DC Medical Malpractice & Patient Safety Blog

A subway station might seem an unusual place to try to educate the public about protecting the rights of injured patients -- but maybe not so much when that station is the nearest to the Capitol building in Washington, D.C., and is traveled by thousands of staffers who work on Capitol Hill.

"Tell Congress to put patients first," the ads say. "There are 98,000 reasons why you should. 98000reasons.org."

The number refers to an oft-quoted report from the National Academies issued ten years ago that estimated that 98,000 patients died unnecessarily each year from medical errors.

Since then, as this blog has reported, the estimates of preventable deaths have climbed, despite a spate of efforts to make medical care safer.

The new ads are sponsored by the American Association for Justice, the lawyers' group that includes attorneys like me who represent patients in malpractice lawsuits. The ads are discussed in an article by Elizabeth Olson in the New York Times.

Several thought-provoking letters appear in the New York Times responding to the recent piece about the cancer treatment industry's advertisements. One letter was from Dr. James Rickert, of Bloomington, Ind., president of the Society for Patient Centered Orthopedics:

To the Editor:

As a cancer survivor who has faced recurrent bouts of disease, I agree that the intense marketing campaigns used by cancer centers only heighten the stress and anxiety of the difficult treatment decisions that all cancer patients face. It becomes nearly impossible, at a time when one feels that any poor decision could be fatal, to wade through all the non-science-based claims for success.

As a physician who treats many patients with terminal metastatic disease, I have seen that this marketing often leads to heart-wrenching guilt and second-guessing by patient and family alike when treatments fail. Rather than being allowed to accept that their disease was incurable despite the best medical care, patients often feel that they are somehow to blame for choosing the wrong institution in which to receive treatment.

This is a distressing example by our nation’s finest medical centers of the shameful practice of placing financial concerns before the needs of the patients that they claim to serve.

If our academic medical centers cannot offer better patient-centered, evidence-based care than this, where in the world shall the medical community look for leadership?

Dr. Rickert makes an even better case than I could about the dangers of relying on advertising to make important decisions.

A physician writes in the New York Times about her own emotionally trying experience being sued for malpractice by a patient's family, and seeing the case dropped after four long years of litigation. The case happened to be against an internist for colon cancer, something where I have fresh experience. Here is the text of my comment on the Times' website:

In Dr. Savitsky’s account, it’s hard to understand how an internist would be sued for a patient’s colon cancer, and many commenters railed that this was an example of “frivolous” lawsuits or patients suing their doctors for being guilty of mere human error.

I know nothing of the facts of Dr. Savitsky’s case. But I do know how an internist can come to be sued for colon cancer. I just mailed a settlement check today to my client, a widow who lost her husband at age 59 from an entirely curable colon cancer. We successfully sued her husband’s internist for egregiously failing on multiple occasions to follow basic rules of medical practice in treating middle-aged men. I wrote more about this case a few months ago on Huffington Post.

Yes, there are occasions when our litigation system bruises people who don’t deserve it. Far more often, it is the only way that ordinary folks have to call to account those who have broken the rules and caused serious harm.

There are many other thoughtful responses to the doctor's column on the Times' site. Here is just one:

I have very mixed feelings about all of this.

It’s easy for outsiders to pass judgment on how the patient/family is supposed to feel after a bad outcome. It’s easy to apply cheap armchair psychology and decide the family is angry, or in denial, or looking for someone to blame, or that they have a lottery mentality or that they don’t know how to constructively handle their grief. The attitude seems to be that they should just shut up and be grateful for the health care they received.

Unless it’s happened to you, you really have no idea of how you’re “supposed” to feel. Take it from someone who’s been there: I was truly shocked at the level of rage and depression I experienced. I never, ever thought I would say this, but I now understand a lot better why some people sue… and I am a lot less likely to judge them harshly for it.

That said, I appreciate Dr. Savitsky’s story and I’m glad she shared it. If only we could have heard the family’s side of the story as well. Maybe then we would all have a better understanding of what the experience is like on both sides of the fence. Because right now, judging from the conversation here, most of us don’t understand.
— Perrin

The ads are striking: Handsome, smiling people, very much alive, victors over cancer -- thanks to their choice of a prestigious cancer center for their treatment. But are they true?

