Archive for the 'General' Category
Connecting the Dots
Saturday, September 29th, 2007Sometimes 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.
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Patient Care Dilemmas
Friday, September 21st, 2007There 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.
Healthcare Infrastructure
Saturday, September 8th, 2007The 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.
State Legislators are Clueless About the Practice of Medicine
Friday, August 31st, 2007Beat the drum! The private practice of medicine is the least regulated economic activity in America. And it is a state-regulated economic activity.
Legislators deserve some slack. If ever an issue “slipped under the radar” it was the regulation of the practice of medicine. Few persons, regardless of standing, questioned doctors before healthcare became one of the largest economic elements within our nation. The evolution from being treated by a family doctor to hopping from one medical specialist to another happened within one generation. Case in point: AMA annual dues in 1950 were $25.00. Those were the days.
No one had ever successfully sued a hospital for medical malpractice, won, and won the appeal, before the Darling case which took place in Southern Illinois in the mid-1960s. The Darling case should have sent state legislatures back to the drawing boards regarding the regulation of medicine. Unfortunately, Organized Medicine was able to turn a groundbreaking case into a mere legal after-thought.
State legislators of that period, suddenly forced with creating original regulatory legislation regarding the practice of medicine didn’t have a clue. The majority of the legislators had lived through WW I and II, the Depression, the Korean War and were then confronted with the Cold War, an issue far more pressing then, than currently perceived.
Their primary consultants were (who else?) doctors and others closely aligned with medical practitioners. Study in detail the content and the date of creation of any state statutes regulating hospital medical staffs and the practice of individual doctors. Next, study any modifications made later to those original statutory regulations. You’ll see right away how little there is to study.
Think about this: What if you were to remove all forms of traffic regulation in a small community? Chaos would quickly reign. There is no doubt that humans benefit from regulation. And large numbers of people require functional regulation. That is as true for the practice of medicine as it is for any other human endeavor.
It is rare that a person can get through life without the need for medical care. Therefore, doctors provide a universally necessary service to society. A burgeoning population, of both people and doctors, demands effective regulation.
Every congressional and state legislator should have to take a 1-2 day course on any existing federal or state regulation regarding the private practice of medicine. Perhaps then they could decide where healthcare change in America should begin.
Is there anyone who can prove that the private practice of medicine is not the least regulated economic activity in America?
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Stop the Blame Game
Friday, August 24th, 2007The AMA blames attorneys for the medical malpractice crisis.
In the movie Sicko, Michael Moore blames politicians (primarily Republicans) and insurance companies for our healthcare problems.
The Duke Transplant Service team blamed “system errors” for a young girl’s tragic death.
We need to STOP the blame game!
No one set out to deliberately create a poorly structured national healthcare system, but unfortunately, one has evolved. The urgent need now is deliberate consideration rather than impulsive change.
Take the Minneapolis bridge tragedy as an analogy of our healthcare problems. Repair was underway on the visible portions of that Minneapolis bridge when the collapse occurred due to suspected, but specifically unrecognized flaws in its foundation. Right now, no one really understands how our healthcare system is “organized” and what major flaws may exist in its present form. Instead, all of the talk regarding healthcare change is centered upon cost and access, two very important elements which are readily visible and must be addressed. But what lies beneath that could cause a catastrophic collapse? What can we do to understand and prevent this from happening?
The first step should be a clear demonstration of how our present system of national healthcare came to be. That study should begin with the structure of healthcare immediately post WW II. America’s healthcare system began a rapid transformation in the late 1940s from a family doctor-oriented form of care to a medical specialist-dominated organization.
The practice of medicine was a state-regulated activity even though each state’s form of medical practice regulation was almost non-existent. The practice of medicine is the least regulated economic activity in America.
In 1965 the Congressional enactment of Medicare radically changed everything. Most states were just beginning to create their first statutes regulating hospital medical staffs when the federal government suddenly became the huge gorilla everyone tried unsuccessfully to ignore.
All functions of any healthcare system begin at the beginning with one doctor treating one patient. That simple, basic, undeniable fact is completely overlooked in every current discussion regarding healthcare change. If “everything” in healthcare begins with the doctor and the patient, how can deliberate, well-conceived change not begin at that point as well?
People are perplexed as to why our present healthcare system performs so poorly, while ignoring the obvious source. Our healthcare system is laughably “regulated” by 52 separate governmental entities, Congress, 50 states legislatures and DC. How can such a system not eventually implode?
