Below, a memo and a chart that a hospitalist recently sent to his residents. To protect his identity, I have removed the name of his hospital from the memo. Suffice to say that it is a well-known hospital in one of the 20 largest cities in the U.S., and that it is located in a very affluent section of that city. This hospital does not serve an unusually large number of very poor or very sick patients.
The memo itself seems to me a splendid and courageous example of what physicians should be teaching residents. And he is an excellent teacher: the chart makes its points in a way that is easy for a busy resident to read quickly—and it drives the message home.
In an e-mail to me, this hospitalist explained what he is trying to do: “without leadership, residents won’t act.” It’s crucial “to promote the right behavior and mentor them up. If Hospital Chief Financial Officers continue to promote business as usual, that won’t happen. It is important to emphasize, and you have said this as well, that we are all creatures of the culture we created–why should change occur until signals modulate? To quote a Chief Medical Officer:
"Despite my very supportive board of directors, they will not allow me to lead our organization into bankruptcy by doing the right thing"
Yet as this teacher warns his students at the end of the memo—people are taking a closer look at hospital waste. Healthcare reform means that financial incentives will be aligned to encourage hospitals to “do the right thing”—while imposing financial penalties on those that don’t. Doctors need to be in the front lines, leading change in ways that they know will lead to better care for patients.
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The hospitalist begins his memo by noting that “Often, physicians request tests, never asking, ‘What am I getting in return for this masterful technology?’ or ‘Why am I being asked to order this study in the first place?’ He then points his residents to “one of many papers illustrating how we ‘rubber stamp’ work-ups and never think about what the end result might be, and how we are helping (or hurting) patients.”
The article, which was published earlier this year in the Archives of Internal Medicine, looks at diagnostic tests ordered for older patients who have lost consciousness or “blacked out.” The researchers note that sometimes these episodes are benign; sometimes they are life-threatening.
The researchers, who are all based at Yale University, looked at 2106 consecutive patients 65 years or older admitted following such an episode, and analyzed the frequency, yield, and costs of tests obtained to evaluate these patients. What they discovered is that the tests that were ordered most frequently ( Electrocardiograms in 99% of admissions; telemetry in 95%; cardiac enzyme tests in 95%; and head computed tomographic (CT) scans in 63%) affected diagnosis or management [of the patient] in less than 5% of cases and helped determine the [cause] of the black-out “less than 2% of the time.”
By contrast, Postural blood pressure (BP) recording, performed in only 38% of episodes, had the highest yield with respect to affecting diagnosis (18%-26%) or management (25%-30%) and determining the cause of the episode (15%-21%).
Meanwhile, cost per test affecting diagnosis or management was highest for tests that provided little help (electroencephalography, CT scans, and cardiac enzymes tests) and lowest for the more useful postural BP recording.
The authors conclude: “Many unnecessary tests are obtained to evaluate [black-outs.] Selecting tests based on history and examination and prioritizing less expensive and higher yield tests would ensure a more informed and cost-effective approach to evaluating [these] patients.”
Writing to his residents, our hospitalist then puts this study in a larger context: “OK, now the interesting stuff. Some of you might have heard of the Dartmouth Atlas. Yes, Dartmouth puts it together, and it is an amazing and fun resource to play with and learn from. It culls Medicare data and breaks it down into very granular pieces making comparisons between regions, states, hospitals, etc., possible.
“When you hear folks talking about Miami costing three times as much as Seattle for ‘x, y, and z’ procedures, it is getting lifted right from their data set. Their site is easy to use, and just for fun, I want to show you where our hospital stands in reference to some other hospitals in terms of intensity of resource utilization. I chose Duke and Hopkins for comparison (random picks, I did not look at their numbers in advance):
(Click on the chart or here to enlarge)
“Look at us,” our hospitalist writes in his memo. We are at the top 1% in terms of cost intensity and we use a hell of a lot of specialists.
Granted, the chart above is not focused solely on patients who experienced black-outs (again, this is all care that Medicare beneficiaries received in the last 2 years of life). But you can glean a lot from this data.
