Editore"s Note
Tilting at Windmills

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December 4, 2007
By: Kevin Drum

OVERTREATED....A new report from the Institute on Medicine as a Profession concludes that doctors could stand to police themselves a little better:

46 percent said they had failed to report at least one serious medical error that they knew about, despite the fact that 93 percent of doctors said physicians should report all significant medical errors that they observe.

....A majority said they would refer patients to an imaging facility in which they had a financial interest, but only 24 percent would inform patients of that financial tie.

....More than a third of physicians, 36 percent, said they would order an unneeded MRI (magnetic resonance imaging) test if it were requested by a patient with low back pain, though most doctors say they do not want to waste scarce resources.

I'm not sure where the Post got these numbers. I don't have access to the journal article this is based on, but the accompanying chartbook (here) says that 40% of physicians knew of a serious error in their practice in the last three years, and of those 31% failed to report it. That's 12% of physicians, not 46%. The imaging facility number is 26%, not 24%. And the MRI number is 42% not 36%.

I'm not sure who's wrong here, the Post or the folks who put together the charts. But in any case, it gives me an excuse to comment on the imaging stuff. Back in September, when Shannon Brownlee was blogging here about her book Overtreated, I hadn't yet received a copy of the book and so I wasn't able to comment about it. I've since read it (it's very good), and one of the things she discusses in some detail is the fact that a huge number of MRIs and CT scans are ordered not because they're necessary, but simply because they're available (and, of course, very, very cool). A little bit of this is malpractice-driven defensive medicine, but the vast majority isn't. Doctors do it because it's convenient, because they don't want to say no to patients, and because it's a moneymaker. The IMAP study seems to bear this out.

Anyway, read the book. It's good. Nickel summary: Hospitals are about as likely to kill you as to cure you. Stay away if you can.

Kevin Drum 12:55 AM Permalink | Trackbacks | Comments (29)

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Comments

I'll second Kevin's advice to stay away from hospitals if you can. My cousin's wife was expected to die because of a staph infection. She's hanging on to life, but apparently will never recover. A lawyer I'm working with was luckier: the hospital managed to eventually cure his staph infection, but his recovery was not easy.

I will add that one more reason why doctors order unnecessary tests is that they're usually covered by insurance, so they're free to the patient.

Posted by: ex-liberal on December 4, 2007 at 1:04 AM | PERMALINK

That's 12% of physicians, not 46%.

Sounds like a serious error. In wonder if anyone is going to report it.

Posted by: JS on December 4, 2007 at 1:37 AM | PERMALINK

Recently had a stress test done, ordered by my internist. Shortly after, got a worried call from the people who ran it, saying my results were "abnormal" and that I needed to get a cardiac catheterization right away (this is a procedure where they run a probe up into your heart, and it's both risky and expensive).

Given that I was asymptomatic and had in fact performed above average on the exercise portion of the test, I was skeptical. Eventually my cardiologist looked at the results and realized the "abnormality" was the result of the leads being put on wrong during the stress test. Luckily I hadn't agreed to undergo the catheterization.

Kevin's right. Stay away from those bastards if you can.

Posted by: jimBOB on December 4, 2007 at 1:44 AM | PERMALINK

The people who performed the test called you??? That is highly irregular and possibly illegal! I am a lab scientist - My job is to take the guesswork out of the physicians job, and I can not, under penalty of losing my license, my ASCP registration and membership, and perhaps facing prosecution for practicing without a license, tell a patient what their lab results are. Only a physician can deliver information like that to a patient.

If I worked for or had any professional affiliation with that facility, the air would be filled with yellow paper as I furiously wrote incident reports.

Posted by: Blue Girl, Red State (aka G.C.) on December 4, 2007 at 1:53 AM | PERMALINK

It was someone from the facility that conducted the test. Don't remember what their title was - could have been a doctor or nurse. They were giving me a heads-up as they passed along the results to my internist.

Posted by: jimBOB on December 4, 2007 at 2:06 AM | PERMALINK

If it was not a physician, it was illegal (in every state I have ever worked in). If it was a physician but not your physician, it was irregular and your cardiologist should lodge a complaint with the facility. And stop referring patients there.

Posted by: Blue Girl, Red State (aka G.C.) on December 4, 2007 at 2:09 AM | PERMALINK

What's the big deal?

Posted by: Walt on December 4, 2007 at 2:15 AM | PERMALINK

What's the big deal?

