Tag: Patient Safety

Data-Driven Health Care: An Interview with Jerry Reeves, MD

Jun 8, 2009• 17

An under-the-radar debate is occurring in health care between those who say data shows that practice variations across the land are “unwarranted” and those who maintain that such variation is inevitable given socioeconomic population differences and cost of practice differences in major metropolitan and rural areas.

Data transparency proponents say costs of medical practice, to achieve the same outcomes, should not vary much.
Data transparency opponents say data can be shaped to fit a premise that variation is unwarranted, while ignoring the human and economic realities and inherent variability driven by different regional cultures.

That Medicare law forbids doctors to compare fee schedules to avoid monopolitistic behavior, that costs of episodes of care vary greatly with points of patient entry into the system, that third parties generally set physician payments, and that reformers and physicians have fundamentally different economic points of view confounds and complicates the argument.

What follows is an interview with Jerry Reeves, MD, an articulate spokesperson for using data to reduce practice variation, promoting value-based purchasing by payers, and achieving higher levels of physician performance.

“In God we trust, all others bring data.”

…..W. Edwards Deming. 1900-1993, American statistician who taught top management how to improve design, product quality, and sales in global markets

“Researchers have estimated nearly 30 percent of Medicine’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level of low-cost areas – and those estimates could probably be extrapolated to the health system as a whole.”

…..Statement of Peter Orszag, Director of the Congressional Budget Office, “Opportunities to Increase Efficiencies in Health Care”, June 16, 2008

It is no surprise that the I.T. candidate, Barack Obama, is intent on being the I.T. president. To succeed, he will have to remind his administration early and often, that he is committed to transparency – and that the threat of embarrassment is no justification for secrecy.

“Data.gov,” New York Times editorial, May 26, 2009

*****

Prelude:

Dr. Reeves is Chief Medical Officer of Hotel Employees and Restaurant Employees International Union (H.E.R.E.I.U.) Welfare Fund. The Fund offers multi-employer health insurance coverage for 90,000 eligible employees and their family members. He is also Principal of Health Innovations LLC which provides health benefits, wellness, and health management consulting services for health plan sponsors and coalitions. He is a Director and Chairman of the Board of Health Insight, the Quality Improvement Organization for Nevada. And he is Medical Director of the Nevada Business Coalition for Health Improvement. Dr. Reeves previously served as Chairman of WorldDoc Inc., Chief Medical Officer of Humana Inc. and Sierra Health Services Inc., and as Chief of Clinical Medicine at USAF Headquarters in Europe. He served two terms on the Board of Health of the State of Nevada and has served on the faculty of three medical schools.

*****

Q: What does Health Innovations do?

Reeves: We work with self-insured employers, Taft-Hartley Trusts, and business coalitions on health to promote programs of transparency and accountability that engage hospitals, doctors and patients in improving their health with a focus on primary and secondary prevention and wellness. We engage people in more rational lifestyle choices.

Q: And what about your work at HEREIU Welfare Fund, the health plan for Hotel Employees and Restaurant Employees International Union members and their families?

Reeves: We align incentives in the benefit designs of our health insurance coverage to engage beneficiaries in taking their medications, getting their tests, and seeing the same doctor regularly. We collaborate with doctors, hospitals and utilization management firms to modify behaviors that generate excessive costs and to minimize payments for low value services to achieve better control of costs and outcomes. Much of my work involves analyzing medical and pharmacy claims data and other self reported data reflecting patient risks and provider practice patterns. The findings help us prioritize interventions. We then use ongoing measures to monitor and improve the impacts of our chosen interventions.

Q: You have been doing a study and giving a slide presentation with the title “Variations of Care, Comparisons of more than 450 Episode Treatment Groups – Evaluating Physicians in 4 States.” Tell us about that study, and the 4 states you are talking about.

Reeves: The 4 states are Nevada, Illinois, New York, and Pennsylvania. The study is based on health plan data. We pay medical and pharmacy claims for our members who seek medical services under our health plan. We collect information from those claims and from health risk questionnaires and other biometric measures to track patterns of care.

We can compare plans geographically because we have plans spread across several states. I can see significant patterns between providers in the same specialty not only in multiple States but also in the same town. They are treating hotel and restaurant workers with many socio-demographic similarities and are paid using similar fee schedules.

The variations in physician preferences are substantial For high volume episodes in primary care – otitis media, bronchitis, urinary tract infections, or chest pain – the most expensive high volume adult primary care doctor is about 7 to 8 times more expensive per episode than the least expensive doctor in the same specialty within the same town paid on the same fee schedule. The outcomes – no more ear pain, no more cough, no more dysuria, and no more chest pain – are the same.

These variations are not just in the primary care arena. They exist in the specialty arenas as well – cardiology, ob/gyn, orthopedics. The most expensive cardiologist who takes care of an episode of angina is 5 times as expensive as the least expensive cardiologist; the most expensive orthopedic knee surgeon is on average 2 ½ times more expensive than the least expensive. We see no differences in outcomes.

So there are dramatic differences. The question is: with health care as expensive as it is already, can we as a country afford to sustain overpayment to outliers who are so much more expensive than their peers in the same town when they are each achieving the same results?

Admittedly there may be variation in the severity of the cases. But we attempt to minimize the impacts of varied illness burden by comparing multiple cases, typically more than 30 cases per doctor. That probably washes out most of the severity related variations. To make things fair, we also take the top 3% and the bottom 3% outliers out of the comparisons to make our estimates more reliable.

Are these variations sustainable in today’s economic environment and in today’s era of global competition?

Q: Are doctors you are comparing aware of what their peers are doing? Do you send them de-identified information on these variations?

Reeves: We do. We also sit down with them and share comparative information when we believe we’re using fair measures. In some cases, there’s a reasonable explanation for the variations. For instance, we learned that an outlier orthopedist was known throughout the town as the doctor who did the best job with redoing surgery for patients with failed back surgeries. That likely explained why episode costs were higher for him. We want to learn from them what a rational explanation might be. Sometimes we get logical valid explanations. What we notice, though, is that after we’ve had these discussions, the trends move more towards the middle instead of staying at the extremes.

Q: So there’s a swing towards the mean?

Reeves: Yes, there’s a regression towards the mean. The overall system becomes more efficient, and cost trends decrease.

