Defensive medicine is more of a problem than you think

You may have missed this when it first appeared.

Experts from Harvard and the University of Southern California say assumptions made by some analysts that defensive medicine is not an important facet of the high cost of healthcare may be wrong.

Those assumptions were based on data showing that malpractice reforms instituted in some states did little to reduce healthcare spending. 

According to the report from the National Center for Policy Analysis about an article in the wall Street Journal, defensive medicine ("ordering some tests or consultations simply to avoid the appearance of malpractice") is just as common in states with low as it is in those with high malpractice risk. In fact, about 2/3 of doctors in both the low and high risk states admitted to practicing defensive medicine. 

My experience is that the 2/3 figure is probably a very low estimate. Just about every physician I know has  ordered a test or consult strictly to "cover his/her ass" if something were to go wrong. I am certain it happens tens of thousands of times per day in the US.

UK doctors' work hours limits are a fraud

The other day someone tweeted a link to a story that was headlined "NHS junior doctors have little time to eat or sleep." The article—from the Herald in Edinburgh, Scotland—told of a manual from the NHS (National Health Service) that advised trainees to keep water and a food bar handy because they would rarely have a chance to eat.

The manual, which also told the junior docs to "be prepared for dehydration and hunger," is no longer posted on the Internet.

A man whose daughter, a junior doctor, was killed in an auto accident on her way home from the hospital blamed it on the fact that she had worked a long shift. For the record, she had worked a 12-hour shift overnight.

Of junior doctors, he said, "They are under intense pressure, they are working excessive hours, they are getting no respite."

I retweeted the link to the story with a question wondering how it could be that conditions are so bad in the UK. After all, I thought the European Working Time Directive (EWTD) stated that trainees in the European Union could only work 48 hours per week.

A flood of tweets in response soon explained the true situation to me. I was amazed, and you will be too.

It seems that the so-called 48-hour work week is a sham. Trainees can work only 48 hours per week, but it's averaged over 6 months—6 months!

What hospitals apparently do is work the junior docs like dogs and then give them a week off so that the average is 48 hours.

Here are quotes from some of the UK physicians:

That's the key; as long as they give you a week off and the average is ok, all bets off

What the working rules are & what occurs (& are paid for) are 2 very different things.

In my case, was asked to do the 36 hr shift by hospital manager and consultant.

Upcoming survey results from Association of Surgeons in Training show majority [of trainees] come in on their time off.

Shorter shifts with no more doctors means more shifts. Gaps in rotations mean longer shifts

It's not much different to how it was before, just lower pay now!

The Herald piece also said that a survey of 4913 junior doctors in Scotland … "found almost 20% were short of sleep because of their shift patterns and more than half worked beyond their rostered hours daily or weekly [emphasis mine]. Some 40% described the intensity of work as heavy or very heavy." In an editorial, the Herald said, "In practice, the [EWTD] directive is being broken every day in hospitals across the country."

The understatement of the millennium was made by the chairman of the Scottish Junior Doctors Committee, who said, "Although all the rotas [rotations] are compliant with the European Working Time Directive they are not necessarily in the spirit of what the law intended." No kidding?

He also said that junior doctors could be scheduled to work up to 12 days in a row without breaks and confirmed that they sometimes "struggle" to find time to eat.

Some of those who responded to my tweet said they would much rather work a scheduled 24 hours in a row than the life-disrupting shift work that the "48-hour" week has resulted in.

What is my point?

We have all been led to believe that all is well with the 48-hour work week in Europe—clearly not so.

And let's just keep ratcheting down the hours here in the US so we can achieve the same nirvana enjoyed by the trainees over there.

As always, I welcome your comments.

An MD's thoughts on medical education

Here’s an email I received from a surgeon who asked that his name be withheld. I have edited it for length.

I practiced general surgery for 16 years before becoming fed-up with the paperwork, the hours, the unpaid call, the unpaid operations, the contracts, and, eventually, the patients. So, I turned toward teaching anatomy at a medical school.

