Friday, June 15, 2012

Why are physicians minimizing the problem of preventable errors?

CNN recently had an article describing 10 common mistakes in healthcare  This article stimulated a huge response (>1200 comments).  For the most part physicians criticized the piece as naive. My take? I was very pleased the CNN was making effort to explore a very important issue that continues to evade significant public scrutiny. We simply don't have the proper sense of urgency.
   Are there 250,000 or 100,000 deaths per year due to preventable mistakes? Does the exact figure matter? Think about it. If 100,000 die each year each life touched at least 10 others. Based on my own personal experience those 10 close family members and friends will never forget the loss of their loved one. That makes 1 million people affected. The personal price for ignoring medical errors is far too high. All caregivers need to feel a sense of urgency and WE MUST CHANGE.

Wednesday, January 4, 2012

How reliance on expensive and unnecessary tests can endanger our patients

I just completed two weeks as the inpatient attending on the medical wards. As the attending I supervise residents and care for 12-20 patients in the hospital. One patient exemplifies how over dependence on sophisticated imaging studies can endanger our patients. I admitted a patient with severe abdominal pain, and serum tests demonstrated an elevated amylase and lipase indicating pancreatitis (inflammation of the pancrease). An abdominal CT scan showed minimal swelling of the pancrease and a normal common duct (drains bile from the liver); however his gallbladder was filled with gallstones. Initially we treated him with intravenous fluids, held all food by mouth, and administered pain medications.

Over the first two days he improved; however, on the third day he developed fever to 103 degrees and his blood pressure dropped to 70. He became confused and complained of worse abdominal pain that had moved from the midabdomen to his right upper quadrant (near the liver). On abdominal exam he had severe tenderness in the area of the liver. His peripheral WBC increased from 8,000 to 24,000 (normal 4,000-10,000) indicating a new bacterial infection. His serum bicarbonate dropped from 25 to 19, and his serum lactate increased to 4.0 (indicated lactic acidosis a very dangerous condition). His liver function tests suggested early obstruction of the biliary duct draining bile from the liver.

All his clinical findings indicated that a stone in his gallbladder had blocked off bile drainage and that he now had what is called "cholangitis".  Gallbladder obstruction leads to inflammation of the walls and the high pressure in this small pouch causes bacteria to spill into the blood stream. My patient was in septic shock!

At 8AM I  called our interventional radiologist to emergently place a drain (tube) in his gallbladder to relieve this pressure build up, drain the pus, and stop bacteria from spilling into his blood stream.  Despite the classic signs of gallbladder infection and septic shock, the radiologist refused to place a drain without a repeat CT scan! But I insisted there was no need for another test, he needed the drain NOW. The diagnosis was clear, however he again refused. I transferred my patient to the ICU and arranged for a critical care nurse to accompany him to have his unnecessary CT scan. The test showed inflammation of the gallbladder and his drain was finally placed 12 hours later at 8PM. Pus gushed from the gallbladder and within 8 hours he no longer had fever, and his blood pressure returned to normal.

He had survived, but this inordinate delay for an unnecessary and expensive test could have proved fatal.  The radiologist understood imaging, but he had not examined the patient, and did not accept my clinical assessment. He only trusted his expensive test. As this case exemplifies, in this era of extreme specialization the lack of trust and teamwork can result in unnecessary tests and can endanger our patients.

Sunday, November 6, 2011

Examples of how doctors push tests and procedures on patients

One of the most common ways that doctors increase the cost of patient care is by over ordering imaging studies. CT scans are one example. One of the simplest ways to document overuse is by examining the number of double CT scans ordered, that is sequential scans, one with iodine contrast and the other without. According to experts there is no need to perform both. The contrast scan provides all the information of a non-contrast scan. Not only does the double scan increase costs, but also increases radiation exposure. It is estimated that radiation from one CT scan = 350 chest X-rays and two would equal 700 CXRs. Concerns have been raised that CT scans may be predisposing patients to cancer. Just as observed with per capita health care expenditures, and costs in the last two years of life, the percentage of double CT scans varies in different regions of the country, being 1% in Massachusetts and 13% in Oklahoma (for more details see

MRI is another overused, imaging procedure. The good news is this test is not harmful to the patient, but is harmful to the pocketbook.  The New York Times recently reported the observations of Dr. James Andrews, a widely known sports medicine orthopedist in Gulf Breeze, Fla. He performed an MRI on 31 health professional baseball pitchers (see and found abnormalities of the shoulder rotator cuff in 87% despite the fact that they had no complaints of shoulder pain and felt perfectly healthy. Such abnormalities too often are used to justify unnecessary shoulder surgery in the unsuspecting athlete.

Why do physicians overuse tests in some parts of the country and some hospitals and not in others? And how can physicians and patients improve our push model of health care?  I will share my thoughts in my next piece.

Thursday, November 3, 2011

Medical Care Too Often is Being Pushed on the Elderly

Another important measure of the push model in health care is expenditures during the last two years of life. Senior citizens need to beware. Some doctors see the elderly as "cash cows" because those over 65 years of age have nearly unlimited health insurance coverage through medicare. These doctors make more money the more tests they order and the more procedures they do. I read just the other day that a significant percentage of our seniors undergo surgery during their last year of life.

 One of the simplest ways to assess the overall medical culture of a region or a hospital is by determining the amount of money expended on health care during the final two years of life. In medical cultures where overtreatment is the rule, the costs per patient are often 2 times higher than in cultures where physicians understand and respect that life eventually comes to an end for us all. For example, looking at the Dartmouth Atlas we can compare two Florida hospital systems: Tallahassee Memorial Healthcare, in Tallahassee, to Mt. Sinai Hospital in Miami Beach. The average per capita Medicare expenditures during the final two years of life was $40,000 for Tallahassee Memorial Healthcare and $83,000 for Mt. Sinai Hospital. Why was Mt. Sinai over twice as expensive? Patients in Mt. Sinai Hospital visited their physicians far more frequently (99th percentile for number of physician visits as compared to patients in other hospitals throughout United States), remained in the hospital far longer (99th percentile) and receive more intensive care (99th percentile) than patients treated in Tallahassee Memorial Healthcare, or for that matter nearly ever other hospital system in the United States. How can we guard against this push mentality?  Further thoughts on prevention tomorrow.

