Category: culture of doctors

When You’re a Lawyer, Everything Looks Like an Opportunity to Argue

Seth Roberts5 Comments

I recently posted about Unaccountable by Mart Makary, a book about the bad behavior of doctors. One of his points is “The when-you’re-a-hammer problem plagues modern medicine at every level.” He illustrated this with a case where transplant surgeons said an otherwise-healthy person with a small liver tumor should get a liver transplant. Which struck Makary as ridiculous.

A lawyer who reads this blog sees the same thing in lawyers. He told me the following story:

One of the sixteen defendants we sued moved to transfer the venue of our case from [Southern California city] to [Northern California city]. Both plaintiffs, all of his doctors (over a dozen), all of the witnesses (again, about a dozen), and all of locations where the incident took place are in or near [N. California city]. When we got the motion I took it to my boss who said, “Huh. We should’ve filed it in [N. California city] to begin with. I don’t know why we didn’t.” It would’ve been inconvenient for us, b/c we’re in [S. California city], but we’ve filed cases up there before, so we could handle it.
So, did we stipulate with the defendant and just transfer the case up north? No. We filed a pathetic, perfunctory opposition. We had an argument, but it was very weak: one of the defendants was located in [S. California city]. That’s basically all we had to hang our hat on.
We filed our opposition, defendant filed their reply. We all trekked down to court to argue our positions in front of the judge. The hearing should’ve taken 30 seconds – “Defendant’s motion granted.” — but the judge actually entertained oral argument. Finally, he granted the motion.
When I got back to the office, I noted to my secretary what a huge waste of time all of this was. The law was clear, virtually all of the facts were on opposing counsel’s side, we should’ve filed up north to begin with, so why fight it? Why not save everyone — us, opposing counsel, the judge and his staff — time and just agree? “Well, you gotta take a shot,” was her reply. Which is what I hear from attorneys all the time. “You gotta try, you gotta make the argument.” In other words, we have hammers so the hammers must be used no matter what.

No, it isn’t quite like a transplant surgeon who says a new liver is needed b/c of a small tumor – no one’s life or health is at risk — but how much time and resources are wasted in the legal system on bullshit like this?

Extremely Disappointing Facts About Doctors

Seth Roberts11 Comments

The gist of Unaccountable: What Hospitals Won’t Tell You — and How Transparency Can Revolutionize Health Care (copy sent me by publisher) by Mart Makary, a med school professor at Johns Hopkins, is that doctors have failed to regulate themselves. Nobody else regulates them, so they are unaccountable. In many ways, Makary shows, bad behavior (e.g., unnecessary treatment, understating the risks of treatment) is common. Hospitals hide how bad things are. Makary mostly discusses surgeons — he’s a surgeon — but gives plenty of reasons to think other specialties are no better.

The book is one horror story after another. At one point, Makary quit medical school. He was disgusted and appalled by seeing doctors — his teachers — push an old woman to consent to an operation she didn’t want and didn’t need. She refused, again and again, but the doctors kept pushing. Makary objected. He was ignored. Finally she agreed. The operation killed her.

I know Peter Attia as a co-founder, with Gary Taubes, of the recently formed Nutritional Science Initiative. Makary met him when Attia did a surgery residency at John Hopkins Hospital. Attia had seen a doctor about back pain and had been told he needed surgery. They operated on the wrong side, causing damage that prevents Attia, an excellent athlete, from playing most sports. Eventually Attia left medicine. He felt “modern medicine was too frequently dishonest with patients, at times understating risks and overtreating patients as a matter of reflex” — “as a matter of reflex” meaning “as a matter of course”, i.e., usually. And Johns Hopkins Hospital is one of the better hospitals in America. “Almost everyone I talk to has a story about a friend or a family member who was hurt, disfigured, or killed by a medical mistake,” writes Makary. He has six such stories, including his grandfather and his brother. His grandfather died from unnecessary surgery.

The “when-you’re-a-hammer problem” says Makary, “plagues modern medicine at every level.” He witnessed a case conference where a young otherwise-healthy patient had a small liver tumor. “The transplant surgeons [more than one] in the audience recommended a liver transplant. I was flabbergasted. Why on earth would any doctor recommend a transplant?” Makary asked around. He discovered there was nothing unusual about the transplant surgeons in the audience. He called a friend who was one of the few surgeons trained in both cancer treatment and transplants. His friend said “there was a battle for turf taking place nationwide between transplant surgeons and cancer surgeons. Both claim to be liver experts.”