Bottom line: When it is time for hospitals to take a haircut, even taking into account higher spending in our area—and this is a reality as well—we are still inefficent by the gobful. Trust me, people that matter are watching and they know we can do a lot better. Something to keep in mind as we think about how to practice sensibly. More does not equal better and it is only a matter of time before we are requested to step up and get out our ‘A’ game. The folks who will be asking by the way, won’t be bringing cookies.
Take home—and think before you order!
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It is worth noting that while this hospital ranks in the bottom 1%, when it comes to overusing resources, all of the hospitals in this city rank in the bottom 5%. This is yet another piece of evidence confirming regional variations in the intensity of care that patients receive—variations that cannot be explained by patients’ needs, patients’ desires, or the underlying health of the patient. After adjusting for income, race and the health of the poulation, the Dartmouth research shows that much of this over-treatment is supply-driven. In areas where there are more specialists, and more hospital beds, patients receive more aggressive, more intensive care. As the chart shows “our hospital” has both more beds and more specialists per 1,000 decedents.
In the past, critics who attempted to poke holes in the Dartmouth research have suggested that perhaps patients in certain cities and regions are simply more demanding. But the fact is , patients rarely ask for the opportunity spend more
days in the hospital during their final two years of life—or to be poked, and prodded by 22 specialists. Few want to die in the hospital; most would prefer to die at home, or in a hospice.
The premier example of medical excess and wastefulness I have seen in my medical career is the emergency room. My posting this week (www.MDWhistleblower.blogspot.com)on this has generated heat from my colleagues offline. While every physician, including me, contributes to unnecessary medical care and treatment, we are left inthe dust by our ER colleagues. Ask any physician about this issue, and I suspect you will hear a similar view.
I was struck by the comment that every hospital in this city is among the worst 5% in the country for aggressive treatment and high costs. This is why I favor tiering for hospitals and doctors. If co-pays varied based on cost-effectiveness enough to get patients’ attention, it should create some pushback against high costs, especially if every hospital in the city winds up in the highest co-pay tier. Beneficiaries with standard Medicare should pay differentiated premiums for their Part B benefits based on costs where they live. Medicare already varies their Medicare Advantage benchmark bid levels based on average spending at the county level. Why shouldn’t beneficiaries pay 25% of the actual costs for Part B in the county they live in, perhaps subject to some reasonable maximum amount? Private health insurance, and all other insurance for that matter, varies in cost based on geographic region among other factors. Alternatively, insurers might show more interest in medical tourism within the U.S. Inpatient surgeries are the highest profit care category for most hospitals. If comparable care can be provided at significantly lower costs a few hundred miles away, insurers could offer to waive co-pays that would otherwise be due if the patient agreed to travel for more cost-effective care. Insurance could also pay for a family member to accompany the patient and probably still save money. For end of life care, a good palliative care program combined with more aggressive efforts to get people to execute living wills and advance directives would be helpful.
As for ER doctors providing more wasteful care than other doctors, I think this is understandable. They are most likely to encounter patients they don’t know and have not seen before. They don’t know the medical history, probably don’t have access to any useful records, don’t know the patient’s personality and fear they could be sued for failure to correctly diagnose the patient’s problem. And, they’re often extremely busy. The whole situation is tailor made for defensive medicine on steroids. That’s another argument for tort reform but don’t expect the Obama Administration or Democrats in Congress to ask their trial lawyer friends to give up anything.
this is interesting, but unsurprising. hard to think of an enterprise where workers try to make things more efficient in the absence of draconian outside pressure. auto factories? post office? and in fact those who achieve greater efficiencies are putting someone’s job at risk, perhaps their own.
Dr. Kirsch
I wonder if these ER doctors fit into this statistic? Just 5.3% of doctors are responsible for 56% of medical malpractice payouts nationally, according to the NPDB. Doctors who get sued this often are bad doctors. Of those bad doctors, only 7.6% have ever been disciplined by state medical boards. State Medical boards have to do a better job of weeding out the bad doctors who cause most of the harm.