Q: I notice you indicate variations in total costs of certain episodes of care differ greatly depending on the site of patient entry into the system – the hospital, the ER, an urgent care clinic, or the office.

Reeves: People have known for years that when the first visit is at the hospital, expenses soar. The typical hospital admission costs 12.7 times as much as an ER visit; an ER visit costs 10.7 times as much as an office visit; a hospitalization costs 136 times as much as an office visit.

When you think about it, you could get a lot more office visits for the cost of one hospital admission or one emergency room visit. We would rather pay more for patients regularly visiting their continuing care physician than going into the hospital or emergency room.

From our point of view, a patient showing up at the hospital or ER represents a failure of outpatient management. The great majority of all care should be going on between doctor and patient in less restrictive settings and safer environments than hospitals and ERs.

Q: You must offer some educational process informing your members of these cost considerations.

Reeves: We do. We expend a lot of effort on developing systems to engage our members – posters and brochures, newsletters and explanation of payment (EOP) stuffers, reminders, making available telephonic nurses and health coaches, making it easy for people to call in, making it convenient to reserve a next day appointment. We show them the comparative out of pocket cost of going to the ER and hospital and explain alternatives that can get their problems solved faster and at less cost.

There is value derived from this approach. For instance, Microsoft has found they can save a lot of money for both the company and the beneficiary if they pay for a doctor to spend an hour at a patient’s home rather than having that patient go to the ER. Also it’s more personal and more likely to lead to a continuous care process that identifies needs earlier.

Also, to align incentives with desired behaviors, we’ve made it much more costly for our members to go the ER rather than seeing their doctor. We also work with our doctors to make sure they have slots available so people can be seen within one business day when they are worried they are getting worse.

It takes two to tango. We need to engage both the doctor and the patient in improving the availability and affordability of care that improves health. We combine a number of incentives for members and information campaigns about choices resulting in less out of pocket costs, with incentives and interventions with doctors to provide more efficient care.

Q: Do you have data indicating significant cost reductions

Reeves: We do. In Las Vegas, we ran three campaigns: one, to have more patients adhering to their chronic medications; second, a community wide campaign to champion the use of generic drugs; and third, free pharmacies where our people could come to fill prescriptions for generic drugs for chronic conditions with no out-of-pocket expense. Simultaneously, we profiled and gave performance feedback to primary care physicians displaying their apparent adherence to quality of care guidelines and their comparative efficiency expressed in terms of average costs per episode. We used things like ratios of HbA1C testing, microalbuminuria testing, hypertension management, compared to their peers – 22 quality indicators in all. The episode comparisons were for those episodes most common to their specialty with ratios expressed in comparison with the median values among their peers.

We rewarded 155 of those primary care physicians with bonuses and displayed them as Gold Star physician in our provider directory. At the same time, there were 50 doctors who persistently underperformed despite our sitting down with them and showing them their patterns. We discontinued our contracts with them for lack of a business reason to continue their contracts. At the same time, we intervened regarding the use of Oxycontin, which was being hugely overused at the time. It turned out that the physicians discontinued from the network had been prescribing more than 50% of the Oxycontin used for our whole population in that town.

The result of our suite of interventions was that out of the $268 million spent the baseline year, we saved $69 million over the next two years according to actuarial projections; our medication adherence for chronic conditions went up 8% even while our drug costs went down dramatically; and our adherence to mammography, Pap smears, and lipid management guidelines improved.

Q: Just to give us perspective, how many people live in Las Vegas and how many doctors are in your network?

Reeves: The total population is about 1.6 million and we had about 1900 doctors in our network then. Our patient base was about 120,000 lives including children then.

Q: Is inpatient cost control a different animal?

Reeves: Inpatient cost control has similar patterns. We looked at inpatient costs obligated by physicians who sometimes admit patients to hospital in 4 different states – Nevada, Illinois, New York, and Pennsylvania. In this group, we focused on the inpatient facility costs as part of the overall costs of episodes of care that might result in hospitalization.

When we compared the variance from the expected median inpatient facility costs for various episodes managed by internists, the most expensive internist was $71,000 more expensive than the least expensive internist. The most expensive cardiologist was $203,000 more expensive than the least expensive cardiologist for episodes managed by cardiologists. The discrepancy between the most expensive and least expensive general surgeons was $284,000; and for obstetricians the discrepancy was $305,000.

It appeared that a primary driver for excess cost among obstetricians related to wide variations in the prevalence of primary cesarean section deliveries (among women in their first pregnancy). Among obstetricians delivering more than 200 births per year, we had obstetricians with 54% primary c-section rates and others with 9% primary c-section rates.

It is not defensible or believable that all of these obstetricians can be right. There are some variations that go on that are frankly just plain unsafe. Malpractice insurer underwriters told me they spend much more malpractice insurance payouts for major surgery complications of c-sections than payments for babies who might have fared better from cesarean delivery.

Q: What incentives do you use to encourage doctors to perform better? What are your techniques? You’ve mentioned sitting down with them, showing them data, rewarding them with bonuses. Anything else?

Reeves: We’ve used a suite of multiple interventions. Doctors deserve multiple opportunities to correct these variations. It should be three strikes before you’re out.

The most common comment I get back is: “Nobody ever told me this.” “How come nobody has ever said this before?” It’s a little bit like patients who have previously seen urgent care doctors for quick symptom relief when you tell them they have hypertension or diabetes. They often say, “Nobody ever told me that.” The doctors are right. Few payers give comparative performance feedback to rank and file physicians.

Essentially once doctors finish their residency program, they are on their own unless they work in a large multispecialty group with internal peer review. By and large in private practice offices, there is not much performance feedback.

Q: So many private practice physicians, if you will, function in a data-vacuum?

Reeves: Exactly. Once you share the information, they will often point out deficits in the data, even though the data ultimately comes from them. We are open to challenges and want to continuously improve the quality, accuracy, and reliability of the data.

The first strike is defined by a doctor’s or hospital’s response to reviewing the data so they can internalize it and take action to address the root causes that lead to these variations.

The second strike we may take toward corrective action is sharing the information more widely so that doctors and hospitals understand payers are reluctant to keep paying extra for something that doesn’t result in a superior outcome. The people paying these bills are hurting, trying to pay their employees and to stay afloat and to compete with other companies. On a larger scale, they are trying to compete with companies in other countries making the same product but not bearing the same costs. This kind of understanding can sometimes bring accountability and behavior change. We have doctors who call us and ask when they can see their next report. Of course, most of those are performing well and want to disseminate that news.