Furthermore, tragedies equal to or greater than the one in Minneapolis occur everyday in our current healthcare system, but as random mistakes involving one person (patient) at a time, and pass with little notice. The Minneapolis bridge collapse will be carefully investigated and those findings will be reported extensively in the media. Perhaps someday the same can occur in healthcare. Beginning perhaps with a published monthly death-toll of hospital accidental deaths. Right now almost all of these occur with NO coverage and NO regulatory in-depth inquiry.
Change can be positive or negative. Deliberate, thoughtful and proactive is the kind of change healthcare needs right now. A careful examination of how our system began and how it works, or doesn’t. Knee-jerk reactions and finger-pointing blame games are like making surface repairs on a bridge whose foundations are crumbling. It will collapse. It is just a matter of time.
How the Minneapolis Bridge Tragedy Mirrors a Potential Disaster for Healthcare
Friday, August 17th, 2007It is a miracle that more lives were not lost during a time when the traffic load on the bridge was so heavy. Yet each death is devastating to the families involved. Hopefully, this regional catastrophe can galvanize the nation toward a far better understanding of defects within our infrastructure.
There are lessons that can and must be learned through tragic events such as this one. Lessons that reach far beyond Minneapolis and bridge construction to the multitude of people currently working in healthcare. The collapse of this bridge can also provide new insight into much needed healthcare change.
Repairs were being made on the roadway and on other easily visible aspects of that bridge. The sudden fall, however, was due to known and existing infrastructure defects. Likewise, surface repairs continue to be made in healthcare. But uncontrollable cost increases and lack of access for far too many are deep defects within our present healthcare system. Repairs are accepted as an absolute necessity that requires immediate attention.
Yet no consideration is being given to the present, still unrecognized problems within our current healthcare system. Googling “Defensive Medicine” brings up a lot of documentation on what is argued as one, if not the, major cause of constantly increasing costs. However, no in-depth discussion takes place regarding how the practice of medicine is regulated in America and who does the regulating.
The vast majority of doctors treating patients practice within the private sector, which is presumed to be regulated by the fifty states and the District of Columbia. Congress, through Medicare and followed by Medicaid, has blurred the lines of regulating the practice of medicine.
The practice of medicine is the least regulated economic activity in America.
Until the organizational infrastructure of medical practice is fully understood and clarified for all, a Minneapolis-type disaster will be waiting in the wings and may very well topple our healthcare system in the same way.
Lawyers vs Doctors
Friday, August 17th, 2007Most legislators are attorneys. Almost all universities, hospitals, large companies, etc. have risk management business components populated largely with lawyers. Wills, trusts, pre-nuptial agreements, and other legal contracts impact countless aspects of every day life in America.
We as a society have come to assume that attorneys must put a legal stamp of approval on most basic managerial functions. Otherwise, the threat of litigation can dominate behavior to the point that organized entities feel prevented from doing what they are expected to do.
Example: Hospital medical staffs far too often fail to take remedial action against disruptive or marginally-qualified practitioners for fear of retaliatory litigation.
The American College of Obstetricians and Gynecologists (ACOG) created a voluntary peer review system for hospital Ob/Gyn departments. A journal article reported the findings of that peer review system in 2003 after the first 100 inspections. There were 3,003 Ob/Gyn hospital departments at that time.
A disheartening number of deficiencies were noted in that report, but one specific deficiency was that 38 of the 100 Ob/Gyn hospital departments had “substandard or disruptive physicians” as members. Many, if not most, hospital medical staffs have failed to reprimand or alter staff privilege of those less-qualified staff members purely due to that threat of being sued.
IF the medical profession can NOT create a system of medical peer review acceptable to every court in the nation – that is NOT the legal system’s fault!
Such lack of proper administrative control illustrates an absence of understanding of fundamental judicial demands. There is absolute need for a system of peer review done by a hospital medical staff which:
a. provides a uniform system of patient care review in all instances
b. subjects every medical staff member, regardless of status, to the exact same review process
NO court in America, up to and including the Supreme Court, would sanction retaliatory litigation against such an unbiased, standardized system of medical peer review.
There are those both within the medical profession and within the field of non-physician medical expertise who would argue that such a system of medical peer review can never be established.
I have formed a social response that proves useful in certain occasions:
First, one should politely walk away from those persons who can tell you what they are against, but can not tell you what they are for.
Second, one should run away from those persons who state they can recognize the impossible.
The impossible is yet to be clearly established.
