> the doctors or hospitals are not necessarily held liable (unless it's gross negligence)

I've had friends who have worked retained surgical instruments cases.

Meet one or two of those victims and you will never support tort reform again.

If this were a problem of gross negligence, then I would agree with you that we should focus there. But the problem isn't gross negligence, it's a problem of "business as usual." It's a thousand doctors following procedures with a 0.1% error rate and 999 thinking, "nothing bad's happened to me so I must be doing everything fine," even though they could each reduce that to a 0.001% error rate with a simple checklist or by actually washing their hands.

Put another way, if you put someone's life in your hands and you're not focusing a significant percentage of your efforts on procedures designed to radically reduce risk, then you're engaged in gross negligence.

There's another area where we all have that philosophy.

We send a million people hurtling through the air each day in incredibly complex machines. Airlines focus on safety because (a) they are actually responsible for their passengers and can't just call a mulligan because, hey, people make mistakes; and additionally, (b) they suffer massive reputational costs for safety errors.

So my medical malpractice reform would make medicine more like other industries with far better safety records. It would include a requirement that hospitals post their mistakes on their front door as people walk in.

> Meet one or two of those victims and you will never support tort reform again.

Remarks like this are really counterproductive and frankly bizarre. Were character assessments ever relevant in lawsuits against tobacco companies? It's not hard to find unlikeable plaintiffs.

However it is increasingly hard to keep your rights to a _public trial_ in a courtroom when it's a tort case [0]. When doctors ask you to give up your right to a public trial, then the rest of society (in my view) demonstrably loses out.

And in fact, per-capita, Americans file fewer law cases now than in the 1840s. [1]

> If this were a problem of gross negligence, then I would agree with you that we should focus there. But the problem isn't gross negligence...

Gross negligence is literally the problem in the medical industry. The Johns Hopkins study found "medical errors account for more than 9.5% of all fatalities in the US." I'm uncertain that any "business as usual" by doctors is really a problem, but rather the checks and balances once offered to patients is being severely eroded.

[0] http://harpers.org/archive/2016/04/suing-for-justice/ [1] http://harpers.org/archive/2016/04/suing-for-justice/6/

> Remarks like this are really counterproductive and frankly bizarre.

I think that's both untrue and unfair. Typical tort reform discussion focus on how doctors can have their lives ruined without ever mentioning how patients can have their lives ruined. You cannot make a fair cost benefit comparison without understanding both sides. Most people don't understand both sides.

Judging by your point about unlikable plaintiffs, perhaps you misread me. I'm not trying to argue that anecdotal experiences should replace facts in our cost benefit calculation. What I see in this area, though, is that people intuitively know what it means to lose a business, but have no intuitive grasp of what the consequence of a common medical error is (perhaps because there's no typical medical error).

I'm essentially just saying that "People should know more about the details of this issue, they commonly misunderstand the harms involved," which is just how careful decisions should work.

> per-capita, Americans file fewer law cases now than in the 1840s.

Exactly so, and another reason the need for tort reform is overstated.

> Gross negligence is literally the problem in the medical industry. The Johns Hopkins study found "medical errors account for more than 9.5% of all fatalities in the US."

Gross negligence is a term of art, it's not literally equivalent to any fatal mistake. Though I was saying, metaphorically, that we should treat it that way in this industry.

I think we actually agree on most of these points... just in the most heated way possible.

It's actually common for retired pilots to teach risk mitigation classes for doctors and nurses. Something as simple as a small checklist can make a huge difference.

Capt. Sullenberger has given interviews and presentations on this very subject. His work on flight safety started 30 years before US Airways Flight 1549 made him famous.

I know a few pilot-physicians who treat the NATOPS-style [0] procedures for medicine and surgery as rules to live by.

-----------------

NATOPS is a positive approach toward improving combat readiness and achieving a substantial reduction in the aircraft accident rate. Standardization, based on professional knowledge and experience, provides the basis for development of an efficient and sound operational procedure. The standardization program is not planned to stifle individual initiative, but rather to aid the commanding officer in increasing the unit’s combat potential without reducing command prestige or responsibility. -- OPNAV Instruction 3710.7U

[0] https://en.wikipedia.org/wiki/NATOPS

Checklists applied rigorously have been _demonstrated_ to make a huge difference, see The Checklist Manifesto: How to Get Things Right by Atul Gawande [1]

[1] http://smile.amazon.com/Checklist-Manifesto-How-Things-Right...

Whoops, it turns out this idea maybe isn't as real as the pop-science makes it seem: http://www.nejm.org/doi/full/10.1056/NEJMsa1308261

If it's any consolation, all the studies examined in that meta-analysis show improvements in outcomes, they just vary on how much.

When they say "The effect of mandatory checklist implementation is unclear" they really mean that the magnitude of the effect is still unclear.

Also, the metaanalysis describes which studies have gotten the same profound results:

"Only studies including team training or a more comprehensive safety system that includes multiple checklists have shown effectiveness similar to that seen in the WHO study."

Maybe the benefits are overhyped, but there appear to be reductions in mortality during hospital stays, and the studies suggest ways hospitals can improve results (ie, team training and systems with multiple checklists).

Wow, 60 lives were saved and 40 persons less had surgical complications! Just in 3 month in Ontario.

Of course, there was not enough data yet to conclude any improvement within the 95% confidence interval, but still, it does hint at a great reduction in serious mistakes.

BBC Horizon actually did a show on the importance of checklists and how they save lives in medical settings, and because of that I'm trying to start using checklists at work as well when practicable.

The episode is called How To Avoid Mistakes In Surgery for those interested.

Available at torrent sites near you!

These can help in software development, too. Everyone is so obsessed with speed, but often the thinking is short-term.

Slow down a little bit and use a checklist when deploying. Use a checklist when reviewing code. Iterate so you aren’t wasting time or limiting your thinking.

Developers have something superior to a checklist much of the time, automation. Deployment should be fully automated, no checklist necessary. But yes on non-automatable things like code review, a checklist is certainly a plus.

Also unit tests provide a type of checklist.

Not all parts of a deployment can be automated in every case.

I've helped craft a checklist we use on our releases based on lessons learned over several years, an awful lot of it is about communication to end users / other teams. Especially if the release is one that involves downtime it's important to have consistent practices and clarity about who is going communicate what and when. Checklists are a good way to capture the "what could have gone better" outputs of retrospectives.

Fair points about client communication.

:D I have a friend who does this. Great guy loves procedures.

> It's a thousand doctors following procedures with a 0.1% error rate and 999 thinking, "nothing bad's happened to me so I must be doing everything fine," even though they could each reduce that to a 0.001% error rate with a simple checklist or by actually washing their hands.

Seems like that's an argument for a very discerning insurance company. Following the checklist should reduce their insurance premiums 10 times. And that's noticeable.

(Of course, the ideal insurance company in question needs to collect the information how doctors behave, and needs to be legally able to act on it.)

> Seems like that's an argument for a very discerning insurance company.

It's an argument based on a made up or uncited statistic.

Forget the example---it's only for illustration. The argument is:

An insurance policy transforms a spiky stream of obligations into a steady stream. If priced correctly, this will make people directly pay for the risks they take, removing the element of good or bad luck. Thus giving us a much more direct link between risky behaviour and consequences.

Malpractice insurance already exists

Yes. Do you know if the existing malpractice insurance takes into account whether a doctor follows eg checklists and stuff?

Might not be on an individual level, but perhaps if you work for a hospital that has these procedures, one might pay less?

In order for insurance to transmit the incentives right---and not create a moral hazard at worst---they have to have access to a lot of information.

> Do you know if the existing malpractice insurance takes into account whether a doctor follows eg checklists and stuff?

