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Physician, police thyself!

August 31, 2015

OK, I can’t possibly let this one go.

New York Times, today, the Opinion Pages: When Bad Doctors Happen to Good Patients (  These two guys, Thomas Moore and Steve Cohen… well, maybe they were dropped at birth or beaten by the nuns at catholic school or didn’t get vaccinated, I don’t know, but they are not purveyors of peace and love between all beings.  Here is a sampling of the things they say:

“Doctors and hospitals are doing a poor job of policing themselves, yet they have been successful at keeping anyone else from doing it.”

“When juries do award large pain-and-suffering amounts, it is because that is the only way our system allows people who have been grievously harmed to recoup some measure of what they have lost.”

“Don’t limit what injured people may collect, and don’t make it more difficult for victims to get their cases heard.”

“As long as hospitals and doctors block legislation and fight regulation, patients will remain in peril.”

“The greater shame is that hospitals don’t put more emphasis on patient safety.”

You get the gist.  The comments section pretty much says everything I would say about all this, except for one thing, one sentence of reason in a sea of nonsense:

“Even better for all concerned, keep the negligent act from ever happening in the first place.”

Let’s forget for a moment the most salient part of this statement from Moore and Cohen’s viewpoint, which is that it would most definitely not be better for THEM.  The truth is that it would, in fact, be better if we could prevent medical errors from happening.  Very rarely is an error the result of one “negligent act”.  Virtually nothing that happens in hospitals is the result of the unilateral action of one person.  Let the comments on the OP-Ed piece tell that story.

But let’s imagine, just for now, that patients are harmed by the individual negligent acts of doctors, so-called Bad Doctors.  There are Bad Doctors out there.  They’re generally not evil, just incompetent.  They exist.  Everyone who works with them knows who they are.  And the medical profession hasn’t been great at preventing incompetent doctors from practicing.  I’ll give the lawyers that one.

The thing is, doctors are not created in a vacuum.  Doctors are created from medical students and residents.  Medical students and residents are, or are supposed to be, closely watched by senior doctors, whose job is not only to teach them but to evaluate their skills.  It is a well-known trope among young students that medical school is hard to get into but once you’re in it’s virtually impossible to get kicked out.  The same goes for residency.  Residency directors will go to great lengths to get poorly-performing residents through their program of training.  It is, of course, very hard to tell a young person who has invested so many years of their lives that they have to go find some other line of work.  In sports the natural process of sorting out incompetence happens all the time:  If you win you’re in, if you lose you find another job.  It’s true in business as well.  In medicine, once you’re in you’re pretty much in.

Once that under-performing resident is released into the world, they can’t be taken back.  They’re launched.  They’re doctors.

Suing more doctors for more money will not prevent incompetence.  It hasn’t yet and people have been suing doctors for a couple hundred years.  If there needs to be a weeding-out process, or a “policing” process, perhaps we need to focus our efforts earlier on in the educational process.

  1. I don’t know if I totally agree with this solution either. Whereas I agree that those sued for malpractice are not the most egregious practitioners of bad medicine, there are many circumstances that contribute to the situation.
    1. Poor reimbursement for excellent patient care. The fee-for-service system does not reward disease prevention or indeed good/adequate interaction between physicians and their patients. In fact, it rewards the opposite supporting shorter interactions to make ends meet.
    2. In a system where lifelong education is necessary, ongoing mentoring is necessary. New interventions become available and often first line docs are not aware of these. We have to improve bothe early and continuing education.
    3. The fee-for-service and short weekend or 1/2 day courses encourage use of ultra sound or other testing but those not adequately trained to interpret the results. These contribute to cost of care with both false positive and false negative screening tests that were billed but added nothing to opitmum health. They encourage legitimately to patients questioning physician motives.

    Doctors go into medicine with at least some wish to help people. Otherwise, their marks, GPA, etc. would all get them into investment banking. Assuming that hypothesis is true, we need to encourage ongoing longitudinal care, which is actually worsened with this shift-like mentality arising from not wanting trainees to be overworked. Whereas the end is laudable, the means is not. Rather than havning docs be responsible for patients in a shift manner, we should encourage all trainees to be following patients that they admitted once they are back on the service. We need to encourage mor opportunities for some of those patients to be followed up by those docs in the clinic. Only through this way, will trainees learn the importance of longitudinal follow up and the joy of interactions as a physician to a patient.

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