DC Medical Malpractice & Patient Safety Blog

If you don't have high cholesterol, but you do have a high level of inflammation in your blood, you are about to be targeted by a new marketing campaign for Crestor, the statin drug. You will be told the drug can lower heart attack risk by as much as 50 percent. Should you swallow this advice, and should you take a daily dose of these pills for the rest of your life?

The downside of statin pills is the possibility that they increase risk of diabetes and liver damage. The upside, of course, is reducing your risk of dying from the nation's No. 1 killer, heart disease. So it's important to know accurate numbers to make an intelligent decision.

The 50% reduction in heart attack is actually a statistical sleight of hand. The correct risk reduction number is actually around one in 500, or 0.2%. To understand the number manipulation involved, read on for a gentle short course in medical statistics.

These numbers come from a big study that the FDA used to give the green light to Crestor's new marketing campaign. The researchers found that around four in 1,000 patients with a high level of C-Reactive Protein (an inflammation marker in the blood) but with normal cholesterol had heart attacks if they took a dummy (placebo) pill in the study. Similar patients who took Crestor had a heart attack rate of around two in 1,000. These numbers come from the tail end of a new article in the New York Times on the FDA's approval of the new Crestor campaign.

Now the difference between four and two is 50 percent, but that conveniently leaves out the denominator in the statistic. The real risk reduction is from four in 1,000 to two in 1,000, or a difference of two in 1,000, which is the same as 0.2 percent. The 50 percent number is called the relative risk, and the 0.2 percent number is the absolute risk. Absolute risk is what measures real people and is the one we should focus on, but marketers like relative risk because it produces more dramatic numbers. Put another way, you can have statistically significant benefits from taking a drug on paper, but the clinically significant benefit, in real life, is much much smaller.

In my book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, I discuss the Crestor story because it's just one example of how consumers can be misled by medical numbers. There's a straightforward solution, which I call "counting the people," when you are looking at any supposed medical breakthrough. Here's what I said in the book:

The real number [of how many patients benefit from a drug] might be enough to persuade some patients to take the drug. But it's a lot different than fifty percent. Bottom line: to make intelligent choices about treatments, patients need to understand how many patients like them are really expected to benefit from the treatment. You can get these answers by focusing on how many actual people are helped by the treatment. Do not focus on misleading vague numbers like “50 percent improvement.” Fifty percent of what? Focusing on real numbers of real people will give you the answer.

As a patient safety advocate, I want all smart consumers of health care to know at least a little bit about statistics -- because the real numbers can be very eye-opening.

It's helpful to look at the actual facts, not supposition, about so-called "tort reform" and medical malpractice, because so many medical leaders persist in arguing that curbing victims' rights to accountability for medical injuries would make the health care system better.

The following discussion is courtesy of Joanne Doroshow, the head of Center for Justice & Democracy, and based on a submission she made to the Medicare payment review board.

No serious economist believes that medical malpractice litigation is a major driver of health care costs. In over 30 years, medical malpractice premiums and claims have never been greater than 1% of our nation’s health care costs.

Senator Orrin Hatch asked the Congressional Budget Office to look into the cost issue. CBO responded in an October 9, 2009 letter, trying to determine health care cost savings if Congress enacted a menu of extreme tort restrictions advocated by the medical lobbies, the insurance industry and a lot misinformed doctors. CBO could go no further than to find an extremely small percentage - about 0.5% - of health care savings by wiping out most litigation, legitimate and otherwise (which is what these measures would do – see the Texas example, below). This is far lower than the highly exaggerated numbers thrown around by those who would like to restrict patients’ rights. Alexander C. Hart, “Medical malpractice reform savings would be small, report says,” Los Angeles Times, October 10, 2009;

To reach the 0.5% savings figure, CBO determined that 0.3% was specifically due to defensive medicine. That’s it. Moreover, CBO found little evidence of this “defensive medicine” phenomenon except in studies of Medicare, not studies of private managed care systems. Obviously doctors operate under the same liability rules no matter the system of payment or the age of the patient, so the explanation for this disparity cannot lie with the legal system. Rather, according to CBO, the problem is Medicare’s emphasis on “fee-for-service” spending, whereas private managed care “limit[s] the use of services that have marginal or no benefit to patients (some of which might otherwise be provided as ‘defensive medicine’).” In other words, CBO suggests that to the extent defensive medicine exists at all, it can be controlled through simply managing care correctly as opposed to taking away patients’ rights and possibly killing and injuring more people.

