It’s not that often that I agree with Mike Magee, the doctor who’s Health Politics is funded by Pfizer and tends to reflect big pharma’s viewpoints. But in his latest piece called The Road from Medical Malpractice to Safety: You Can’t Get There from Here, he lays out a convincing argument that the malpractice system directly impedes the goals of the patient safety movement. He states the core of this problem very succintly here:

The American malpractice system, embedded in personal injury law, fundamentally undermines the patient safety movement. A head-to-head comparison tells the story. The tort system uses litigation as its lever for change. The safety movement uses quality improvement analysis. Tort law focuses on the individual. Safety focuses on the process. The tort system’s punitive and adversarial style drives information down, encouraging secrecy. The safety movement uses a non-punitive and collaborative approach, which encourages openness, transparency, and continuous improvement. With tort law, exposing oneself can end one’s career and harm one’s mental health. In the safety movement, contributing is career-enhancing and therapeutic. It may seem counterintuitive, but for medical malpractice to achieve its stated social purpose it must abandon the emphasis on a tort-based approach and embrace safety.

This has the massive implication that organized medicine’s proposed reforms to the medical malpractice system, particularly their desire for limits on pain and suffering awards, are irrelevant and counter-productive. Instead, the system needs to be replaced with a regulatory structure focused on patient safety. And by no means would that be a difficult transition for just the lawyers. It would be even more of a challenge for doctors, who would have to end what Mike Millenson has called “The Silence” of professional courtesy and expose themselves and their colleagues’ decisions to public review.

The AMA and the rest of organized medicine need to take the lead here, get off their high horse about the malpractice issue, and while they have a very sympathetic (i.e. Republican) Congress, develop some real bipartisan consensus on replacing the current tort system with a legally mandated patient safety system. That system will need real teeth to assure the public that it’s not biased in favor of physicians and providers. And of course we need a neutral public education campaign about why such a system is required; reason number one being that most malpractice currently goes on unimpeded, and this system will stop that.

Leonard Soloniuk, MD had this to say about my recent post on the obesity issue:

I have seen the assertion that obesity is not a health problem in several different contexts, but Paul Campos appears to be quite flamboyant in his arguments. There seem to be several issues here including the utility of BMI is categorizing people at risk. The whole question of the efficacy of interventions is also subject to question.

One of the reasons Campos’s arguments are worth considering is the recent history of the abuse of science and epidemiology in the pursuit of political goals. Examples would be the HIV epidemic and the medicalization of handgun restrictions. In these cases, interpretations of data have been distorted to fit predetermined policy goals. Thus,
when the usual suspects (e.g. the CDC, JAMA, etc.) declare a new health crisis, skepticism is in order.

There are a number of issues that need clarification in this debate: What is the role of BMI? Is body fat a better predictor and a better secondary outcome to follow? What are the true risks for mildly overweight patients? Which interventions lead to improved outcomes.

However, it is difficult to take seriously an attack on Americans, ascribing to them the need to discriminate. This seriously lessens his credibility for all of his arguments. And that’s unfortunate, because a reasoned analysis of this issue would be quite welcome

I’m inclined to agree with with Leonard that the generic attack on Americans as “wanting to discriminate” is simply not helpful to serious discsussion of this topic, even if there is 200+ years of history showing way more discrimination in the US than we’d like. However, you can make an argument that handgun wounds showing up in emergency rooms constitute, or at least cause, a health crisis (morbidity and mortality in young inner-city men) even if the initial study of the article was clearly politically motivated. So we should not be ready as Leonard to dismiss the CDC/JAMA “establishment” and their views on obesity just because (for instance) as NRA members we didn’t like their views on gun control. (I’m more confused by Leonard’s critique of the CDC’s actions around HIV, but maybe he’ll enlighten me).

However, Leonard does get to the right set of questions, when he asks whether BMI, body fat percentage or anything else really matters, and what the outcomes for overweight people truly are. These clearly require more study with real data rather than emotion amongst the medical community, and I suspect there is emotion on both sides–as there clearly is in Campos’ views.

As a non-medical healthcare blogger, I’m though asking a slightly different question which is, “will these opinions become mainstream” and if so “will that change the way healthcare services (including drugs) are used?” And if you don’t think that psycho-social changes in attitudes to health can change service provisions in health care you might want to take a look at this article about how the Atkins low-carb diet fad has revolutionized the restuarant and food business. (Arrgghh. Can”t find the NY Times article I read last night so here’s one about the chain Ruby Tuesday’s profit rise on the back of their low carb menu).

