Comparisons between aviation safety and patient safety should only go so far...

Are medical errors really the “third leading cause of death”?

There are many apt comparisons to be made between aviation and healthcare.  As a (lapsed) instrument-rated pilot, I may have some insight about the system in which planes function on a daily basis in the United States.  It is truly an impressive system which is (to paraphrase Don Berwick) well-designed to achieve the safety results that it does.  However, the kind of statement that some healthcare safety leaders make in which they compare the raw mortality rates of acute hospital care and airline fatal accident rates is not so apt.  Let me see if I can explain why. 

First, just to be clear, I have no illusions that we have a long way to go in optimizing the safety of medical care.  I am a vocal advocate for transparent safety culture and adequate resource allocation for patient, staff and family safety.  But, we don’t do anyone any favors by sensationalizing and mis-characterizing where the problems are. 

First, remember that in these aviation/medicine metaphors, airplanes are patients and “flying” is providing medical care. The thing is that the commercial aircraft that fly every day are required to regularly demonstrate that the performance of their critical systems meets or exceeds strict standards.  If a radio, compressor blade, hydraulic line, or pressurization fan is not operating within a very narrow performance range the simply plane does not fly.  With our fellow humans we of course do not have this luxury.  We don’t have too many replacement parts – and they have their own problems.  When we admit a 72 year old with heart failure, COPD and CRD we must do our best to keep them “flying” despite multiple marginally functioning critical systems. 

Imagine flying a plane in which engine power is only 50% of normal and control surfaces do not respond to input from the pilot reliably and where the radio is not always capable of receiving ground communications that are understandable to the pilots and crew.  Also, the fuel tank is leaking.  BUT you HAVE TO FLY it no matter how many systems are semi or non-functional.  At this point, you can’t simply follow the “standard procedures”, all of these accumulated problems make this plane a unique, untested system.  At some point, in the process of trying to improvise to keep this plane in the air, you may do something that results in an accident.  However, it was really, “an accident waiting to happen”.  Almost unavoidable for the brave souls who were trying their best to keep the plane flying.  This is what taking care of someone with critical illnesses is like.  It is NOT like flying a 737 that has had each and every critical system brought to 6-sigma levels of performance before it is allowed out of the hanger.

I don’t have access to the primary data that drives estimates of hospital mortality from adverse events, but if you actually reviewed the charts, how many of the “medical errors” occurred in very sick patients with multiple system disease?  Massive trauma?  A pain medicine overdose in a healthy 37 y/o in the hospital for a hysterectomy is not the same as a pain medicine overdose in a 78 year old with CAD and multiple myeloma who is admitted with a hip fracture.  We should continue to learn whatever we can from the praiseworthy culture of safety and performance of our airplanes and pilots. But let’s not take the metaphor where it doesn’t fit and let’s not assume that every very sick person who dies in a hospital from an adverse event is an example of a truly preventable death rather than dedicated clinicians trying their best to keep someone alive and eventually failing. 

ICU patient.  Every patient is a unique, uncharacterized system.  NOT the same as a 737. 

ICU patient.  Every patient is a unique, uncharacterized system.  NOT the same as a 737. 

Older Airline Cockpit.  EVERY one looks exactly the same.  Every control is in exactly the same place and responds exactly (within 1%) the same way to inputs. 

Older Airline Cockpit.  EVERY one looks exactly the same.  Every control is in exactly the same place and responds exactly (within 1%) the same way to inputs. 

A bit more of a very rough and simplistic vision of health care reform

1) No one involved in the direct clinical care of patients likes the health-care system right now.  I live in China and work in a Chinese public hospital and I can tell you that the feelings of doctors, nurses, patients and hospital leaders is 80% congruent with what we are experiencing in the US! 

2) There are many contributing factors, but I would argue that the fundamental illness is a problem of doctors needing to see too many patients in order to generate what they consider to be fair compensation for their years of training,the daily challenges of their jobs and comparisons with their professional peers.  This makes doctors unhappy, patients unhappy and produces huge amounts of unneccessary (and harmful) medical care. 