The cancer centers -- with brand names like Sloan-Kettering and Massachusetts General -- cannot prove that the patients are alive because of something unique about their institutions. But they don't have to prove anything, under the law. If a drug manufacturer wanted to make a similar claim, it would have to line up statistical evidence, and the ads would have to have a lot of disclaimers. The ads from the cancer centers have no such disclaimers, and little to no backup from statistics.

Natasha Singer has a thoughtful article in the New York Times exploring these ads and what patients who are looking for cancer treatment should do.

The marketing executives who craft these ads say they're not even aimed at current patients -- but are more "reputation advertising," as one told the Times.

The article has a good sidebar that gives tips for how patients should shop for cancer treatment.

A regular community hospital can be fine for common cancers like colon, but for anything unusual, it's best to look for a center that sees a lot of that condition.

The National Cancer Institute designates Comprehensive Cancer Centers for their scientific excellence and comprehensive approach. Here is a list from the NCI. Ironically, these are some of the same centers with the heavy advertising budgets.

In my book, "The Life You Save: Nine Steps for Finding the Best Medical Care -- and Avoiding the Worst," I discuss the importance of a multi-disciplinary approach where doctors from different specialties collaborate together on figuring the best line of attack to a particular patient's cancer. Most advanced centers have "tumor boards," where these collaborative discussions occur, usually at no extra charge to the patient.

An interview with patient safety leader Dr. Robert Wachter in the New York Times was both encouraging and dismaying. Encouraging because Dr. Wachter gets it right about what the medical system needs to do to make health care safer. Dismaying for some of the shrill and hysterical comments from physicians posted on the NYT blog in response.

Dr. Wachter, a hospitalist at UC-San Francisco, made a number of sensible points, including:

* Financial incentives need to be better aligned with safety. Instead, the incentives are mostly focused on getting paid by insurance companies. Quote:

"For instance, I can lose my hospital privileges if I fail to sign a dictated discharge summary or operative note. But if I don’t clean my hands for the next 10 years, nothing will happen to me."

* More honesty is needed when confronting errors. Quote:

"The only way we are going to fix this problem is to become much more open and transparent. That transparency will drive us to improve and allows us to educate each other."

* Standardizing safety routines is urgently needed. Quote:

"The chaos of everyone doing things their own way is incredibly dangerous, and it is that chaos which gets in the way of the [doctor-patient] relationship. You can make health care better, safer and less expensive while strengthening the core of the patient-doctor relationship. You can standardize certain parts of care based on clear evidence, which will free up doctors to focus on those pieces of the health care puzzle where there is no data — those issues that are uniquely human and that require judgment, expertise and empathy."

Now for the dismaying part. If you scroll through the "Well" blog comments on Dr. Pauline Chen's interview with Dr. Wachter, the ones with "MD" behind their name jump out for their ... well, judge for yourself:

A reader who identified himself as Dr. Mark Johnson: "Wachter is attention-craving sensationist, apparently employed by NYT on their anti-doctor crusade. Is he even practicing medicine? Has he ever worked outside of academia?"

Another reader who signed as Anonymous: "It’s simple. If you don’t trust the medical system, just don’t use it. Don’t come see me when you’re in a trauma. Don’t come see me when you want an elective procedure. Just don’t come see me. It saves me the energy that I waste catering to people who hate me and distrust everything I do."

Another one, who identified himself as Mark Davis, M.D., had a similar suggestion that patients should just move out of the country if they don't like it.

Back to a more encouraging take:

It was good to see many, many other readers writing in with thoughtful comments and ideas about how we can improve health care for everyone. The only ones that made me wince were those that demonized lawyers who represent injured patients. Some of them have the naive idea that if lawsuits were lessened, everyone in health care would come forward with more honest confessions about their errors, which would lead to vast improvement. The fact is that even countries with very little malpractice litigation, like England, have the same problem with the culture of secrecy in medicine.

Killing the messenger who delivers the bad news won't solve the problem.

A drug that can cut a woman's risk of breast cancer in half when taken regularly is proving to be a tough sell when women have a chance to fully understand the pros and cons of the medication.

