My corrrespondent the Industry Veteran was upset to see me teetering on the doctors’ side, while trying vainly to take the middle road, in the malpractice debate that I highlighted here last week. Meanwhile the same issue (the web site that identifies plaintiffs for doctors) has been busying a slew of doctors and a few of their detractors over at MedRants. The Veteran writes to point out the error of my ways!:

I was sorry to see your statement that you "take the doctors’ side" in their battle against the malpractice lawyers. Among those who deserve blame for the shortcomings and inequities in this country’s two-tier healthcare system, organized medicine is at least as blameworthy as hospitals, Big Pharma and insurance companies. Although you back away from this ill-considered partisanship in subsequent sentences, your initial sentiment reveals a reflexive simpatico that you should try to eradicate.In the first place, efforts to assign principal blame for the healthcare system’s problems remind me of the old Chicago scholasticism that sought to place responsibility for the city’s corruption on either the politicians, the police, the gangsters or big business. All the participants have historically sought to dip their beaks in the public’s blood and, in the case of healthcare, the providers have enacted the Tony Soprano role to an extent equalling that of manufacturers and payers. Paul Starr’s Social Transformation of American Medicine and other monographs have described the tactics that organized medicine used to elevate medical practice from a middling, lower-middle class occupation at the start of the 20th century (when the requirement for admission to Harvard’s medical school consisted of the ability to read and write) into the significant holder of gross domestic product that it is today. "In the physicians’ view," according to Starr, "the competitive market represented a threat not only to their incomes, but also to their status and autonomy…and threatened to turn them into mere employees."While increasing a profession’s exposure to tort liability is rarely the sole means of reforming public policy, I believe that in this case malpractice actions do help to advance the process. Dragging physicians into the dock furthers the demystification and dissipates the profession’s unchallenged self-judgment, both of which permit physicians to insert economic bottlenecks into healthcare while making the provider sector a two-caste system. Other positive functions of malpractice activity include making medicine less attractive to the spoiled princes (and, increasingly, princesses) of American society. Certainly I agree with your contention that the necessary process of knocking physicians from their pedestal can be abetted by the increased use of physician extenders (I prefer the term used by labor historians: "de-skilling") and the enforcement of evidence-based logarithms to constrain self-indulgent, self-dealing, cost escalating "autonomy." Despite the nervous handwringing from some of your fellow bloggers, I also want to advance the feminization (more accurately, the "mom-ification") of medicine to deter avaricious ambition from the profession (keep the Jeff Skillings and the Billy Tauzins in business and policitics where they belong) while making it more hospitable to the needs of 9-5, live-and-let-live employees.I think we can proceed through a long, tedious dialogue on this issue, and we’d probably conclude with more agreement than disagreement. I don’t wish to engage in such a colloquoy, and would instead urge a way for you to expunge your reflexive sympathy for physicians. Instead of maintaining the preconscious image of a workaday British physician such as your father, think instead of the two-dollar whores who demand that the pharmaceutical companies entice them to breach fiduciary responsibilities to patients.

UPDATE: (late Weds) The Veteran‘s anti-physician line may be a little extreme for me, but nothing to the extent to which it’s upset the medblogshpere’s favorite surgeon. Go see Bard Parker‘s reply at A Chance to Cut…

If you live in Boston you can go to your health plan’s web site and use their technology to both choose and rate your hospitals. But don’t let your doctors know about this as they are mad as hell!

In Friday’s NY Times there’s an article called In Texas, Hire a Lawyer, Forget About a Doctor?. The article features a database online called DoctorsKnow which allows doctors (for a fee of course!) to find out which of their patients has sued any doctor. The logical conclusion to this is that anyone who has ever sued a doctor cannot get any care. As this behavior starts up for real rather than just as a philosophical debate in Medrants, it strikes me that we are getting to the point at which war is starting. Many doctors might say that the trial lawyers have already been at war with them and they’re just responding. Most of you know that I’m on the physicians’ side in this battle, but believe that averting the war is a much more desirable outcome than fighting it (which reminds me of the Iraq situation!).

Matt Quinn, who some of you may suspect is on the lawyers’ side captures my feelings in this note:

This article speaks to the need for someone to be a moderating force in this debate: of course, all trial lawyers aren’t bad, all doctors aren’t bad, and all people who sue for malpractice aren’t bad. Perhaps the government (CMS?, AHRQ?, ???) could convene the AMA, ATLA and other entities to come together to propose a centrist solution that provides justice for all. That would require both of those organizations to set aside some of the immediate narrow self-interests of their memberships and work together for a sustainable solution that solves the problem – something that would benefit all stakeholders involved, including (last but not least) the thousands of people who are harmed each year by malpractice. Not likely in an election year.