Fascinating article extracted in The Guardian from a new book from Paul Campos suggests that obesity is not a health problem. Well worth reading the article, but basically he suggests that while fitness and excercise have some impact on health outcomes, in general people with a Body-Mass Index (BMI) in the “recommended range” don’t do any better and in some cases do worse than those who are above that range. In fact it’s better to be overweight by several pounds than underweight by a few. Additionally the desire to reduce BMI suggests that people who become thinner have the same health outcomes as those who were thin all along, and although there have never been studies to support this (because you can’t get fat people to stay thin long enough) the evidence suggests that it’s not true. Further, the “propaganda” causes health problems by encouraging yo-yo dieting and poor body image, particularly amongst young white women. This leads of course to the serious medical and psychological consequences of eating disorders.

I’m not sure I know enough to be convinced of his arguments, but of course the treament of obesity is big business and getting bigger for the pharmaceutical industry. Campos lays at least some of the blame for the acceptance of the argument that “obesity is a disease that needs treatment” at their door. The rest he ascribes to the desires of Americans to discriminate, and now that civil rights and political correctness have taken away the ability to aim that discrimination at ethnic minorities, obese people are an easy target.

So basically I can have that bacon sandwich so long as I go to the gym. But on an industry level this conversation about what to do about obesity has serious implications for physicians and pharmaceutical manufacturers. And if the answer is not to worry about reducing obesity per se, that has some profound implications for how we may treat some of our biggest disease classes–diabetes and cardio-vascular disease–in the future. We are very quick to go to the pill when “diet and excercise” hasn’t worked. But what if, even if the pill works in reducing obesity, it doesn’t in improving outcomes?

In a slightly embarrassing article for the local state medical society, an article in the Allentown Morning Call suggests that stories of doctors leaving the state because of the malpractice crisis in Pennsylvania are massively exaggerated. Now this is in a state which has raised tobacco taxes to provide public money to pay physicians’ malpractice premiums, because of said crisis. However, the source for this information was organized medicine itself:

The state medical society’s own statistics — never before disclosed publicly — show a gain of 800 doctors statewide from 2002 to 2003.”I would be willing to admit up to an 800 physician gain since 2002,” said Steve Foreman, who runs the society’s research department. ”But if we’re trading experienced specialists for general practitioners, we have a problem.” Yet here too state statistics show that the specialists hardest hit by rising medical malpractice rates are not leaving in large numbers.The number of neurosurgeons, general surgeons, ob-gyns and orthopedic surgeons in 2002 was 4,721, as measured by doctors who paid their insurance premiums. The number of those same specialists who applied in February for the state’s relief money: 4,665. That’s a loss of 56 specialists, but even 56 may overstate the situation.

Overall the article essentially says that the doctors have sold a bill of goods to the state and that their demands for immunity from lawsuits are invalid. The medical society has responded by saying that experienced older specialists are leaving and are being replaced by newly trained physicians (via Modern Physician):

In addition, the society said Foreman “cautioned the reporter that Pennsylvania has seen a temporary increase of more than 1,000 doctors in training during the past two years that are included in the total number reported by the newspaper.” Meanwhile Pennsylvania’s licensing board for physicians indicated a drop of approximately 1,400 licenses during the same year the reporter used, the society said. Instead, the reporter chose to ignore the data, resulting in an apples-to-oranges comparison, and creating the erroneous impression that there was a significant increase in actively practicing physicians.

Positioning myself in the neutral ground between the crowd at MedRants and Ross the Bloviator (plus my own contributors Matt Quinn and The Industry Veteran), I end up feeling here like the med-blogger equivalent of the last moderate in the Israel/Palastine conflict. I do think that the malpractice situation needs reform, but I also think that the impact of soaring malpractice rates has been massively overstated by organized medicine, and that most of the cause is due to the price war among insurers in the 1990s. However, the lawyers don’t exactly cover themselves in glory either. What I keep reminding the universe, and what no one ever bothers paying attention to is the fact that anyway you cut it, malpractice itself accounts for well under 1% of health care costs. Defensive medicine, though, does have a big impact, of maybe up to 6-8% of all spending. But of course in general if they do more, doctors and the health care system make more. So parsing out the real incentives behind defensive medicine is very difficult. And this kind of article, which lays bare the aggressive politics on both sides of the conflict, reminds me more of an Israeli air strike in Gaza than a peace meeting at a Norwegian hotel.

