The eminent physicians Martin Samuels and Nortin Hadler have piled onto the patient safety movement, wielding a deft verbal knife along with a questionable command of the facts.
They are the defenders of the “nobility” of medicine against the algorithm-driven “fellow travelers” of the safety movement. On the one side, apparatchiks; on the other, Captain America.
They are the fierce guardians of physician autonomy, albeit mostly against imaginary initiatives to turn doctors into automatons. By sounding a shrill alarm about straw men, however, they duck any need to define appropriate physician accountability.
Finally, as befits nobility, they condescend to their inferiors. How else to explain the tone of their response to the former chief executive officer of Beth Israel Deaconess Medical Center, Paul Levy? As for patients, Samuels and Hadler defend our “humanity.” How…noble.
To me, healing the sick is an act of holiness, not noblesse oblige. Fortunately, we Jews cherish a long tradition of arguing even with God Himself. A famous Talmudic story ends with God acknowledging that even Divine opinion isn’t enough to override the rule of law. Let’s take a closer look at Samuels’s and Hadler’s opinions in relation to the rules of medical evidence.Continue reading…
In a recent post, the renowned neurologist, Martin Samuels, paid homage to the degree to which uncertainties create more than just anxious clinicians, they can lead to clinical errors. That post was followed by another by Paul Levy, a former CEO of a Boston hospital, arguing that the errors can be diminished and the anxieties assuaged if institutions adhered to an efficient, salutary systems approach. Both Dr. Samuels and Mr. Levy anchor their perspective in the 1999 report of Institute of Medicine Report, “To Err is Human”, which purported to expose an alarming frequency of fatal iatrogenic errors. However, Dr. Samuels reads the Report as a documentation of the price we pay for imperfect knowledge; Mr. Levy as the price we pay for an imperfect organization of health care delivery. These two posts engendered numerous comments and several subsequent posts unfurling one banner or the other.
I crossed paths with Dr Samuels a long time ago when we were both speakers at a CME course held by the American Geriatrics Society and the American College of Physicians. I still remember his talk for its content and for its clinical perspective. His post on THCB is similarly worthy for championing the role of the physician in confronting the challenge of doing well by one patient at a time. Mr. Levy and his fellow travelers are convinced they can create settings and algorithms that compensate for the idiosyncrasies of clinical care. I will argue that there is nobility in Dr. Samuels’ quest for clinical excellence. I will further argue that Mr Levy is misled by systems theories that are more appropriate for rendering manufacturing industries profitable than for rendering patient care effective.
The American health care delivery system is reprehensible for the degree to which it tolerates the under-treatment of those in need and supports the over-treatment of those who are entitled. It invests vast wealth in its own entropy. I don’t want to belabor all this shamefulness. The best we can do is to superimpose rationality on the current system—iron clad, science supported, and patient driven rationality with the goal of assuring health and providing recourse when that assurance falls short. We are advantaged by a cadre of physicians who are culled from the ranks of the best and the brightest and who would like nothing better than to do what is right by their patients. The moral charge to our society is to design a system that exists for no reason other than to provide for the wellbeing of both the sick people and the sick peoples amongst us1. To begin to do so demands confronting 3 of the current system’s most intransigent and least recognized moral lapses: licensing overtreatment, institutionalizing conflictive relationships, and promoting perverse incentives.Continue reading…