key part of the pattern is that medical boards are dominated by physician members. There is no reason why this needs to be. Any intelligent public-minded citizen can understand issues like sex abuse of patients, drug addiction, wrong-site surgery and the other serious transgressions that the boards deal with.

Yet another problem is that even when boards act, their actions are so shrouded in secrecy that patients often never find out that their doctor has any issues. That is why in my book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, I counsel patients looking for a doctor not to rely heavily on a "clean slate" when they search for medical disciplinary actions. That can often be meaningless. Even an empty listing on medical malpractice lawsuits can be meaningless, when those are settled quietly and the records sealed.

The CEO of Beth Israel Deaconess Medical Center in Boston is speaking out about his hospital's efforts to prevent deadly infections. The question is: How come few other hospital executives are talking about their efforts? Are they not making vigorous efforts? Or are they obsessed with secrecy, as so many in the medical industry are?

Paul Levy posted his hospital's numbers on reducing "central line" infections -- the infections that patients in ICUs get in the large-bore tubes that have to be inserted to monitor activity in the heart and deliver medicines to really sick people. When these infections occur, the already sick patient often dies. Pioneering work by Dr. Peter Pronovost proved that rigorous hand washing and other sanitation practices can reduce these infections to close to zero.

Mr. Levy is justifiably proud of Beth Israel's hard work at getting its infection rate down. But he wrote a blog entry that talked about his disappointment that others have not joined in. Here's an excerpt:

The response to my public and private entreaties in this realm has been silence -- from hospital professionals, from insurance executives who care about a transformation of this industry, and, indeed, from public advocacy groups who care about access to care and the quality of care delivered. Some observers attribute the medical profession's lack of engagement to an underlying fear of transparency. And yesterday, a world expert in this field, whose wisdom and advice I treasure, told me that he has come to accept gradual progress in quality and safety improvement, citing the kind of training doctors get, which does not emphasize these areas. That such a person has become content with gradual changes in the status quo is an indication of what it must be like to beat your head against this wall of recalcitrance for several decades.

My advantage, being without medical training and having had but a short tenure in this field, is that I retain a sense of outrage. Our collective failure to approach this problem using well established methods of process improvement -- including publication of current performance results -- represents a moral and ethical lapse by the clinical and administrative leadership of the medical establishment in this city. Why? Simply put, a profession that takes an oath to do no harm is, by inaction or incomplete action, doing harm. 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?

Here's the full blog entry, which has comments below it.

I learned about Mr. Levy's blog from Consumer Union's excellent blog at their Safe Patient Project website.

Dale Ann Micalizzi took her 11-year-old son Justin to a hospital in upstate New York one evening because his ankle had an infection that needed to be drained. It was supposed to be a 10-minute procedure. Justin never woke up.

That happened in 2001. Today, Dale and her husband Gary head up a non-profit group called Justin's HOPE, which is dedicated to improving health care for children. She speaks often to medical staff in hospitals. One important message she gives to hospital administrators: When a mistake has happened, deal openly and honestly with the parents.

Any parent who can turn their grief into something positive is a real hero. Especially when that child has died an unnecessary, preventable death due to medical errors, the easier thing would be to retreat into numbness and bitterness. So I salute Dale Micalizzi.

I celebrate a number of heroes of the patient safety movement in my book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst.

You can read more about Dale's advocacy in an article in the Schenectady Gazette.

A North Carolina mother who lost her 6-year-old son to preventable medical errors writes a moving response to talk of "malpractice reform" and "defensive medicine." Laurie Sanders opens her story in the Charlotte Observer with these lines:

Medical negligence isn't a topic I gave much thought to until my 6-year-old son went to the hospital sick for the first time in his life and died of oxygen deprivation. A happy little boy, with no history of breathing problems, no allergies ... never sick. Christopher was my only son. His daddy, my husband, had died of cancer a few years earlier.

In experiencing the death of my husband and son, I have seen the best medical professionals and the worst. I have seen the most caring, and the least.

I buried my husband knowing that medical professionals did everything they could. I buried my son knowing that medical professionals failed him at the most basic level.

Ms. Sanders tells what happened to her son, including the legal investigation she launched to get at the truth, and then offers these thoughts:

One of the lessons of Christopher's unnecessary death - and my necessary lawsuit - is not that health care providers need to engage in cost-inflating "defensive medicine." Instead, it is that doctors and nurses must pay attention, communicate with their colleagues and adhere to well-recognized standards of practice.

Patrick Malone was interviewed on the People's Pharmacy radio show on how to avoid medical injuries and get the best care for you and your loved ones. You can listen to a podcast of the show by clicking here.

The hosts of this syndicated public radio show are an interesting couple. Joe Graedon is a pharmacist, and Terry Graedon is a medical anthropologist.

In their interview with Patrick Malone, Joe Graedon shares his own story about a medical tragedy that happened to his mother. The lesson: Any time you have a loved one in the hospital, you need to arrange for 24/7 presence there by a family member or close friend. It's very important to have an advocate with you at all times. Patrick Malone's book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, has an entire chapter on all the ways that an advocate can help prevent injury and get you home safely from a hospital stay.