Malpractice

For most patients in the real world, getting good medical care involves complicated decisions. It’s not as simple as what often gets shown on TV, where a patient goes in, the doctor figures out what’s wrong, and then he performs some lifesaving surgery. Most of modern medicine, especially for the elderly, is a lot messier — usually there’s not “right” answer, no perfect treatment. And a patient needs to be an active participant in making choices in treatment.

If you missed the broadcast (and our live-tweeting!) this morning, be sure to check out the great discussion of Choosing Wisely, unnecessary care, and what patients and providers can do about it on the Diane Rehm show this morning! The panel included our program director, Shannon Brownlee, Dr Christine Cassel of the ABIM Foundation, Dr. Eric Topol of Scripps Health, and Dr. Ranit Mishori of the Georgetown University School of Medicine.

The panel was well-informed and willing to admit the strengths and weaknesses of the Choosing Wisely program. They all agreed that patients can't fix overtreatment on their own--doctors have to take responsibility for making evidence-based recommendations, and for considering whether test results have any real clinical consequences. In cases where a test doesn't provide any useful or consequential information, the responsible thing to do is skip the test. They also agreed that the problem goes beyond fear of malpractice lawsuits--overtreatment and unnecessary care comes from a culture of "more medical care is better," and the financial incentives that go along with that assumption.

There's a lot more in the program: check it out! And don't forget to look at the website for the Avoiding Avoidable Care conference, coming up later this month!

Imagine you are sitting in first class on a plane, waiting for the plane to push off from the gate, when you see two people in uniform, the pilot and co-pilot, dash from the Jetway into the cockpit. A few seconds later, a voice comes over the intercom, saying, “This is Captain Jones, please be sure your seat belts are fastened. We’re ready for takeoff.” What crucial event could not have occurred in this scenario? The pilot and co-pilot did not go through their checklist of safety measures. Fuel tanks full? Check! Flaps up? Check!

For those who have been following the back and forth over the Less is More blog I posted last week, here's the poster that upset some cardiologists when it was up on the Parsemus Foundation's site.

Over the top? Of course it is -- it's satire! And like all good satire, it contains a few grains of truth mixed with a hefty dose of exaggeration. 

Still, it's only fair to point out that stents aren't really the modern equivalent of leeches. Back when bloodletting was in vogue, it was believed that an excess of blood (one of the four "humors") was to blame for everything from epilepsy to rheumatism to tuberculosis. Got a fever? Let's bleed you! Given the prevailing view of physiology, leeches were an obvious, if entirely wrong-headed, way to rid the body of disease. 

Angioplasty and stents, on the other hand, are backed up by more than belief and theory. In fact, to cardiology's credit, there is a wealth of valid scientific evidence to guide their use. (These two treatments are often called percutaneous coronary intervention, or PCI.) Among the most important studies was the COURAGE trial, published in 2007, which prompted cardiologists to re-examine their assumptions about the effectiveness of PCI, and according to a thoughtful post by Larry Husten (@cardiobrief) at Forbes, has led to a steep decline in their use.

Shannon Brownlee is the Acting Director of the New America Foundation Health Policy Program and the author of the groundbreaking book, "Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer." For a cardiologist's perspective on the need to reduce overdiagnosis, check out the companion piece by Dr. Vikas Saini entitled, "The Price of Avoidable Care."

If you ever want a reason to question your cardiologist very closely when he or she recommends you undergo an angiogram, the imaging test that precedes an angioplasty or stent, read this paper by Grace Lin and Rita Redberg, cardiologists at the University of California, San Francisco. Lin and Redberg conducted three focus groups, where they gathered groups of cardiologists and asked them to talk about three hypothetical patients. All three patients had heart disease, but none would benefit from getting an angioplasty or stent – and that’s according to guidelines created by cardiologists themselves.

Nevertheless, nearly all of the cardiologists who participated said they would go ahead and give the patients a stent or angioplasty. They overestimated the benefits of their procedures, and ignored the evidence from multiple studies.

When the New York Times looked East to the nuclear crisis in Japan, they deployed standard radiation doses from medical imaging studies as the scale by which to judge the nuclear plant’s radioactivity. This comparison struck an interesting parallel, but one which made the health policy team here stop and think. Instead of being relieved that the Fukushima radiation releases were on the scale of commonplace medical procedures, we asked instead, how can we be so terrified of a distant crisis – so much so that farmers in Illinois are worrying about the availability of Potassium Iodide tablets – but not afraid of the significantly greater exposures posed by CT scanning?

