Patient Safety Blog

A new study from the journal Quality and Safety in Health Care, and discussed in the NY Times Well blog, reveals common testing mistakes by primary-care doctors.

Out of close to the 1,000 mistakes experienced by 590 patients, the following testing mistakes were the most common:

-13% involved ordering the wrong test or failing to order a test

-18% involved performing the right test, but doing it improperly

-25% involved delays in getting tests back from the laboratory, failure to get the tests back at all, or errors on the results report

-7% involved failing to follow up with patients after receiving results from the laboratory

-75% of the mistakes caused the patient to suffer (through delays in proper treatment, greater expense, physical pain or worsened overall health).

What can a patient do about this? A possible solution would be to carefully ask and write down what specific test your doctor has ordered for you. Ask when the results of the test are expected from the lab. Then make sure you call to follow up after the doctor's office should have received the results. Read the results report, if you can get hold of it, to see the name of the test and make sure that the results are for the same test that was ordered and performed. All of these things might help reduce your risk. Calling the doctor to follow up is probably the most important item on the list, as Dr. Lamberts says in his quotation in the linked NY Times blog post.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Communication , Doctor-Patient Relationship , Medical Error , Medical Records , Testing

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Tara Parker-Pope recently had an article on how fewer and fewer patients trust their doctors.

About one in four patients feel that their physicians sometimes expose them to unnecessary risk, according to data from a Johns Hopkins study published this year in the journal Medicine. And two recent studies show that whether patients trust a doctor strongly influences whether they take their medication.

The distrust and animosity between doctors and patients has shown up in a variety of places. In bookstores, there is now a genre of “what your doctor won’t tell you” books promising previously withheld information on everything from weight loss to heart disease.

What are the reasons for this new distrust? Several factors appear to be involved:

(1) Patients often don't understand what is going on with their health care because doctors and nurses are too rushed to explain things to them. Dr. Sandeep Jauhar, cardiologist and author of Intern: A Doctor's Initiation, is quoted in the article with a story of a patient who was transferred from one hospital to another with no explanation for why. He blamed a "broken system" for such failures to communicate.

(2) There has been greater coverage in the news of medical error, the power of the drug industry and the flaws in health care administration.

(3) The Internet makes information much more available, so patients can be informed skeptics. Drug companies also market directly to patients, so they come into the doctor's office with their own desires and opinions on what medications they should take. The upside to this is that patients have the information to challenge a doctor's errors. The downside is that many end up taking a drug commercial, for instance, at face value and will not listen to a doctor's reservations about the efficacy of a drug.

Again, from the article:

“Doctors used to be the only source for information on medical problems and what to do, but now our knowledge is demystified,” said Dr. Robert Lamberts, an internal medicine physician and medical blogger in Augusta, Ga. “When patients come in with preconceived ideas about what we should do, they do get perturbed at us for not listening. I do my best to explain why I do what I do, but some people are not satisfied until we do what they want.”

The whole article is worth reading. In addition, the article's page also has an embedded video clip of interviews with people discussing their attitudes to their doctors.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Communication , Disclosure , Doctor-Patient Relationship , General , Medications , Standard of Care--Hospitals , Testing

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In our previous post, we discussed Dr. Peter Bach's comments on Medicare funding for unnecessary (in his opinion) testing. In response to Bach's article on the subject, the NY Times published readers' letters, most of which were highly critical of Bach's proposals about Medicare and testing.

The first letter, from Dr. Brant S. Miller, is especially interesting because Miller argues that Bach's proposals are nothing new:

We already tried capitation with H.M.O.’s in the 1990s, and that turned out to be a disaster. The media reported countless abuses by H.M.O.’s that killed or maimed patients as the insurers paid doctors more for denying care and less for providing care. Fee for service turned into plea for service. So, here we go again.

Since the 1990s, patients have been told that your doctor is greedy and doing unnecessary tests. And by the way, you shouldn’t have to pay much out of pocket, and there shouldn’t be any forms to fill out. Meanwhile, Tim Russert dropped dead when a one-minute CT scan could have shown progression of disease in his left anterior descending coronary artery.

Another interesting letter is from professor of neurology Michael Hutchinson. Hutchinson criticizes Bach for making "sweeping statements" and corrects his portrayal of the facts regarding testing and equipment use:

In fact, an extensive study done by doctors at Massachusetts General Hospital on physician ownership of imaging equipment was published last year. The study failed to define a major increase in imaging by doctors who own their equipment compared with doctors who do not.

Perhaps this has to do with strict government regulation, but imaging costs have actually been declining in the last two years. The total cost of M.R.I. scanning is now a fraction of 1 percent of health care.

Hutchinson also points out that imaging leads to fewer hospital and emergency room visits and also fewer procedures done, which helps reduce health care costs overall.

Those two letters were intriguing, but all of the letters responding to Bach are worth perusing.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Testing

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Peter Bach, former adviser to the Medicare and Medicaid administrator, wrote a NY Times op-ed arguing that the Medicare system pays doctors for how many tests they run with a given piece of equipment but not for how much time they spend with patients. Readers responded with letters on the subject.

From the op-ed:

Medicare pays doctors for specific services. If a patient has a checkup that includes an X-ray, a urine analysis and a physical, Medicare pays the doctor three separate fees.

Each fee is meant to reimburse the doctor for the time and skill he or she devotes to the patient. But it is also supposed to pay for overhead, and this is where the problem begins. To Medicare, a doctor’s overhead (or “practice expense”) includes such items as rent, staff salaries and the cost of high-tech medical equipment. When the agency pays a fee to a doctor who has performed a CT scan, it is meant to cover some of the cost of buying or leasing the scanner itself. Services using more expensive equipment generate higher fees.

Any first-year business school student can see the profit opportunity here. The cost of a CT scanner is fixed, but a doctor earns fees each time it is used. This means that a scanner becomes highly profitable as soon as it’s paid for.

In contrast, the doctor-patient visit, which involves no expensive equipment, offers no significant profit opportunity. So the best way for a doctor to make money in his practice is not to spend time with patients but to use equipment as much as possible. That means moving the maximum number of patients through the practice, and spending the minimum amount of time with each one.

Bach offers suggestions for how the system should be reformed. He also includes evidence showing the increase of testing.

The informed patient on Medicare should ask questions about exactly what tests are being performed and why, and should not be concerned with taking up too much of the doctor's time.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Testing

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The NY Times has a long and informative article on the pressures physicians face to give patients with heart problems unnecessary CT angiogram scans, which are very expensive and not demonstrably more effective than cheaper tests.

Aside from the expense, the scans come with radiation exposure equal to as much as 1,000 chest X-rays.

Further, each scan creates an additional lifetime risk of cancer that is somewhere between 1 in 200 and 1 in 5,000, said Dr. David J. Brenner, director of the Center for Radiological Research at Columbia University. Younger patients and women are at higher risk.

Many patients do find it emotionally reassuring to get the results of these tests, since the CT scan allows the patient and doctor to actually see if the heart has any problems. However, perhaps part of the love of these tests stems from what Johns Hopkins professor of medicine Bruce Leff calls (in a letter to the NY Times editor) "gizmo idolatry":

As a geriatrician and health services researcher, I believe that the demand for cardiac CT scans is a textbook example of gizmo idolatry, or the implicit conviction that a more technological approach is intrinsically better than one that is less technological.

The other letters are worth reading as well.

Despite concerns about the efficacy of these tests, many doctors and patients swear by them and they will probably remain popular. As the article notes, Medicare decided to fund these CT scans despite lack of clear evidence of their usefulness, and private insurers will most likely follow suit.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Cancer , Testing

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