The third strike is discontinuing contracts with physicians or hospitals that do not alter excessive charging and wasteful practices. Sometimes it may involve discontinuing payment for particular services being overused. For doctors this might mean payers would discontinue payments to a primary care physician who owns a machine for nerve conduction velocity testing or ultrasound imaging who orders dramatically more of these tests per 100 patients compared to their peers who do not own and profit from such equipment. For hospitals, CMS and some other payers have discontinued paying for “Never Events” – high costs incurred as a result of certain hospital acquired conditions like venous thromboembolic events occurring after knee or hip surgery.

Q: As you know, as a nation, we are in the hot heat of the health reform debate, and the Obama administration, particularly Peter Orszag, the budget director, has put a lot of stock in John Wennberg’s work at Dartmouth. Wennberg and his colleagues, using Medicare data, keep emphasizing that most practice variation is “unwarranted,” and the nation could save 30% on total costs by bringing down costs in high spending regions, like some large cities, to those in low spending regions, like the upper Midwest and the South.

But some critics of the Dartmouth studies, like Dr. Richard Cooper, a professor of medicine at Penn and a principal at the Leonard Davis Institute of Health Economics at Penn, have challenged the Dartmouth interpretation of the data in Health Affairs and his blog, www. Buzcooper.com by saying you can’t compare spending, say in Los Angeles with a 70% Hispanic population, many of whom are poor and sick, with Rochester, Minnesota, with a 90% white population, most of whom are well.

Is your approach similar to the Dartmouth studies on Medicare studies, except that it’s done on a more local level and includes data from commercial insurers on the under 65 population?

Reeves: The Dartmouth and Obama Administration approaches are similar except their focus is mostly on Medicare hospital data. The end-of-life years are the most expensive by far. Our data is on hotel and restaurant workers and their families, perhaps more similar to Medicaid patients, but covering a wider spectrum of diseases and conditions. Most of our costs are for prescription drugs and professional services and new technologies.

Even so, our experience is that the overall patterns of practice variation in the commercial world and the Medicare world are parallel. I believe we need to merge the doctor and hospital data from Medicare and Medicaid payments with data available from other commercial payers serving working age populations. We need to consolidate all that data into common data warehouses.

The data should include not only the professional services of doctors and other clinicians but also the laboratory and diagnostic data, the inpatient and outpatient facility data, and data on high technology hardware (imaging procedures, implants,) and drugs (biologics, cancer therapies) at least by regions so we can compare these regions against each another. Then adequate sample sizes could become generally available to analyze and display care patterns, technologies, and drugs offering the most value (best outcomes) for the dollars invested.

Q: I just read in the May 22 New York Times a piece entitled “I.B.M. Unveils Software to Process Vast Amounts of Data “for quick analyses of massive chunks of combined data. Is that what it will take to carry out your vision? Would that be a breakthrough?

Reeves: It would be breakthrough, but I do not see technology as our major challenge. The challenge is political will. We have a competitive risk issue that leads to carriers not wanting to share their data in a data warehouse for fear that proprietary rates or payments might be revealed or confidentiality agreements that they have negotiated with various providers might be breeched. Some also worry that personal health information might be revealed.

The banking industry has been able to deal with the issues relating to money for many years and has brought dramatic improvements in efficiency and choice. I remember waiting in long lines to deposit a check on payday. Now I am irritated if it takes an ATM window more than 30 seconds to complete my transaction at a drive through window at midnight. Much of the fear of disclosure of health information is already addressed by HIPAA law and protected by reliable systems of maintaining confidentiality and security.

I cannot emphasize enough how important it is to merge the various data sources into master data files like the Dartmouth Atlas to include physician patterns of care and physician groups’ patterns to enable purchasers, consumers, and patients to get fairer representation of the choices they have, much like they do for buying cars and dishwashers.

Q: Are you talking of public disclosure?

Reeves: I would start out with feedback to the providers for their internal quality improvement initiatives and root cause analyses. We do not need to start with public disclosure. But we will need to move down the track of accountability and transparency in order to keep our country afloat because we simply can’t maintain competitive advantage globally with current health care cost trends.

Q: The Dartmouth Group did a study of five major academic centers – Mayo, UCLA, the Cleveland Clinic, NYU, and Hopkins – and it showed a significant variation in costs.

Reeves: That’s absolutely true, and I see the same thing happening in our domains. Take our data in Chicago and Pittsburgh. We can rank order costs in hospitals in those cities by diagnostic group, and the most expensive hospital may often be 5 to 8 times as expensive as the least expensive hospital with the same outcomes for patients with apparently similar risk and case mix.

Q: Is it realistic to believe we can homogenize these cost differences across the country, given the different institutional, regional, and cultural differences? After all, there are different expenses and profits required in New York City and rural Alabama.

Reeves: I don’t know we can do that, but I think we can compare rural Alabama to rural Georgia. And we can compare Chicago to New York. What’s right is right.

The right way to practice family practice is the right way the world around. The right way to practice internal medicine is the right way the world around. It is both feasible and advisable to decrease the incredible discrepancies between good and bad practices of medicine in our country and elsewhere.

Yes, there are culture differences, and there are habits and preferences that vary from location to location. For example, we have more problems with back surgeries and re-dos and excessive narcotic use in places like Las Vegas than in New York. And we have a lot bigger problem with obesity and bariatric surgery in West Virginia than in Chicago.

There are variations driven by demographics, socioeconomics, and patterns of living. But when it comes to delivering effective, efficient care, 800% differences are not defensible. If you have two cars that drive the same speed, look similar, and last the same thousands of miles, and one is eight times more expensive than the other, how many people would buy the more expensive car at the 700% higher cost?

If you apply that same principle to health care, how long do we really believe we can sustain this kind of variation and turn a blind eye to it? It doesn’t seem like a reasonable proposition to me.

Q: Do you think the Obama administration’s proposal to create a National Comparative Effectiveness Institute would address these issues?