As far as medical malpractice premiums, CBO attributed 0.2% to this cost. This insurance industry continuously fights its own figures on this, but I think they speak for themselves. (See, e.g, a New York Times article.) And here’s what the figures say:

• Medical malpractice premiums, inflation-adjusted, are nearly the lowest they have been in over 30 years. The periodic premium spikes that doctors experience, as they did from 2002 until 2005, are not related to claims, which have been steady or dropping for many years, but to the economic cycle of insurers and to drops in investment income. In fact, medical malpractice claims, inflation-adjusted, are down 45 percent since 2000.

• Medical malpractice insurer profits are higher than the rest of the property casualty industry, which has been remarkably profitable over the last five years.

• Many states that have resisted enacting severe restrictions on injured patients’ legal rights experienced rate changes (i.e., premium increases or decreases for doctors) similar to those states that enacted severe restrictions on patients’ rights, i.e., there is no correlation between “tort reform” and insurance rates for doctors.

All the data backing up these statistics can be found here: For more information, contact the study’s main author, actuary J. Robert Hunter, former Federal Insurance Administrator under Presidents Carter and Ford, former Texas Insurance Commissioner, and now Director of Insurance for the Consumer Federation of America.

Finally, you may be familiar with the widely-read and cited June 1, 2009, New Yorker magazine article by Dr. Atul Gawande, “The Cost Conundrum; What a Texas town can teach us about health care,” which explored why the town of McAllen, Texas, “was the country’s most expensive place for health care.” The following exchange took place with a group of doctors and Dr. Gawande:

“It’s malpractice,” a family physician who had practiced here for thirty-three years said. “McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down? “Practically to zero,” the cardiologist admitted.

“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.

This is true for all states that have enacted "caps" and other restrictions on patients' rights. Moreover, CBO noted that “imposing limits on [the right to sue for damages] might be expected to have a negative impact on health outcomes” and cites one study finding such tort restrictions would lead to a 0.2 % increase in the nation’s overall death rate. If true, that would be an additional 4,853 Americans killed every year by medical malpractice, or 48,250 Americans over the ten-year period CBO examines. This should be unacceptable to us as a nation.

It's a wonderful, Star-Trek kind of fantasy: have a machine scan your body and turn up any abnormalities in minutes, with no pain, no inconvenience and little fuss. Some patients actually do it: with whole-body CT scans, or more targeted CT scans aimed at the colon (often called virtual colonoscopy -- President Obama had one) or the heart.

The problem is there's no good evidence yet that these scans are worth the expense or the huge dose of X-ray radiation that a patient receives: typically the equivalent of 400 chest X-rays with a single CT scan.

General Electric, a manufacturer of CT scan machines, is trying to get the Food and Drug Administration to give its official approval to the use of CT scans as a substitute for traditional colonoscopy. The application is still pending. At a hearing this week, FDA scientists are expected to complain about the pressure they felt from agency superiors to approve the application despite their concerns about the radiation risks. Read more on this in an article by Gardiner Harris in the New York Times.

Whole body screening with CT scans is something that few sober doctors recommend, unless they own one of the machines. The FDA has a good discussion here explaining why an apparent "abnormality" found with a whole-body scan can mean nothing, while the scan can also miss true disease.

The bottom line is that the images produced by these machines are good, but not good enough to start cutting out the abnormalities they seem to show. With colon, heart and other body parts, no surgeon will operate based solely on a CT scan. They want a closer look with a scope that shows the actual organ -- as a colonoscope does.