A question: Are ER MDs sued more often than other specialists? I can understand ordering redundant and unnecessary tests if you’ll have to defend yourself on the witness stand. Medical malpractice lawyers are very aggressive. It seems to me that all the cost-effectiveness reform in the world will not change this pattern without meaningful tort reform alongside it. Then there’s the whole issue of guideline-based medicine: KevinMD recently posted about how very few of the ACC/AHA guidelines (11%, IIRC) were rated as A-level in terms of research quality. Who writes these things, and how are they incentivized? I wonder at all this not because I’m a health care professional (I’m not), but I am one of the ordinary joes trying to make sense of all this. And man, is it dense stuff!
Most of the doctors that provide the medical care you actually need in an emergency are in that “5.6%” that Gregory D. Pawelski refers to.
The reason these doctors are not disciplined is they are likely not bad doctors. Ususally they are victims of a terrible judiciary system.
It is a small percentage of doctors who are sued for jackpot verdicts, but this includes essentially all OB’s, ER doctors and Neurosurgeons. Eliminate those specialties and suits will go down. Is that what you want?
Maggie has elsewhere pointed out that only a prohibition of medical lawsuits, as they essentially have in Europe will tame defensive medicine. The right to threaten your doctor with litigation is, I think, the only thing Maggie likes about our medical care system.
European style medical spending, European style waiting lists and rationing, without European style tort protection will not work.
Don’t hold your breath.
There are definitely arguments for tort reform, and I’d even be open to scrapping our system of medical malpractice litigation altogether and replacing it with something like the “Scandinavian” no-fault system. The question is, can fear of malpractice suits really explain such signifigant varations in Medicare expenditures between the 3 hospitals? It certainly can’t explain the Medicare spending variations between El Paso & McAllen counties that Atul Gatwande highlighted in his now-famous New Yorker article.
Several points:
ER docs are on the front lines of Medicine, they deal with patients they don’t know, some of whom are intoxicated, drug addicted, psychotic, and being brought in by the police with bullets in them and knives sticking out of them (the “Knife and Gun Club”). And for this, they get second guessed by Monday morning quarterbacks and sued by malpractice attorneys. We should support our ER docs, help them develop good protocols to follow, then protect them when they do their jobs. If we don’t support and protect them, they will protect themselves, and ordering a lot of tests is an easy way to do it.
The problem of overuse is getting worse. I work as a “Nighthawk” reading X-Rays, CT scans, etc. for 7 hospitals in my area. There are differences in ordering patterns related to age. Older ER docs order fewer tests and have a higher “hit rate”, younger doctors order more tests and have a lower “hit rate”. You can guess what will happen as the older docs retire.
Many tests are ordered by triage nurses before the patient is even seen by a doc – for very good reasons. One of the main parameters that hospitals measure is waiting time in the ER and the main reason that they are concerned about it is patient satisfaction surveys. I was taught during my ER rotation back in the 70’s that the object of an ER doc is to “treat ‘em and street ‘em”. It is much faster and more time efficient (but not money efficient) to order everything that you MIGHT need right off the bat – before the patient even sees the ER doc – than to wait and order later. Hence the practice of “shotgunning” the patient with tests that may or may not be necessary.
Finally, I would like to add my disagreement to Gregory Pawelski’s statement:
“Just 5.3% of doctors are responsible for 56% of medical malpractice payouts nationally, according to the NPDB. Doctors who get sued this often are bad doctors.”
The statistic quoted – “5.3% of doctors are responsible for 56% of payments” says nothing about the number of times these 5.3% were sued but instead describes a particular distribution of payments in malpractice cases. Example: suppose 20 physicians were sued and payments of $10,000 were made on behalf of 19 of these physicians. A payment of 1Million was made on behalf of the other physician. Thus 1 in 20 of the physicians sued accounted for over 50% of the payments. What does this mean – nothing except that there was a large payment probably due to a particularly bad outcome (but not necessarily any malpractice committed) in one case.