On the very day that a fascinating article confirms that high spending does not equal high quality overall care, Pfizer-sponsored doc Mike Magee has a new presentation out based on the industry report which suggested that every dollar spent on health care returned several dollars back to society. THCB regulars will remember me losing my cool over the methodology and PR behind that report. Incidentally the PR was put together by the same actors (and I mean that literally) who were involved in faked "news releases" that promoted the Bush Medicare bill.

But there is the tacit acceptance in healthcare that more technology is better, and similarly that more specialist-based care required to use that technology is better. There’s never really been an answer to Larry Weed’s question — "if the radical prostatectomy rate in Denver is 3 times what it is in Salt Lake City, should you move to Denver to get your cancer taken care of properly or should you move to Salt Lake to avoid unneccessary surgery."

However, for the first time I’ve seen, someone has now come out and answered the question. And of course the someones are the folks from Dartmouth, who’s leader and guru Jack Wennberg really deserves much greater recognition for his pioneering work in area practice variation.

For many years it has been known that in some states Medicare (and by extension) other payers, are spending more, by a factor of up to three, on similar populations than in other states. This Wennberg presentations from 2000 shows that spending on patients in the last 6 months of life varies dramatically, with South Florida’s costs being up to three times those in Minnesota. Now Wennberg’s colleagues Katherine Baicker and Amitabh Chandra have a new Health Affairs article which shows that there is at the least an inverse relationship between spending levels and general care quality measures. Their conclusion is pretty brutal:

Higher spending is associated with lower quality of care…..These relationships are statistically significant: Spending is not merely uncorrelated with the quality of care provided. Exhibit 1 quantifies the relationship between an increase in spending of $1,000 per beneficiary (roughly the rise in average spending from 1995 to 1999) and the twenty-four individual quality measures, as well as end-of-life care and patient satisfaction……The effect of increased spending on fifteen of the measures is estimated to be negative and statistically significant, and there is no statistical effect on the remaining nine. The first row demonstrates that a state spending $1,000 more per beneficiary dropped almost ten positions in overall quality ranking (p < .001). Similarly, states spending $1,000 more per Medicare beneficiary had beta-blocker usage rates at discharge that were 3.5 percentage points lower (p < .02), and mammography rates that were 2.1 percentage points lower (p < .01) than the average usage in 2000.

They can’t overall prove that commonly accepted quality processes, such as prescribing of beta-blockers and ACE inhibitors for post-MI patients, are not being followed because spending is higher, and in fact it’s probably circular, as the patients end up back in the hospital because their follow-up care wasn’t good. But if they can’t show the cause, they certainly point out the striking collinearity. And it’s what the Enthoven’s of the world have been saying forever–poor quality care costs more money. Why? Well among other things there is of course the incentive that performing heroic interventions at the last moment is much better rewarded than good quality primary preventative care. And of course that is related to the greater pre-ponderance of specialists (as a proxy for expensive technology), which the article says is responsible for 42% of the difference in spending.

No one is going to pretend that this will be easy to change. We have a structural preponderance of specialists and a Medicare payment schedule that continues to favor increased reimbursements for procedures on the very sick rather than improving care processes for the near-sick. (To be fair MedPAC has been advising changing this for some time). And we have GOGME calling for more specialists in the future. Plus, if you hadn’t noticed, specialists make a heck of a lot more money than generalists, so why would a smart young doc become a generalist?

But this research is a clarion call for the improvement of care processes and evidence-based medicine. And it is a counter-weight to ill-informed trumpeting of the benefits of technology from health care industry groups, who should be spending much less on their PR and more on helping clinicians improve the quality of the care they deliver. In the meantime, if you intend to get old, move to New Hampshire.

So I had arthroscopic surgery at a Healthsouth facility from a Brown & Toland surgeon on Friday. The admin staff and the nursing staff were superb, and the majority of my information from the physician’s office had in fact got over to the surgi-center, so there was no need for me to repeat everything. They also allowed me to not pay anything up front, as I explained that I thought my previous office visits and MRI would take up all my deductible and out of pocket. I even have a new MSA (should be HSA) card from the "MSA Bank" which I should be able to use to make those payments tax-free. So I am now one of those health care consumers I’ve been warning you about!