It does not. The checklist research hasn't been sufficiently replicated, and checklists do not guarantee focus and awareness. There is not a one-size-fits-all solution for increasing people's focus. The solution is not simple. The checklist researcher admits this. I wrote more in a reply to brownbat [1]

> Might not be on an individual level, but perhaps if you work for a hospital that has these procedures, one might pay less?

I suppose that'd be up to the insurer to decide whether it's profitable or not to offer an option that includes such a clause.

> In order for insurance to transmit the incentives right---and not create a moral hazard at worst---they have to have access to a lot of information.

Absolutely. As a data science guy, I'm a huge fan of more data. I also believe in the observer effect and that in the case of doctors their stress level needs to be balanced with the additional obligations we impose. Asking hospitals for more data does not necessarily translate into better care.

"Doctors need to be able to work one-on-one with their patients, without the added pressure of survey scores and ratings that have little insight into the entire patient experience" [2]

Convincing doctors to provide more data is critical in the process of data collection. That process is probably best begun by a significant effort to understand the doctors' hardships and workflows.

I suspect people have tried but do not have time to interview every doctor. Even then, you will never get everyone to agree. So it's a matter of working with whatever data we have, supporting good doctors and practices, and crossing our fingers that we haven't overlooked some practice that worked better in the past.

[1] https://news.ycombinator.com/item?id=11635532

[2] http://observer.com/2015/06/the-supreme-court-obamacare-rx-l...

> I suppose that'd be up to the insurer to decide whether it's profitable or not to offer an option that includes such a clause.

Alas, insurers are not included to discriminate on arbitrary things. Ie even if male doctors had statistically a higher chance of malpractice than female doctors, I doubt the laws would allow the premiums to reflect that?

For sure you can't discriminate based on protected classes such as race or sex. I think that's a good thing even if in the short term it led to more accurate premiums. There is nothing about a human's race or sex, etc that predisposes them to being a bad doctor. Even if data showed that men make more mistakes than women, there'd still be plenty of individual men who don't. So basing rates on that data would be discriminatory and bad for society.

I think this gets trickier when you look at health insurance for individuals. My google research tells me that under ObamaCare you can't be charged more for being unhealthy, but that you can be charged more for smoking. I suppose the logic goes there that quitting smoking is easier than telling your defective heart to be healthy. A smoking addiction is relatively more under your control than some other health conditions.

Thanks for the discussion! I've learned a lot from trying to do research and formulate my own views about healthcare in this thread.

Airlines are good at safety not because liability charges are astronomical, they are good at safety because of an enormous set of not too unreasonable regulations.

Liability is a very bad substitute for regulation when risks are comprised of high damage at low incidence. That's why you have speed limits instead of responsible self-determination and potentially rich surviving dependents.

> Airlines are good at safety not because liability charges are astronomical, they are good at safety because of an enormous set of not too unreasonable regulations.

Agreed. Checklist proponents in this thread oversimplify the issue. In a 2007 article, Atul Gawande, author of the 2009 book Checklist Manifesto, discusses how Peter Pronovost trained his hospital to better follow known surgical procedures,

> The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene. [1]

So, he didn't just use a checklist. He convinced staff they were making mistakes. The administration changed hospital rules. Then, Atul says,

> They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.

He claims the checklist is what saved people's lives. He continues saying so for the rest of the article and in his book. It's an oversimplification and misleads the public into believing medicine is simple. The result is the comments you see in this thread. Training people is not simple. Everyone forgets things, even with checklists.

Atul himself later says so,

"It turns out to be much more complex that just having the checklist in hand." [2]

People want to hear about simple solutions. They disengage when a problem is described as complex.

[1] http://www.newyorker.com/magazine/2007/12/10/the-checklist

[2] http://www.nature.com/news/hospital-checklists-are-meant-to-...

This is why the Lean healthcare movement (and Lean in general) is so great.

It takes procedures into account, like checklists and workflows and all that, but more importantly it takes into account the human psychological factors in the workplace that prevent success on even the simple solutions.

However, this could not be more perfect an explanation:

> People want to hear about simple solutions. They disengage when a problem is described as complex.

This is where true leadership is required to breach the barrier of complexity and lead systems thinking across a (naturally) complex organization. Any organization. It's extremely difficult to get people to look outside their bubble or change the way they think, and that's required to manage any complex system with any success. This leadership is the main barrier to improvement in any org.

Lean sounds cool, I didn't know about that movement. I'd support that over the checklist movement any day.

I like that it's based on Toyota's core principle of respect for people. Toyota is a great example of how to inspire people to work smarter and harder. Their core values were initially based on how Ford ran his factories.

Actually, that's false. The principles of Toyota are rooted in statistical quality control, passed down by Walter Shewhart and W. Edwards Deming directly to the Japanese after WWII.

Sure, indirectly, Henry Ford made strides in both scientific management (alongside but not directly associated with Taylor), and moreso, respecting his workers. But the holistic management philosophy that Deming pushed forward was as much a revolt against Ford-era factory ideas as it was based in them; similarly, you might say the core values of Agile were initially based on how IBM ran their software development—nothing but a distant relative.

From lean.org,

> They therefore revisited Ford's original thinking, and invented the Toyota Production System. [1]

Both Ford and Toyota made contributions to each other's processes at different times.

Also, Ford showed a healthy respect for people. This influenced other businesses to compete for talent. Ford doubled wages, increased productivity, etc. in the first half of the 20th century. Toyota made its own contributions later when Ford began to lag. Neither can be discounted from the equation.

[1] http://www.lean.org/WhatsLean/History.cfm

> my medical malpractice reform would make medicine more like other industries with far better safety records

It's impossible in medicine because we're not at that level yet.

Speaking as someone whose father was a physician, I feel a few of your comments are unfounded.

Generally, I think there must be a way to hold most problematic doctors accountable while not causing excessive burdens for most good doctors. Also, any system will not be perfect, and the goal should be to maximize the health of most patients.

> it's a problem of "business as usual." It's a thousand doctors following procedures with a 0.1% error rate and 999 thinking, "nothing bad's happened to me so I must be doing everything fine,"

I see no evidence of this, and I doubt you have the audacity to say this in the presence of your own physicians.

> they could each reduce that to a 0.001% error rate with a simple checklist or by actually washing their hands

I'm not sure where you live where doctors do not wash their hands, or how you know that they do not, but wherever I have been, doctors wash their hands vigorously. Infection in hospitals is common. Everything needs to be super sterile. It's more than just washing hands. Everything needs to be packaged air tight and used once in one part of the body, and then thrown away. It's already much more involved than you're suggesting.

Doctors complete between 11 and 16 years of training [1]

Doctors spend an average of 60 hours working per week. They work on average 1.5 times more than the average American [2]

Doctors have too many patients and too little time.

They are already well educated and don't have time for checklists to remind them of every little detail they learned during their 10-year long training program. They don't sleep much and don't get paid very well for the debt that they incur.

Many doctors got into the field because they want to help people.

My father was a physician until 2004ish, and the stress induced by bureaucracy nearly killed him. He was a great doctor. You're suggesting making the system more complex. I'm saying, that's going to make patient care worse, not better.

If you choose to look only at court cases and do not read medical research, then trust is required in this system. Any procedural changes should be vetted by researchers using the scientific method, not bureaucrats who seek to make unscientific sweeping changes based on anecdotes to further their own political careers.

> Put another way, if you put someone's life in your hands and you're not focusing a significant percentage of your efforts on procedures designed to radically reduce risk, then you're engaged in gross negligence.

This is the job of a doctor. They focus on reducing risks to your health.

The solution isn't to add arbitrary checklists and make doctors more busy. The solution is to use the scientific method to add doctors, make our population healthier and capable of maintaining their own health, and reduce the load of patients per doctor.