I was the Chairman of a Department at a hospital for 6 years and during that time did the Q/A for the department. I had a pretty good idea (and statistics to back it up) of the error rate of the 5 docs who worked there regularly. During those 6 years the doctor with the lowest error rate (not me) was sued along with the doctor who had the highest error rate (also not me). Of the other three docs, two of them (including me) have been sued during their career. More than half of my 85 partners have been sued during the course of their career. As far as I can see, a malpractice lawsuit is largely a random event and has more to do with specialty and geographic location than anything else. I am not saying that malpractice does not occur and that there are not doctors who are practicing poor quality medicine. What I am saying is that malpractice lawsuits don’t reliably identify them.
One further word about malpractice. My group used to cover 6 hospitals; one in the city (a plaintiff friendly jurisdiction) and 5 in the surrounding counties (less plaintiff friendly). A couple of years ago, we were short of docs so to ease our staffing problems we left one of our hospitals. We chose to leave the one in the city (partly) because creative malpractice attorneys were able to drag cases that had occurred in other jurisdictions into the city because we did business there. Now they can no longer drag us into the most plaintiff friendly jurisdiction.
Great post, Maggie,
because it probes a component of the roots of the health care mess. The over utilization has as its genesis decades of insurance company and government controls and manipulation of fees and more, summed with tort protection care.
Hospital administrators get in the act to protect their multi million dollar compensation by leaning on its doctors, many of whom are employed, to keep the scanners humming and the operating rooms full.
In addition, they churn beds by employing nag nurses hustling patients out too quick and encouraging admits for soft reasons by the ER doctors who are also employed.
In your examples, doctors are not being paid to spend hours of cost effective time (for society and insurance carriers) with families explaining futility to curtail end of life care. It is easier and more economical for the doctor to continue the full court press.
Doctors should be paid to provide cost effective care. Each can save, on average, at least one quarter of a million dollars of overall costs and not compromise quality. That is quite a few billion dollars.
Health reform boils down to insurance reform (doing away with the 40% administrative waste), tort reform, and paying doctors to be cost effective and accountable.
It really is that simple.
Excellent post. I admire this hospitalist. I’m also concerned what his superiors would think if they found out he was saying this. The culture at that hospital is clearly to milk the system.
I notice the trend of the doctor comments as they range from from waste to malpractice…What is the association? I believe it is docs both deflecting and blaming for the guilt they feel for obviously not doing a good job.
Docs are very acculturated/trained to do their best / make no mistakes. And when there’s evidence we regularly make mistakes, practice poorly the guilt is strong.
Legacy Flyer evidenced the years of Q/A and the lack of correlation of malpractice claims to quality. There is no doubt the goal and function of malpractice claims is not to improve the quality of healthcare. But was there any process that did improve quality? Can we teach docs to do better?
My experience is not good. And I heard alot of excuses. The beset primary care doc is so worried about the bottom line (business pressure) they will do bad medicine to “please the customer”. Or, if they don’t please the customer, pretty soome they are out of business and working for a salary, then pleasing their new boss, same as the old boss( Insurance, hospital, group)
We all feel the conflict to serve the individual patient vs. the “greater good”. And we all have excuses for how we behave in the face of such struggle.
First, we blame all the lawyers.
I believe we cannot improve our care of the population until we reflect on our motivations and then review the data regarding our behavior. The Hospitalist in Maggies post is doing the reflecting. And trying to model to his students.
Unfortunately, “why I went to medical school” is not an essay we write to apply to retire…
Ddx:dx,
I would like to respond to your post because it seems to be directed (partially) toward me.
“I notice the trend of the doctor comments as they range from waste to malpractice…What is the association?”
The association between waste and malpractice is what is called “defensive medicine”. In essence, doctors are ordering tests that they do not feel are “indicated” in order to CYA (cover your ass). The costs associated with “defensive medicine” are hard to quantify, but are estimated to be as much as 10% of total health care costs.
“I believe it is docs both deflecting and blaming for the guilt they feel for obviously not doing a good job.”