Reeves: It would simply be an extension of what’s going on already. A number of organizations have been doing comparisons of relative therapeutic effectiveness and cost efficiency of new technologies and drugs for years. They have graded the scientific evidence for level of proof of what works best, cost effectiveness, and safety. Managed care plans and carriers have been using these rank order grades to help them decide what their insurance plans are going to cover. We already have a long history of comparative effectiveness studies. For instance, the Medical Letter does this kind of thing for drugs, and looks in a nonbiased way at outcomes and costs. Do we really need more “me too” drugs and expensive images that don’t change care effectiveness and outcomes commensurate with their costs? I sometimes think new technologies are developed mostly because it’s possible, then the developers go looking for problems the technology might help. Can we really afford that? Who should pay for all of that? Under what special circumstances should society as a whole pay for that?

I think in the future we will see the rank ordering of ratings of various health care services much like in Consumer Reports. The day of secrecy and behind the scenes behaviors hidden to the public will eventually be coming to an end. There are multiple initiatives going on in state legislatures, business coalitions, and other organizations that are collecting comparative effectiveness data and displaying them to the public. For instance, you have the Leapfrog measures of safety, and the Institute for Healthcare Improvement’s 5 Million Lives campaign and the publicly displayed CMS core measures of hospital performance. You have publicly available data bases of Medicare claims payments in most States and all payer data bases in 17 states comparing hospitals’ data to that of competitors in the same market. And the National Business Coalition on Health and some States are collecting data comparing health plans to each other and displaying performance metrics on public websites. It’s all about transparency and accountability. Congress has a track record of strongly favoring this approach.

Q: And yet, despites all these rankings and initiatives and talk of transparency and accountability and nearly 40 years after Wennberg’s original paper on Medicare practice variation, the variations remain high.

Reeves: They do, but progress is occurring. Over a 3 year period in Las Vegas, we’ve been giving quarterly reports to hospitals comparing their Leapfrog results, patient satisfaction results, and CMS core measure national percentile rankings to those of their Las Vegas hospital peers. At the beginning, the rankings ranged from the 88^th percentile for one hospital to 2^nd percentile rank for another.

After regular meetings with senior executives of these hospitals, discussing their quality improvement initiatives, the hospital at the 2^nd percentile moved up to the 38^th percentile nationally at the end of the 3^rd year. So substantial improvement is possible through transparency. Even more improvement is possible through incentives such as bonuses, as demonstrated by the Premier Project with CMS, in which hospitals received 2% more in payments for meeting quality standards. Those hospitals participating in the Pay for Performance cohort showed substantially more improvements than those subjected only to public reporting.

Value-based design of CMS and private health plan coverage works. They decrease out of pocket costs for high value services and treatments and may raise the out of pocket costs for interventions with marginal effectiveness and value. Cost trends bend downward, and value and quality go up. They have to, if this country is going to survive in a competitive world economy.

Along with 4 large company CEOs, a large company benefits manager, and a State health officer, I met recently with President Obama in the White House. This was the day after his historic meeting with national health leaders – the AHA, the AMA, America’s health Insurance Plans, PharMa, the Service Employees International Union, and others – who pledged to reduce national health care spending by $2 trillion over the next decade. Our roles were to explain our interventions that have lowered cost trends and improved health outcomes so they could be adopted for federal employees and other Americans. President Obama and his administration are determined to reform the system to achieve lower cost trends and better health status for Americans. It will take insurance plan designs that align incentives with desired behaviors, and data based reporting of impacts of positive and negative incentives that engage physicians and patients more actively for this effort to succeed. Working together, we can do a lot better than we have the past several years.

*****

The interviewer is Richard L. Reece, MD, author of Innovation-Driven Health Care: 34 Keys to Transformation (Jones and Bartlett, 2007), Obama, Doctors, and Health Reform; A Doctor Assesses Odds for Success (Universe, 2009), and blogger, www.medinnovationblog.blogspot.com.

Is Hospital Peer Review a Sham? Well, Mostly Yes

Jun 3, 2009• 16

By BOB WACHTER, MD

Dr. Sidney Wolfe, healthcare’s answer to Ralph Nader, spends most of his days unhappy with somebody. Pragmatic, see-both-sides types like me naturally recoil from Wolfe’s reflexive indictment of institutions ranging from the FDA to Medicare.

But Wolfe’s blistering condemnation of medical staff peer review contained in the new report, Hospitals Drop the Ball on Physician Oversight (co-written by Alan Levine, both of Public Citizen’s Health Research Group) is timely and, I believe, largely correct.

The report focuses on the National Practitioner Data Bank (NPDB), established in 1986 to collect data about problem physicians, mostly to help credentials committees make informed decisions about medical staff privileging. The legislation that established the NPDB requires hospitals to submit a report whenever a physician is suspended from a medical staff for over 30 days for unprofessional behavior or incompetence. Although the public cannot access NPDB reports on individual physicians, healthcare organizations (mostly hospitals) ping the database about 4 million times per year. When it was inaugurated, the best estimates (including those of the AMA) were that the NPDB would receive 5,000-10,000 physician reports each year.

Not so much. Since its launch two decades ago, NPDB reports have averaged 650/year, and nearly half of US hospitals (2845 of 5823) have never reported a single physician! The most extreme case is that of South Dakota, where three-quarters of the hospitals have never reported a single case to the NPDB. I’m sure South Dakota has some wonderful doctors, but the idea that the state’s 56 hospitals have never had a physician who needed to be suspended for incompetence, substance abuse, sexual harassment, or disruptive behavior since the Reagan presidency is a bit of a stretch, don’t you think?

Public Citizen chronicles several cases of egregious behavior by physicians who dodged NPDB reports – the cases either received no peer sanctions or were dealt with in ways designed to skirt the reporting requirements, such as – wink-wink – leaves-of-absence and 29-day suspensions. Most famously, a cardiologist and CT surgeon at Redding Medical Center in Northern California performed hundreds of unnecessary cardiac procedures but were not reported to the NPDB – largely because Redding’s medical staff and hospital were cowed by the physicians’ power and reluctant to kill two geese who laid many golden eggs. (Interestingly, the Joint Commission whiffed on this one too, a major reason why Congress removed its near monopoly on the hospital accreditation business last year.)

Levine and Wolfe recommend powerful medicine to fix the NPDB system, including much more vigorous legislative oversight, substantial fines to hospitals for failing to report, and linking NPDB reporting practices to accreditation standards and to Medicare’s Conditions of Participation.