> So my medical malpractice reform would make medicine more like other industries with far better safety records. It would include a requirement that hospitals post their mistakes on their front door as people walk in.

At first you argue against tort reform and then you argue for it.

I think things like Zocdoc will help good doctors be recognized and allow patients to self select their level of care. Reviews are just one thing. It's a complicated system that needs to balance many factors in order to maximize patient health.

[1] https://www.google.com/search?client=ubuntu&channel=fs&q=how...

[2] https://www.google.com/search?safe=off&client=ubuntu&hs=o9p&...

Are you familiar with the work of Atul Gawande (a surgeon) and related work around checklists? [1] I would highly recommend you take a look at those and see if you still feel the same way about checklists. They are not about minimizing physicians' training & expertise. They're about procedural rigor, process standardization, and reducing inevitable human error. They're about shifting mental loads away from "rote" or "routine" tasks which are amenable to checklists and instead over to those complex thought processes that really need the specialized years of training.

I don't think people are trying to suggest doctors are maliciously saying "XYZ error rate is good enough, we don't need to do better", but more that there is some ego at play in the reactionary shunning of checklists, when in fact checklists can be a relatively easy way to produce better outcomes.

[1] http://www.nature.com/news/hospital-checklists-are-meant-to-...

> Are you familiar with the work of Atul Gawande (a surgeon) and related work around checklists?

I am now. The author of the research on which this article is based [0] is Marty Makary (MM). Marty claims to have co-developed the checklist which was further popularized by Atul in his book [1]

Marty advocates transparency in healthcare in his book "Unaccountable". He laments existing bureaucracy and his solution is more bureaucracy. I find this review illuminating [2]. The reviewer makes good points, and the replies he gets show how many missed his point.

This is the world of medicine. People get pumped up into believing the entire medical profession is flawed, there's a massive debate about how much money should be paid out, and the world keeps turning. In the middle of this, good doctors can become victims of stress induced by bureaucracy. That's a cost on which you simply cannot put a dollar figure. Patients can end up receiving worse care, and lawyers walk away happy to have drummed up more business.

I wrote more in my second response to brownbat in this thread. Basically, the checklist research hasn't been sufficiently replicated, and checklists do not guarantee focus and awareness. There is not a one-size-fits-all solution for increasing people's focus. It's not as simple as brownbat implies. Atul admits this,

"It turns out to be much more complex that just having the checklist in hand." [3]

[0] http://www.bmj.com/content/353/bmj.i2139

[1] https://en.wikipedia.org/wiki/Marty_Makary

[2] http://archive.is/9SYXz

[3] http://www.nature.com/news/hospital-checklists-are-meant-to-...

> They are already educated and don't have time for checklists to remind them of every little detail they learned during their 10-year long training program.

Medicine is not a static field. Evidence-based guidelines and checklists save time, money and lives. Time: because over-worked docs already have a hard time keeping up with new standards and guidelines. Money: because best practices reduce errors and poor outcomes, and ultimately reduce malpractice premiums. Lives: because good medicine is based on evidence that reduces harm, and not based statically on what was learned at the start of a career.

If you want to hold the most problematic doctors accountable, do away with the tort reform that protects them. The faster the incompetents are driven out (and not just relegated to a state with lower standards and more protection), the better we'll all be.

Overwork contributes to all kinds of problems, but it's not an excuse to avoid practices shown to produce better outcomes. It's roughly equivalent to a coder saying "I shouldn't have to run unit tests because I'm already working 60 hours a week and have 16 years of experience, and I got into this field because I like to write code." There are other ways to attack the cost of education and the doctor supply, but they are slow to gain traction because of professional protectionism.

>They are already well educated and don't have time for checklists to remind them of every little detail they learned during their 10-year long training program.

Sorry, but no one is too good for checklists. Not doctors, not 747 pilots with 35 years of experience.

On the contrary, the amount of training training and job complexity that physicians deal with are actually good reasons to have checklists in the first place.

> Speaking as someone whose father was a physician, I feel a few of your comments are unfounded.

I have several family members in the medical field, nurses, physicians, surgeons, as well as colleagues who have worked in malpractice, some on defense and for insurers and hospitals who have fought to get hospitals to implement correct procedures.

> I'm not sure where you live where doctors do not wash their hands,

This is a massive and well studied problem in the US and around the world. If asked about the risks, sure, doctors admit they know them. They still don't wash their hands at safe rates. The CDC claims that medical professionals still wash their hands only half as often as they should. The Lancet found poor handwashing practices by medical professionals due to low compliance with recommendations worldwide. In American ICUs, handwashing compliance baselines at about 26%.

http://www.cdc.gov/handhygiene/

http://www.thelancet.com/journals/laninf/article/PIIS1473-30...

http://ajm.sagepub.com/content/24/3/205.abstract

> The solution isn't to add arbitrary checklists and make doctors more busy. The solution is to use the scientific method

The scientific method is exactly where these measures come from. Atul Gawande's work on checklists and the discussions of handwashing are more publicly known, but proper interventions against bedsores through patient turning and proper cleaning in hospital facilities by maintenance staff contribute to patient outcomes too, along with a hundred other boring procedural improvements. All of them are adopted or recommended only after examining outcomes with those procedures according to some scientific study.

> At first you argue against tort reform and then you argue for it.

For the record, the second bit was facetious. "Add reputational costs" isn't what people usually mean by tort reform.

EDIT: shortened

It's great that Atul feels checklists improve his work, and that he's been able to show efficacy in studies he directed.

Has the work been replicated? My research indicates it hasn't yet been tested enough to be proven [1]

His book promoting checklists seems premature without sufficient replicated research.

My gut tells me that a checklist would improve patient care when the carer is focused on the list. I feel this is already known. The problem is not that medical professionals do not know cleanliness is critical, it's that they're not focused. Introducing a checklist does not guarantee focus. I feel Atul's research is colored by the fact that he's probably a good teacher and he is instructing those who are directing the studies. It seems unlikely to me that checklists will be the savior of doctors' lack of focus. Better for this is rest and increased awareness by doctors that they do sometimes lose focus and forget. We can do this by sharing research showing that basic steps are sometimes not followed.

The thing that's worked best for me to increase my focus has been meditation and hobbies like running that take my mind off of everything but what I'm doing at the moment. That may not be true for everyone. The same can be said for checklists.

From the article titled "Hospital checklists are meant to save lives — so why do they often fail?" [1]

> Some experts suspect that the failure to replicate could be a matter of how the initial trials or the follow-up studies were designed. Gawande's pilot study of the WHO surgical checklist, for example, was not randomized and had no control group. Instead, it compared complication and death rates before and after the checklist was introduced. Critics say that this makes it difficult to determine what other factors might have influenced outcomes.

> Gawande acknowledges the limitation, which was due to cost restrictions, but he points out that many subsequent trials, including ones that were randomized, have also demonstrated large reductions in complications and mortality following the introduction of the checklist. The list works, he says — as long as it is implemented well. "It turns out to be much more complex that just having the checklist in hand."

Atul himself says it is not so simple as you and he originally implied.

[1] http://www.nature.com/news/hospital-checklists-are-meant-to-...

Why would anyone be against promoting a technique that has demonstrated a real reduction in fatalities? Sure, in some implementations, there has not been as much reduction. But, I didn't read anything that said the risks increased. Did I miss that?

Or, put another way, instead of 100% chance of reducing fatalities by 50%, you get a X% chance of reducing fatalities by 50%. Still seems like a great improvement.

Checklist proponents in this thread oversimplify the issue [1]

The reason I comment is not to support or disapprove of the use of checklists.

I'm saying, it's more involved than that. Checklists should be a part of a process that includes evaluating their efficacy wherever they're introduced. Pushing the idea that it is simple takes away from the value of the original implementation by Peter Pronovost. Poor marketing can cause what was initially a good idea to fail.