Over the past 3.5 years, I become increasingly disillusioned with medical education, too. Having lived in a world of "arrogant doctors" being berated by hospital administrators as disruptive, I've had an interesting reflective experience here.

If I hear, one more time, from a PhD, who has never seen, treated, or managed an acutely-ill patient, that "The students need to know THIS (this = piece of anatomical, microbiological, or pharmacological minutiae), I am going to go ballistic. This week, my "colleague" in anatomy said, "It's my job to teach doctors the anatomy they need to know to become doctors." I said, "No, as an MD, it is my job to teach doctors the anatomy they need to know to become doctors. It is your job to LEARN that clinically-relevant anatomy that you need to teach them. It is not my job to re-learn minutiae of anatomy never used in 20 years of practice because "you" know it. This isn't grad school. We're not creating PhD anatomists. If you want me to re-learn, and to teach the anatomical minutiae I've long since forgotten, it isn't going to happen. You're in MY world. I'm not in yours. Go teach at a grad school for a PhD program if you want that. We are training medical doctors. And, you, my friend, have never practiced MEDICINE."

Surgical training in Brazil

Here is an email I received from a reader in Brazil describing the way surgeons are trained there. You may notice some remarkable similarities and a few differences. My comments are in italics.

After finishing high school, usually at 17 years of age, to enter med school one must pass the tests. At public universities, the tuition is entirely funded by the state. These are the most difficult ones to enter, so the students are generally better. Then there are the private universities, and they are expensive.

Med school is organized into two years of basics, two years of clinics and two years of internship (internal medicine, family medicine, surgery, ob-gyn and pediatrics). Notice—no college. I also have a feeling that students aren't studying that much nowadays, but it's also impossible to fail. Sounds quite familiar. See "Medical school grading and T-ball: Everyone gets a trophy."

As med school goes on and they meet with the awful parts of medicine, they tend to focus on quality of life and moneymaking. Therefore, the most difficult specialties to enter are dermatology, radiology, anesthesia. Also sounds familiar. Although some exams are unified, each hospital establishes its own residency exam and interview. Very different from the US.

General surgery is a two year residency. Different. In the past, general surgery was more general, but each subspecialty grabbed its cases and now what is mostly done are cholecystectomy, appendectomy and hernia. Similar in some ways to the US model. So there is another exam to enter the subspecialty residency: urology, plastic surgery (again, due to quality of life issues, no inpatients, income, status, the most popular Similar), coloproctology, vascular, thoracic surgery, surgical oncology, head and neck surgery. Orthopedics, neurosurgery, ENT don't need general surgery.

I finished general surgery last year, and this year I've been operating by myself. I've done cholecystectomy, appendectomy, hernioplasty, Hartmann procedure, skin lesions, abscesses, etc. Of course, at the beginning, I was not completely confident (which is good in some ways), but I have had nice results.

I can relate with a lot you posted, your blog makes me remember residency and my teachers.

I'm out of time now, in the future I'll catch on some other things. I hope my English isn't too bad, but reading the comments I've seen that even USA citizens have trouble typing. :D

Of course, this is just one doctor's perspective, but it's thought-provoking.

What do you think about the Brazilian system of training surgeons?

Despite checklists, wrong-site surgery still occurs. Why?

Not long ago, two California hospitals were cited by the state for wrong site surgery.

At one hospital, a skin incision was made in the right groin of a patient who was to have had a left orchiectomy. Fortunately the error was discovered, and the skin was closed. The correct testicle was removed. To his credit, the surgeon told the patient and his wife what happened immediately after the operation.

An investigation found that the patient's groin had not been marked. The time out did not prevent the error because the OR team did not verify the operative site as the protocol mandates. In other words, they had gone through the motions.

The hospital was fined $75,000.