3) Most estimates suggest that somewhere between 20-40% of all medical resource use is unnecessary – waste.  BUT doctors and hospitals currently have little to no incentives to curtail waste – because the current reimbursement systems only rewards production.  Sure, there are some programs tinkering at the edges of the envelope to reward “value”, but they are not making much of a difference right now. 

4) The reimbursement structure for health care is so far and away NOT a free market that it seems quite irrational to pretend otherwise.  Most doctors work in a “piecework” economy and the price for each piece of work(patient encounter, procedure) is almost completely determined by CMS, and RUC.  Yes, there are a few intrepid souls who have moved to a completely insurance-independent model and I applaud them, but that is not the reality for most of us (again, essentially the same situation here in China).  So, let’s not pretend otherwise:  we are largely determining the incomes of doctors by setting these prices.  If we are determining the incomes of doctors, shouldn’t we have a conversation about what those incomes “should” be? 

5)Imagine you could do the following:

a) eliminate most of the overtesting and overtreatment – the physicians net productivity (in terms of health care VALUE) would stay the same, but the number of patients/office visits/procedures/tests ordered would drop by 30%.  The amount of support staff, time spent on the phone, tests reviewed, time in the hospital, etc would also drop similarly. 

b) find a way to maintain the income of physicians in this scenario.  We would be “producing” the same amount of value after all.  This probably means a largely fixed salary (based on that conversation we should be having?) with a modest “balanced scorecard” of potential incentives (maybe 20% at most)  including quality, patient experience, productivity, teaching/training, etc. 

I am not proposing any technology “moon shots” here.  Doctors in the audience:  would you be willing to trade in your lottery ticket for a 7-figure income for a decent 6 figure income with a job that is fulfilling and sustainable?

One year in Guangzhou!

Happy new year!!  We are starting year 2 in Guangzhou.  My family deserves credit for putting up with many harships and frustrations - even as we enjoy the overall good QOL in Guangzhou. 

Trump and North Korea:   It’s like watching a train crash in slow motion.  From “over here” next to North Korea but in a country with some influence and perhaps some understanding of what is really going on there, I imagine it is easier to see my own country at risk.  At the very least, North Korea is an enormous distraction.  Diverting the attention of our military and parts of our government.  Using much of our geopolitical influence to ask everyone else to try and reign in this tiny country. 

The China strategy seems to be to ignore the internal politics of all countries equally.  They are interested in trade and an opportunity to export their ability to design and deliver huge infrastructure projects – now that the domestic economy can no longer be poweredthis way.  They are willing and able to invest billions in infrastructure projects that enable local economic development which naturally orients toward the country and the people who brought them the railroad, the port, or the refinery. 

I am not finished deciding how I feel about this somewhat “amoral” approach to international relations.  “The Chinese Way” has brought opportunity to millions of people in places we can’t seem to penetrate.  At the same time, they steadfastly refuse to get involved in the judgement of unsavory leaders and regimes.  Are we doing so much better?  The US tries to pick “winners” and makes a big fuss over “defending liberty” and protecting human rights.  Those are worthy causes to be sure, but on balance over the past 20 years, have we succeeded in advancing those causes?  Are people in Columbia, Iraq, and Afghanistan better off?  What helps more:  moral leadership or economic development?

Healthcare: On the domestic, medical front there is another train crash that I am watching in slow motion:  the Chinese public health care system.  I have outlined some of the struggles in previous posts.  None of them are unfamiliar to us in the US.  Overtesting, overtreatment, lack of trust, poor health literacy, worship of technology, demoralized doctors and nurses, nearly absent primary care.  My challenge is to teach what I can, without getting too preachy and losing my audience.  I know some very wise and knowledgeable people who insist that changing the costly behavior of doctors (and it really is mostly in our purvue) is not all about money – but really, let’s call a spade a spade.  I am all for professionalism, satisfaction, joy, etc, but how many people reading this would choose to cut their income by 20-30%, while creating difficult conversations with patients who want technology and their problem fixed NOW and watch the guy or girl in the next office suite doing well operating on anything that moves (and has insurance) while the hospital fawns all over them?