[1] https://news.ycombinator.com/item?id=11641970

>don't get paid very well for the debt that they incur.

Risk adjusted returns on that financial investment into their education and training is one of the best, if not best career routes available given the very low volatility of the profession compared to industries like finance (up or out, layoffs), tech (cyclical layoffs), or law (contracting industry).

That being said, the physical and emotional toll of that training is something I would not wish upon anyone.

>Doctors have too many patients and too little time.

Thanks in part to artificial caps by the AMA.

I don't see why the the anesthesiologist should not be held liable in this case (and possibly the hospital). In my opinion, it would be very reasonable for them both to pay a significant penalty.

These abnormally low (and capped) penalties make it easier for those who should not be doing this work to keep showing up every day. I understand that we don't want to scare people in health care out of the field, but those who are clearly inept certainly should be afraid to keep working.

The problems are not inept individuals, nor will scaring people out of the field improve conditions.

More than likely, the fear of recourse causes more error and malpractice than the errors themselves.

Think for a moment: why are commercial airplanes so safe? Why when an airplane crashes is it so rarely "pilot error?" And why, when it really is pilot error, does the pilot not get blamed? It is because of profound realizations in the design of the air travel system that veered toward systemic control of air traffic and its safety, rather than individual pilot accountability.

I will say unequivocally and factually: our health care would be orders of magnitude safer and higher quality if we treated it in exactly the same way.

In my experience, in an unrelated field, most human errors are actually a cumulation of other systematic errors.

Pilots are responsible for safety, sure, but there are multiple checks in case the pilot suddenly passes out (or stops paying attention, or whatever). Control towers, copilots, etc.

I know nothing of anesthesiology, but it seems to me that a doctor shouldn't be a single point-of-failure. If he is, it seems like that should fall under systematic-errors.

In medicine, one big thing is people working long hours, exhausted. My understanding is that airline personnel have strict rules about this. I have long thought medicine should seriously tighten up on making sure medical personnel are adequately well rested instead of insisting that residents work 36 hours straight and things like that.

We allow doctors to cut into other people in the same circumstances in which we (at least in EU) forbid a truck driver to drive because he's a danger to others because of insufficient rest.

Worst case scenario for the surgeon is a single death, worst case scenario for the truck driver is dozens. Better stay out of hospitals...

There is a tradeoff, though. A doctor once explained to me that she did 24 hour shifts to minimize the mistakes that can occur when handing a complicated case off to someone else.

I think that sort of thing accounts for an extremely tiny minority of too-long shifts in the medical industry.

What a great point. Raver kids have quick and easy litmus tests they can use to make sure the illegal drugs they're taking are the ones they expect to be taking. If it turns blue, you take it. If it doesn't, you don't.

It seems the procedure for injecting medicine into your spine should have at least as much fail-safety built in.

In cases of wrong medication, I wonder if its a mislabeling or someone just not reading? Maybe a doctor writing the wrong thing down?

You are missing the forest by looking at the trees. You need a foolproof way to determine 2 tests:

1. Is the contents of the bottle what I think (or the label says, or the nurse told me) it is?

2. Is the verified contest of the bottle what we previously agreed this patient needs?

1a. Is the concentration of the solution is this bottle as high or as low as I think?

Read "The Checklist Manifesto" by Atul Gawande. Chock full of tiny, easy steps like this that make huge differences in outcomes.

Medicine would do well to learn from aviation.

Aviation safety is all about treating errors as facts of life, and erecting as many barriers as possible between errors and a catastrophic outcome. When errors do happen, everything is designed to trap them as early as possible before they cascade into something worse.

There are compelling incentives (such as amnesty or leniency) for pilots to self-report the mistakes they make. The entire industry has robust safety reporting mechanisms, and virtually every non-trivial error is dissected in reports for later study. When there's fatalities involved, you're talking a full NTSB investigation.

For pilots, its called the NASA Aviation Safety Reporting System [0], which does have immunity (from FAA enforcement actions) for self-reporting pilot mistakes.

The NTSB often "full" investigations into serious incidents involving airliners, such as runway incursions or other near-misses.

In the USAF there is a legal Accident Investigation Board, and a Safety Investigation Board. The SIB is legally privileged, and testimony cannot be used in disciplinary action or legal proceedings.

For doctors, there is whats known as a Morbidity and Mortality conference [1]. This is a meeting between doctors at a hospital in which the discussions are privileged and confidential.

[0] https://en.wikipedia.org/wiki/Aviation_Safety_Reporting_Syst...

[1] https://en.wikipedia.org/wiki/Morbidity_and_mortality_confer...

Google also has a robust `post mortem' culture. (Transporting the term back to medicine where it came from might be a bit morbid, if used in the newly acquired wider meaning of any analysis of failure after the fact.)

In the Army (90s), we called them "after-action reviews" (AARs), for the avoidance of highlighting morbid parallels.

> Treating errors as facts of life.

Even the passengers are part of the system. Example: those cigarette ashtrays in the bathrooms? They're not left over from some mid-century period where you could smoke on planes—they're very intentional and there to prevent fires in the event someone does smoke on a plane, which, since it's a very plausible and easy to make human error, must be accounted for safely and systemically.

That way of thinking permeates air safety thinking, and it's why air travel is safe, period.

I strongly disagree - it sometimes is inept individuals in the medical field who cause mishaps, I watched a young clearly inexperienced anesthesiologist attempt to perform a spinal on my wife during labor - he spent an entire hour attempting to insert the needle between the blades of my wife's spinal column before calling for help. Rather than admitting he had either:

a) never done the procedure or b) was unskilled in its application

he attempted to perform it himself, and for reasons unknown thank god he didn't insert the needle into the spine incorrectly. The experienced anesthesiologist took a minute or so to do the same procedure.

So yes, even in the medical field there are inept individuals who think too highly of themselves to admit & seek help when they're clearly incapable of performing the task at hand. Unfortunately those weaknesses cannot always be detected (i.e. diagnosis, etc.) without second opinions - but hey, that's why there's malpractice insurance...

Plane crashes caused by pilots and doctors with medical malpractice incidents cannot be compared. In the event an airline pilot causes a plane to crash - the pilot is committed to the outcome, he's in the plane. There's no equivalent in the medical field - inject the wrong drug in a patient and its a learning experience with possible negative side effects for the patient.

You can ask why that anesthesiologist didn't ask for help. Or you can ask why a clearly inexperienced anesthesiologist was assigned to perform a dangerous procedure with no supervision.

He was afraid of punishment for not knowing how to do his job.

Remove the punishment, create a systemic environment of improvement rather than individual blame, and he can easily speak up and say he's not prepared for the procedure and get help.

Without that, he's afraid of being fired or discovered as "inept," none of which will help him become less inept, which is the only goal that matters.

The question is not how we weed out inept doctors, but rather how we create a system that improves doctors systemically so that as few as possible are unqualified for as little time as possible. Thinking about this as an individual problem is unhelpful and inconsequential to any real change.

Actually, despite air travel being so safe, the primary cause of fatal airplane crashes is pilot error[1]. And I see no proof in those instances that the pilot isn't being blamed.

1.http://www.planecrashinfo.com/cause.htm

EDITED to add "fatal."

Just because the pilot is identified as the cause does not mean that anyone is blaming the pilot for being negligent. If a pilot sneezed while landing he's still the cause but that certainly doesn't make him negligent just because he made a mistake. Aviation (and computer science for that matter) is built around mitigating faults and mistakes at every level, that's the biggest part of why air travel is so safe is that it's designed around failure being acceptable. There are contingencies for anything that can foreseeably go wrong because in reality nothing is perfect, and certainly not the pilots.

We need to be treating doctors how we treat pilots.