The other important fact to know about whole-body screening is that if you feel good and have no disease symptoms, the odds are very high that nothing is wrong with you. No screening device yet beats the human brain at picking up signals of abnormality (with a few exceptions like the silent disease of high blood pressure).

The free meals, trinkets and other goodies now lavished on doctors by the prescription drug industry will soon be a matter of public record for each doctor in the United States, under a provision of the new health care reform law. A searchable database goes into effect in 2013 that will let anyone plug in a doctor's name and find out how much largesse that doctor received in the past year. This is a positive development for patient safety in the United States.

Readers of this blog know from past reports that even small "gifts" from manufacturers are highly effective in influencing doctors' prescription writing habits. The industry spends about $1 billion a year in free meals for doctors and many more dollars in countless free pens, scratch pads, textbooks and other trinkets branded with the names of various drugs being promoted. (As we reported in another post, deep-sea fishing trips and golf junkets are also part of the blandishments.)

Do small gifts matter? Yes, as the Pew Prescription Project points out in an excellent fact sheet that summarizes the studies on how doctors' decisions about drugs are influenced by manufacturers. As the Pew researchers write:

[T]he evidence is clear: gifts, even small ones, change behavior. Such marketing drives up drug costs and sometimes puts patients at risk. Social science research ... shows that a gift of any size imposes on the recipient a sense of indebtedness. This need for reciprocity is a deep-seated human reaction. It creates in the recipient, whether consciously or not, a sense of obligation to repay favors, gifts, invitations, etc. Research shows that it takes extraordinarily little to bias an individual’s interpretation and processing of information. Such bias is both subtle and unintentional.

Now, that's "subtle and unintentional" bias on the part of the doctor receiving the gift. Most doctors will deny heatedly -- and honestly -- that drug freebies have any role in how they prescribe medicines. The manufacturers, who study this closely, know otherwise. There is nothing "unintentional" about the way they spend money on seemingly innocuous trinkets like pens.

The new reporting law requires the drug manufacturers to report to the government everything of value given to any doctor or teaching hospital, starting January 1, 2012 (and the government web site has to be up by September 30, 2013).

Manufacturers do not have to report gifts worth less than $10, but if the total of those gifts in one year to any doctor reaches $100, then all gifts have to be reported. There are a few other exemptions and other details worth reading in this "Sunshine" fact sheet from Pew.

Free samples of drugs also will be covered by another part of the law. As I have reported before, thoughtful doctors don't even accept free samples because that can bias their prescriptions away from "tried-and-true" medicines toward newer drugs with uncertain safety records.

I have a chapter in my book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, educating consumers on how to use prescription drugs safely. One of my key points is that people need to realize that the first few years a new drug is on the market -- during the time of its heaviest promotion by the manufacturer -- is also the most dangerous time for the patient to try the drug, because early users are basically guinea pigs.

This new law infringes no doctor's freedom to accept gifts from industry, and doesn't impact any patient's freedom to patronize such doctors. But with education and "sunshine" about how these gifts create conflicts of interest for the doctor, we can hope that the torrent of freebies will start to slow. All patients will be better off if the education doctors get about new drugs is not influenced by industry gifts.

American medicine is moving rapidly from small doctor-owned medical practices to large corporate-run clinics, a trend that will likely mean safer care for patients, but with a loss of close relationships with personal doctors.

Just since 2005, the percentage of doctor-owned practices has declined from over two-thirds to less than half, as doctors face a myriad of financial pressures, according to an article by Gardiner Harris in the New York Times.

Patients typically get better coordinated care in the large group practices now emerging as the model for medical practice. When doctors work together under one umbrella, it's easier to pass the patient from primary care to specialist to hospital without the communication gaps that cause so many tragedies and give rise to malpractice lawsuits. The larger practices also can better afford the electronic medical record systems that help this coordination.

Big practices also spell loosening of the intimate bond between doctor and patient, just like Costco and Walmart spelled the end of close relationships that many of us had growing up with our neighborhood merchants. But closeness and a sense of trust are much more important to the healing process than buying groceries. So the challenge for medical leaders will be to find ways to keep big medical practices from becoming too impersonal.