A few years ago in our book Internal Bleeding, Kaveh Shojania and I described the limits of peer review; the Public Citizen report provides statistical confirmation of our observations. We wrote,

It is undeniable that hospitals do have a tendency to protect their own, sometimes at the expense of patients. Hospital “credentials committees,” which certify and periodically recertify individual doctors, are toothless tigers. Most committees rarely limit a provider’s privileges, even when there is stark evidence he presents a clear and present danger to patients. Instead, they assign a committee member to “have a chat” with the physician in question, perhaps gently suggesting he or she shouldn’t do a particular procedure anymore. They might even ask another physician, not on the committee but in a similar specialty, to “keep an eye on old Doug” and let them know if he continues to screw up, even if patients or other staff members don’t report it….

It is not that hospital credentials committees never take action. They do – removing a physician’s privileges at a hospital or recommending to the state board that a doctor’s license be suspended – when there is clear, repetitive evidence of gross negligence and incompetence. But when this happens – and it is really rare – it comes only after an orgy of soul-searching, handwringing, buck-passing, second-guessing and second chances that is painful, and sometimes embarrassing, to watch. In most cases, committee members just swallow hard and – unless the physician is under felony indictment or is so stewed that he can’t walk down a corridor without banging into both walls – the credentials are rubber-stamped.

Kaveh and I offered three reasons why medical staff self-policing is so wimpy. The first is the “fraternity of medicine” thing – no gang members like to “rat out their pals,” and in this regard, we’re no different from the Crips. The second is that credentials committee members are acutely aware of the amount of time and effort that it takes to become a practicing physician, which makes them reluctant to take away a doc’s livelihood.

A third reason, we wrote,

is simply that doctors aren’t very good organizational managers. Their people skills are usually confined to bedside chats and working with colleagues and support staff in task-oriented jobs; they aren’t particularly adept at managing conflicts and confrontations, so they avoid them. This is a pretty dumb reason to let an error-prone doctor continue to prowl the hospital wards, but because litigation… lurks behind any challenge to professional competence… many physicians are reluctant to go into that particular swamp unless the trail is awfully solid.

The fear of litigation is undoubtedly one of the major reasons why peer review doesn’t work. Although the statute establishing the NPBD provides immunity to physicians who perform good faith peer review, many hospitals and reviewers lack confidence in these protections. An American Hospital Association analysis of the NPDB concluded, “The specter of baseless, time-consuming and expensive litigation serves as a powerful disincentive to effective peer review.” If peer review is to be strengthened, these protections must be unambiguously robust.

Writing in his book Complications, Harvard surgeon and bestselling author Atul Gawande sees in the medical profession’s failure to perform aggressive peer review something understandable, even a tad noble. When it comes to disciplining a basically good but troubled doctor, “no one,” he says, “really has the heart for it.” Atul writes:

When a skilled, decent, ordinarily conscientious colleague, whom you’ve known and worked with for years, starts popping Percodans, or becomes preoccupied with personal problems, and neglects the proper care of patients, you want to help, not destroy the doctor’s career. There is no easy way to help, though. In private practice, there are no sabbaticals to offer, no leaves of absence, only disciplinary proceedings and public reports of misdeeds. As a consequence, when people try to help, they do it quietly, privately. Their intentions are good; the result usually isn’t.

There are still other reasons for the failure of peer review. When questions of clinical competency arise, there are often insufficient data to refute the inevitable arguments that “my patients are older and sicker.” When the issue is disruptive behavior, unless there has been documented scalpel throwing (by a surgeon with good aim), finding the bright line that separates the behavior of an aggressive, passionate, patient-advocate-of-a surgeon from the surgeon whose disruptive behavior creates a hostile work environment or places patients at risk can be elusive. Finally, peer review conducted by professional colleagues is fundamentally tricky – one the one hand, how could one’s practice be dispassionately reviewed by a golfing buddy? On the other, peer reviewers might well be competitors of the physician-in-question, with a financial stake in the outcome.

Is it any wonder that medical staffs kick this particular can down the road so often?

Layered on top of these traditional impediments is a new one: the paradigm shift introduced by the patient safety field. Remember, our patient safety mantra has been “no blame,” which is unlikely to be in the first verse of the Peer Review Fight Song. Haven’t we just finished convincing ourselves that most errors are due to dysfunctional systems and not bad apples? If that’s the case, who really needs peer review, anyway?

But this represents a fundamental misunderstanding of “no blame.” I struggled with this tension while writing Internal Bleeding, and went to The Source for guidance: Dr. Lucian Leape, the father of the patient safety movement. Lucian, I asked, how can we reconcile systems thinking with the necessity of standards and peer review? His answer was spot on:

There is no accountability. When we identify doctors who harm patients, we need to try to be compassionate and help them. But in the end, if they are a danger to patients, they shouldn’t be caring for them. A fundamental principle has to be the development and then the enforcement of procedures and standards. We can’t make real progress without them. When a doctor doesn’t follow them, something has to happen. Today, nothing does, and you have a vicious cycle in which people have no real incentive to follow the rules because they know there are no consequences if they don’t. So there are bad doctors and bad nurses, but the fact that we tolerate them is just another systems problem.

I’m proud to say that over the past five years, my hospital (UCSF Medical Center) has taken Leape’s challenge to heart, withdrawing clinical privileges (and filing accompanying NPDB reports) in several cases for behavior that, I’m quite confident, would have been tolerated a decade ago. This is progress. As Kissinger once said, “weakness is provocative.” As more hospitals take this tougher stance, I think we’ll see the boundaries of acceptable behavior shift everywhere. And patients will be safer for it.

A profession is group of individuals with special knowledge, who are granted privileges by society in deference to their expertise and in exchange for self-regulation. When thousands of hospitals can go 20 years without disciplining a single physician on their medical staff, our status as a profession is called into question.

In the end, peer review is about answering one deceptively simple question: Is it more important to protect problem physicians or vulnerable patients? If we can’t answer that question correctly, we should not be surprised when the Sid Wolfes of the world call us to task, nor when we find ourselves under an unpleasant media, legislative, and regulatory microscope. Professions don’t need that kind of outside scrutiny to do the right thing, but we just might.

Dr. Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”

Dennis Quaid Overlooks Too Much

Apr 6, 2009• 3

By Michael Millenson

Anyone who cares about patient safety has to be grateful to Dennis Quaid
for the way he and his wife Kimberly reacted to the near-death from a
medication error of their twin baby girls. Using his celebrity and his
contacts as an award-winning actor, Quaid launched a crusade to stop
similar errors from ever happening again. He has appeared on 60 minutes , testified before Congress and, Sunday, came to HIMSS to tell his story once again.