I think that the acceptance of failure in certain domains is a problem of system design. Why shouldn't doctor, pilots, ship's captains, train conductors etc be held accountable (blamed) for mistakes? I don't agree with your statement that air travel is designed around the acceptance of failure meaning that pilots aren't culpable for their mistakes. Watch a NTSB hearing into a pilots failures, and there's plenty of blame assigned when appropriate. Doctors and other medical professionals should be similarly scrutinized and ostracized when they perform poorly.

The pilot is deemed at fault, but he usually isn't fired or heavily fined for the accident unless it was a flagrant violation (like he was trying to join the 410 club and core locked the engines). The passengers don't sue the pilots.

> but he usually isn't fired or heavily fined for the accident unless it was a flagrant violation

> passengers don't sue the pilots.

Well, a lot of the times they're all dead.

In fact, passengers are "all dead" in far fewer plane accidents than people tend to think (even if there are fatalities or injuries).

However, it looks like families are more eager to sue than actual victims...

Well, I was referring primarily (and in the referenced link) to fatal accidents. Usually it's a bit harsh to punish one of the most likely fatalities.

> Well, I was referring primarily (and in the referenced link) to fatal accidents. Usually it's a bit harsh to punish one of the most likely fatalities.

Aside from being harsh, its usually also, you know, impossible.

> And why, when it really is pilot error, does the pilot not get blamed?

Because he's dead? The airlines (the hospitals) do get blamed: http://www.usatoday.com/story/news/nation/2013/07/08/asiana-....

It's actually much easier to blame a dead pilot. Dead men mount no legal defenses.

Yes, but dying is basically the stiffest penalty for errors you can think of.

It certainly simplifies things, which is why perhaps the air travel question is so much easier to make a conclusion on.

"Well, if a pilot makes a mistake, we can't exactly punish him after the fact in most cases... so our normal primitive blame systems won't work here. Hmm, what can we do instead?"

And by George, we stumbled upon an actual way to improve the whole damn thing. Perhaps only by a trick of psychology that we couldn't apply blame and fool ourselves into thinking it was working.

Its relatively rare for a pilot to crash an airliner and be formally cleared by the NTSB. My understanding is that Capt. Chesley "Sully" Sullenberger was formally cleared by the NTSB after US Airway 1549, as there was no way that Capt. Sully could have avoided the birds, or returned to LaGuardia, when following appropriate procedures.

Its more common that the NTSB rule that "human factors" was one of the factors in an accident. This would include what is (often incorrectly) called "pilot error".

Pilots are often fired when they screw up and wreck the aircraft. The Captain of the Southwest 737 that crashed landed at LaGuardia was fired.

You can't go too far off the deep end and never place blame, but I think it's safe to say that the air travel system has considerable incentives for acting in favor of the system's improvement vs. in favor of individual blame/responsibility, and that's made it what it is today.

"Human factors" is another way of saying "this is something in the system that's error-prone that we haven't controlled yet, but maybe we should if the statistics say so."

> why are commercial airplanes so safe?

Because the planes fly themselves. The pilots are only there for the occasional emergency (where they often screw up because they're not used to actually having to fly the plane).

And in reality, the operation of an aircraft is not the principle point of failure. Rather, mechanical failures, weather, sabotage, etc. are much more easily eliminated by rigorous inspection and heuristics with multiple failure points.

The fact that commercial pilots (with numerous hours of experience, strict certification and simulator requirements and often, military backgrounds) are considered a principle risk point is only because the safety standards of all the other modes of failure have been so robustly reduced.

Exactly. If pilots (humans) cause errors, the safest system removes them from the equation as much as possible, except in the parts of the process where it would be more error-prone not to.

Point re: screwing up because the plane is normally flown for you; yes, but that's still safer overall without a doubt than optimizing for pilots doing much of the flying manually much of the time. Occasional emergencies are far better than predictable human error all the time.

I would imagine it's partly an emotional thing; it's hard to blame the pilot or think that the pilot was negligent, when clearly any error he makes can be fatal to him as well as the passengers.

Whereas if a doctor makes a mistake, nothing really happens to him. Thus it's easier to imagine he's just being negligent / doesn't care, which generates more anger than an honest mistake.

Forgetting blame, why don't pilots screw up as often?

How many pilots are in a cockpit?

How many anesthesiologists are in a surgery room?

There's your problem.

How costly is it to train a pilot? How costly is it to train an anesthesiologist? How costly is it to hire a pilot? How costly is it to hire an anesthesiologist?

How many customers can an anesthesiology team service per day? How many customers can a pilot team service per day?

Is this from Charles Duhig's or Gerd Gigerenzer's book? I remember reading somewhere this exact thing.

Most of the problems are systemic. Most people are probably not "clearly inept". You probably make dozens of mistakes in a week but, just by the nature of your job, nobody dies. Procedures, policies, and even technology should exist to prevent and mitigate mistakes because humans are deeply flawed.

Unfortunately the fact that the situation is life-and-death with huge liabilities that there really isn't significant effort to improve things. It's legally safer to continue practices that mostly work but are already standard than try something new.

Another industry faced systemic life-and-death problems like this. Air travel. They use extensive checklists that they run like human computers before every flight, from the smallest cessna to the largest airbus.

My mom, the NP, says doctors, as a group are too proud to ever use lists like that. She asked me how the "pride issue" was dealt with among pilots. I suggested that when it comes to airplanes, prideful pilots have a way of sorting themselves out one way or another.

Source: I'm a timid GA pilot who actually shouted "I'm a leaf on the wind" at my plane during my first solo...

There is a push to use 'pilot' checklists in medicine as tools for reducing human error!

Harvard surgeon Atul Gawande wrote a book on it:

http://atulgawande.com/book/the-checklist-manifesto/

http://www.amazon.com/Checklist-Manifesto-How-Things-Right/d...

I'm a timid GA pilot too and you're absolutely right.

Another big differentiator is the way accidents and liability is managed. When a pilot makes a mistake, they file an ASRS report and instead of being disciplined or hit with a huge legal liability they can be open and transparent while NASA and the FAA work to mitigate those accidents from happening in the future. Unfortunately, no such system exists in healthcare. Physicians and hospitals have every incentive to cover up mistakes and hope they don't reoccur instead of reporting them and ensuring that they dont.

This can't be overstated.

I'm not sure the risk profile in medicine is similar enough to expect the same magnitude of improvement that aviation got.

I am sure, however, that the systematic way of viewing errors as an opportunity for improvement and transparent evaluation, rather than an opportunity for blame throwing and obfuscation, was absolutely key to the success of ASRS and related.

The key takeaway isn't a checklist system, it it is the report and reviewing that arrived at what is on the checklist, and why.

Exactly. The checklist is actually a product of the solution - transparent reporting and rigorous analysis of those reports.

Unfortunately, the healthcare system is basically cargo-culting checklists without putting in place the underlying processes to get to the "right" checklist. Or perhaps a solution that is even better for healthcare than checklists.

There's significant argument in aviation community about how checklists should be designed as well.

I personally don't think an 8-page checklist (6 pages for normals) to fly a Piper Cherokee or Cessna 172 is the safest approach or most sensible operational tool. Many pilots seem to agree and make up their own checklists that they actually use with only the "killer items" and I think that probably increases safety; certainly it increases safety over the 8 page checklist that stays in the map pocket for the whole flight. Why doesn't the factory do that? Well, if they remove something from a checklist and a pilot comes to grief, they're thinking of how it will look in a courtroom. "No charge to add something to the list..."

You'd probably enjoy reading Checklist Manifesto by Dr Atul Gawande: http://amzn.to/1ZlTjoJ I read it years ago, but I seem to recall he did cover some of the processes and social aspects of checklist usage.