I think it's a big deal when unqualified personnel call up patients and tell them they need risky and expensive procedures and scare the hell out of them, when the real culprit is a technician so incompetent that they can't even properly place leads!

Ugh...I gotta call it a night. later on, all.

Posted by: Blue Girl, Red State (aka G.C.) on December 4, 2007 at 2:23 AM | PERMALINK

Thanks, Blue Girl. The facility is a hospital I've heard not-great things about, but going there saved me a bit on my insurance deductible and I figured they ought to be able to do a stress test. Live and learn.

Posted by: jimBOB on December 4, 2007 at 2:47 AM | PERMALINK

"Doctors do it because it's convenient, because they don't want to say no to patients, and because it's a moneymaker."

that "moneymaker" part, don't forget that sometimes the clinic in which the prescribing physician is a partner also owns the machine. that's a little more concrete than "a moneymaker for somebody". no conflict of interest I'm sure.

one of my kids recently went to the ER for an acute back pain that turned out to be nothing. the afternoon's bill including a scan, some drugs and no hospital admission was over $6,000. try that without insurance.

Posted by: supersaurus on December 4, 2007 at 5:09 AM | PERMALINK

A friend's wife died recently after going in for a "routine" hysterectomy. Unless they say I am going to die immediately unless I have surgery - I am not having any invasive procedures done in a hospital. Period. Too risky.

Posted by: The Conservative Deflator on December 4, 2007 at 5:39 AM | PERMALINK

I agree with supersaurus in that you get the worst deal when you have no insurance and no one to negotiate for you. Or course this needs to be fixed. As for the moneymaker and Kevin's MRI comments, I won't go so far as to say it doesn't happen, maybe it happens sometimes, but I have never seen a physician order an MRI to make money. I haven't even seen it affect someone's decision to order the test. I now work in an HMO which loses money when MRIs are ordered, and the docs order zillions of them. The reason is, there's a lot of pressure to make the right diagnosis and not miss anything. You learn early on that you don't suffer for ordering too many tests, only for missing the diagnosis.

As for the study, it's kind of a Tim Russert gotcha thing. Almost all docs said they would report majors errors, as a rule. But then 46% said that rather than (a) always, they would either (b) usually (c) sometimes or (d) never report a major error to the clinic, hospital, state board, etc. That's pretty slick, to lump the usually's with the never's, especially when they don't probe as to why a doc might have not always reported an apparent error to their state board. Maybe they weren't 100% certain of the facts of the case . . .

Kevin would say "you should read a journal article that as an influential writer you report on". Yet he admitted to not reading the article. He's just as bad as these physicians.

Posted by: Brian MD on December 4, 2007 at 5:53 AM | PERMALINK

JimBOB, I'm going to assume you were called by the cardiologist who's service performed the stress test, not a lab tech. That wouldn't violate any laws, Blue Girl, and while a minor issue/negative result would probably be reported to the patient through the internist, the cardiologist would want to report abnormalities directly to the patient, since this is a referral...

I'm curious as to how your internist determined the leads were put on wrong. Most internists I know don't know enough about an EKG to tell a tech (let alone a cardiologist) what they did wrong...

Posted by: Crusty Dem on December 4, 2007 at 7:43 AM | PERMALINK

The article mentioned MRI's and I haven't found any strong reports of problems with the Strong magnetic fields used in MRI analysis.

However unneeded Cat Scans (not mentioned in the article) may not only have economic consequences but health consequences too.

Up to 2% of Future cancers may be caused by X-ray radiation from CT scans given today according to this AP report that was in the Philly Inquirer on Dec 2nd. Based on a New England Journal of Medicine Article from Thursday November 29th.

http://www.philly.com/philly/wires/ap/features/health/11905772.html

Posted by: Tree Hugger on December 4, 2007 at 8:23 AM | PERMALINK

780,000+ iatrogenic deaths* per year, or maybe up to a million.

Along the same lines, a couple of studies have shown that the patients who do best in the hospital are the ones who have pushy relatives making sure things happen right.

*"Deaths induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures"

Posted by: anandine on December 4, 2007 at 8:47 AM | PERMALINK

The facility is a hospital I've heard not-great things about...

Lemme guess...a facility in a for-profit chain? HCA, perhaps?

Worst C-Diff and MRSA prevalence I have ever seen was in an HCA facility.