At HIMSS, Quaid was amusing (“I am not a doctor [and] I have never
played a doctor on television or in the movies”) and moving, as he
detailed how two massive heparin overdoses turned his newborn twins’
blood to the consistency of water and left them bleeding inside and
out. He was also generous and humble, repeatedly thanking the HIMSS
membership for the work they did in developing the technology that can
prevent inevitable human error from causing harm.

Op-Ed: Healthcare Reform Lessons From Mayo Clinic

Jan 21, 2009• 45

By LEONARD L. BERRY and KENT D. SELTMAN

Three goals underscore our nation’s ongoing healthcare reform debate:1) insurance for the uninsured, 2) improved quality, and 3) reduced cost. Mayo Clinic serves as a model for higher quality healthcare at a lower cost.President Obama, after referencing Mayo Clinic and Cleveland Clinic, advised, “We should learn from their successes and promote the best practices, not the most expensive ones.”

Atul Gawande writes in The New Yorker, “Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country-$6,688 per enrollee in 2006.”Two pivotal lessons from our recent in-depth study of Mayo Clinic demonstrate cost efficiency and clinical effectiveness.

Should the FDA relax in the search for new cures?

Jan 9, 2009• 1

By Matthew Holt

Over at DiabetesMine #1 health blogger Amy Tenderich has very important post. She and several fellow travelers are appealing to the FDA to strike a balance between safety and progress in allowing new diabetes treatments.

The FDA of course has been beaten to a pulp these last few years because it’s played footsie with the drug industry and ignored several potentially damning studies, with the result that the number of drugs withdrawn from the market has been much higher than in previous years.(Vioxx, Phen-Fen, Baycol, et al).

I’ve always felt that the FDA’s role should not to be a black/white (dangerous/safe) stamp of approval, but instead it should be the honest broker of getting all the data out there. As Amy and her crew point out, some diabetics may be prepared to take a risk of higher long-term cardiac complications in return for a medium term gain from a new medication. Something similar is certainly true in terms of hormone replacement therapy.

A new year’s resolution for greater hospital transparency

Jan 3, 2009• 6

By Paul Levy

Just thinking, along the lines of a New Year’s resolution. What if all
of the hospitals in the Boston metropolitan area — academic medical
centers and community hospitals — decided as a group to eliminate
certain kinds of hospital-acquired infections and other kinds of
preventable harm? And what if they all committed to share their best
practices with one another and to engage in joint training and case
reviews in these arena? And what if they all agreed to publicly post
their progress on a single website for the world to see?

Low tech ways to improve patient care: sleep and manners

Dec 17, 2008• 4

By Michael Miller, MD

A few recent reports point to ways for improving the quality of physician delivered care that has little to do with technology or complex interventions. The first involves how physicians interact with patients, and the second examines the work hours for physicians in training.

Etiquette in Medicine
The first article, by Dr. Michael Kahn in the New York Times, describes six recommended actions for physician to create a good rapport with hospitalized patients. Dr. Kahn collectively calls these actions “etiquette-based medicine”:

Ask permission to enter the room; wait for an answer
Introduce yourself; show your ID badge
Shake hands
Sit down. Smile if appropriate
Explain your role on the health care team
Ask how the patient feels about being in the hospital

Clearly these actions are all directed towards creating a stronger person-to-person connection between the physician and the patient as a step toward improved communications – which is the foundation for developing and effectively delivering a treatment plan to and for the patient.

Physicians Getting Rest
Another challenge physicians have in this process is being awake and aware enough to actually engage in those 6 steps. (Having enough energy also would effect their ability to engage patients empathetically – something I’ve written about before.) [Also see the previous posting about napping being better than caffeine for improving verbal and physical memory and learning.]

How much sleep physicians need to act appropriately – and avoid making errors – is the subject of a recent Institute of Medicine report, (“Resident Duty Hours: Enhancing Sleep, Supervision and Safety”), that makes new recommendations for limits to the work hours for physicians in training:

Duty hours should not exceed 16 hours per shift; For 30 hour shifts there should be an uninterrupted five hour break for sleep
Residents should have variable off-duty periods between shifts based on the timing and duration of shifts to increase residents’ opportunities for sleep each day, as well as regular days off that enable residents to recover from chronic sleep deprivation.
Medical moonlighting, (additional paid healthcare work), should be restricted
[A chart comparing the current and new recommendations is available here.]

While all these changes would certainly make for more aware and awake residents, the IOM also estimates that recruiting and paying professional staff to substitutefor the work hours the residents would have been (over)working, would cost about $1.7 billion.

Besides figuring out how to pay for these new staff hours, one policy question for implementing these recommendations is how to find the clinicians to actually work these hours considering there is such a shortage of non-physician clinicians.

Anther policy question these recommendations raise, is why they should they only apply to physicians in training? Why shouldn’t they also apply to physicians who’ve finished their training and are supervising, teaching, and mentoring residents and medical students – and of course are directly responsible for patients? While it might be argued that most physicians don’t work these long hours, for some that may not be the case – particularly in hospitals without many residents.

Considering that many quality improvements for medicine have been taken from the airline industry – such as the pre-flight/pre-surgery checklist – then why shouldn’t the limits on pilot shifts and hours also be applied to fully licensed physicians? [I suspect that this will not make me popular with some physicians, but I wonder how they will defend their right to treat patients round-the-clock without sleep?]

Conclusions
Perhaps work hours and etiquette should be other aspects of quality improvement and patient safety that are considered as part of health reform discussions at the Federal and State levels. Certainly well-rested, empathetic physicians trained to interact with their patients with etiquette should improve the quality of healthcare by reducing errors and making physician-patient communications more effective.

How to integrate all these “innovations” into physician training and practice will be a significant challenge, because teaching such skills and promoting their use is not very exciting or technological, and it will be hard for such behaviors to be tied to economic incentives – which are often the carrot or stick for quality improvement initiatives. Hopefully, as health reform ideas move forward and become crafted into comprehensive packages and plans, they will expand beyond direct economic incentives for improving clinical processes, to include non-economic inducements to promote quality enhancing actions and attitudes for clinicians as well as patients.