> When a pilot makes a mistake, they file an ASRS report and instead of being disciplined or hit with a huge legal liability they can be open and transparent while NASA and the FAA work to mitigate those accidents from happening in the future.

When a pilot "makes a mistake" that falls outside of the norms expected of the profession, and through that mistake causes injury or death to another person, they don't face the risk of losing their license and/or facing large legal liability?

That seems...improbable.

ASRS doesn't grant immunity to certificate actions or fines when an accident is involved. (Most deviations do not involve accidents, of course.)

GP was (presumably) comparing the situation of legal liability or discipline to the case of a medical practitioner self-reporting a mistake.

Yes, that is correct. I was a bit imprecise in my langauge but was referring to something like a case where a nurse is about to accidentally deliver a lethal misdose of medicine but then catches and rectifies the mistake before causing any harm. In healthcare, there is a strong incentive not to report that potential error whereas the ASRS system incentivizes reporting these kinds of "pre-accidents".

The issue is that medicine is not air travel. For example, if an airplane doesn't pass safety checks that plane doesn't fly. What is the equivalent in the ER? Furthermore, because of the way planes are engineered, (and because of the stringent safety standards), it is rarely the case that a mechanic has to make repairs on an already compromised vehicle, and even in that scenario most systems are designed to fail independently of other systems (i.e the fact that the electrical system is on the fritz doesn't change the way you inspect the propeller). In the medical realm, all of the systems interact. Reducing blood pressure may put undue stress on the kidneys, etc, so any hypothetical flow-chart is going to get really complicated really fast. The issue is partially pride, but it's also that it's not obvious that blindly adding checklists makes sense in every scenario.

If you have a chance I'd recommend reading The Checklist Manifesto [1]. There's data showing that checklists are effective in medical settings. The point of checklists is not to give you a flow-chart of exactly what to do. Their purpose is to minimize human error in routine-but-complex tasks while still allowing professionals the freedom to respond to irregular situations. Medicine, like flying a modern aircraft, has become so complex that even the best practitioners make errors in routine tasks at a surprising frequency, unless they have effective systems in place to prevent them.

[1] http://atulgawande.com/book/the-checklist-manifesto/

> What is the equivalent in the ER?

A checklist that the ER is correctly cleaned and equipped, that all equipment is in correct order and in the right place, connected, powered up and configured correctly. That all consumables are sufficient. That the correct combination of staff is present and sufficiently rested for the shift, and that lines of communication and escalation are open. A clear procedure for what happens if something isn't up to snuff, but the ER needs to operate anyway, especially making sure that everybody knows what doesn't work.

Clear checklists for all standard operations. Second pair of eyes and clear unambiguous concurrency from two different qualified members of staff before any medicine is administered or other non-trivial decision is made.

Etc etc etc.

I don't know if checklists can be used in every medical scenario, but they do have a significant positive effect in surgery [1].

1. http://www.nytimes.com/2009/01/20/health/20surgery.html?_r=0

I think checklists can be used in literally almost any scenario. They can prevent basic errors from occurring, and can save time on unnecessary redundancy. I'm not sure what the process would be for a medical procedure but it could be 1. Admit patient 2. Consult about problem 3. Decide effective treatment 4. Perform and run through checklist of that treatment. Each step would have it's own checklist that follows the patient and that can be seen and reviewed by other caregivers.

Checklists have made my life easier. For example, I got in to work today and if I hadn't made a checklist of my daily procedure I might be stuck on HN all day, but just looking over today's tasks I know what my first step and final steps look like so I can begin immediately upon entering the building. If I make a mistake I won't kill anyone, but if my life is in someone's hands I'd very much hope that they are running through a checklist built around the priority of keeping me alive first, and making me healthy second.

Interesting. I sat in on a few surgeries years ago when I thinking about going pre-med and I saw many checklists. There were counts of instruments used, rags used, checking and double checking all through the surgery. Maybe it was only these 2 older surgeons who did this, but it seemed pretty useful.

I distinctly remember having a hanging shoe rack like thing where each rag used was put to make counting easy. The count was off at the end of one of the surgeries so they went through it again, and it turned out one of the slots had 2 rags.

I was just in a hospital lab and saw a very prominent checklist on the wall for use with some procedures (but not what I was there for, so I didn't see whether they used the checklist in practice).

counting the instruments/sponges is not the kind of checklist they are referring to. They mean "I'm going to do an appendectomy: sterile instruments [X], wash hands[X], open instrument pack [X], apply iodine solution [X], make 4cm abdominal incision [X]....

Air travel also does not overwork their professionals as a rule, and have a clear policy of liability waving from parties that did not practice negligence or willful malpractice (just like the GP is asking for).

On the other hand, any accident carries a huge cost that companies can not wave away, because it is not set by tribunals.

I really don't know what factor it the most relevant here.

The sorting out is exactly the problem. A mistake in an aircraft, combined with some bad luck, leads to a crash. Everyone knows what that is and it triggers a government review.

In medicine, most mistakes are not obvious. A doctor who makes 5 or 10 times as many mistakes as average might be known to a few colleagues as "that guy who probably shouldn't have his license", but the vast majority of those won't even lead to malpractice cases, let alone clear-cut malpractice verdicts.

That said, we should be engaged in understanding and judging these cases, and figure out how to properly attribute deaths to preventable medical errors. It will be messy but the status quo is a large-scale ongoing disaster.

> A mistake in an aircraft, combined with some bad luck, leads to a crash.

Not always. You can actually push your luck pretty hard in an airplane and get away with it 99% of the time. There are pilots out there who are accidents waiting to happen.

Example where the pilots involved pushed their luck until that 1% chance finally killed them (and their passengers): http://fearoflanding.com/accidents/accident-reports/how-to-d...

The point is that there is almost never a single cause for any accident. It is almost always due to a confluence of multiple events. This should be expected. Engineers can be reasonably expected to think of the contingencies related to the system they are actively working on, but generally work under the assumption that the rest of the device is functioning normally. A nonfatal error in a normal situation can become fatal when combined with two or three other nonfatal conditions.

You'd think with the embarrassing history (as a profession) of being too prideful to do things like wash their hands there would be a bit more humility.

My father was a private pilot. Owned a plane (1996(?) Mooney Bravo, it really moved), so we flew around quite a bit. If I got in a small plane, and the guy I was flying with wasn't going through his checklist, I would get out.

This seems like a really good idea. Otherwise brilliant and highly trained humans make mistakes.

Any process or plan that requires everything going perfect as the only acceptable outcome seems like a terrible one.

Do you think that the air travel industry's roots in the military is a significant factor? I would guess so but I have no experience to back it up, just curious. (I'm asking this on the assumption that the US air travel industry has significant military roots, which I think is true but could be wrong?)

If that is a factor, looking at how the military does medicine might be instructive.

There are old pilots, and bold pilots, but not too many old, bold pilots...

I'd argue that there so many differences between air travel and medicine that it's not a useful comparison. A single passenger doesn't even interact with a Pilot, as just one example.

It's not difficult to see how the concept of following strict procedures and double-checking your work might be adapted to medicine.

There's really no use in arguing about an analogy. Focus on the point.

It sort of implies that there aren't strict procedures and double-checking in medicine. But there are. The problem is that medicine is more complicated with more people involved. You can't just say "hey, look in Engineering we can build bridges on time and under budget, why can't you do that with software?" The same issue here.

I understand the evidence indicates that checklists in medicine can make a significant improvement.

http://www.who.int/patientsafety/implementation/checklists/b...

"This study revealed an overall significant reduction in mortality and morbidity after implementation of the checklist."