Makary tells about trying to obtain informed consent for a surgery when he was an intern. He didn’t know much about the surgery. The patient didn’t agree. “It was well-known among interns that if an attending senior surgeon found out that a patient refused surgery close to surgery date, duck for cover. Mine would surely be livid.” Makary spoke to an upper resident. He couldn’t get approval. They went to the chief resident. He got approval. Congratulations all around amongst the doctors, “glad that the wrath of the attending surgeon would be averted.”

Supposedly state medical boards oversee doctors. Makary devotes part of a chapter to describing how they don’t. He asked state medical boards why they don’t search a national database before issuing a medical license. “My favorite excuse was that they could not afford the four-dollar-per-doctor fee.”

In 1978, the Shah of Iran needed an operation. The United States government set him up with a Texan named Michael DeBakey, “considered by many to be the best surgeon in the world.” During the surgery, DeBakey failed to take “a simple standard safety measure.” Due to this failure, the Shah developed a serious complication, became very sick, and died. The Shah and the United States government had failed to realize — and, more important, none of the experts they consulted had told them (I assume) — is that DeBakey was a famous heart surgeon. The Shah’s operation involved his spleen. DeBakey knew little about such operations and had done almost none — but (I assume) didn’t point this out.

A survey done at many hospitals asks employees if they “feel comfortable speaking up when [they] sense a patient safety concern.” At the median hospital, the percentage is about 70%. In the Milgram experiment (where subjects are ordered to give painful shocks), when audiences were asked by Milgram to predict what they would do in that situation almost all said they wouldn’t give the shocks. In fact, most people did give the shocks — indicating that people vastly overestimated their likelihood of resistance and speaking up. So 70% is likely an overestimate. (A study of nurses found that about 95% of them broke safety rules when ordered to do so. Roughly all of them had said they would never do such a thing.) Since talk is cheap, why is the median percentage as low as 70%? No doubt many respondents had seen themselves fail to speak up.

These aren’t the worst stories, these are average, I just opened the book here and there. There are dozens more. No previous book has spelled out so clearly the depth and width of doctor misbehavior, especially how common it is, and the failure of those supposedly responsible, such as hospital administrators and state boards, to do anything about it.

Title from 12 extremely disappointing facts about popular music.

 

 

Unaccountable by Marty Makary

Seth Roberts2 Comments

The not-yet-released book Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care by Marty Makary, a professor of surgery at Johns Hopkins, may or may not make good arguments — I haven’t read it — but it certainly begins with a good story:

Harvard surgeon Dr. Luctan Leape at a national surgeon’s conference . . . opened the gathering’s keynote speech by looking out over the audience of thousands and asking the doctors to “raise your hand if you know of a physician that you work with who should not be practicing because he or she is dangerous.”

Every hand went up.

The author, Marty Makary, asked the same question at his talks and got the same response. Both of them — Leape and Makary — should have started asking “What fraction of the surgeons you work with are unfit to practice?”

I wonder how the rest of us can identify those unfit-to-practice surgeons. My experience has taught me not to trust a surgeon who says I need surgery.

“How Ignorant Doctors Kill Patients”

Seth Roberts4 Comments

I have already linked to this 2004 article (“How Ignorant Doctors Kill Patients”) by Russell Blaylock, a neurosurgeon, but after rereading think it deserves a second link and extended quotation.

I recently spoke to a large group concerning the harmful effects of glutamate, explaining it is now known that glutamate, as added to foods, significantly accelerates the growth and spread of cancers. I [rhetorically] asked the crowd when was the last time an oncologist told his or her patient to avoid MSG or foods high in glutamate. The answer, I said, was never.

After the talk, a crowd gathered to ask more questions. Suddenly I was interrupted by a young woman who identified herself as a radiation oncologist. She angrily stated, “I really took offense to your comment about oncologists not telling their patients about glutamate.”

