My hospital, UCSF Medical Center, is thriving. Our profits this year will be nearly $200 million. We’re building a sparkling clinical complex – a combined women’s, children’s, and cancer hospital – adjacent to our new downtown biomedical research campus.We are installing a state-of-the-art computer system. US News & World Report calls us the 7th best hospital in the country. Our students, residents, and fellows have never been better.Yet angst is in the ...
Bob Wachter, MD
The radiation delivered by CT scanners has gone largely unregulated
Although the medical profession has been harming unlucky patients for centuries, the patient safety movement didn’t take flight until 1999, when the Institute of Medicine published its seminal report, To Err is Human. And that report would have ended up as just another doorstop if not for its estimate that 44,000-98,000 Americans each year die from medical mistakes, the equivalent of a jumbo jet crashing each day.Come ...
Specialty hospitalists joining forces with the generalist hospitalists
I recall with fondness many meetings in 1996-98, when the hospitalist field was still in its infancy. We had invented a new medical specialty, and our gatherings were vibrant and purposeful.We were determined to remake the healthcare system, learn from each other’s triumphs and disasters, and chart a course that would improve the care of hospitalized patients. These ...
Teamwork helps doctors with patient safety
One of the central tenets of the patient safety movement is that modern medicine is a team sport. Unfortunately, its players – particularly physicians – were trained and socialized to be free-spirited individualists. We need the Celtics of the 80s; what we have is a collection of young John McEnroes.
While this theory has been generally accepted, there is less agreement regarding how to change things. When I speak about
Why physicians ignore fatigue
Several years ago, I spoke at Baylor College of Medicine in Houston, where Michael DeBakey, the legendary heart surgeon, was master of the universe for nearly half a century.I heard lots of DeBakey stories during my visit, but one in particular really stuck with me. “A few years back,” someone told me in a voice of hushed reverence usually reserved for descriptions of flawless beach days and single ...
If there’s a doctor on board, please ring your call button!
Well, it happened again. Recently, I was somewhere over Saskatchewan, returning from a lovely Mediterranean cruise, in that uncomfortable semi-conscious state that passes for sleep when you’re flying coach, when the airplane’s PA system rang out:“If there’s a doctor on board, please ring your call button!”If you’re old enough to remember the show “To Tell the Truth,” you know what happened next. In the show, four B-list celebrity ...
Social science requirements for pre-medical students
I thought I was an oddball in college. I've only recently learned that I was avant garde.Right before beginning college in 1975, I decided I wanted to be a doctor. Being the first-born son – with decent SATs – of an upwardly mobile Long Island Jewish family, I had relatively little choice in the matter. Notwithstanding this predestiny, I felt confident that medicine was a good fit for my interests ...
Will the new resident duty hour rules improve patient safety?
One of the mantras of performance improvement is that caregivers and provider organizations should learn from their experiences. That’s all well and good, but how about policy-setting organizations?Recently, in the New England Journal of Medicine, two of the Biggest Kahunas in the safety and quality worlds – the Joint Commission (TJC) and the Accreditation Council for Graduate Medical Education (ACGME) – announced bold new policies. To their credit, both organizations ...
Mark Midei and the failure of peer review
A couple of months ago, a Baltimore reporter called to get my take on a scandal at St. Joseph’s Hospital in Towson, an upscale suburb.A rainmaker cardiologist there, Dr. Mark Midei, had been accused of placing more than 500 stents in patients who didn’t need them, justifying the procedures by purposely misreading cath films. In several of the cases, Midei allegedly read a 90 percent coronary stenosis when the actual ...
Primary care is more than just office visits
If you’ve ever been on a diet, you know that it really helps to keep a food log. Seeing your consumption chronicled in one place is illuminating – and often explains why those love handles aren’t melting away despite two hours on the treadmill each week.In a recent issue of the New England Journal of Medicine, internist Rich Baron Rich Baron chronicles the work of his 5-person Philadelphia office practice ...
