People are fallible, but health systems need not be

When I heard in October that Superstorm Sandy was projected to make landfall somewhere in the vicinity of DC and Maryland, I prepared for the worst. I stocked up on non-perishable goods and evacuated to higher ground. (The rest of my family was already coincidentally out of town and harm’s way.)

I put fresh batteries into two flashlights and installed a flashlight app on my smartphone for good measure. Although I didn’t give it much thought at the time, I assumed that hospitals in Sandy’s path were taking similar precautions – stocking medical supplies, testing backup generators and so forth. So when a power failure at NYU Langone Medical Center forced an evacuation of the entire hospital, with heart-stopping scenes of neonatal ICU nurses cradling respirator-dependent newborns down several flights of stairs to safety, I couldn’t understand what had happened. How had they not been better prepared? Had NYU administrators been the equivalent of residents of low-lying coastal areas who ignored repeated warnings and defied evacuation orders?

As it turned out, NYU did a lot of things right before the storm. According to an article in ProPublica, after the scare of last year’s Hurricane Irene, the hospital moved its emergency generators from street level to the rooftop and thoroughly waterproofed the generators’ fuel pumps. Unfortunately, they neglected to relocate or protect the electricity distribution circuits, which remained in the basement and were quickly disabled by the flooding. As in many areas of health care, doing everything “almost right” wasn’t good enough.

All people are fallible, and health professionals no less so than others. But medicine is usually less forgiving of simple mistakes. A technically perfect surgery is a disaster because it was performed on the wrong body part. A patient develops a life-threatening infection because a doctor forgot to wash his hands. A child dies three days after being discharged from an emergency room because his parents were not notified of critical lab values that came back hours after they left.

People are fallible, but health systems need not be. Despite the staggering complexity involved in flying passenger jets and constructing skyscrapers, commercial airline accidents are rare and building collapses even rarer. Atul Gawande argues in The Checklist Manifesto that checklists are the best way to make sure that small but critical details of health care are addressed systematically, so that every member of a care team feels empowered to preempt potential disasters. I believe that checklists and decision support tools are applicable not only to surgery or intensive care settings, but to primary care as well.

Fortunately, the emergency evacuation of NYU Langone Medical Center went off smoothly, and none of the patients who were transferred seem to have suffered as a result. But the good outcome of this near-miss and the low likelihood of another Sandy in the near future should not make anyone at NYU – or in any hospital or health system, for that matter – complacent about addressing the little details and vulnerabilities of health care that make all the difference.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

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  • margo

    ninguem, Good work!! I am always amazed that no one ever focuses on medicare fraud which is promoted by the program itself. If they are willing to be taken advantage of and pay 4 times for medical devices than of course scam artists are going to come in!!
    I once went to a medical supply store to buy shin splints to sleep in –for runners. It is made of mostly cloth and some metal. The medical supply store was selling it for close to $400 which they said was medicare rate!!!! I went on line and got it for $75!!!!!!!!!!! Once again the lobbies for big business–medical device co. I assume buy off the gov’t/medicare and seldom is it mentioned as a reason for medicare going down the tubes!! Thanks for the article!!!!

    • ninguem

      I’d say the story is straight-on accurate by the way, including the part about how the scooter stores bully the doctors and turn the patients against them.

      You could buy a car for what they charge Medicare for the scooters.

      For all the time spent looking at physician billing, the majority of which is a difference of opinion on the complexity of the visit……..the real outright fraud is in the DME industry.

      And everything from that story, any doctor could have told you fifteen years ago. The feds have finally caught up.

      • margo

        So I guess the truth of the matter is the Scooter store has now become the treating physician. They have a diagnosis of scooter deficiency and a treatment plan of scooters. I don’t have a lot of hope in the government really fixing the problem when the DME industry has such lobbying power but what do you think?

        • ninguem

          It gets better.

          If I want to provide a splint to my Medicare patient……well, I’m not allowed to provide splints to my Medicare patients, because it makes me a DME company. They treat me rougher than the scooter company.

          I’d send my Medicare patient to the medical supply company across the street, but they’re not interested in selling that splint for a few dollar markup.

          But they’re stuffed to the gills with scooters and walk-in bathtubs and those easy chairs with the lifting platform to get your butt up in the air.

          Not a splint to be found.

          • margo

            OMG! ridiculous. I’m not clear. What is the risk of putting on that splint other than not getting paid? How can medicare define your practice in that way and what can they really do about it anyway?

  • margo

    So I guess the truth of the matter is the Scooter store has now become the treating physician. They have a diagnosis of scooter deficiency and a treatment plan of scooters. I don’t have a lot of hope in the government really fixing the problem when the DME industry has such lobbying power but what do you think?