The drug is tamoxifen. For women at high risk of breast cancer (who have a gene associated with it or a close relative with breast cancer), tamoxifen can reduce the odds of developing breast cancer by 50 percent. Yet recent studies show that when the statistics are laid out for women to make an informed choice, only one in 100 actually fill the prescription.

Are the women who decline to take tamoxifen being illogical? Or just making their own personal choices about what is important to them?

Tamoxifen interferes with the body's use of estrogen. That can lower the risk of estrogen-dependent breast cancers but can increase the risk of other estrogen-related side effects like cancer of the endometrium (the lining of the uterus), blood clots and sexual dysfunction.

Here is how the numbers were spelled out to women in a recent study at the University of Michigan, as reported by Tara Parker Pope in the New York Times:

The risks of breast cancer vary with age, family history, and age of first childbirth. So a 52-year-old woman who had her first baby after age 30 and whose mother had breast cancer, has about a 1.9% risk of developing breast cancer over the next five years. If 1,000 women just like this 52-year-old took tamoxifen over those five years, the research says that here is what would happen:

* Of the nineteen women (same as 1.9%) who otherwise would have developed breast cancer, nine will not develop breast cancer. (Thus the statistic about lowering the odds by half.)

* Thirteen women would avoid broken bones from osteoporosis, another benefit of tamoxifen.

* Twenty-one women would develop endometrial cancer (typically more treatable and less deadly than breast cancer if caught early).

* Twenty-one women would develop blood clots.

* Thirty-one women would develop cataracts.

* Twelve women would experience sexual problems.

* One hundred twenty extra women would get hot flashes and other menopausal symptoms (in addition to those who would get such symptoms anyway).

Behavioral economists might say this is an example of "omission bias," where we are more worried about a small risk from doing something new (taking a pill) than we worry about a larger risk from doing nothing. Put another way, we often see the status quo of doing nothing as safer when it really isn't.

At least that's how the researchers quoted in the NYT article explained the unpopularity of tamoxifen. But for readers who posted comments on the newspaper's blog, they tended to see the women voting against tamoxifen as being quite sensible. It just doesn't sound worth the downside.

Part of the problem is the apples-to-oranges comparisons involved when a fatal condition is compared to a non-fatal one. As one commenter posted:

What might make women make better choices is if they had data on whether the pill reduced the risk of DEATH from all causes. If only some of the breast cancers avoided would have resulted in death but all of the endometrial cancers aquired resulted in death, women might make the choice to avoid tamoxifen. If the risks were reversed, they might choose to take tamoxifen. We have to move beyond a discussion of risk of cancer and towards a discussion of risk of cancer DEATH. http://www.medpie.com — Barbara Lock, MD

If we had the same careful discussion about mammograms, women likely would opt for far fewer of these tests, which save lives on a similar scale as tamoxifen, with plenty of downside.

My conclusions from this debate:

* Patients need to know there are no magic bullet drugs that are all gain, no pain. Tamoxifen interferes with estrogen, which is good for some diseases, not so good for others. This is typical. Each drug must be carefully weighed for its pros and cons.

* We're all better off with a full exploration of the odds and then make our own decisions. There is no right or wrong.

* The best way to understand risk is the way it's spelled out here: with numbers of actual people in a given standard-sized group. It's too confusing when we talk about percent this and percent that.

I tell readers how to do this technique of "counting the people" in my book: The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst.

Almost nothing is worse in medicine than a cold-hearted delivery of bad news that sucks all the hope out of a patient's lungs. And almost nothing is better than an honest dialogue between doctor and patient that explores the hopes and fears of a patient faced with a very serious condition, in a way that allows for hope in some form to continue to exist. Because we know that when all hope ends, life does too.

Dr. Chris Feudtner, a bioethicist at Children's Hospital of Pennsylvania, has a sensitive essay on this topic in the New England Journal of Medicine. He titled it "The Breadth of Hopes."

His idea is that all of us have a range of hopes that are necessary to carry on with daily life; some are fanciful and others are very concrete and specific.

Doctors need to nurture hope while helping patients redefine what it is they hope for. Even hoping for a miracle in the face of an incurable disease is not necessarily something that doctors should scoff at. As he writes:

Judging such a hope as either realistic or false misses the point; rather, we should judge ourselves as clinicians by the degree to which we can help nurture our patients' collection of diverse hopes.