There is significant effort to improve things in the right way, it's via a systemic approach called Lean Healthcare (that takes into account processes, statistics, culture, leadership, and management), and you can check out leaders like Mark Graban for more information.

http://www.leanblog.org/

https://twitter.com/markgraban

Fun fact: the current battle is that Lean has roots in Toyota's production system (which is mainly centered around the tenets of 'respect for people' and 'continuous improvement'), and certain recent opinion pieces have cited poorly-implemented Lean efforts as making hospitals more like production lines and dehumanizing healthcare. No True Scotsman, but still, it's a hard fight to change the whole system of care to be based in working systems of people and quality improvement, and any link in the chain missing can make the outcome fall.

They are certainly over worked and probably sleep deprived. I'd love it if they staffed more people...

Tragedy of the commons.

Literally every doctor will make a mistake that kills someone. Every one. Every doctor will kill someone. And every mistake that causes someone to die will have been preventable.

An eye for an eye leaves the whole world blind. Harsh punishment for the inevitable doesn't result in positive outcomes. Quite the opposite. It leads to death and suffering.

I strongly, strongly recommend reading this: http://www.newstatesman.com/2014/05/how-mistakes-can-save-li...

There is a big difference between "malpractice" and "mistakes". A mistake that occurs despite the exercise of the degree of care expected in the profession is not malpractice.

But yet our current system of malpractice is directly responsible for inhibiting systems that would help prevent mistakes.

An anesthesiologist in the US is the highest paid profession, period. They earn more than surgeons. They should be responsible and liable for their mistakes.

My family friend was top cardiologist in the Bay Area... His grandson became an anesthesiologist - and he paid his grandsons medical school bills with the edict for him to pay it forward.

The kid graduated at ~22 with an initial base salary of $350k

---

I work in health tech. I designed and built many of the Bay Area hospitals you might be familiar with. I can't even break 200k

He completed a 4-year undergraduate degree, medical school, and residency by age 22?

Hmm, that was my recollection - but I could be wrong. I knew he was quite young though... so that number may be inaccurate.

My brother, for example, had to do the following:

EDUCATION

1988 Bachelor of Science, Biology, U.S. Air Force Academy, Colorado Springs, Colo.

1992 Doctor of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md.

1995 Family Practice Residency (Staff Physician), David Grant Medical Center, Travis AFB, Calif.

1996 Aerospace Medicine Primary Course (Flight Surgeon Wings), U.S. Air Force School of Aerospace Medicine, Brooks Air Force Base, Texas

2001 Air Command and Staff College, by correspondence

2006 Air War College, by correspondence

2008 Occupational Medicine Residency and Master of Science, Environmental Health, University of Cincinnati, Cincinnati

Hmm. I think it's pretty well-known that medical personnel tend to be overworked and stressed out. Is that perhaps because there's a shortage of qualified personnel? If so, and if people are pushed out of the industry because they made a mistake while stressed and sleep-deprived because there aren't enough people in the industry, it seems that that could lead to a continuing decline in the quality of care.

>I understand that we don't want to scare people in health care out of the field, but those who are clearly inept certainly should be afraid to keep working.

Actually, it doesn't seem like you do understand. Mistakes happen. Do you make them? Are you "inept"? Should you be fired or should your company face massive financial consequences for them, regardless of negligence? It's absurd.

I make mistakes all of the time and most of the time I don't even think about it. But there are times where I understand that I am doing something that, if I make an error, would have a significant negative effect on others. At those times I check and double-check my work and I strive to avoid making an error. I may even have someone check my work, just to be sure.

In my opinion, this is difference that prevents be from being "inept".

As others have mentioned, checklists help in this regard. I am sure that there are other ways to mitigate the negative effects if a mistake is made. These certainly should be embraced and used extensively. If I make a mistake, people lose data; if the anesthesiologist makes an error, there is much much more at stake.

In regards to this particular story, I am having a very hard time with the attitude of "well, even an anesthesiologist makes a mistake". Unlike many situations in a hospital where something like a checklist would make a big difference, there are already procedures in place that need to be followed to minimize and in many cases prevent just this kind of error. In my opinion, it does not sound like those procedures were followed.

There is significant variance in how many mistakes different doctors make, though.

Because the solution isn't to punish people who make mistakes, it's to improve processes to the point where mistakes are unable (or it at least takes more than a single doctor misreading a drug or miscalculating a dosage amount) to occur.

Not being held monetarily liable for damages doesn't necessarily mean you still have a job.

Statistics on patient outcomes are rarely even tracked at hospitals. Even the administrators don't know which surgeons have the most complications, and the bad doctors are at least an order of magnitude worse than the good ones according to some studies which have attempted to track outcomes.

That's just not true. You will have a hard time keeping and finding a job if you can't adequately explain any open malpractice suits.

Many patients have adverse outcomes which do not result in malpractice suits; one example of a surgical issue that should be tracked is artificial joint replacement surgery. There are many people who are put under the knife multiple times due to surgical errors.

But the risk of being held monetarily liable for damages might mean people stop doing work they shouldn't before damage is done.

Of course, this relies on people correctly assessing their likelihood of making a mistake.

Giving incorrect medicine is borderline to criminal negligence. If this had happened in India, the said doctor's license to practice would have been revoked. I'm astounded how come a developed country like USA can tolerate this!

Punishing doctors for making human errors will not result in perfection. It will result in doctors hiding and denying their mistakes.

A better approach is to acknowledge that people will make mistakes, and work with doctors to identify why the mistakes are made and how procedures can be altered to prevent those mistakes in the future. This is how it is done in the aviation business. Punishment will not work.

>Punishing doctors for making human errors will not result in perfection.

Yeah but it's not just about punishment. A small portion of medical professionals account for a disproportionately large amount of all medical malpractice claims. The worst 1% accounted for a third of all malpractice claims according to a recent study. I agree that we shouldn't be cracking down on individual mistakes, but we certainly do need to crack down on doctors who are significantly more likely to harm patients in the future.

http://www.medscape.com/viewarticle/857885

> The US needs a system where victims of malpractice get compensated but the doctors or hospitals are not necessarily held liable (unless it's gross negligence).

Malpractice, by definition, is action falling below the standard of care set by the profession. If malpractice occurs, "improving procedures" is not necessary, because the harm results from failing to meet the the procedural norms of the profession.

Improving procedures is called for when adverse outcomes result from problems that are not malpractice.

The problem is that most people don't realize that its relatively easy to for a patient (or their lawyer) to formally notify the state medical board of a complaint. Even billing issues are sometimes investigated by the state board.

For smaller claims, the doctor may settle the case for less than the threshold for listing in the public provider record. The National Practitioner Data Bank [0] is more strict in what gets recorded and doctors can't cover it up as easily.

Doctors and hospitals might try and deny the issue but in some states, if the complaint is substantiated (but the doctor is not formally reprimanded) it still gets noted in the National Practitioner Data Bank. This will be checked by any prospective employers in the future.

In aviation, there is a philosophy that its better to admit a mistake, and learn from it. This is known as the "Asoh Defense" [1]. Doctors could learn a lot from Capt. Asoh. The NASA Aviation Safety Reporting System [2] is for aviators to self-report a safety issue without fear of being violated by the FAA for their admission. There is even an immunity policy for non-deliberate pilot errors.

[0] https://en.wikipedia.org/wiki/National_Practitioner_Data_Ban...

[1] https://en.wikipedia.org/wiki/Japan_Airlines_Flight_2#The_.2...

[2] https://en.wikipedia.org/wiki/Aviation_Safety_Reporting_Syst...

>In my view there should be a nationwide malpractice insurance pool and the medical associations should push for better quality standards within their ranks.

It's an interesting idea, but who pays for it? Taxpayers? Have fun with that politically. The doctors? You'll drive out those on the margins of "doctor or other career". We here in Canada already have a massive doctor shortage everywhere but major cities, so that's a problem.

