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/
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.
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
[1] http://smile.amazon.com/Checklist-Manifesto-How-Things-Right...
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).
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.
The episode is called How To Avoid Mistakes In Surgery for those interested.
Available at torrent sites near you!
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.
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.
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.)
It's an argument based on a made up or uncited statistic.
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.
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.
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...
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?
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.
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.
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-...
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.
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.
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.
> 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.
It's impossible in medicine because we're not at that level yet.
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&...
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-...
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
[3] http://www.nature.com/news/hospital-checklists-are-meant-to-...
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.
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.
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
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-...
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.
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.
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.
Thanks in part to artificial caps by the AMA.
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.