I turned to her and asked, “Well, do you tell your patients to avoid glutamate?” She looked puzzled and said, “No one told us to.” I asked her who this person or persons were whose job it was to provide her with this information. I then reminded her that I obtained this information from her oncology journals. Did she not read her own journals?

Yet, this is the attitude of the modern doctor. An elitist group is in charge of disseminating all the information physicians are to know. If they do not tell them, then, in their way of thinking, the information was of no value.

The incentive structure of modern medicine in action. If you do harm, you are not punished — thus the high error rate. If you do good, you are not rewarded — so why bother to think (“no one told us”)? The similarity to pre-1980 Chinese communism, where it didn’t matter if you were a good farmer or a bad farmer, is obvious. It is a big step forward that the rest of us can now search the medical literature and see the evidence for ourselves.

Another Unintentionally Revealing Response From the American Medical Association

Seth Roberts5 Comments

A few weeks ago I blogged about the lame response of the American Medical Association to HealthTap, a website that solicits doctors’ answers to medical questions. Their criticism was so weak it amounted to praise.

More recently, the AMA was asked about its position on doctor rating websites. Here’s what happened:

Robert Mills, a spokesman, sent me a statement that he said was from the A.M.A.’s president, Dr. Peter W. Carmel, that read, in part, “Anonymous online opinions of physicians should be taken with grain of salt and should not be a patient’s sole source of information when looking for a new physician.” This, however, is almost exactly the same statement it provided to its own publication, American Medical News, in 2008, when it was attributed to Dr. Nancy H. Nielsen, the president-elect of the A.M.A. at the time.

Such plagiarism is more consistent with what Jane Jacobs in Systems of Survival called guardian values (where honesty is unimportant) than commercial values (where honesty is very important). When you grasp that doctors follow guardian values rather than commercial ones their behavior becomes far more predictable — and plainly in need of control by outsiders. That doctors are allowed to charge for their services resembles allowing policemen to write as many parking tickets as they like and pocket the fines.

Thanks to Bryan Castañeda.

Assorted Links

Seth Roberts3 Comments

Thanks to Anne Weiss.

“Thou Shalt Not Testify Against Another Doctor”

Seth Roberts2 Comments

First do no harm . . . As Robin Hanson has said, what does that mean? In contrast, the rule illustrated by this story, from Bryan Castañeda, who works for a Los Angeles law firm, is quite clear:

At the old firm I used to work at, I was talking to one of the senior attorneys and the topic of medical malpractice cases came up. He said he avoids them. Why, I asked. He said — I’m paraphrasing here — “Because you won’t find a doctor who will testify against another doctor in open court. They may advise you in private, ‘Oh yeah, so-and-so definitely screwed up,’ but you won’t get them to say that on the stand. They all protect each other.”

Judging by this story, if your doctor makes a mistake, the only person who will suffer consequences is you. Thank heavens the rest of us have more power than ever before. A recent survey of doctors found that “more than a 10th (11.3%) admitted to telling patients something that was not true.” The survey did not ask about lies of omission (when silence is misleading); unwillingness to testify that someone else made a mistake is that sort of lie. The survey also showed that doctors (at least, those who took the survey) have a self-serving interpretation of the term not true. Although only about 10% said they had said something “that was not true” — meaning something that they knew wasn’t true — “more than half had described a patient’s prognosis more optimistically than warranted.” Apparently they consider such descriptions not instances of “not true”.

In Systems of Survival, Jane Jacobs described two moral systems (lists of rules/values): The guardian syndrome and the commercial syndrome. In certain areas of life (e.g., military), the guardian syndrome prevailed; in other areas (e.g., small business), the commercial syndrome prevailed. Loyalty (e.g., “never testify against a fellow doctor”) is a guardian value — indeed, the main guardian value. In contrast, honesty is the main commercial value. Jacobs said that the two syndromes corresponded to two ways of making a living: taking and trading. Doctors do not represent themselves as predatory (= taking). But, according to Jacobs, this sort of rule (“never testify against a fellow doctor”) puts them squarely in that camp.

I asked Jim Jacobs, one of Jane Jacobs’s sons, for comment. He replied:

Exactly right. Jane experienced this herself, unfortunately. It’s really a major problem. I see the very same behavior among medical researchers too.