The surgery was in some ways rather fun, particularly as it was minor enough that I was able to be woken up after a quick general anesthetic and was able to watch the monitor as it happened. I could see a huge drill blasting the odd bit of white scar tissue, and although there was a cloth barrier stopping me from seeing the surgeon, I was even able to get the nurse to bring it down by joking that I was watching a tape from another surgery. But there he was slicing/drilling away, and describing to me what he was doing. I’ve since told several people about this but none of them seemed to be anything other than queasy.

The most amazing thing is that although I had a couple of Percocet in the facility, I have taken none of the Vicodin I thought I’d need over the past 48 hours. The knee is pretty swollen, but I can already walk OK–it’s stiff but not painful. Hopefully in a couple of weeks I’ll be better than before. I’ll keep you in touch, but going through this experience is always interesting for those of us in the health care business who don’t often see things from the "business" end!

By the way, if you don’t know the history, the surgery was follow up to much more significant knee surgery 2 years ago when I had ACL/PCL grafts following a violent snowboarding accident.

A new study out from Jury Verdict Research shows that the median malpractice award for 2002 was stuck at $1m–no real increase from 2001. The proportion of successful cases brought against doctors went up slightly but was still only 42%. This is though up from 29% in 1996. Although the denominator is not in this report, the total amount awarded was estimated at $4.2 billion in 2002 according to these data from the National Practitioner Databank. The figures disagree from Jury Research’s in that in 2002 the National Practitioner Databank estimated that there were 452 awards for a median of $286K and a mean of $506K (implying some 650 odd cases that made it to court and were won by the defendant physician). But in any even the vast majority of the $4.2 billion handed over was in settlements, of which there were 14,852 in 2002. In other words around 7% of cases make it to court, and around 15,000 cases end up with money paid to the plaintiff each year.

Given that there are around 550,000 practicing doctors in the US, this means that roughly 3% are in some way being successfully sued for malpractice each year. When you look at it that way, it’s not that big a problem. (Cue barrage of email, no doubt!).

THCB is now so influential that people are seeking to advertise on it. Really! (Stop that sniggering). I did get a message from John Riley at Keep Antibiotics Working to ask if he could advertise to my readers. As this site is designed to produce neutral but opinionated reporting (that advertises only me and my services as a by-product) and also I’m not set up to take advertising, I declined. But after I saw what the site was about and read this post from Family Medicine Notes about the dangers of antibiotic overuse in humans, I thought that it would be worth giving John some space to explain why antibiotic overuse in animals is such a health and policy problem. So here’s his argument:

Over the last 60 years, effective antibiotics have turned bacterial infections into treatable conditions, rather than the life-threatening scourges they once were. The effectiveness of many life-saving antibiotics is, however, waning. Health experts have deemed the rise in antibiotic resistance a public health crisis. Everyone is at risk from antibiotic-resistant infections, but children, the elderly, and people with weakened immune systems are particularly vulnerable.

The overuse of antibiotics is to blame. A major source of this overuse is routine use of antibiotics as feed additives for livestock and poultry–not to treat disease, but instead to promote growth and compensate for crowded, stressful, unsanitary conditions. The Union of Concerned Scientists estimates that 70% of all antibiotics in the U.S. are used as feed additives for pigs, poultry and cattle. In June 2001, the American Medical Association went on record opposing the routine feeding of medically important antibiotics to livestock and poultry (i.e., “nontherapeutic” use).

Antibiotic use in animal agriculture has been linked definitively to human bacterial infections resistant to antibiotics. Mounting evidence suggests that widespread overuse of agricultural antibiotics also may be contaminating surface waters and groundwater, including drinking water sources in many rural areas. Nonetheless, agribusiness and the pharmaceutical industry are fighting hard to thwart restrictions on the use of antibiotics in agriculture.
While medical use of antibiotics is a major contributor to the emergence of antibiotic resistance, agricultural uses also pose a significant problem since they promote the development of resistant bacteria that can reach humans through several different pathways – directly via contaminated food or indirectly via environmental contamination.

