Justice Louis Brandeis urged sunshine for government: let the people see what their legislators are doing. Democracy will thrive when citizens glimpse the inner workings of government. Those workings may be messy, corrupt, woefully inefficient, laden with self-interested power ploys. Compare the making of laws to the making of sausages: we dont really want to know what goes into the mix. But the alternative ignorance is worse.
So newspapers, muckrakers, ethicists all struggle to let the sun shine into the sometimes closed (but probably no longer smoke-filled) back rooms.
Sunshine may be just as good in medicine.
Mistakes, born from ignorance, inattention, malfeasance, sometimes just bad luck, happen in medicine (as in the rest of life). A patient goes to a physician, hoping for, expecting, one outcome; and the result is dire, unexpected.
Enter the lawyers, shouting malpractice. Maybe the family should sue. Maybe the family can recoup money for lost earnings, for pain, for suffering, for a radical shift in life expectations.
Enter the hospital risk-managers. The physician recedes to the background. The case proceeds, or not, depending on the lawyers expectations.
The premiums for malpractice insurance mount.
As for the family, it is left with an abiding distrust of everything medical. Lawyers for the hospital, for the physician, for the family take center stage.
What if we re-staged the scenario, to push lawyers to the background, and keep physicians center-stage?
In reality, malpractice, denoting inexcusable incompetence and/or malfeasance, is one point along an M continuum of Mistakes. We dont understand out bodies as well as we understand our cars (we didnt design our bodies); and glitches emerge in treatment, in surgery, with drug regimens. A patient doesnt respond as predicted. Sometimes a physician has cited the odds of success, but the patient hasnt accepted those odds. Sometimes a confluence of bad-luck events beset an operation: the super duper specialist on call has an accident en route to the hospital; the emergency room is swamped when the patient arrives; the translator was not instantly available; the first-year resident hadnt seen a similar case. See any random episode of a hospital-based drama on cable to glimpse more of these. On television most of the patients end up OK. In reality, many patients dont.
In 2001, the University of Michigan Health System re-staged the scenario. When a patient suffered an untoward event, the hospital and physicians met with the patients and their families. They explained what happened. If warranted, the physicians and hospital apologized. They explained the steps taken to minimize the recurrence of such a mishap. And, if warranted, the hospital offered compensation. In the world of risk-management and of malpractice lawyers, this transparency was not just bold, but brash. Surely malpractice claims would soar, once the hospital admitted error.
Claims did not soar.
Researchers compared claims filed between 1995 and 2007. In an article in the Annals of Internal Medicine, researchers offered the statistical good news. (Kachalia, Kaufman, et al. Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program, Aug. 17) The result: fewer lawsuits under transparency. The hospital saw lower costs for liability, even for patient compensation.
As for patients, at this hospital they remained primarily patients, not litigants. Even in this era of super duper technology, treatment begins with a patient-physician bond. The start of treatment is not a CAT scan or x-rays, but a conversation. The patient trusts the physician to use his/her expertise, skill and art to help him get better. When the patient gets worse, the bond of trust requires an honest conversation about what went awry. Indeed, nobody may be able to explain why a procedure went awry. But the conversation should still happen. Patients and their families will benefit.
Now it seems that hospitals and physicians may also benefit in lower costs for malpractice litigation.
Joan Retsinas writes about health care in Providence, R.I. Email firstname.lastname@example.org.
From The Progressive Populist, October 1, 2010
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