Monday, January 13, 2014

Power Corrupts

For many years, the health care system generally and the medical profession in particular was left free to manage its own affairs.  “Doctor knows best” was a guiding principle and nobody wanted to be accused of interfering in the practice of medicine or in the doctor-patient relationship.

The result was the conferring of great power, and as Baron Acton observed a century and a quarter ago, power corrupts.

That principle was vividly illustrated in an article appearing in the January 11 edition of the Omaha World Herald and headlined “For ‘never events,’ stray surgery items are disturbingly common.”  The article, over the by-line of local columnist Matthew Hansen, was occasioned by a lawsuit brought by a lady in whom a fluid-filled surgical glove had been left following surgery at an Omaha hospital.

‘Never events’ are events that should never happen, like leaving foreign objects in patients after surgery.  The most common such items are sponges used to soak up blood.  Hansen quoted a number of apparently authoritative estimates of how often sponges are left in patients in US hospitals and the numbers ranged from 500 to 6,000 per year.

According to the article, techniques involving bar codes and tiny radio-frequency tags are available to prevent this from happening.  Using them. the Mayo Clinic has not lost a sponge in four years.  Indiana University Health System hasn’t lost one in five years.   

The cost is about $10 per procedure but no hospital in Omaha is using the technology.  I consider that to be inexcusable negligence attributable to the power granted to those institutions.  Corruption in the sense of an erosion of standards seems like a suitable word to describe the condition.

Sunday, January 05, 2014

ER Mythology

I never cease to be surprised at the durability of myths that become imbedded in the culture.  Hospital emergency rooms are a case in point.  One such myth is that the cost of health care would be lower if ER patients got their care from clinics and doctors’ offices instead.  Another is that patients go to ERs because they lack insurance to pay for private care.
The latter is getting shot down in Oregon.  Lacking enough money to cover everybody eligible for Medicaid, the state resorted to a lottery.  Winners got coverage and losers did not.  Some clever researchers then studied the ER utilization of the two groups in the Portland area.  What they found was that people in the insured group made 40 per cent more ER visits than those without coverage.
I read about this in a New York Times article carried in the January 3 issue of the Omaha World Herald.  The headline was “Surprise finding; Newly insured poor make more trips to the ER.”  Well, the World Herald might have been surprised, as were many luminaries it quoted, but I was not.
So far as I can tell, the anti-ER mythology has its origins in the time when private practice physicians ruled health care.  Those physicians did not like to be called to the ER on Sunday afternoon to treat a runny nose.  They provided ER coverage on a rotating basis, raising the disconcerting possibility that a doctor on call would see another doctor’s patient in the ER and elect to provide follow-up himself.  Doctors not on call were also mindful of the possibility of missed fees when patients of theirs who might have come to their offices sought ER care instead.
The consequence was that ERs got a bad name that has persisted despite their continually growing popularity as a source of care.
People use ER’s because they are conveniently available when care is felt to be needed.  Not such a difficult thing to comprehend if the opposing mythology can be overcome.
Maybe the Oregon experience will help do that.

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