Whether this trend will slow rising medical costs is another question. Many of the large companies gobbling up doctors' practices are monopolies in the towns where they operate, making them more able to resist reimbursement cuts by insurance companies.

An article by Jane Brody in the New York Times, "When Your Looks Take Over Your Life," draws attention to a tragic mental health issue called "body dysmorphic disorder."

These are people who are obsessed about a "flaw" in some aspect of their bodily appearance, and who sometimes subject themselves to repeated rounds of cosmetic surgery to "cure" this problem. And of course the surgery never works because the problem is much deeper than the skin. A malpractice lawsuit is not the answer for these patients, as I explained in a comment on the New York Times' "Well" blog:

As a malpractice attorney who represents patients, I have been consulted several times by potential clients whom I later realized had body dysmorphic disorder. When they called for the appointment, the story on the telephone was that they had been grotesquely disfigured by a cosmetic surgeon, often with repeat surgery. Then when I met them, I would not be able to see anything wrong with their appearance, even when they pointed it out to me.

One man in his mid-20s had had his nose operated on three times by the same surgeon. All I could see was that one nostril was slightly larger than the other. He was talking about needing to have yet another surgery. I politely urged him to see a psychiatrist first, and told him I could not represent him in any legal action against the surgeon.

My personal belief is that an ethical cosmetic surgeon would decline to operate on anyone with obvious signs of body dysmorphic disorder (if for no other reason than that this will be a hard-to-please patient), but a willing patient with the means to pay for the surgery can be persuasive for some surgeons, it seems. (Witness Michael Jackson.)

The legal system does not have good answers for these patients. A lawsuit would only perpetuate the patient's idea that their appearance can be "fixed" and that it's the doctor's fault for not doing so. Still, my heart goes out to people with this disorder especially when they subject themselves to a fruitless round of surgeries. They definitely need counseling.

Read more comments on the Well blog here.

A new website has tools for learning how to speak up effectively when you've had a bad health care experience. That can be anything from being on the wrong end of someone's rudeness to being the victim of a serious malpractice event. The website is called The Assertive Patient. Click here for the link. It comes out of Massachusetts but has good resources for patients everywhere.

The website has a good diagram here that shows the steps involved in getting resolution to a bad experience, especially if it's in a hospital. You start with talking with the providers involved and if they are non-responsive, the hospital will have some sort of patient advocate or ombudsman or quality assurance officer or "risk manager" (many different terms cover the same thing). If this doesn't work, formal complaints to regulatory bodies are the next step, or talking to a lawyer.

The final chapter in my book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, also gives a step-by-step approach to getting to the bottom of poor quality care. And you can get the same information at my law firm's website, by filling out the form to download our free Injury Fact Kit.

When a 44-year-old male friend dropped dead the other day from a massive heart attack -- no prior symptoms, no warning of any kind -- I wondered if modern medicine could have done anything to prevent the tragedy. The answer I learned is that low-tech still beats high-tech hands down in preventing America's No. 1 killer.

Low-tech means getting regular exercise, eating right and paying attention to cholesterol, blood pressure and the other risk factors for heart disease, and it also means moving fast to get to a medical facility with any symptoms whatsoever that might be signaling heart attack. Those are the proven ways to lengthen your life span and avoid early death.

But my friend didn't have any symptoms or risk factors. What could he have done? That's where high tech comes in, but the answers are not encouraging. The available treatments are expensive and not very effective for people without symptoms.

He could have had the gold-standard test for narrowed arteries in the heart: an angiogram. That's an X-ray movie of the arteries that involves putting a tube into the groin, threading it up to the surface of the heart, and squirting dye through the tube to outline the inside of the blood vessels as high-speed multiple X-rays are taken. I've watched these movies for some of my medical malpractice lawsuits, and they are eerily fascinating: the dye looks like smoke as it pushes out of the tube and mingles with the blood in the arteries, which suddenly light up as if a switch has been turned on, with the heart quivering all the while behind the arteries.