There is a kernel of truth in the above statement. Although I feel that I personally do a good job, I do not feel that the total health care system (of which I am a small part) always does the best job. It bothers me because, believe it or not, I would like to be a part of something that is always (or mostly) doing a good job.
I would make the analogy to a dedicated teacher in a school system in which the majority of students are dropping out. The teacher is frustrated by the lack of success of the system despite their best efforts. This teacher would point out the systemic issues that are causing their students to drop out despite the individual efforts of the people in the system who are giving their best.
Michael, Barry, Jim, Gregory, Sam, Peter H., Legacy, Healthcare Reformer, J.D., Ddx:dx Legacy (second comment)
Michael– yes, ERs do tend to order more tests. In some cases, ERs order a battery of tests even before a doctor has laid eyes on the patient-
-A nurse orders all of the tests that might possibly be relevant based on what the patients says in the brief time that she has to listen to him or her.
Why? Some ER teams are paid for volume. The more patients they process through the assembly line in a short period of time, the more they make.
Ordering the tests even before the doctor examines the patient saves time.
Of course, it may also confuse the diagnosis–while adding to the bill . . .
Barry–
The fact that all of the hospitals in this very large city fall in the bottom 5% suggests that providing incentives for patients to go to more efficent hospitals wouldn’t work. There are no efficient hospitals in this city.
You suggest giving patients financial incentives to go to a hospital in another city, maybe 200 miles away.
Let’s say the city where all of the hospitals are in the bottom 5 percent is Los Angeles.
How many patients do you think would be willing to leave LA and go to a hospital outside the city–even if the insurer was willing to give the a discount?
They believe that LA’s modern well-apppointed hospitals must be the best.
Also, patients would probably have to go further than 200 miles. (Inefficency tends to be cocentrated in particular regions) Very likely they would have to go to San Francisco.
As for medical tourism . . the only much less expensive country where I would feel safe undergoing major medical procedures is India.(They have many excellent doctors and some excellent hospitals.)
But I’ve flown to India. I loved the vacation–but flying to India is Not something I would want to do if I were sick or in pain.
80% of our healthcare doctors are spent when patients are suffering form serious chronic illnesses: cancer, congestive heart failure, etc.
Jim– You wrote: “hard to think of an enterprise where workers try to make things more efficient in the absence of draconian outside pressure. auto factories? post office? and in fact those who achieve greater efficiencies are putting someone’s job at risk, perhaps their own.”
This just doesn’t square with my life experience. .I know people who own small restaurants, wonderful carpenters who have their own businesses and employees, a man who developed the very first business that manufactured plastic grocery bags that you can carry by putting them over your arm, a film-maker, a film distributor, and a couple of excellent CEOs . .
They all
wanted to make their product better, and make it available for less–so that more people could enjoy the product.
No outside “draconian pressure” was not needed.
They loved their work.
Gregory–
I agree, some (though not all) of the “malpractice problem” could be solved if we reduced malpractice. Docs should do a better job of policing their own.
I realize that this is difficult– if a doctor blows the whistle on another doctor, the accused physician may sue him. We need better laws to protect doctors and nurses who turn in incompentent or negligent doctors.
Sam–
Welcome to the blog!
Yes, ER docs are sued more often–in many cases for not getting the right diagnosis.
We need to restructure health care delivery in this country so that ERS are less crowded and less hectic–and so that ER docs are never paid for “volume” (earning more if they see more patients in a short period of time )
(See my response to Michael Kirsch at the top of this thread.)
My daughter, who grew up in NYC, went to college in Montreal. A couple of times, she had to take a friend to an ER in the evening.. She was amazed by how quiet the ERS were. Canadians all have health care– and primary care docs. They don’t need to go to the ER for basic care.
You are right, health care is very copmlicated! Too many special interests involved.
But if you keep on reading about it, you’ll see a pattern . . .
Peter H–
You wrote: “The question is, can fear of malpractice suits really explain such signifigant varations in Medicare expenditures between the 3 hospitals? It certainly can’t explain the Medicare spending variations between El Paso & McAllen counties that Atul Gatwande highlighted in his now-famous New Yorker article.”