Unfortunately Matt’s right. While this fight get politicized it cannot be changed into a sensible peace settlement. Unless of course organized medicine breaks away from the mainstream "tort-reform" movement that’s really a part of corporate America wanting to pursue unmitigated bad behavior, and proposes a different tack in cooperation with moderate voices for sanity in medicine like the IOM.

From the THCB Sacramento bureau, Matt Quinn chimes in on the “value” of malpractice litigation. Matt has been annoying the doctors over at DB’s Medical Rants (in these long, varied and interesting comments) by defending trial lawyers–which is a little akin to a Satanist wondering into a Catholic mass. Over here in the more rarefied air of THCB, I’ve been trying to suggest that there’s a middle path in the malpractice debate. But like Matt I don’t think that the AMA policy of just putting a $250,000 limit on pain and suffering awards does anything to solve the problem. Matt picks up on a tragic case in Sacramento, where apparently one hospital follows a stricter guideline than another, and it really made a big difference. Matt comments:

I’m not sure that we need malpractice litigation in this case (especially as a California taxpayer I’m picking up the defense’s tab), but something should be done to make sure that UC Davis Medical Center does much better in the future, and that guidelines/processes aren’t implemented so differently in the same town. And if it takes a lawsuit to do that? Well, surely we can do better.

I’ve spent the last two days in a huge planning conference for Ascension Health, a Catholic multi-system (or multi-Ministry) chain that’s looking to transform its future. In fact they have a huge ongoing project they term their Call to Action and they have a system wide commitment to providing Health Care That’s Safe, that Works and that Leaves No One Behind. It’s a very ambitious program, and it’s great to see a provider system do something big and proactive. One arena that they are looking at transforming is their relations with consumers. I spent yesterday with a group of hospital marketing folks who essentially admitted that their organizations have not to this point made the patient experience their hospital’s central priority. And that is pretty typical of hospitals and providers across the country. For this system at least, that is going to change over the coming months and years.

This is not to say that the folks in the room don’t have shining examples of great patient-centered programs in their own facilities. One example is the Breast Cancer Center at St Agnes, Baltimore which provides a dedicated nurse to each patient to work as their advocate, and also puts together an immediate cross-specialty team to give each patient and their family the full range of information about available treatment choices. Longer-term observers of the health care scene may recall the experience of Andy Grove, then CEO of Intel, when as a newly diagnosed prostate cancer patient had to traipse around visiting multiple physicians, none of whom could give him accurate information about the relative likely outcomes of the procedures they offered.

Well as the WSJ’s Informed Patient column reported yesterday (sub req’d) there’s a new report out from a conference on Disease Management Outcomes sponsored by Johns Hopkins and American Healthways on the patient-physician relationship. Many of the informed consumer issues are reflected and it’s worth reading the full report. Here’s the executive summary/recommendations:

1. All parties should acknowledge patients as most knowledgeable about their symptoms, and patient self-assessments should guide the nature and timing of both the physician’s response and of scheduled visits.

2. Patients should recognize the importance of providing feedback for improving their care. Physicians and their offices should welcome patient feedback and establish safe ways that patients can provide it.

3. Physicians should implement a social questionnaire as part of the initial intake, allowing the patient to communicate essential, non-medical information about their lives. This information should be integrated into ongoing care. Information captured on the social questionnaire should include: marital status and/or significant others, education and occupation, hobbies, religious preference, preferred methods of communication and the patient’s preferred level of involvement in health care decisions. Understanding what makes each patient unique can help personalize care and reduce the risk of misunderstanding, error or loss of rapport.

4. Physicians and support staff must recognize the role of patients’ gender, age, race and religion in their treatment and ongoing care.

5. Delivering traumatic news to the patient demands that physicians find an appropriate environment with adequate time and ample consideration for the concerns of the patient, family and/or advocate.

6. Physicians must respect and incorporate the patient’s designated advocate into the care relationship. Patient advocates, caregivers and family members should be present when appropriate, so that their roles are integrated into the care plan from its outset. In recognizing the legitimate role of advocates and caregivers, physicians should be prepared to fully discuss (1) limitations imposed on their participation by privacy laws and other statutory and regulatory requirements and (2) how other legal instruments (such as durable powers of attorney, living wills and advance directives) may enhance their roles.