Tuesday, November 1, 2011

What patients need to know about the push model of health care.

Not long ago General Motors and Chrysler were bailed out by the US Government. They were in danger of going bankrupt, while Toyota had reached the status of the number one car manufacturer in the world. Why?  One major reason was a fundamentally different business model. GM and Chrysler ascribed to a batch processing model that saves labor, but requires the manufacturer to push the excess number of newly manufactured cars onto their customers. If GM built 5000 blue Chevrolets they used sales promotions and discounts to convince customers that they wanted and needed a blue Chevy. They created an artificial demand. When the economy was prospering this strategy generated remarkable profits; however, when the economy slowed this model failed. Toyota on the other hand has and continues to ascribe to a pull model. A customer orders a red Corolla. The order comes to the factory and a chassis and all other parts are manufactured just in time for that specific car. The company only makes the number of cars wanted and needed by its customers. In other words the cars are pulled by the demands of their customers.

You may ask how does this relate to health care? In certain regions of the United States, just like the American automotive industry, physicians have pushed care on their patients by performing unnecessary surgery, ordering unnecessary diagnostic tests, and requiring excessive visits to maximize income. For example the per capita cost of health care in Miami, Florida was $16, 351 in 2006, as compared to Salem, Oregon $5,877, and physicians in Miami were far more likely to recommend tests that were not clearly indicated and to schedule unnecessarily frequent office visits (see the Dartmouth Atlas

These differences cannot simply be explained away by differences in the cost of living, demographics, or geographic distances. Comparisons of regions within single states and contiguous counties have also uncovered extreme differences in per capita spending on health care. In McAllen, Texas the per capita cost was second to Miami, $14,946, while in nearby El Paso the health care expenditure averaged $7, 504 per person.  This statistic is even more shocking when one discovers that the average household income in McAllen was only $12,000. The McAllen physicians were motivated by an entrepreneurial spirit, and were trained to perform specific procedures. They consistently recommended diagnostic tests or procedures for their patients disregarding the lack of evidence that these interventions were of benefit.   Both doctors and patients assumed that more care was better care. When asked about the high cost of medical care in McAllen, a local surgeon admitted there was “overutilization here, pure and simple”(A, Gwande, The Cost Conundrum. The New Yorker, 2009)

Analysts agree that a push business philosophy is likely to be one of the primary drivers causing the great variations in per capita health care spending in United States.  One of the tenets of capitalism has been “you get what you pay for”. However, patients as well as health care providers need to remember that when it comes to health care, under the present volume-oriented reimbursement system, higher cost health care often translates into more unnecessary procedures and tests. The more you do, the greater the likelihood of errors and complications. Analysis of regional health care quality and per capita spending have no positive correlation, in fact there may be a subtle negative correlation. In other words, higher cost health care may actually yield worse outcomes than less wasteful, lower cost care5.  One of the primary charges of the Hippocratic Oath is to “Do no harm”, and physicians enamored with procedures need to remember this charge (no pun intended) when the indications for a diagnostic or therapeutic procedure are equivocal.

Patients beware of over treatment. As a patient you need to ask, "Is this procedure indicated based on guidelines from your subspecialty society? Are there simpler less expensive and less invasive tests that could be performed first? We all need to understand that the push model of health care is driving up our health care costs, and has the potential to cause us bodily harm.

Monday, October 31, 2011

Campaigning for quality and safety in your hospital

   Why has health care quality failed to improve? One of the major reasons is the old fashioned and maladaptive culture that exists in nearly all of our medical centers, particularly our academic medical centers (AMCs). Each department is a silo with a hierarchical structure, and as one physician told me "I feel like a grain of sand." Other than managing their individual patients physicians rarely have any say in what goes on. Nurses in most AMCs are all but ignored by physicians. The other day I saw a physician turn his back when a nurse asked him a question. "Nurses annoy me all the time by paging me", he stated. How can there be improvements on the front lines with this culture and these attitudes?
  I have begun a new initiative to organize our caregivers around a simple goal: How do I as a caregiver improve the experience of my patients?  Because I view a health care leader as anyone who influences others to improve the health of our patients, I believe everyone can be a leader, and we will need a distributive leadership model in order to improve quality and safety. But how can I and others encourage leadership?
   By using the techniques first employed by the American founding father, Samuel Adams I believe we can transform the cultures of our AMCs. Through one-on-one meetings, creation of leadership teams, large gatherings, and newspaper editorials he built a powerful community of like minded colonists to transform the 13 colonies from complacent subjects of the British Empire to independent citizens who demanded a true democracy. Using one-on-one meetings I have been able to build a campaign leadership team. We have set as our goal to recruit 200 caregivers to our campaign by February of 2011. We had our kickoff, A Forum on Doctor-Patient Communication, last Thursday. Approximately 75 people came and participated, including surgeons, internists, obstetricians, pediatricians, anesthesiologists, patients, nurses, social workers, and a chaplain. Two patients spoke about what they expected from their caregivers. Following their very personal and meaningful presentations, the entire audience began contributing their views. As the conversations continued the spirit in the room lifted. A sense of community and of shared goals became ever more apparent. We are off and running. Our next Forum will be on Doctor-Nurse communication, followed by Doctor-Doctor communication. I will keep you posted.