Thank you. Defensive medicine is a problem, but it defintely cannot explain these huge variations.
See Ddx/dx Aug 9 comment. There is no one single explanation for all of the overtreatment.
Legacy Flyer–
Thank you for corrobarating what I had read about ERs ordering tests first, examing patients later.
But I have to say, you seem too fixated on malpractice as the root of all evil.
Scroll down to see healthcare reformer’s post and jd’s response –and my comments.
Healthcare Reformer–
Thank you for your comment–and welcome to HealthBeat.
You write: “Doctors should be paid to provide cost effective care. Each can save, on average, at least one quarter of a million dollars of overall costs and not compromise quality. That is quite a few billion dollars.
“Health reform boils down to insurance reform (doing away with the 40% administrative waste), tort reform, and paying doctors to be cost effective and accountable.”
I agree–though I would add a few more components to what needs to be done. Most imporantly, we need to get the information to patients that “More care is not necessarily better care.”
Also, insurers are responsible for only a part of the administrative waste in our system.
Much of the adminstrative cost stems from the fact that we have a fragmented system, with a great many solo practioners, and small group practices–as well as small hospitals.
Very large multi-specialty practices and very large hospitals enjoy great economies of scale in their back offices. These small practices and hospitals do not.
Ultimately, we need to provide incentives for more physicans to join large accountable care organizations where doctors and hopsitals work together.
And, in our medical schools, we need to begin teaching students that medicine is a team sport.
jd– I also respect this hospitalist very much. And I too was concerned about how administrators at his hospital might react. But I’m quite certain that, as he put it to me he knows how to take care of himself. .
He is very experienced, over 40, and familiar with hospital politics. Also, his hospital needs him.
Ddx:dx– Yes, I agree. Rather than deflecting criticism, we all need to reflect on the role that we play in adding to the problems in our heatlhcare system.
For example: Patients need to take better care of themslves, and try to avoid becoming
hypochondriacs, especially as they age.
doctors and hospitals also need to reflect on their own role.
This is what this excellent hospitalist is teaching his students.
Legacy–
I completely believe that you personally do your best in your job–and that you are frustrated to be in a system that makes it very difficult for doctors, nurses and others to do the job they want to do.
At the same time, doctors and nurses are, in some sense, the only people who can change the system.
Yes, payers can change the finacial incentives, and that can make a huge difference–but not withotu all of the people inside the system who understand what should be happening.
If I could make a suggestion: please buy “Escape Fire” by Dr. Don aldBerwick on Amazon.
It’s is a deeply intelligent book, extraordinarily well-written, and speaks directly to what you are talking about.
Don Berwick is in the film of my book. If you e-mail me to say you’ve read the book, I’ll send you a free
DVD! (Honor system–no pop-quiz on the film.)
Dr. Pawelski, I agree that we do not have an effective means for ensuring quality in physicians, or other aspects of medical care. The state medical boards are ineffective and the profession does not police itself. These are arguments in favor or legal oversight, although the current tort system, paradoxically, diminishes medical quality. Regretably, tort reform is not part of Obama’s health care reform plan. All physicians are practicing excessive medicine. My point is that the clearest and most concentrated example of this is in our ERs.
This reminds me of an episode when I was a medical student ~25 years ago at Yale. We had a patient that had intermittent fevers, and we couldn’t find a source. Someone – either the attending of chief resident – decided that we should do random blood cultures, i.e. not when the patient spiked a fever, but at various random times during the day. I balked at this strategy – since it seemed like truly shooting in the dark and not supported by any evidence or standard of care practice that anyone on the team could point to or even remember hearing about. However, a junior resident basically said, “if you don’t do this, then I will have to, and you’ll just get in trouble.” Any guesses what happened?
It’s not just fear of lawsuits, though that certainly contributes. Docs can be sued for not doing a test that is not indicated simply because everyone else in the area does the unnecessary test.