Posted by: Blue Girl, Red State (aka G.C.) on December 4, 2007 at 10:01 AM | PERMALINK

"I hadn't yet received a copy of the book and so I wasn't able to comment about it."

That kind of attitude is not going to get you to The Atlantic, fella.

Posted by: Ghost of Joe Liebling's Dog on December 4, 2007 at 10:14 AM | PERMALINK

What's the big deal?
--Walt

Here's the big deal:

I went seven years with chronic lower back pain, and was on the opposite side: I didn't get an MRI nor a CT scan. I went through physical therapy, had tons of x-rays, and was handed hundreds of Vioxx and muscle relaxers, but never one of the two things that could determine if it was a structural issue.

It was, of course, as the first MRI I got clearly showed.

Then?

Well, the doc that did my first surgery screwed it up and never told me, and neither did the other doc I saw in the same practice. That gets to the other part of the story -- that docs don't tell anyone when the goof. Whether it's ego or a fear of a lawsuit (which, in my case, wasn't an option since there wasn't quite enough evidence).

After a couple of thousand bucks worth of procedures within the same practice, I finally went to a doc outside of it — it took him ten seconds to discover the error the first surgeon had made. This led to a second surgery and several grand in medical bills.

So that's why this is a big deal: It effects real people who go through life-changing and soul-crushing pain ... who wind up with thousands in medical bills ... who go through unncessary procedures that can make the problem worse ... and who wind up irreparably injured because of a system that is fundamentally flawed.

Posted by: Mark D on December 4, 2007 at 10:25 AM | PERMALINK

Just in my circle of close friends there are three cases of HORRIBLE malpractice, two leading to death, and a third to permanent left side paralysis. I'm leaving out the glassy eyed dentist who tried to sell me an unnecessary root canal, and the dematologist who, along with his entire staff, lied to me after they lost tissue he'd removed from my arms for cancer testing. "Oh, we don't have those test results back yet. We'll call YOU, when they're in." "Oh, those tissues were placed in a bottle labeled 'Mr. Ford' and the tests look fine."

After weeks, I tracked down the lab techs, who called the doctor, who called me VERY ANGRY. Turns out there was no Mr. Ford, the tissues were lost, there were no lab reports, and the doctor, his staff, and the hospital were trying to cover it up. No lawsuit. Just rode it out, and am still cancer free 10 years on.

Lying, arrogant, sometimes drug addled, rich, often incompetent "professionals" all around.

Posted by: stig on December 4, 2007 at 10:31 AM | PERMALINK

MRI's are moneymakers. Some physicians are the owners or the MRI clinics that they send their patients to. The last time I had an MRI I had to sign a waiver acknowledging I understood the MRI clinic was a business the physician was a partner in. After the Dr. said the MRI indicated I did not require knee surgery, he wanted to perform knee surgery to 'look around.'

This nonreporting of medical errors is very disturbing. It is a result of the business side of health care in America. Doctors are not health care technicians as much as they are small business owners more concerned with protecting their revenues. Oversight and quality controls have been gamed out of the medical system for profits.

Posted by: Brojo on December 4, 2007 at 11:29 AM | PERMALINK

If you're surprised that doctors don't report their partners, then you're probably surprised that athletes don't turn in their teammates who use steroids, that Conservatives don't get worked up about NRO lying, and that people who made a lot of money by selling Enron before the fall don't donate it to charity.

If 69% of doctors who had reason to do so actually reported their partners, then doctors are more ethical than I thought.

Posted by: reino on December 4, 2007 at 11:32 AM | PERMALINK

Well I dunno. I have personally visited the ER twice (dislocated shoulder and sliced eyelid) and the hospital once (laminectomy for slipped disk in myneck) and as far as I know I'm still alive.

Maybe there are one and a half other dead guys walking around out there.

Posted by: Tripp on December 4, 2007 at 11:33 AM | PERMALINK

You're a pariah/whore forever if as a Doc you turn in a Doc who made a mistake, every doctor makes some mistake everyday. It just sucks that
Docs who shouldn't be surgeons anymore remain surgeons because of the code of silence. I don't know what I would do except just try to keep my sh*t together and make sure my practice is sound.

Posted by: All Kinds of Stuff on December 4, 2007 at 11:42 AM | PERMALINK

Hospitals are about as likely to kill you as to cure you. Stay away if you can.