Joint Commission hospital inspections have improved
Until about 8 years ago, inspections by the Joint Commission (TJC) were predictable and fairly silly.Hospitals were given a couple of years' notice of the week that “The Joint” would be visiting. Everybody scurried around preparing – waxing the floors, locking up all the medications, that sort of thing. (It always struck me as the most dangerous day to be in the hospital, since nobody could find any of the ...
Residency team changes can improve education and patient care
In the early 90s, I had the privilege of directing UCSF’s exceptional internal medicine residency program. It was a time of transition. A decade earlier, residency accreditation requirements (dictated by the Accreditation Council for Graduate Medical Education, ACGME) were fairly benign and largely ignored – marquee programs like ours were generally given carte blanche to organize our residents’ experience as we saw fit.When I took over our residency in 1992, ...
Don Berwick to lead Medicare and Medicaid
While the health reform bill will have many effects, one of its most profound will be to unshackle the Centers for Medicare & Medicaid Services (CMS).Under the legislation, CMS is now far freer to undertake a variety of pilot programs and demonstration projects designed to improve quality, safety and efficiency, and to convert the successful ones into policy. And, if that wasn't enough for those who have long been praying ...
Jargon dominates medicine and how doctors verbalize nouns
One of my interns was “running the list” with me last week (giving me a thumbnail update on the plans for each of our inpatients). It was standard stuff until he got to Ms. X, a 80ish-year-old woman admitted with urosepsis who was now ready for discharge. “I stopped her antibiotics, advanced her diet, called her daughter, and YoJo’ed her.”Say whaa?I’m pretty sure that the most valuable thing I’ve done ...
Healthcare reform is an achievement but isn’t perfect
Heading into the final weekend of Mr. Toad’s Wild Ride, who could have guessed that in a year that brought us Death Panels, Pickup Trucks, “You Lie”, The Cornhusker Compromise, Bart Stupak (boy, that must have been a tough name to grow up with), and the Senate Parliamentarian-as-Rock-Star, we would be on the cusp of passing a perfectly ...
Atul Gawande’s The Checklist Manifesto reviewed
Every now and then, I read and enjoy a book, but only later fully appreciate it as its lessons and insights slowly become apparent. Judging by the number of times I’ve said, “That reminds me of Gawande’s observations about ___” over the past month, The Checklist Manifesto is one such book.In this short, deceptively simple volume, Atul (who I count as both friend and inspiration) discusses the history ...
How to make your medical grand rounds thrive
Early last year, my boss Talmadge King and I were at an ABIM meeting (we’re both on the board), and the group was debating a controversial topic. Another participant at the meeting, like Talmadge the chair of a prominent department of medicine, said, “We polled 250 people at our grand rounds last week, and they said ‘X’.” The audience gasped – ‘X’ was a completely unexpected ...
How root cause analysis can improve patient safety
Hospitals face so many urgent tasks in safety – computerize, promote teamwork, implement evidence-based safety practices, discover unsafe conditions – that it’s hard to know where to start. If you’re struggling, I recommend that you put your Root Cause Analysis enterprise on steroids. This is what we did at UCSF Medical Center, and it was the most important change we’ve made in our safety journey. Here’s the story, ...
Should health care workers go to jail for medical errors?
Two years ago, I wrote about the case of Julie Thao, the Wisconsin nurse sent to prison for a medication error. I argued then that – although Julie bypassed some safety rules – she most certainly did not deserve jail time.Along comes another case involving jail time for a medical mistake, this one featuring an Ohio pharmacist named Eric ...
Implementing an EMR or health IT system is harder than it looks
In 2001, when my colleagues and I ranked nearly 100 patient safety practices on the strength of their supporting evidence (for an AHRQ report), healthcare IT didn’t make the top 25. We took a lot of heat for, as one prominent patient safety advocate chided me, “slowing down the momentum.” Some called us Luddites.Although we hated to be skunks at the IT ...