Sam Wainwright and Shannon Brownlee teamed up to explore this dissonant response to the risks of radiation and answer the question, “Is Fukushima scarier than your doctor’s office?” (Full article on the Huffington Post)

Just when we thought health care reform had a clear roadmap, the specific directions are getting harder to interpret. At a March 31 event at the Newseum, Bloomberg Government brought together several health care and insurance leaders to discuss health care’s “Iron Triangle”—cost, access, and quality—as the implementation of the Affordable Care Act moves into its second year.

After an introductory address by House Ways and Means Oversight Subcommittee Chairman Charles Boustany, Jr. (R-LA), a panel discussion led by Bloomberg’s Mike Riley quickly turned to issues of cost containment in the post-ACA environment.

Karen Ignani, CEO of America’s Hospital Insurance Plans, highlighted the challenge of cost control within the existing fee-for-service (FFS) reimbursement model, saying, “My cost containment is someone else’s revenue reduction.” Under FFS schemes, lowering costs by reducing procedure rates or relying on more preventive care means that facilities, specialists, and other downstream stakeholders will see their own volume-based income decline. The system rewards unnecessary care by incentivizing overutilization at all levels of care delivery, which incentivizes specialists to practice medicine that is economically inefficient, but also potentially harmful to patients. Hospitals likewise lack financial incentives to lower admission rates or to rely on primary care physicians to minimize utilization of expensive—and highly profitable—inpatient services and procedures.

The current zero-sum game guides practice patterns as well as much of the public discourse around cost control. The ACA strives to change this calcifying calculus by allowing providers to directly benefit from cost savings in the care of their patients.

Let’s talk about risk for a moment. Statistically, you are far more likely to experience a fatal accident in the car on the road than you are in an airplane. But somehow, hurtling through the sky thousands of feet in the air just feels more risky than being planted firmly on the ground. We perceive that we’re taking on more risk in an airplane than we are in a car, statistics be damned. According to a recent article in Health Affairs, a similar phenomenon happens to doctors when they think about malpractice. And it doesn't diminish all that much even when their states impose caps on malpractice damages.

We attended an event this morning, Medical Liability and Emergency Care, to mark the release of the September issue of Health Affairs. (Not that September Issue.) We got to listen to the minds behind the articles talk about some major issues in the health policy world -- medical malpractice reform, avoiding and managing medical errors, and problems surrounding emergency room use. Emily Carrier, Senior Health Researcher at the Center for Studying Health System Change, and one of the co-authors of the article about physician perception of malpractice risk, explained the article’s main conclusions.

The grants that President Obama authorized for new approaches to malpractice and patient safety -- including variants of the "disclose and apologize" model -- were awarded earlier this month. (See the full list here). One of the grantees was the University of Illinois team we wrote about both on the blog and for Miller-McCune magazine. Dr. Tim McDonald helped us understand some of the technical and legal barriers to moving toward an early disclosure system. It's a lot easier in an academic medical center where the doctors, nurses, hospital are all covered under the same malpractice policy, it's far more difficult in community settings where the doctors aren't hospital employees and a half dozen insurers with different economic interests and philosophies can be involved in a single case. We also came to understand it's not just the "apology" that matters, it is the commitment to identifying, analyzing and most importantly fixing problems that can lead to patient harm. The Illinois project attempts to go to the heart of this problem, taking the model from the university into community hospitals.

A couple of the grantees look at perinatal patient safety -- right before and after childbirth, a high risk for malpractice suits. One looks at malpractice in the outpatient setting.

When we think about medical errors, we tend to think about treatment that went wrong -- a patient who was injured or died during surgery, a test result that was misinterpreted, or a medication mix-up. In the past few years, we've started learning about another kind of error -- overtreatment. Too much is not always a good thing -- which goes against a lot of our cultural grains about "more is better" in health care.

Rosemary Gibson, author of The Treatment Trap, a book that looks at this issue, teamed up with the Consumers Union's Safe Patient Project, to start gathering stories of overtreatment from patients -- and doctors and nurses -- nationwide. (Get to the survey via her website or via the CU safe patient page here.) It's obviously not a scientific survey, but the story bank can shed light on what patients experience, and inform health care leaders and policy makers.