Dr. Michael Miller started HealthPolCom Consulting in 2000 after 12 years in health policy positions in Washington, DC. He works with an extensive network of policy and communications consultants. He blogs regularly at Health Policy & Communications, where this post first appeared.

Dispatches from IHI’s quality forum

Dec 14, 2008• 2

By Amanda Goltz 5million

Don Berwick is one of the leading lights of the health care quality world; an
oft-quoted and published visionary who founded the Institute for Healthcare Improvement to spread the gospel of transformation and improvement around the world. Sometimes, however, he can come across as messianic, especially when preaching to the choir in a setting like the IHI Forum, which took place last week in Nashville.

Some criticize Berwick and IHI for a lack of measurable outcomes for the interventions they preach. The most recent complaint like this concerns IHI’s 5 Million Lives campaign, which recommended that hospitals adopt a series of interventions to improve patient safety, promising that if they did so, 5 million patients would be saved.

The campaign officially ended at this week’s conference, and no one at IHI can show data on the number of lives saved. It’s true that Berwick has a powerful voice and a broad platform, and he could use it to structure the work that needs to be done, rather than sticking to a combination of inspirational cheerleading and emotional appeal. But back when no one was thinking about quality, Berwick was championing it; and for some community hospital quality leaders who feel like they are the lone voice in the wilderness, his words keep them going all throughout the year.

Transforming medicine and saving lives

Dec 9, 2008• 5

By Sarah Arnquist Bestpractice

This week, Don Berwick will announce the results of the 5 Million Lives Campaign
before thousands of people in Nashville attending the National Forum on Quality Improvement in Health Care.

Twenty years ago, it was almost heretical to question the quality of American health care. The common refrain being that it was unarguably the best in the world.

Decades of work by Berwick and others, however, have dispelled that myth, and the underlying belief that medical errors and hospital acquired infections are simply an artifact of the business. These quality champions deem it unacceptable that as many as 98,000 Americans die annually from preventable medical errors, and that most Americans receive the recommended care only half the time. They’ve spent years building their case, and in turn created a social movement around their cause.

In the book, "The Best Practice," Charles Kenney chronicles this long march toward a culture within American health care that demands continuous quality improvement.

Resident Duty Hours and Patient Safety: Did The IOM Get It Right?

Dec 9, 2008• 2

By Bob Wachter Robert_wachter

The Institute of Medicine just released its long-awaited report on trainee duty hours. It is well researched and balanced, and its recommendations appropriately reflect what we know vs. what we believe. Now the fun begins.

Let’s start with a little background, some of it drawn from my book Understanding Patient Safety:

Let’s be honest. Traditional resident schedules – on call every third night, staying up for 48 hours in a row, and working 120 hours per week – were both inhumane and immoral.

The “Days of the Giants” view that such training was needed to “turn boys into men” (before women became the majority of medical students) was machismo garbage. This was a hazing ritual formed when people believed that one should sacrifice one’s life on the Altar of Medicine, perpetuated because all of our egos are such that we said, “Well, that was brutal, but just look how great I turned out – so that must have been a good system!”

And, because housestaff labor is easily the cheapest in the building (what intern hasn’t done this math – my own 1983 internship salary of $17,600 translated into about $4.50/hour, less than I made caddying), what began as a rite of passage quickly morphed into an economic imperative. Having fallen asleep at the wheel once or twice driving home during my internship, I have little sympathy for those who wistfully long for the Days of Yore.

Beginning with the famous Libby Zion case at New York Hospital in 1984, the public and media have pressured “the system” to fix the problem of long trainee hours. A 1989 New York State regulation limiting duty hours to 80 per week was largely ignored, and no other state followed suit for over a decade. But the overarching pressure to improve patient safety, which began with the IOM’s 1999 report, To Err is Human, was enough to give the Accreditation Council for Graduate Medical Education (ACGME) the courage to gore this particular sacred cow, and to withstand the subsequent mooing.

In 2003, the ACGME, which accredits the nation’s 7,800 training programs, decreed that residents’ hours would be limited to 80 a week, with no shifts longer than 30 hours. Both numbers were completely arbitrary – there is no research that helps tell us the “right” number of hours per week or per shift. In fact, the research on sleep deprivation as it pertains to resident performance is surprisingly mixed. While it is well appreciated that 24 hours of sustained wakefulness results in performance equivalent to that of a person with a blood alcohol level of 0.1% – legally drunk in every state – studies have shown that tired radiology residents made no more mistakes reading x-rays than well-rested ones, and sleepy ER residents performed physical examinations and recorded patient histories with equal reliability in both tired and rested conditions.

That said, most folks find this to be one of those issues in which common sense trumps evidence-based medicine – pointing to the tongue-in-cheek BMJ piece challenging EBM zealots to participate in a randomized trial of jumping out of an airplane with and without parachutes (since the value of parachutes has never been subjected to evidence-based scrutiny). On this one, I agree: given the substantial evidence of the harms of sleep deprivation, the burden of proof should be on those defending the old schedules, not on those proposing more humane variations.

Several studies have examined the impact of the 2003 ACGME regs. It is fair to say that the jury remains out. The studies generally show no real effect on clinical outcomes or patient safety, and significant concerns have been voiced by both faculty and residents regarding unintended consequences. But the pressure to do more from a wary public remains, and there have been studies that have convincingly demonstrated that shorter shifts in the ICU environment lead to fewer errors.

When the ACGME regulations first came out, programs did what they always do with regulations they don’t like – they tried to skirt them. The ACGME did something clever in response – it fired two shots over the academic bow, placing two of the most prestigious programs in the country (Yale Surgery and Hopkins Medicine) on probation. The message was clear: we’re not screwing around. That said, this week’s IOM report was critical of what it deemed lax enforcement of the existing standards, calling for unannounced surveys, periodic audits, and stronger protections for whistleblowers. I think they were right to do so.

Programs responded to the 2003 duty hours regulations in a number of ways. When the rules hit, I was virtually certain that our residency at UCSF would go to a Night Float-on-Steroids system, sending the on-call team home at 10pm, having the nights covered by a fresh crew, and handing those patients back to a new team in the morning. But that’s not how it turned out.

One of the great things about UCSF is that our residents rotate through three separate hospitals, so we tried three different strategies to see what worked best. And the Night Float/Send The Primary Team Home idea proved to be a disaster – we couldn’t get housestaff to leave the hospital soon after admitting a desperately ill patient (that damn professionalism), so they were getting home in the wee hours of the morning, leaving them well over the hours limits and exhausted the next afternoon.