Second part, good. Don't go to a hospital if you don't need or won't benefit from the treatment. Also, if you do go to hospital, get out as soon as you can.

First part, gross. If you do need a hospital, go there. You are not likely to heal a broken hand, broken hip, heart attack, or breast cancer (to pick a few) on your own.

Posted by: MatthewRmarler on December 4, 2007 at 11:42 AM | PERMALINK

One of the questions I have long had about the 750k-1mil iatrogenic deaths statistic that Brownlee has put forth is as to how many of those deaths are counted as a result of things like line infections in the very ill? Sad to say, many of these folks are unfortunately going to die regardless, yet they are also at very high risk for iatrogenic infections and other such complications secondary to their wounds or numerous tubes and lines. Malnutrition is a big cause of mortality/morbidity, but is a very difficult thing to address in critically ill patients (who are often already malnourished). Similarly, sometimes you simply have to do a surgery or use a medicine with possible side serious side effects... "iatrogenic" does not necessarily imply "error." I am not going to defend grievous mistakes of my future colleagues, particularly those who cover them up, but at the same time one has to be very care as to the nature of how these stats are compiled and what they mean.

As to Kevin's comment about "as likely to kill as to cure," I should rather think that this is likely a hyperbolic take on Brownlee's message, and is irresponsible. I agree with the "avoid them if you can" portion in that people should be proactive about their own health (eat smart, exercise, avoid tobacco, etc.) and should maintain a good relationship with their primary care physician to manage issues that arise and engage in preventative medicine. The profession and system definitely have issues to address, but to imply that hospitals are somehow keystone kops charnel houses is a little absurd.

Posted by: DCH on December 4, 2007 at 11:46 AM | PERMALINK

Along the same lines, a couple of studies have shown that the patients who do best in the hospital are the ones who have pushy relatives making sure things happen right.

Jerome Groopman, who writes on medicine in The New Yorker, discusses the types of questions patients can ask doctors in order to help prevent them from making the kinds of errors they sometimes seem predisposed toward making. His most recent book (not sure -- maybe it's his only book) is called How Doctors Think. There's also a pretty fascinating chapter about radiologists, which completely made me rethink the degree of confidence I've placed in their images. While they're certainly valuable tools, I had no idea about the frequency of interpretive errors.

Posted by: junebug on December 4, 2007 at 3:56 PM | PERMALINK

Why is doing a non-invasive, non-threatening test at the patient's request 'overtreatment'?

Are we going to deny patients other tests, like examinations, next?

"Oh, I saw you six months ago, you couldn't have a lump on your bum now."

Posted by: Crissa on December 4, 2007 at 4:56 PM | PERMALINK

Sorry been out today, only now able to check this thread.

I'm curious as to how your internist determined the leads were put on wrong. Most internists I know don't know enough about an EKG to tell a tech (let alone a cardiologist) what they did wrong...

It was the cardiologist who made that determination, not my internist.

Lemme guess...a facility in a for-profit chain? HCA, perhaps?

Actually, a Catholic, Sisters of Mercy hospital.

In their defense, the reason they called me directly was that it was a weekend and they couldn't get ahold of my internist right away. And the good news is it was a happy ending - I didn't get an unnecessary catheterization. My next stress test will not be at that facility.

Posted by: jimBOB on December 4, 2007 at 6:09 PM | PERMALINK

Crissa:

The reason for that is that even a non-invasive test can produce harmful results. Let's take low back pain... 80-90% of low back pain resolves within the first month or so with some mild treatment (exercises, NSAIDs, etc.). You shouldn't even get an X-ray at the time of presentation in most cases.

But let's say a patient walks in and demands an MRI. Now, not only does this waste resources, but about 30% of people out there with no back problems will have positive findings on their MRI. So say this guy has some soft findings, but it is not definitive that they are causing his symptoms. However, now you are set on a course to treat, and the resources continue to be used, etc. when he had a really good chance of getting better with essentially nothing.

An even example: mammograms. There is a reason we don't screen 30 year old women for breast cancer: the number of false positives is way higher than the cancers you do actually catch that early. So in all those false positives you are now causing the patient distress, doing biopsies (sometimes multiple), and even worse.

A patient opening a conversation with their doctor on diagnosis and treatment is good, but there are also good reasons for avoiding even non-invasive tests if you don't need them.

Posted by: DCH on December 4, 2007 at 7:53 PM | PERMALINK




 

 

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