This is not to say doctors should encourage unrealistic Pollyanna thinking by patients.

Dr. Feudtner hopes to develop better tools to help patients and families in the emotional end of coping with disease. He concludes: "as clinicians, we need to more carefully work through what separates the appropriate management of hopes from their inappropriate manipulation, because whether we want the responsibility or not, we constantly interact with our patients' hopes."

Actor James Woods' brother Michael died of a heart attack three years ago in an emergency room hallway in Rhode Island because no one was paying attention. Now, something good will come from Michael Woods' death, thanks to a settlement reached between the Woods family and Kent Hospital in the middle of a jury trial.

The settlement creates a new institute to help teach hospital staff how to pay better attention to patients and develop a more "human-centered" standard of care.

An impasse between the two sides in the trial was broken when the president of the hospital, Sandra Coletta, called James Woods the night before the actor was going to testify about his brother's death. As reported in the Providence Journal:

In that call, he said he heard something he’d never heard from Kent Hospital before, someone saying she was sorry for his family’s loss. ... Woods said the family’s peace of mind about the agreement was helped when Coletta met his mother, Martha.

“Sandra and my mother had a very personal moment, a mother-to-mother conversation,” Woods said, calling it a “sweet and dear way to express sorrow.”

“It was all I ever needed to see in my life,” Woods said, “one human being saying to another human being ‘I’m sorry for your loss.’ ”

In announcing the new Michael J. Woods Institute, which will be funded by $1.25 million of the hospital's money, hospital president Coletta said:

"We know we're not perfect at Kent Hospital. Mistakes were made. We can do better. The Michael J. Woods Institute will help establish a leadership role in promoting patient safety and developing new ways to improve the patient experience and clinical outcomes."

This is one often-overlooked benefit of the civil justice system: producing positive safety reforms to try to reduce the toll of medical error. An actor's celebrity helped make that a reality in Rhode Island. On a quieter level, similar positive events happen at the end of many lawsuits, where families who have lost a loved one insist that part of the settlement go toward education and system reforms to make hospitals safer places. Patient safety advocates like me believe this is one of our highest callings.

How is our medical care system like American agriculture before the era of modern food-growing practices? Pretty similar, argues Dr. Atul Gawande in the New Yorker. Both were expensive, wasteful of human resources and completely fragmented. And the cures for their problems could be similar too.

What reformed American farming and turned it into a world leader in producing low-cost food was the "extension" system that the government set up for teaching farmers, one county at a time, what worked and what didn't work.

Dr. Gawande argues that the 2,000-page health care reform bill now in Congress has an optimistic prospect for using many pilot projects in funding health care to figure out what works to lower costs and increase safety and quality. It's a fascinating argument, and I hope he is right.

I only differ from Gawande on one thing: he takes swipes at malpractice attorneys and the lawsuit system as contributing to the waste. That has not been borne out by careful studies. Moreover, patients need a robust system of advocacy for when preventable injuries have occurred. So far, no better system has been developed for getting to the bottom of what happened, to try to prevent it from happening again, and to give the patient fair compensation.

Medicare's "Hospital Compare" website is something every patient needs to know about. Based on statistics collected by the government program for medical care for patients over age 65, the website has a wealth of information -- not always easy to find, but interesting.

One recent addition to the site is information about the volume of business a hospital has for a variety of selected common surgical procedures -- such as coronary artery bypass, gall bladder surgery, intestinal surgery and a number of others. The numbers give you an idea of what a particular hospital's bread and butter is, and whether there is some hospital in town that does a lot more of that surgery.

As I wrote in my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst," it's best for a bunch of reasons to go with a hospital that sees many patients just like you. The doctors and nurses have more practice in handling your type of condition and are more aware of the kinds of complications that can occur and what to do to prevent or stop them short of disaster.

Another important website run by Medicare is "Nursing Home Compare.". This site is even easier to use because it has a five-star system of rating nursing homes. Within a short distance, you can find a huge range of quality, as measured by staffing, inspections and other quality indicators.

It's a lot harder to compare hospitals, because a hospital that is excellent for one kind of patient can be not-so-good for another. But both Medicare websites are worth a close look if you have a loved one who needs to go to a hospital or nursing home.