7. Physicians are responsible for providing current, scientifically based “best medical practices” in an ethical and timely fashion. They should instruct patients on benefits and risks and inform them of all reasonable diagnostic and therapeutic options, even if an option isn’t covered by insurance or requires referral to another physician.

8. Patients should seek–and physicians should promote–active, collaborative discussions with patients. They should take care to express medical information in laypersons’ terms to ensure full comprehension by patients. The
stresses of illness can impair a patient’s ability to absorb details of the visit. Effective physicians summarize their recommendations and assess patients’ (and/or their advocates’) level of understanding, leaving time for additional
clarification.

9. The patient-physician relationship must mirror our daily lives by relying on methods of communication that are not limited to inflexible, one-on-one visits but may include e-mail and phone communication, disease management
services, Internet access, written or verbal agreements, group visits and universal medical records that are accessible at the point of care.

OUTCOMES
The outcomes we expect from improving patient-physician communication include:
–Improved patient adherence to recommended therapies
–Improved patient self-care
–Improved comprehension of information given by the physician
–Increased patient satisfaction and more word-of-mouth referrals from happy, established patients to potential
new patients
–Increased physician satisfaction
–Improved capacity for physicians to see patients as whole persons, rather than diseases or organ systems
–Improved ability for patients to see physicians as people who also want and need mutually satisfying, therapeutic
relationships and are doing their very best to help patients

By any stretch of the imagination this is an ambitious set of goals. But nothing on this list is impossible, and if it’s all implemented successfully, those outcomes (and they are not purely clinical outcomes) will be the reward. Of course, as the group I met with yesterday acknowledges, health care organizations need to make some big changes to accomplish these goals.

The San Francisco chronicle had a couple of interesting pieces that I read on the plane east this morning.  The first was an interview with Robert Wachter about his new book Internal Bleeding. He has a lot of sensible opinions that are mainstream in the Quality movement, but are yet to really make it into public consciousness.

The reason he’s getting good press is because the book tell stories.  A "fun" one is this about a physician’s poor hand writing causing a little problem. The prescription is reprinted in the book

We asked 159 physicians to look at the handwritten prescription. Half thought it was for Plendil, a calcium channel-blocker; a third said Isordil, a longer-lasting version of nitroglycerine taken for angina; and others thought it was Zestril, a blood pressure medication. We reproduced the prescription in our book. … Take a look. What do you see?

Plendil.

Wachter: You would have killed the patient. The prescription was for Isordil, but the pharmacist thought it said Plendil. The daily dosage for Isordil is 80 milligrams; for Plendil, 10 milligrams. The pharmacist read Plendil, the patient took 80 milligrams. He had an eightfold overdose.

(The patient, Ramon Vasquez, suffered a severe drop in blood pressure, and 24 hours after starting the regimen had a massive heart attack. He died several days later. A jury awarded his widow $450,000.)

Maybe if word gets around we might find some progress on the eRx issue, but recall that this case was in 1991 (or at least that’s what it said in the dead tree edition–edited for space in the electronic version).

A CDC study shows that one prescription in every twelve written for elderly patients is potentially dangerous. The full abstract is here while here’s the rather more user-friendly news release.  What’s somewheat depressing is that this is 2000 data and despite the IOM report and other news about, nothing had improved since 1995.  Hopefull it’ll be better by the time the study is done in 2005, with more attention to the issue and more electronic prescribing.

Modern Physician has an interview with Bob Wachter, who’s new book is called Internal Bleeding. There are something in the region of 20 odd medical errors written up in the book, with a view to showing the system problems behind them.  This is something of an old story, and Michael Millenson’s Demanding Medical Excellence gave a great account of the overall safety/quality environment a few years back.  But the more the story can be told the better the chance that the battleship will be turned in the direction of safer medical care. In fact several large health organizations are actively working on these programs, such as Ascension’s Healthcare that’s safe.

With a hat-tip to Lisa Williams, this month’s Atlantic Monthly Journal has the first article I’ve ever seen in a mainstream magazine on EBM. The author calls for a national clinical institute to supplant the NIH and AHCQ, and actually make pronouncements on what works, and try to get the medical profession and health care industry to follow it. I’m so knocked out by an article on this topic getting into a major non-health care journal, that it would churlish to point out that our British cousins have already got one.