Much of mankind has been bred with a flawed gene. Descendents of the “flat-earth society” have done their best to impede social advancement throughout the ages. Where would civilization be if the great thinkers had succumbed to the masses of small minds with limited vision?
One Doctor - One Patient
Friday, August 10th, 2007Everything in healthcare begins when a doctor and a patient agree upon a medical collaboration. The patient may come from any walk of life in America, including other doctors.
The doctor can only come from one of two regulated sources: federal or state.
Probably 90% of all doctors actively treating patients are in the private practice system regulated by the fifty states and the District of Columbia.
Federal healthcare, through Medicare, Medicaid, the Department of Defense, the Veterans Administration and Public Health, may account for almost one half of all healthcare costs, but those Medicare and Medicaid patients are primarily treated in private practice.
Therefore state legislatures are the principle source of medical practice regulation. And they aren’t up to the task.
The practice of medicine is the least regulated economic activity in America.
Someone, somewhere, hopefully, will test the validity of that statement, which demands to be tested.
The first clue that medical practice truly is the least regulated economic activity is that NO state government can produce one single person who has complete knowledge of:
1. Every existing statute, rule, regulation, and policy governing the practice of medicine in that state.
2. Regulatory mechanisms created by the above listed legislated requirements.
3. Evidence of effective regulatory results.
The second clue will appear when it becomes evident:
1. How many different persons are necessary to obtain the above data.
2. How long it takes to obtain the data.
3. How little regulatory mechanism truly exists.
The regulatory lines were blurred beginning with Medicare in 1965. Prior to that they were faint, if not non-existent in most, if not all the fifty states.
While most states were trying to establish some semblance of medical practice regulation, particularly at the hospital medical staff level, the federal government was establishing their immense presence.
Both houses of Congress have had numerous committees and subcommittees dealing with healthcare issues. The same can be said for the fifty state legislatures. There are also a plethora of governmental and non-governmental agencies, groups, organizations, foundations, etc., “focused” on healthcare issues, yet none of them has ever thought that a clear distinction between federal and state regulatory responsibility was necessary.
No consideration for healthcare change should take place before establishing a clear delineation between federally-controlled healthcare and state-regulated healthcare.
Precipitous Congressional healthcare change would be, “putting the cart before the horse.” Currently both Congress and all state legislatures are all asleep at the switch
Delay Healthcare Change
Friday, August 3rd, 2007The demand to change healthcare is reaching a crescendo now.
I advocate an immediate delay in all such discussions.
Why?
Simple: Never, ever attempt to change a large social system until you are able to describe (in detail) how that system is organized.
Case in point: The U.S. Defense Department is enormous, but the Pentagon could easily draw a complete organizational chart starting with the Secretary of Defense at the top and the newest recruits in all branches of the armed services at the bottom.
No one in America has ever drawn up a comparable chart detailing our present system of healthcare. If they had, it would be very clear we have two distinctly different healthcare systems operating in America: federal and private.
No one has ever done it, yet multitudes want to change a huge system they can’t describe. That is a scary thought, but actually only half of the problem. Who does everyone assume will create this anticipated marvelous make-over?
The federal healthcare system includes Medicare, Medicaid, Department of Defense, the VA and Public Health. This consumes about 45% of the total healthcare cost. The private healthcare system (1 doctor/1 patient) is regulated by 50 state legislatures and DC and consumes about 55% of the total cost.
Though over 90% of all practicing physicians are in the private sector, they also treat the Medicare/Medicaid patients. Therefore, about 90% of the total cost of direct patient care goes through the private practice sector of our healthcare system.
Congress made a monumental impact on healthcare in America in 1965 when it passed Medicare. It has periodically continued to blur the line between the state and federal regulation of the practice of medicine.
What got lost in that blurring of lines? The entire healthcare quandary begins with one doctor and one patient and over 90% of all practicing physicians are primarily regulated by the state legislatures.
If Congress, or anyone else, wants fast results, let them begin by imposing a system of medical peer review within the Defense Department and/or the VA. There is already a proven track record of positive change in federally controlled healthcare. The Defense Department did it in the mid-1980s and the VA in the 1990s. Successful use of medical peer review within the federal systems would pave the way for state legislatures to follow suit.
The practice of medicine is the least regulated economic activity in America. “Defensive medicine” is said to be the greatest cause of the constant rising cost of healthcare. To change this, there should be a dramatic shift in the regulation of doctors. When medical peer review replaces medical malpractice litigation as the primary system for questionable patient care review, costs will be lowered.