Ask Dr. Ira Williams

Sometimes a child’s game can be used to dissect and understand complex and important issues. Connecting the dots is just such a game. Questionable patient care is just such an issue.

How might one connect the dots regarding questionable patient care?

Begin at dot #1 by recognizing there are three systems with the potential to review questionable patient care:
State medical examining boards – basically of little value
Medical malpractice litigation – a legalistic nightmare
Medical peer review – like fog, it is known to exist, but due to legislative-created secrecy, its value is intangible

How then might an interested party prove the value of the nebulous system of medical peer review?

Connect dot #1 with dot #2 and review:
The Joint Commission Manual Credentialing and Privileging Your Medical Staff, 2007 Responsibilities of the Hospital.
Applicable Joint Commission Standards: Standard MS.4.20.
Elements of Performance for MS.4.20 “The governing body or delegated governing body committee has final authority for granting, renewing or denying privileges.”

Draw a line to dot #3:
Procedures for appointing and replacing outgoing members of hospital boards of directors/trustees will vary from state to state, but that process will periodically occur at all hospitals.

Continue to dot #4:
Conduct a very simple test in any community containing one or more hospitals. Hospital trustees/directors usually are among the most highly respected members of their community.

Proceed to dot #5
Assemble as many past hospital trustees/directors as possible. Hospital trustees/directors command the final step regarding the viability of any hospital medical staff peer review system.

Dot #6:
Ask them to provide, in general terms and without specific doctor’s names, their past experience in granting, renewing and most importantly, denying hospital medical staff privileges (medical peer review). Past hospital trustees/directors, freed of immediate formal responsibility and declining to name names, are the best source in determining if medical peer review regarding questionable patient care is a local myth or a professional reality.

dot #7
Another untapped reservoir of information might well be obtained from retired and semi-retired physicians. There are far more senior practitioners who are exceedingly unhappy with the current stature of their profession and those who could, if lead to, describe the truth from inside the medical profession.

The final dot:
This untapped reservoir of information gleaned from a group of respected community leaders could prove to be invaluable, particularly if several communities in the same state ran similar inquiries.

The entire picture emerges:
The only way to separate myth from reality is to seek to identify existence of the reality, or to be prepared to find the myth is the reality. Unfortunately, the time-honored tradition clearly demonstrates the woe which becomes those who break the code of silence.

Hopefully, the current need for positive healthcare change can lead such troubled souls to help clarify the many defects within the medical profession and help create a renewed profession for all concerned.

There are two general dilemmas that arise everyday in the natural course of medical practice:

Even the best doctors sometimes make mistakes.
Not all questionable patient care is negligence or medical malpractice.

Individual Responsibility Peer Review (IRPR) system of medical peer review deals with each of those dilemmas in a most direct manner.

Review the Journal of the American Medical Association (JAMA) during the early years of the Modern Medicine Era (1950s) and read how it said all of the right things such as, “Doctors are the best judges of other doctors.”

Doctors are irrefutably the most qualified individuals for judging the questionable patient care of other doctors. Unfortunately, doctors do not know how to judge other doctors. Non-medical experts and special medical malpractice courts can never provide the same degree of medical expertise as that of fellow hospital medical staff practitioners. Additionally, every review of questionable patient care should occur as rapidly as possible and as close to the site of that care, with that hospital’s medical staff.

Medical peer review is a professional response which is presumed to take place, but rarely does take place.

Hospital medical staff peer review of questionable patient care is the only method which is capable of fulfilling every identifiable element necessary for a true profession to satisfy its ethical obligation to the society they have sworn to serve.

Likewise, each doctor’s documented patient care track record is the only means to tell the difference between the good doctor who has made a typically human error and the marginally qualified practitioner who habitually teeters on potential medical disasters.

The IRPR system of medical peer review would be the best friend of every good doctor. It would be the marginally-qualified doctor’s worst nightmare.

An IRPR system of medical peer review can only be created and sustained by a community of doctors seeking to reestablish the true professionalism of their profession. Is there such a community of doctors present in America in this hour of great need?

People at every level of society continue to lament the need for healthcare change as basic elements, such as the above, go unconsidered. Doctors are the best judges of other doctors but doctors don’t know how to judge other doctors. Two simple, irrefutable facts completely ignored by all the “experts” seeking healthcare change.

The Random House Unabridged Dictionary defines infrastructure as the basic, underlying framework or features of a system or organization. If you were to Google “healthcare infrastructure” you’d find a great number of entries dealing simply with Information Technology (IT).

Information technology is a vital aspect of quality healthcare, but it is NOT part of the infrastructure of our present healthcare system. When well-meaning individuals adapt the use of a fundamental concept for their own purpose they distort its original meaning.

Healthcare infrastructure should only apply to the organizational structure of our healthcare system. NO ONE in America has ever accurately displayed, in detail, how our healthcare system is “organized.”

Think about this:

1. The Department of Defense (DOD) and our healthcare system are comparable in size and scope, yet the organizational structure of the DOD can be demonstrated from the Secretary of Defense down to the newest recruit in all of the armed services. Such organizational detail has never been accomplished for healthcare.

2. The sudden, disastrous collapse of the Minneapolis Bridge was due to infrastructure defects known to exist, but their extent was unrecognized.

The Minneapolis bridge disaster should be a wake-up call for every healthcare expert offering strategies for improvement. “Bridge experts” were repairing visual defects when the infrastructure, with its recognized flaws, collapsed. The very same scenario is being played out in the stampede to change healthcare now.

Cost, access, and information technology are among the very important “visual defects” of our current healthcare system. Yet no one is talking about the true infrastructure of our healthcare system. With very few exceptions, every form of healthcare begins when one doctor sees one patient. But no effort has been made to describe the larger composition of Organized Medicine.

How did that system evolve into its present form and who regulates what portions of that system? Who should society look to for that greatly needed and much anticipated healthcare change?

Doctors and hospitals are primarily regulated by individual states. Congress, except for the DOD, the Veterans Administration, and Public Health had no real participation in our healthcare system until Medicare’s inception in 1965 and Medicaid’s in 1972, Now everyone seems to think the incoming president and Congress will solve the problem, when in fact, neither they or anyone else truly understands where such change should begin.

People are demanding change in a very large, complex system no one can clearly explain. Hopefully, some will find that realization frightening. Only fools would attempt to substantially change something they don’t really understand. But, such thinking has rarely stopped Congress before.

The private practice of medicine is the least regulated economic activity in America.