The other California case did not turn out as well. Instead of removing a cancerous left kidney, surgeons did a right nephrectomy. The error was not discovered until the pathology report was reviewed. A number of assumptions and misunderstandings contributed to this error for which the hospital was fined $100,000.

University to offer 6-year combined college + law degree

The University of Iowa College of Law has established a new program which will enable students to begin law school after three years of undergraduate study. After six years, the student will have a J.D. degree, and credits earned in the first year of law school will count toward an undergraduate degree.

The school says this is not for everyone, but rather only for the "right" students.

Not only will the right students save a year of college tuition, they will also be able to look for work as Starbucks baristas a year sooner than law school graduates who spend four years getting their undergraduate degrees.

Related posts.

Law school applications are way down.

Law schools start firms in order to employ their graduates.

Patient falls off OR table: System error or human error?

An anesthetized patient fell to the floor headfirst from an operating room table during a laparoscopic appendectomy in Scotland. The table had been tilted into an extreme head down position to facilitate the operation. Fortunately, no injury occurred.

The Edinburgh Evening News account says that there were 10 staff members in the room at the time the case started, but no one had placed a safety restraint on the patient.

A follow -up story noted that the hospital has experienced 11 other major surgical errors in the last year including two instances of wrong-site surgery and a case in which five swabs were left inside a single patient.

An investigation by the hospital noted that the level of situational awareness of the operating room staff was inadequate, and teamwork and communication were poor. In addition, the safety culture within the operating room was described as not highly attuned to patient safety.

The staff was also distracted by mobile phone use and idle chatter.

Instead of addressing the obvious human errors such as failure to place the safety strap, which in US hospitals is clearly the duty of the circulating nurse, the hospital's plan of correction focused on the following typical system-type corrections:

• Compulsory training of 1200 staff. Although there were 10 staff for a laparoscopic appendectomy (in the US there would be 4, nurse, scrub tech, surgeon, anesthesiologist), I doubt that there are 1200 people working in the operating room of this 570-bed hospital. What will those not working in the OR have to gain from compulsory training? I wonder if anyone considered that 10 staff for an appendectomy is far too many, and that's why there was a lot of idle chatter. Six of the staff had nothing to do until the patient needed to be picked up off the floor.

• A ban on talking at key times during operations. This one will be hard to enforce. Who decides what the key times are? I also don't see what it had to do with the incident since tilting the table would not be considered a key time in the case.

• Daily meetings to improve patient safety. Good luck with that. What on earth are they going to discuss at daily meetings to improve patient safety? I predict that those meetings won't take place for more than 3 or 4 weeks.

• Sanctions for staff who fail to meet the new standards. Also be hard to enforce. How will this be judged?

I would have talked with the nursing staff and asked them whose job it was to place the safety strap. If you want to make a system change, why not clearly specify which staff member is responsible for that action? And how about using a checklist?

Five years ago, the Scottish Patient Safety Program recommended using pre-surgery meetings and checklists to protect patients. The investigation showed that in this hospital, checklists were completed about 10% of the time and often not properly. The staff claimed that they didn't have time to do the checklists. Ten people in the room for an appendectomy and no one has time to complete a checklist?

Next I would have asked the anesthesiologist where he was. Usually the job of adjusting the table is his, and the controls are at the head of the bed. He should have noticed the patient was beginning to slide off the table and intervened.

Finally I would have asked the surgeon just how much head down tilt he needed. I have never even come close to having a patient more than about 30 degrees of head down during a laparoscopic appendectomy.

Patient falling from an OR table—human error.

Wrong site surgery—human error.

Leaving foreign objects inside patients—human error.

The OR staff of every hospital counts instruments and swabs. Wrong-site surgery is 100% avoidable. This hospital had a number of appropriate systems in place. The staff simply disregarded them. Creating more meetings and rules that are unlikely to be followed or make a difference will not solve the problem of a staff with a "can't do" attitude.