The problem is that most of the time, angiograms on people without chest pain symptoms show nothing. Even when there are some symptoms, the angiogram is just as likely to turn up clean as a whistle, or with only minor narrowing, as it is to show serious disease.

A new study in the New England Journal of Medicine of 400,000 patients found that the odds of finding operation-worthy heart disease in patients getting a first-time angiogram without any known heart disease was only four in ten -- which means that the $2,500 procedure was wasted on six of every ten patients.

Now, you might think that the angiogram can still be worthwhile if it shows some blockages that can be cleaned out. But that's true ONLY IF those blockages are causing symptoms. The usual technique to unblock arteries -- with a balloon and a wire scaffolding (stent) to hold open the artery -- has been shown to work to relieve symptoms of chest pain, but it does NOT extend life in symptom-free patients. In those patients, it's thought that the heart has already learned how to deal with the blockage by shifting blood from another supply.

Here is a very good article from Harvard Medical School on who should get the balloon treatment -- called angioplasty -- and who shouldn't.

The bottom line: Angioplasty can save your life during a heart attack if it can be done fast enough to open the artery before permanent damage is caused to the heart muscle. But for symptom-free patients, angioplasty is worthless and exposes patients to the risk of dying from a complication of having wires and tubes poked into your heart. And for patients with non-debilitating chest pain, angioplasty doesn't work any better than taking drugs and making lifestyle changes.

People who get chest pain and learn they have heart disease should think of the pain as a gift from on high: It's given them a chance for a new lease on life. But for people like my friend whose first symptom is a fatal heart attack, there's not much that medicine can do. We're all fated to die at some time, and we haven't learned how to defeat fate. We can and should pay close heed to getting plenty of exercise, eating right and doing other things to lower our risk. But the risk will always be there.

A new report from Public Citizen puts the lie to claims that doctors and hospitals are burdened by excessive payments to malpractice victims. The report finds that as health care costs have soared, the total payments to victims of preventable errors has continued to decline.

The consumer advocacy group concludes that Congress should focus on ways to cut medical errors, not to reduce the rights of patients to be compensated for injuries.

According to Public Citizen, fewer medical malpractice payments were made on behalf of doctors in 2009 than any year on record, according to its study of the National Practitioner Data Bank numbers.

The value of malpractice payments in actual (unadjusted) dollars was the lowest since 1999. Adjusted for inflation, payments were at their lowest since 1992. Last year was the fifth consecutive year the number of payments has fallen and the sixth straight year in which the value of payments has fallen. In contrast, U.S. health care costs have increased every year since 1965, the earliest year for which such data exist.

A total of 10,772 payments were made on behalf of doctors in 2009, totaling $3.49 billion. That figure equals 0.14 of one percent of the Centers for Medicare and Medcaid Services estimated $2.5 trillion in overall U.S. health care spending for 2009.

As Public Citizen's report notes, numerous studies have found that injuries and deaths caused by medical errors dwarf the number of actual medical malpractice payments. For example, the Institute of Medicine found in 1999 that 44,000 to 98,000 people die every year due to avoidable errors. Subsequent studies have estimated even higher casualty levels.

More and more women with cancer in one breast are now opting to have the other healthy breast removed as well, even though the statistics show survival odds don't improve by having both breasts removed and most patients end up with chests that are numb to sensation.

Peace of mind is cited by many of these cancer patients for their decision.

A new report by Tara Parker-Pope in the New York Times details this trend, and the Times' "Well" blog has a number of interesting comments from women and cancer experts.

As many as three in ten breast cancer surgeries in large urban cancer centers are for preventive removal of the healthy breast, the Times reported.

But what is prevented, exactly?

The only women who get a very slight survival bump from having their healthy breast removed are patients under age 50 who have estrogen-negative cancers that don't respond to drugs like Tamoxifen. For everyone else, there is no real advantage in having the second breast removed. When the second breast gets cancer, as happens sometimes, that is not "spread" from the original cancer but is a new, unrelated cancer.