It’s also fear of missing something. Missing that one in a thousand diagnosis would feel terrible. We have to change our medical culture, as well as general culture, to accept that every once in a while we’ll miss something, and that it’s just going to happen. We should establish clear, evidence-based standards of care that doctors can look to in trying to do tests judiciously.
The other problem is that all this overtesting generates a lot of revenue for the hospitals and physicians, especially those who perform certain highly-compensated procedures or read imaging studies.
Sharon MD, Michael Miller–
Sharon– Thanks for your comment. You write “We have to change our medical culture, as well as general culture, to accept that every once in a while we’ll miss something, and that it’s just going to happen”
I completely agree. And this is something we should teach in med school. Medicine is not perfect.
Patients also need to accept this.
And it definitely would help if we had better clearer national diagnostic guidelines that would help protect doctors (and discourage local cultures that over-tests.
Michael Miller–
I’m not an MD, but random blood cultures sounds– well, like “shooting in the dark” to me.
How do you explain that to the patient: “We’re just going to take a blood sample from time to time because we feel we must be doing something–and we dont’ know what else to do.”
Maybe if you just let the patient rest, made sure she was getting fluids, etc, the body would hea itself. . . . Do you remember what happened to her?
Maggie,
You said: “At the same time, doctors and nurses are, in some sense, the only people who can change the system.”
Obama has an opportunity to get a lot more doctors (I can’t speak for nurses) on board with Health Care Reform if he includes malpractice reform as part of the package. But because the Democratic Party is in the hip pocket of the plaintiff attorneys (Open Secrets Org.) and health care reform legislation won’t include any significant malpractice reforms, most physicians remain hostile/suspicious about health care reform.
I would like to relate an anecdote about cutting costs, teamwork and “who can change the system” that I lived through. I think it illustrates how cost savings and malpractice relate to each other – and it relates to “who can change the system”.
At that time (mid 90’s), there were two kinds of “X-Ray Dye” available; “Ionic Contrast” – the older, cheaper dye and “Non-Ionic Contrast” – the newer, more expensive dye. The newer dye had fewer minor reactions and also slightly fewer serious reactions.
Our group received pressure from the hospital where I was the Chairman to continue to use the older, cheaper dye rather than switch to the newer, more expensive dye. The hospital’s motive was clear – saving money. On behalf of our group, I said that I was willing to continue to use the older, cheaper dye (which I had been using for the past 15 years and was still considered within the standard of care) as long as the hospital would be our “partner” in this decision.
The hospital consulted their attorney, who sent us a memorandum saying that the choice of contrast agent (and the responsibility for any reaction) is the sole responsibility of the physician. We responded saying that we would continue to order the more expensive agent. We went through a similar “dance” with our Medicare intermediate about contrast in our office.
In essence they wanted us to take the bullet for them.
“I’m a fool to do your dirty work” – Steely Dan
Insightful post, Maggie.
To chime in on the nursing and ED triage piece: registered nurses (other than select advanced practice nurses, who usually do not practice as ED triage nurses) do not independently order medical diagnostic tests and procedures. They may do so without specific physician orders when operating under a formalized, published and regulated treatment algorithm.
Ideally, nurses and physicians develop such standards of practice and care in triaging patients collaboratively from the individual practice, organization, local, state and to national professional levels, so that the professional judgment of each profession is preserved, and optimal patient outcomes are consistently achieved.
The Emergency Nurses Association is the US national professional association for registered nurses who practice emergency nursing. (link at my name)
There is an interesting article going around about why the IOM report of 1999 (to Err is Human) was not published and socially advertised too much. Medical errors are a big consequence of the non-transparent, caveat emptor system of today, and needs to be dealt with earnestly in reform because studying these errors will reveal much of what is wrong with the current system, IMO.
http://www.seattlepi.com/health/409134_deadbymistake10.html
seattle pie and Annie-
seattle pi– it’s true that the IOM report didn’t get the publicity in the mainstream media that it deserved.
Americans really don’t want to know about hospital errors–too scarey.
Annie– thank you. I’d like to learn more about your organization ..