I agree this would be politically problematic, but not for the reason you provide. Doctors already spend tons of money on private malpractice insurance; this national pool would just be a different administration of the same insurance payments. In fact, the pool could be effected with different regulation of the existing private insurers and changes to malpractice law. And if done right, it could plausibly lower overall insurance fee burden on doctors.

> Doctors already spend tons of money on private malpractice insurance

In Ontario Canada, the government reimburses most of their malpractice insurance fees. As a result, they're currently paying 1986 rates:

http://www.health.gov.on.ca/en/pro/programs/ohip/mlp/announc...

And how is Ontario doing, generally, with regards to the number of doctors: patients?

I lived there, and know doctors personally. The answer is terrible.

> The doctors? You'll drive out those on the margins of "doctor or other career".

Would that really happen? I know in Australia doctors pay for their own indemnification cover. (http://www.doctorconnect.gov.au/internet/otd/publishing.nsf/...)

>Would that really happen?

Why would it not?

At the margins you make decisions based on a variety of factors. If X costs more than Y, you choose Y. I don't know if, practically, that means 1 potential doctor or 1000 decides not to go to med school. But in a world where we are already short doctors, even the former is "too many".

Because nobody knows X, Y, and other values before they start. It's years of training. Budgets change, rules change, people move to other regions, ...

When you're trying to decide what to do before you start studies, realistically you can't predict your finances and earnings in 10 years. There are some trends you can look at, but that's just one component. Even then it makes more sense in private sector than one funded in very creative and politically dependent ways.

In the US, at least, "doctor shortages" are caused by insufficient capacity upstream. Some combination of not enough medical schools and not enough licenses issued. Which happens because existing doctors are not incentivized to flood their field with more doctors who will then compete with them and lower prices.

That seems like it would raise a serious issue of moral hazard.

Not if you pull the license of repeat offenders. F* up once? It happens, medicine is hard (EDIT: Document what went wrong, put a process in place so it doesn't happen again, issue a notice to all other medical facilities offering related procedures). F* up again? You're out of a job.

No different then how the FAA and the NTSB operate.

EDIT: Medicine can be made safer through the same processes used to ensure air travel is the safest transport method in the world. It can't be as safe, but we can do better.

I disagree entirely. People are known to be fallible. Processes prevent things from accidentally happening. In areas where the life of someone or a large organizational failure hangs in the balance of an action, that action should be wrapped in process to ensure it's correct execution, with fail-safe mechanisms put in place.

Further, these systems should be audited on a regular basis to ensure compliance.

Only in the case of purposeful or willful action or absolute gross negligence or being found unfit for duty (mentally or physically) should someone have their life ruined by removing their status/job/career path.

> Only in the case of purposeful or willful action or absolute gross negligence or being found unfit for duty (mentally or physically) should someone have their life ruined by removing their status/job/career path.

Yes, and that "loss of job" or professional de-registration means many doctors do not seek help for mental illness. That might be one reason the suicide rate in doctors is so high. (Knowledge of effective methods; access to means and methods; and work stress are other reasons).

In the UK Louis Appleby (who does a lot around suicide prevention in England) is doing some work with the General Medical Council (one of the regulators of doctors) around suicide prevention for doctors who are being investigated by GMC during fitness to practice. http://www.gmc-uk.org/Suicide_review___Final_Draft_Proposals...

It also means doctors are more risky for patients. We need a way for doctors to seek help that protects them and their patients.

>Only in the case of purposeful or willful action or absolute gross negligence or being found unfit for duty (mentally or physically) should someone have their life ruined by removing their status/job/career path.

Seriously? Losing your job hardly means that your life is ruined.

More than any other occupation, doctors spend a majority of their young adult lives learning about medicine and everything related to it. By removing them of their license to practice that, you've essentially stripped them of their life's purpose.

They could still work as a research physician, or work for medical device manufacturer or drug company.

If they are really bad at clinical practice, they might get a job on a TV show. Psychologist Dr Phil McGraw [0] stopped practicing after an investigation, and ended up as a talk show host.

[0] https://en.wikipedia.org/wiki/Phil_McGraw

I don't think any of the doctors I've met would consider medicine their life's purpose.

Most people seem to have much more mundane goals.

So you're advocating forgiving the educational loans of doctors who lose their license? Or do you leave them massively in debt, without the (relatively) lucrative profession they had assumed would allow them to pay off that debt?

> So you're advocating forgiving the educational loans of doctors who lose their license?

Yes, although the better solution is to subsidize the education of medical providers directly, instead of burdening them with massive loans that take decades to repay. That's an argument for another thread though.

I'm not advocating anything.

I'm just saying that losing your job/career/whatever doesn't equal a ruined life.

Everybody makes serious errors from time to time. At least me and everybody I know. You should be able to admit them without losing your career or being ruined. Obviously if somebody makes a lot more errors than others he should lose his job.

My point is that the current system encourages denial and cover up. It doesn't encourage improvement.

I don't think anyone wants to kill their patients. So what's the adverse scenario here? Doctors being paid per-operation and skipping safety steps? Doctors wanting to make a name for themselves and taking on ambitious surgeries that shouldn't be done? It seems like you could cover those cases without making individual doctors massively liable for essentially random mistakes.

I would describe being fired if you f* up again as being held liable. Liability doesn't have to be monetary.

I think the above example illustrates why a malpractice insurance pool might be a bad idea. The one who makes the mistake must pay up. This will ensure those who make less mistakes will succeed at faster rate.

Do you also think the doctor who brilliantly saves someone's life should be rewarded the lifetime earnings of the person saved? Introduce "Value Based Pricing" in healthcare?

I think medical errors should be (financially and professionally) punished, but only up to some reasonable amount, aimed at the future and on damage to society, not on compensating the victim (which you can't really anyway).

If you want to be compensated in full for everything that might happen to you, then get personal insurance.

Getting insurance against i.e. disability is a better approach anyway, as this also covers cases where it is caused by no-one, by yourself or just by bad luck.

It seems strange that personal insurance is rarely mentioned as a (partial) solution for these situations in the US. Maybe because collective/social solutions have a bad reputation?

Value of something does not depend on the what the provider is providing but what are the alternatives for the consumers.

A brilliant doctor who saves someone's life should be awarded lifetime earnings of the person if the alternative is dying. Clearly people already spend a fortune getting state of art medical care for the same reason. Value depends on alternatives and not on what a doctor is doing.

Also a lot of medical errors are because doctors can get away with it or they have simply too high egos to go through a checklist. Penalizing doctors is important for their mistakes.

But I do agree to your point that there is no clear way of determining what is good compensation. Sometimes death destroys one life, disability destroys many lives. I think the jury must determine what the compensation is.

Social Security actually has some provision for disability. So we have a collective social system in place (I guess the payments aren't necessarily high enough to call it a solution).

I think people don't carry additional private policies mostly because they are spending most of their budget on other things and are somewhat short sighted.

https://www.ssa.gov/disability/

That's why you need to set up incentives in such a way that the insurance company charges doctors who engage in risky behaviour more.

This way, you directly encourage good behaviour via decreased cost, and remove the element of (bad) luck for the doctor.

Not sure if there is a need for a national insurance pool or not -- but you are quite right. If the issue is getting procedures right, then insurers should have to pay up so they have an incentive to crack down on procedures.

However, I think the tort caps exist because when big bad insurance companies are involved, courts decide to play Santa and inflate damages to huge amounts. Caps are a crude way of getting around the problem though.

how does the pool get funded? You can have some really perverse incentives depending on how its funded...

Can you provide evidence for this claim? I worked in doctors offices as a consultant for 18 months and never noticed doctors spending time "covering up mistakes". They did spend lots of time documenting their analysis and work though.

My girlfriend had a nerve cut during knee surgery. The doctor did not acknowledge that error but waffled around. Only after consultation with two more surgeons it became clear that this was clearly an avoidable mistake.