In an effort to curb the spread of resistant bacteria and protect the efficacy of antibiotic drugs, the “Preservation of Antibiotics for Medical Treatment Act” (S. 1460/H.R. 2932) is bipartisan legislation pending in both houses of Congress that would phase out the routine use of eight classes of medically important antibiotics in animal agriculture, unless their use can be shown not to pose a threat to human health. The legislation would continue to allow antibiotic use for treating sick animals and preventing the spread of documented illnesses in a flock or herd. Over 325 organizations around the country have endorsed this legislation, including 83 professional health groups, such as the American Medical Association and the American Public Health Association.

Keep Antibiotics Working, a coalition of health, consumer, agricultural, environmental and other advocacy groups with over 9 million members, is seeking individuals who have experienced an antibiotic-resistant illness to share their stories and help protect the effectiveness of antibiotics. For more information, please visit www.KeepAntibioticsWorking.com.

My corrrespondent the Industry Veteran was upset to see me teetering on the doctors’ side, while trying vainly to take the middle road, in the malpractice debate that I highlighted here last week. Meanwhile the same issue (the web site that identifies plaintiffs for doctors) has been busying a slew of doctors and a few of their detractors over at MedRants. The Veteran writes to point out the error of my ways!:

I was sorry to see your statement that you "take the doctors’ side" in their battle against the malpractice lawyers. Among those who deserve blame for the shortcomings and inequities in this country’s two-tier healthcare system, organized medicine is at least as blameworthy as hospitals, Big Pharma and insurance companies. Although you back away from this ill-considered partisanship in subsequent sentences, your initial sentiment reveals a reflexive simpatico that you should try to eradicate.In the first place, efforts to assign principal blame for the healthcare system’s problems remind me of the old Chicago scholasticism that sought to place responsibility for the city’s corruption on either the politicians, the police, the gangsters or big business. All the participants have historically sought to dip their beaks in the public’s blood and, in the case of healthcare, the providers have enacted the Tony Soprano role to an extent equalling that of manufacturers and payers. Paul Starr’s Social Transformation of American Medicine and other monographs have described the tactics that organized medicine used to elevate medical practice from a middling, lower-middle class occupation at the start of the 20th century (when the requirement for admission to Harvard’s medical school consisted of the ability to read and write) into the significant holder of gross domestic product that it is today. "In the physicians’ view," according to Starr, "the competitive market represented a threat not only to their incomes, but also to their status and autonomy…and threatened to turn them into mere employees."While increasing a profession’s exposure to tort liability is rarely the sole means of reforming public policy, I believe that in this case malpractice actions do help to advance the process. Dragging physicians into the dock furthers the demystification and dissipates the profession’s unchallenged self-judgment, both of which permit physicians to insert economic bottlenecks into healthcare while making the provider sector a two-caste system. Other positive functions of malpractice activity include making medicine less attractive to the spoiled princes (and, increasingly, princesses) of American society. Certainly I agree with your contention that the necessary process of knocking physicians from their pedestal can be abetted by the increased use of physician extenders (I prefer the term used by labor historians: "de-skilling") and the enforcement of evidence-based logarithms to constrain self-indulgent, self-dealing, cost escalating "autonomy." Despite the nervous handwringing from some of your fellow bloggers, I also want to advance the feminization (more accurately, the "mom-ification") of medicine to deter avaricious ambition from the profession (keep the Jeff Skillings and the Billy Tauzins in business and policitics where they belong) while making it more hospitable to the needs of 9-5, live-and-let-live employees.I think we can proceed through a long, tedious dialogue on this issue, and we’d probably conclude with more agreement than disagreement. I don’t wish to engage in such a colloquoy, and would instead urge a way for you to expunge your reflexive sympathy for physicians. Instead of maintaining the preconscious image of a workaday British physician such as your father, think instead of the two-dollar whores who demand that the pharmaceutical companies entice them to breach fiduciary responsibilities to patients.

UPDATE: (late Weds) The Veteran‘s anti-physician line may be a little extreme for me, but nothing to the extent to which it’s upset the medblogshpere’s favorite surgeon. Go see Bard Parker‘s reply at A Chance to Cut…

If you live in Boston you can go to your health plan’s web site and use their technology to both choose and rate your hospitals. But don’t let your doctors know about this as they are mad as hell!