  • margo

    Ninguem, I really appreciate the website and links. It’s enraging. I suppose it all boils down to the fact that doctors really don’t have a lobby–well the AMA –but only 20 percent of us are members and the AMA from what I read is working against us –i.e. they want doctors to conform to working with the healthcare system.

    Then the DME industry as you have rightfully pointed out has strong lobbying power. So let me see if I get this right. The DME are clever at figuring out how to manipulate the older medicare patients into what they think they want and for free. They have aggressive advertising as we know for this and target tv channels for disabled or elderly medicare pts.

    That sounds overwhelming to deal with. And you did not create this monster so why are they coming to you? I wonder if the medicare population feels very deprived in a way of the basic care that was promised to them. Their access to care and coverage have been diminished in recent years.

    I have a question and I realize you are in a difficult place with these kinds of pts. So Ninguem I am afraid to even ask this question, but what would happen if you just said no and briefly document why? I hope i am not intruding with my question. I just feel for you and think it’s wrong. If they storm out and never come back all for the better. One less medicare pt. Not to be sarcastic but they can’t tell you how to practice medicine. I mean I know they are trying. But at least they know they can’t mess with you. And only between you and the pt. I’m sure it’s a lot more complex than that but it was just a wish I had for you.

    • ninguem

      Margo, are you a physician? I get mixed signals from your post (“us” with respect to AMA members). Just don’t want to say stuff you already know.

      What do the DME vendors do……heck, try TV networks that may have an older demographic. They advertised the pos-t-vac like crazy on the Military Channel. You don’t see commercials for the pos-t-vac on Nickolodeon. I daresay that reflects their viewer profile.

      They flog the scooters, the penis pumps, all sorts of DME on those networks.

      The penis pumps, creating a vacuum to get an erection…….I’ve seen pictures of similar devices going back to the 19th century. Our ancestors were just as concerned with Mr. Happy, for the same reasons.

      The patients come in expecting these. If I refuse, some get mad and go elsewhere. The vast majority of times, the people who leave……lets just say there’s some business you don’t want.

      It’s a nuisance in that it takes time. Anyone in primary care gets the occasional patient, you dread the visit because they get an idea in their head, TV, Internet, beauty shop gossip, whatever, and you have to spend half an hour disabusing them of an idea that’s either expensive, useless, or sometimes downright dangerous.

      When it’s every single visit, it gets old.

      What do the DME vendors want?

      My signature.

      Then all this waste becomes MY fault.
      Yes I HAVE been audited over the damn scooters, and I don’t tend to authorize them.

      The scooter request nowadays, usually turns into a referral to a physical medicine and rehab physician. I get to use the PM+R doc and/or the physical therapists as the bad guys.

      Occasionally, I do, myself, write the authorization truthfully and scuttle the application. I say the patient can walk “X” feet (because he can). or no upper limb weakness that would preclude a manual wheelchair.

      Basically I tell the truth on the application, but it kills the scooter authorization.

      Boy, I’ve had some phone calls from the scooter stores. It would make a sailor blush.

      heh

      • margo

        Hi Ninguem, I am a physician but not primary care and no longer accept medicare. So I appreciate the description of what you go through all the time. I don’t see that particular pt population now. I had no idea how it actually plays out in the PCP office even though I am aware of fraud and those god awful commercials. I just did not realize how it affects PCP on a daily basis!! Forgive my ignorance. When I was asking those questions it was more out of actually wondering in amazement why medicare continues to allow these abuses not so much how they get away with it. You explain that all too well. Seriously this is a great topic for this blog. Have you thought about sending it to Kevin? at kevinmd@gmail.com.

  • southerndoc1

    The belief that health systems can be made infallible is erroneous and very dangerous.

    • ninguem

      I have this image in my mind.

      White smoke out a window in the Board room when they select a new Chief of Staff.

  • margo

    OMG, what a joke!! Yeah and so true your comment about Grandma. The important stuff like doctors visit for HTN is considered less valuable. Unbelievable. They’re not going to have sex if she/he has a stroke.
    Do you have any sense of why the system is such? I mean as you point out it’s ludicrous. A penis pump is paid at what five times the cost an MD visit is for HTN? Why are we in this predicament and how did we get here? That DME’s are overvalued, doctor visits are completely undervalued, medicare is going broke and no one really addresses it as the core problem that it is. They fight over closing or cutting medicare but NOT about the central problem–which sounds like fraud.

  • margo

    ninguem I am not sure Kevin reads this. If you don’t hear back why not email him directly at kevinmd@gmail.com
    I think you have a good idea.

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