Wednesday, September 16, 2009

For Ezra Klein

But I'd also recommend people read "The Malpractice Myth" by Tom Baker. Or this article I wrote on the topic. The great lie of the medical malpractice debate is that the crisis is in our courtrooms. It isn't. It's on our operating tables. Interestingly, Obama and Clinton once coauthored a pretty good article on this stuff. I summarize it in the piece.
-Ezra Klein in his WaPO column 9/10/2009

The bold face was mine. You see, Ezra Klein feels strongly that we live in the dark ages of medicine and surgery. Especially in the United States. The crisis is on our operating tables, he says. If anything, goes the implication, we ought to be having more lawsuits, more litigation in this dangerous country which is apparently densely populated with incompetent, uncaring, hackjob surgeons and physicians.

I feel obligated to remind Mr. Klein of the following:

-95% of heart bypass surgery patients now walk out of the hospital alive and well.
-86% of liver transplant patients are alive 1 year after surgery
-Since 1980 the average American life expectancy has gone from 73 to 78
-With the development of HAART therapy, patients newly diagnosed as HIV positive patients can expect to live a normal lifespan
-Since the 1970's, the 30 day mortality rate associated with the Whipple procedure for pancreatic cancer has gone from 25% to less than 3%
-The five year survival of women diagnosed with breast cancer (including all stages) is about 76%
-Most surgeries for routine problems like cholecystitis and hernias and ovarian issues are treated with minimally invasive techniques on an outpatient basis
-Type I diabetics can now wear insulin pumps that provide a constant infusion of insulin, thereby reducing the number of shots and improving overall glucose control
-Anal cancer is now treated successfully by chemotherapy/radiation protocols, obviating the need for permanent colostomies
-Implantable electrodes in the brain allow patients stricken with Parkinson's to experience a much higher quality of life than that afforded by medications
-Critical care advances allow patients to walk out of hospitals, nearly fully recovered from pathologic insults that universally killed people a mere 30 years ago (perforated colon, bleeding ulcers, ARDS, acute renal failure, etc.)
-Trauma centers across the country routinely save victims of violence/accidents on a nightly basis
-When grandma gets pneumonia, it isn't a death sentence anymore
-Neonatal intensive care units are saving premature babies who weigh less than 1000 grams regularly and even babies less than 500 grams to a moderate degree

Yes, Ezra, it is a dangerous world we live in. Sequester yourself in that insulated little WaPo bubble as much as humanly possible, and stay far far away from doctors and hospitals---they want your lifesource!


Joseph Sucher, MD FACS said...

Please... don't confuse the argument with facts.

Anonymous said...

I think his point is that there are doctors who practice incompetently, get sued, and continue to practice incompetently.

In other words, the mechanism we (as a society) have chosen to try to ensure competent medical care is failing all of us. Failing the patients who might stumble upon a poor provider. Failing the good providers who end up paying insane insurance premiums for no good reason. Failing society who ends up with care that costs much more than the actual cost of delivering care.

I don't know what the solution is, but it's not just limiting the payouts and stopping all lawsuits. We need a system to purge the system of bad providers (retrain; strip licenses; PICC lethal injections?).

I know it's very hard to evaluate these things. When is it just an honest mistake? When is it incompetence? When is it negligence? None of these conclusions are simple. But, I think most people would agree that lay juries and courts should not be the primary venue for these decisions.

I'm disappointed in you. On most subjects you have a nuanced understanding of the complexities of life. I would love to hear from you what you think a real solution to the problem would be. Don't just beat up on lawyers, easy picking as they might be...

(I'm married to an ANP/FNP who was a chemical engineer in a past life. She had _far_ more peer and skill evaluation in her past life than as an NP. This seems wrong.)

Anyway, enough of my babbling.


Buckeye Surgeon said...

I'm working on a longer post onmed mal reform. More reading than I figured!

My problem with the Klein article is that it is of a piece with this common refrain we've seen over the sdummer and into fall that physicians shoulder much of the blame for costs, outcomes, inefficiencies, and whatever else. McAllen. Unnecessary tonsilectomies. Never events. Leg amputations for 50 grand.

The way our profession has been so cavalierly discarded as irrelevant in this debate is objectionable./ That's all I mean.

Anonymous said...

Buckeye - Love your blog and am a fellow surgeon but I disagree with you in this case. This is what people are talking about when they're making an argument for inefficient medicine:

Brought to you by our friends at Darmouth. Figure 2 is where the money is at.

J Swift MD said...

As I recall, the much ballyhooed IOM report "to err is human" does not comport with Ezra's scorn for surgeons. The overwhelming majority of the "mistakes" studied were non surgical, in the "failure to rescue" category. A nice overly inclusive squishy subjective waste basket category cleverly designed to instill public fear and distrust.
Nonetheless, the numbers are reflective of those non surgical patients who were too sick to live and a plethora of nursing and mismanagement driven conditions, not surgical error or incompetence. These errors were by and large deemed to be system errors which could seriously diminish the bottom line of the present kleptocracy unless an immediate politcal strategy to prevent this was employed. So the institutional risk managment doctrine of sanctimonious and pre emptive liability shifting to surgeons through manipulation of data and reeducation of public perception was born. This is Ezra's genre, the genre of the iconic neurotic. Unfortunately, this unsupported but real (to him) fear provides the ideological foundation of our "evidence based" healthcare kleptocracy where fear is the only relevant political currency.