Volume 1, Number 4, January 2001
MUSINGS ABOUT 21ST CENTURY MEDICINE
Leonard Klinghoffer, M.D. (PBK Pennsylvania 1949)
While reading my morning newspaper a few weeks ago, I came across a tiny article in a reprint of page one of a newspaper dated February, 1945. A Pennsylvania state senator, whose 8 year old son died following an operation to remove a birthmark, introduced a bill into the legislature that would require a thorough physical examination of any patient about to undergo a surgical operation. He asserted that no temperature reading, blood pressure or other examination was made before his son's operation. My, what a long way we have come since 1945, and what a longer way since the beginning of the 20th century.
Since the institution of Medicare and the development of various third parties including HMO's, the doctor-patient relationship has suffered and the cost of medical care has risen. There has been a rise in malpractice claims and an increase in liability premiums. Would that 1945 Pennsylvania senator's son still be alive if his operation had been performed in today's medical atmosphere, and if not, what would that senator's behavior be today? I can think of several possible scenarios, all ugly.
As medical treatment has expanded, the delivery of medical care has
become an industry requiring supervision and regulation. As early as 1910, Dr.
Ernest Codman proposed the "End result system of hospital standardization" in
which a hospital would track every patient it treated long enough to determine whether the
treatment was effective. If the treatment was not effective, the hospital would attempt to
determine why so that similar cases could be treated successfully in the future. In 1917
Codman alerted the medical profession to errors, and for his efforts he was labeled the
"Improper Bostonian". At about that time, the American College of Surgeons was
founded by a colleague of Dr. Codman and the " End Result" System became the
stated objective of the College. Minimum standards for hospitals were developed and
on-site inspections of hospitals were begun.
Standards of care improved over time and whereas only 89 of 692 hospitals were approved
initially, by 1950 more than 3200 hospitals achieved approval. In 1951, the American
College of Physicians, the American Hospital
Association, and the Canadian Medical Association joined with the American College of
Surgeons to create the Joint Commission on Accreditation of Hospitals. Since then various
standards have been established for the accreditation of psychiatric facilities,
ambulatory health care, managed care, rural hospitals and laboratories. In 1997, the
American Medical Association together with business organizations formed the National
Patient Safety Foundation.
Medical errors and multiple initiatives proposed to reduce them have received a good deal
of attention lately, and health care providers and their associated institutions cannot
afford to ignore those errors. In June, 1998, the Institute of Medicine Quality of Health
Care in America Committee was formed, and in November, 1999, it released its report,
"To Err is Human: Building a Safer Health System." The report outlined the
magnitude of medical errors in the U.S. and proposed a set of solutions. It
estimated that somewhere between 44,000 and 98,000 Americans die each year as a
result of medical errors, exceeding deaths caused by Aids, motor vehicle accidents or
breast cancer. Further, it offered a combination of recommendations.
The report suggested legislation at the Federal level to create a Center for Patient
Safety to set national goals, track the progress toward those goals and issue reports on
patient safety. It recommended the establishment of a nationwide mandatory reporting
system and the establishment of additional patient safety programs within health care
organizations such as standardization of equipment, supplies and procedures, and enhanced
patient safety programs at the delivery level. It also called for the development of
licensing and accreditation agencies of stronger patient safety standards for health care
organizations. It suggested, for example, that the Food and Drug Administration should
require drug companies to design drug labels to maximize safety and to eliminate
look-alike and sound-alike drug names.
The most controversial of the report's recommendations is the call for a mandatory
reporting system. Because of the concern about increased medical malpractice liability
exposure, the committee suggested a two tiered approach: mandatory reporting of serious
errors and voluntary reporting of less serious errors with legal protection against public
disclosure. The serious errors are those causing death or serious patient injury and would
be the ones most likely to become involved in litigation anyway.
Further controversy erupted after President Clinton's announcement of his approach to
medical errors. Among the President's reforms is a mandatory reporting program, but the official who is leading
federal efforts to reduce medical errors, the Director of the Agency for Health Care
Research and Quality, told Congress that he had no firm evidence that
mandatory reporting as proposed by the President increased the safety of patients or
reduced the number of mistakes in states where it had been tried. He admitted however that
there was one bit of evidence from New York state suggesting that such reporting could
improve the quality of care. Some expressed fear that mandatory public disclosure of
errors that cause death or serious injury will subject doctors and hospitals to ruinous
lawsuits, driving doctors to hide their mistakes and drive underground the very
information needed to improve safety. It seems clear that reliance on self reporting in a
punitive atmosphere is not practical. Is legislation appropriate to protect information in
order to lessen the fear of possible litigation, and is some court reform perhaps in
order?
In 1945 when that Pennsylvania State Senator introduced his bill, there was no Medicare,
the term "HMO" had not yet been coined, and there was little to interfere with
the relationship between the doctor and the patient. Today, medicine-the art, and health
care-the business, seem to be at odds with each other. In 1997 Congress passed drastic
cuts to Medicare, states' reimbursement to hospitals for the care of the indigent is
claimed to be inadequate, managed care companies are tight fisted and do not reimburse
hospitals for their full expenses, and hospitals must struggle and develop cost-cutting
ways to become more efficient. For fear of losing their competitive edge, many large
hospitals went on a rampage of buying primary care physician's practices, but after the
frenzy subsided and the decreased reimbursements began to take their toll, many of those
physicians were asked to leave or take drastic cuts in salary. On the other hand, private
practice physicians, who nowadays rarely treat patients who are themselves responsible for
the cost of their medical care, must deal with decreased reimbursement from Medicare and
HMO's, pressure to get patients out of the hospital sooner, and repeated inability
to order x-rays or blood tests or even the medicine of choice, all for the purposes of
cost cutting.
Physicians in private practice must now deal with more and more time consuming paper work,
and those whose practices have been bought often complain of increased patient load and
compromised quality care.
To add to the above, of course, is the malpractice problem. Not only
are physicians being sued, but we are now seeing more and more attempts to sue HMO's for
failing to authorize payment for treatment and most recently for giving bonuses to doctors
who hold down costs. Malpractice is now the largest growth aspect of the medical industry
with the amount of the awards and the number of suits increasing on a daily basis.
Third party payers and the government are being increasingly parsimonious in their support
of the medical education system. In addition, medical research, which was the recipient of
huge grants and reimbursements for many years, is on the decline, and the bulk of today's
research is funded privately or by industry. This raises the conflict of interest issues
involving doctor scientists who have a personal financial stake in the company funding
their work. How can we ensure that the doctor scientist will remain objective?
So even though we are in a time of unprecedented economic growth and the greatest
acceleration of technological growth in the history of the human race, we are paying a high price in the loss of
human values. As advocates for their patients in the health care system, doctors are
constantly forced to strike a balance between quality and cost. It seems that the primary
motivation to most behavior is wealth . Let us hope that we can all develop a greater
sense of caring for our fellow humans, that the medical profession can regain the
confidence of its patients and society and that we can somehow take greater control of the
profit seekers. Appropriate health care reform seems to be on the way and if that can be
followed by some sort of tort reform, we may see the beginning of a gradual elimination of
the many ills that plague the medical industry. Hopefully, some of this will be
accomplished and we can reap the benefits of the remarkable advances that have occurred
since that Pennsylvania senator's proposal in 1945.