The real risk that women face from the original cancer is that it has already spread beyond the breast, but removal of the second breast doesn't help that risk.

The most striking evidence of how afraid of cancer women are is with DCIS: ductal carcinoma in situ, which is not even considered true cancer by many experts because it either disappears or never progresses in two-thirds of women. Yet still many women with DCIS are electing to have not just the one breast removed, but both.

Ultimately, this is an intensely personal decision. But it helps to get the true facts first.

The FDA says it is re-investigating the issue of whether drugs like Fosamax, which are given to post-menopausal women, can actually cause fractures of the thigh bone (femur).

A number of lawsuits are pending about death of jaw bone tissue allegedly caused by this family of drugs, called biophosphonates.

Previously the FDA said it had seen no link between these drugs and femur fractures. But new studies reported at the annual meeting of the American Academy of Orthopaedic Surgeons raised questions about the risks for long-term use of bisphosphonates by post-menopausal women.

The FDA says it will consult with outside experts. Meantime, it says people on the medications should continue taking them but should talk to their doctors if get any new hip or thigh pain. See the FDA's news release here.

Bisphosphonates have combined annual sales topping $3.5 billion. In addition to Fosamax, drugs in the group includes Actonel marketed by Sanofi-Aventis and Procter & Gamble, Boniva marketed by Roche and GlaxoSmithKline, Novartis’s Reclast and P&G’s Actonel.

The U.S. Senate Finance Committee is investigating deaths of patients at long-term care hospitals, in follow-up to a report in the New York Times last month. That report showed that the profit-making chains who run these hospitals, which cater to chronically ill patients, sometimes skimp on staffing and training, and disasters have resulted.

More on the original report in the Times can be found in our blog entry on the subject here.

These long-term care hospitals occupy a niche between large general hospitals and nursing homes. They do not treat specific kinds of patients but are defined only by the fact that patients tend to stay longer than at a regular acute-care hospital, but less time than at a nursing home. They are typically small, with around 60 beds. Many times they lease space from a regular hospital and will occupy a floor or wing in a larger facility.

The New York Times reports that it has received new information about disturbing events at hospitals run by the Select Medical chain. One example from the Times:

According to a doctor’s deposition in a lawsuit, nurses at a Select hospital in Tulsa, Okla., injected a relatively healthy 79-year-old woman with 10 times the amount of insulin she was supposed to receive back in January 2009. They then failed to notify her doctor for at least 90 minutes after they discovered that she had fallen into a coma. The woman, Ruth Tanner, died a month later without fully regaining consciousness, according to medical records and the lawsuit.

Select Medical generally does not comment on pending lawsuits, so out of respect for the legal process and the parties involved, it will not do so in the Tanner case, the company spokeswoman, Ms. Curnane, said.

Dan Graves, an attorney for Ms. Tanner’s family, said that family members agonized after the overdose. “Now their grief and loss has been multiplied by the knowledge that other families have suffered similar tragedies because of Select’s practices.”

The man who discovered the PSA test for prostate cancer now says the test is so overused it has become a public health disaster with an annual price tag of $3 billion in wasted testing.

Dr. Richard Ablin writes an op-ed piece in the New York Times calling for the test to be abandoned for routine cancer screening for men over age 50. At most the test is useful in men with a family history of prostate cancer and also useful to detect cancer coming back in men who have already has their prostates removed for cancer.

Dr. Ablin notes that the appropriate use of the test is a tiny portion of the amount of testing now occurring, driven by those who profit from use of the test. He concludes:

I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.

As this blog noted in an entry a year ago, large studies have been published showing that the PSA test saves very few, if any lives, when used for routine screening, and it causes many men to undergo unnecessary, painful and potentially harmful biopsies and surgery.

Deaths from preventable medical error kill as many people in the nation's capital as guns, and far more than motor vehicle crashes, according to a new report from the D.C. Department of Health.