Doctors are highly trained professionals who go to school and train for a decade or more after college, work long hours and sometimes (or always, if you work, for example, in the ED, OR, oncology ward, Labor and Delivery) cope with very upset people in very stressful situations.  They expect to earn enough to keep their families solidly in the upper middle class.  That doesn’t mean exactly the same thing to everyone, but I think most feel they should be able to live in a comfortable community with access to good schools when their kids are young, be able to afford to send their kids to college, and retire at a reasonable age.  They expect comparable earnings to lawyers who also work hard and have challenging work interactions at times.  In the news we see the highly successful folks who work in finance and who grow businesses from scratch to billion dollar exits.  We think everyone with an MBA makes that kind of money. 

Another part of the puzzle is the payment system.  Basically, in the US, CMS and the AMA’s RUC sets payments for 95% of the services for 95% of patients.  Yet, we continue to insist that medicine is a “free market”.  Huh? What kind of free market has fixed payments? 

If a doctor feels entitled to something between 200-300k/year (pre-tax) then they will figure out how many procedures and office visits it takes to get them near their goal.  Note that this is not hugely different between those in true private practice and those who are “employed” by larger organizations.   Most of these “employed” docs have a “salary” that is fairly tightly tied to productivity.  This reality is easy to spot.  Studies show that the number of procedures done in a community is largely dependent on the number of doctors who provide that procedure.  If you reduce the reimbursement for a service, doctors respond by doing more of them and spending less time on each one. 

Anyway, this same incentive system and expectation system is driving the same trend to joyless, thoughtless, expensive, overtesting and overtreatment here in China.  But I believe we need to acknowledge that we can’t fix the process of medical services and then expect doctors and hospitals to behave as if prices are a function of equilibrium in a free market. 

Enough pontificating for now.  Stay safe everyone. 

The new old year ended on a sad note.  Daniel our 16 year cat finally went to that big, clean, litterbox in the sky.  Loren adopted him from our back porch after he showed up there yowling with a torn ear, herpes bronchitis and an eye infection.  He had lost another fight and clearly was't cut out for a life on the street.  Conveniently for her, she was pregnant (!) so I had to take care of Daniel for the first several weeks.  He was affectionate, demanding and not MENSA material, but he was always with us and always purred louder than he yowled.  He got along with all of our other human and four-legged family members.  He was famously beloved by our white ferret Pinky - we think Pinky thought he was a relative.  Anyway, we will miss you Daniel. 

The new old year ended on a sad note.  Daniel our 16 year cat finally went to that big, clean, litterbox in the sky.  Loren adopted him from our back porch after he showed up there yowling with a torn ear, herpes bronchitis and an eye infection.  He had lost another fight and clearly was't cut out for a life on the street.  Conveniently for her, she was pregnant (!) so I had to take care of Daniel for the first several weeks.  He was affectionate, demanding and not MENSA material, but he was always with us and always purred louder than he yowled.  He got along with all of our other human and four-legged family members.  He was famously beloved by our white ferret Pinky - we think Pinky thought he was a relative.  Anyway, we will miss you Daniel. 

OK, any guesses on this food item?  I think of myself as someone who will try almost anything and even like the taste of most things.  I have had bugs and worms and pig fallopian tubes in China.  None were inedible and some were good.  These however, will not be on my list to try again.  I will give you a hint:  they are not bugs or worms, and they are animal, not vegetable. 

OK, any guesses on this food item?  I think of myself as someone who will try almost anything and even like the taste of most things.  I have had bugs and worms and pig fallopian tubes in China.  None were inedible and some were good.  These however, will not be on my list to try again.  I will give you a hint:  they are not bugs or worms, and they are animal, not vegetable. 

I think I may have mentioned before how cool the snails are in Guangzhou.  I love how this one picked up some grass and used it to adorn his tail. 

I think I may have mentioned before how cool the snails are in Guangzhou.  I love how this one picked up some grass and used it to adorn his tail.