Surprisingly, the favored system was a robust Day Float system. In it, our teams continue to stay overnight, admitting all patients till about 2 am, after which a night float takes new non-ICU admissions. When I arrive for attending rounds in the morning, my team is there along with a freshly scrubbed day float resident. We hear about all the patients together, and then the team rushes for the doors, the goal being to be out by noon. The day float resident and the attending then spend the post-call afternoon finishing up the plan, notes, etc. It works pretty well.

With that background, let’s turn to this week’s IOM report. Although there was considerable trepidation that the IOM would recommend severe additional limits in duty hours (most other industrialized countries limit resident hours to 50-60 per week), the report recommends relatively mild modifications to the existing regulations (they’re summarized here). The biggest one is a requirement for a minimum sleep period of 5 hours in any 24-hour work period, with a maximum shift length of 16 hours. If we keep the scaffolding of our present UCSF system, this will mandate that the on-call team takes no new admissions and doesn’t cross-cover its own patients overnight; instead they’ll have to have a complete hand-off and a beeper-less interlude from about 2am-7am. That seems pretty do-able, especially considering the fact that we were girding for much more radical restrictions on hours.

What may prove to be a bigger deal is the new requirement that housestaff have “immediate access to an in-house supervising physician” – which I interpret to mean 24-hour in-house attending coverage, most likely by hospitalists. Although we have some moonlighters in the house overnight, we don’t yet have faculty hospitalists. But the tea leaves are clear: It is time to start planning for around-the-clock hospitalist coverage at teaching hospitals.

Efforts to cut duty hours raise a number of questions and concerns, which I’ll separate into five buckets: 1) handoffs, 2) costs, 3) do people really sleep when they’re off?, 4) practice makes perfect, and 5) the culture of medicine. Let’s tackle them each briefly.

First, handoffs. Until 2003, our handoffs were haphazard, on the fly, and completely unsystematized. Early on, we recognized that the 80-hour workweek was markedly increasing the number of handoffs – our own Arpana Vidyarthi found that resident handoffs increased by 40% after the 2003 regulations. Like so many other aspects of the safety field, we essentially had a squeezing balloon phenomenon: one fix (better rested residents) was traded for a new safety hazard (more handoffs).

In my own judgment, patient safety worsened in the first couple of years after the 2003 rules because the handoff hazards trumped the advantages of rested trainees. It was only after we developed standardized sign-out systems that the balance became more favorable, and the new IOM report calls for even more attention to such systems. That said, there are few days when I don’t hear our nurses complain about paging the resident and hearing, “I really don’t know that patient very well. I’m just covering.” (That’s assuming that they can figure out which resident is covering at that particular moment, an immense challenge unto itself.)

The second issue is cost. The new IOM report estimates that the cost of implementing the new standards will be $1.7 billion nationally – including the hiring of about 6000 mid-level providers (NPs, PAs) and 5000 hospitalists. I don’t doubt it. The 2003 regs were the Hospitalist Full Employment Act. At UCSF, while early efforts to deal with duty hour reductions focused on residents covering for themselves coming off non-call electives (didn’t work and was wildly unpopular), they soon shifted to using NPs and PAs (worked sometimes, but some patients were simply too complex and some providers were too expensive and inefficient) and ultimately to using hospitalists.

Of our 42 faculty hospitalists, I’d estimate that about 12 FTEs are here because of the need to replace resident bandwidth on a variety of services. The new restrictions are likely to increase the need for additional coverage, and thus the costs. The reason that the IOM blinked when it came to cutting the hours down to 60 must have been partly due to these cost considerations, especially in an era in which many teaching hospitals are struggling to break even.

The third concern is whether housestaff really sleep when they’re off. Remember, these are young people with significant others, hobbies, laundry, and debts. Not surprisingly, there is some evidence that they don’t use the time out of the hospital to sleep, and the IOM weighed this in choosing to keep the weekly hours at 80. As John Iglehart observes in his excellent editorial in this week’s NEJM, “Although some might propose further reductions in total duty hours, the report notes, ‘evidence suggests it is an indirect and inefficient approach given the moderate correlation that exists between resident duty hours and sleep time.’”

The fourth is Practice Makes Perfect. Particularly in surgery and other procedural specialties, there is real concern that trainees may not be handling enough cases to become fully competent. There are few data to support this concern, and one has to believe that some of the work that residents put in during hours 80-110 in the old days were not highly educational (not to mention safe). But I’ve met many surgical program directors who are quite convinced that their graduating trainees are not prepared to operate independently – both because trainees are doing fewer cases and because of the enhanced supervision that is chipping away at the trainee autonomy necessary to develop clinical instincts and judgment.

Which brings us to the final concern (and my greatest worry): the culture of training. When the 2003 ACGME regulations came out, New England Journal editor Jeff Drazen and Harvard policy maven Arnie Epstein wrote that that traditional residency schedules,

. . . have come with a cost, but they have allowed trainees to learn how the disease process modifies patients’ lives and how they cope with illness. Long hours have also taught a central professional lesson about personal responsibility to one’s patients, above and beyond work schedules and personal plans. Whether this method arose by design or was the fortuitous byproduct of an arduous training program designed primarily for economic reasons is not the point. Limits on hours on call will disrupt one of the ways we’ve taught young physicians these critical values . . . We risk exchanging our sleep-deprived healers for a cadre of wide-awake technicians.

Therein lies the tension: legitimate concerns that medical professionalism might be degraded by “shift work” and that excellence requires lots of practice and the ability to follow many patients from clinical presentation through work-up to denouement, balanced against concerns about the effects of fatigue on performance and morale. Getting this balance right will be the central challenge of medical education over the next decade.

In my view, the IOM is to be commended for thoughtfully reviewing the issues and developing a set of recommendations (likely to be embraced by the ACGME) that seem quite sensible and balanced.

So let us old fogies cast aside the warm afterglow of our residency experiences and admit that we’ve blocked out the memories of the bone-crushing fatigue, the errors caused by the immoral mantra of “see one, do one, teach one”, and the all-consuming fear that we would crash and burn, with nary a safety net in sight. Once we get over romanticizing the past, we can start figuring out how to work within these sensible limits on hours and supervision requirements to create a more perfect system for both our trainees and our patients.

Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”