The report, the first of its kind in the District of Columbia, analyzed the 5,168 total deaths reported to health officials in 2007. It determined that fully half of the deaths could have been prevented. Among the leading causes of preventable death:

1. Tobacco: 860 deaths
2. Poor diet and physical inactivity: 780 deaths
3. Infections (not counting HIV): 240
4. Alcohol abuse: 150
5. Firearms: 140
6. Medical errors: 140
7. Poisons (and pollution): 110 deaths

DC Motor vehicle deaths were a distant 10th place on the list of leading preventable causes of death, with 30 deaths in 2007, according to the Health Department.

Another interesting number: The Department estimates that as many people died from lack of health insurance -- which discourages access to medical care -- as motor vehicles -- 30 people in 2007.

The estimate of deaths from lack of health insurance is based on the number of uninsured people in D.C. and uses methodology from a report by the Kaiser Family Foundation. The estimate of deaths from medical error was made by applying D.C. population numbers to estimates that were made in 2000 by the Institute of Medicine, part of the National Academy of Sciences.

It sure is. Work by Peter Pronovost and other pioneers in the patient safety movement has shown over and over that medicine's culture of "doctor knows best" can be dangerous to patient safety and can cause episodes of medical malpractice. That's because nurses (still mostly female) often see errors in the making and yet feel it is not their place to criticize or correct the (usually male) physician.

Pronovost, a Johns Hopkins critical care doctor, has a new book: Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.

Changing the culture of medicine, to encourage nurses to speak up as valued members of the medical team, is critical to improving patient safety, Dr. Pronovost says.

I interviewed Peter Pronovost last year for my book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst. One of the things I wrote about then was how the simple culture change of having all members of the surgical team introduce themselves by name at the beginning of the operation has been found to have a big impact on improving safety. Why? Because when people know each other by name, and not just by "nurse," or "doctor," they communicate better with each other, and good communications are vital in preventing hospital errors.

Patient Safety And Sexism In Medicine

I've been thinking about sexism in medicine since the news last month about the west Texas nurse who was brought up on criminal charges for having the gumption to report a doctor she thought was endangering patients to the state licensing board. The nurse was ultimately acquitted, as reported on this blog, but of course the outrage was that she was investigated and indicted in the first place (and fired from her job at the hospital where she had watched this doctor).

It's no surprise that the nurse was female, the doctor was male, and the nurse's accusers in the sheriff's office and the local prosecutor were male too.

Of course, it's not just the gender of the people involved, but their power. Doctors admit patients to hospitals and thus are "cash cows" who are often coddled by hospital administrators for fear the doctor will take his business elsewhere.

After the Texas "not guilty" verdict, there were some interesting comments from nurses about their experiences. One posted on the San Antonio Express newspaper web site was revealing:

I am from the east coast. There, the relationship between doctors and nurses is collegial. We respect one another as licensed professionals. I was amazed that the difference here in Tx. One simple example - if a patient being admitted for chest pain, and their blood test that shows they probably had a heart attack is positive, then standard of care is that they should be admitted to a unit that can do constant heart monitoring (telemetry). Where I am from, if the doctor gave written or telephone orders for a standard unit (without telemetry), it is the DUTY of the nurse to remind him/her that the patient has a positive Troponin and needs a telemetry bed. If you did not do that, and the patient had a poor outcome, the review committee would point the finger to the nurse that took the telephone orders for admission on not taking it up the chain of command until that patient had a telemetry bed. She or he would then face a peer review and be potentially turned into their state licensing agency to determine if their license should be suspended or revoked for failure to follow appropriate patient standards of care.

I heard a nurse very politely say "doctor, would you like a telemetry bed for this patient with a high troponin level"?

His response? "Can you put a nurse on the phone that knows how to take orders"?

The issue was dropped, right then and there, and the decision to let it drop was supported by the ER and hospital nursing supervisor, because they didn't want to upset the physician. Now I have met very nice physicians here, but for the most part, this is the attitude of many physicians towards the nurses. Nurses hold a license, and have a duty to ensure quality and safety of care, in addition to taking care of the patient.This includes reporting even the SUSPICION of unsafe care. It is a shame when our ability to do so is threatened by situations like this.