The Best of Times, the Worst of Times

by C. Richard Patterson, MD

 

It’s the end of the year, when lists of one thing or another proliferate.  I thought I’d try my own take, and I considered identifying the luckiest and unluckiest things that happened to me this year.  I’m saving that until next year, though, when I expect the lists to be topped by “Winning Powerball” and “Not Winning MegaMillions, Too”, respectively.

Nope, this is going to be my list of the five worst things that have happened in healthcare.  Not all of them started or ended in 2013, but all have had and continue to have an impact on our profession.

The Worst in Healthcare

1.   Sorry to disappoint my more rock-ribbed friends, but it’s not the Affordable Care Act (AKA “Obamacare”).  The worst thing that happened in US healthcare is

 Doctors Allowing Bureaucrats to Define Quality

We abdicated our responsibility to serve our patients and our colleagues with standards and expectations that could make a real difference.  You can read more of my reasoning for this choice atGeneral Surgery Newsor at KevinMD.

2.   Work Hour Limits for Physicians in Training

Libby Zion, a freshman at Bennington College, died within 24 hours of being admitted to New York Hospital in 1984.  She was cared for by two medical residents, who communicated with the attending physician and family doctor by telephone.  Ms. Zion’s father, an investigative reporter for theNew York Daily News, became convinced that substandard care by over-worked and fatigued residents was the root cause of her death.  His campaign for work hour limits eventually goaded the Accreditation Council for Graduate Medical Education into adopting limits and penalties for non-compliant programs.

 Extensive hearings were conducted by the New York State Board for Professional Conduct, and the two doctors were absolved of any failings.  The New York Board of Regents, numbering only a single physician among its 16 members, subsequently censured the young doctors, despite the Board’s findings.  The Regents’ censure was overturned by an appellate court.

Someone slipped the transcript of the Board’s proceedings under my office door one night.  As I read, I began to hope that my residents and I would perform and document as well as the two who cared for Libby Zion that night.

The cause of Libby Zion’s death has been thoroughly debated, but it is clear to me that it would not have been prevented by restricting weekly or consecutive work hours.  I believe that misjudgments by doctors in training are not the result of inadequate rest but of clinical immaturity combined with a deficiency of senior, on-site supervision and collaboration by faculty physicians. 

Perhaps some in academe who supported work limits thought the system would compensate by increasing funding for more residency slots:  WRONG.

Perhaps some welcomed the tarring of residency fatigue as a welcome distraction from calls for more in-house presence of faculty, a direct threat to the cushiness of attending status:  TSK.

At any rate, I am unaware of any unambiguous evidence that the limits have resulted in better outcomes for either patients or medical education.  Simplicity and simple-mindedness have nothing in common save etymology.

3.    The Canard that Surgery is a “Non-Cognitive” Specialty

This didn’t make the list because it hurts my feelings, although it does.

Setting one side of the professional house against the other has sown further disunity and enervation among doctors, who already had significant challenges in combining as a positive force for reform of the industry.  I rant in more detail atGeneral Surgery NewsandKevinMD.

4.    The Devaluation of the Doctor

A once proud profession is now dispirited.  The causes are multiple, complex, and at least partially self-inflicted, but the indisputable result is one million highly educated and trained individuals with an equally high level of despondency.  More doctors want out of medicine than at any time in our history.  I’ve written about some of the reasons atDailyDudleyandGeneral Surgery News.

5.    The Hired Gun

We have a dysfunctional medical malpractice system.  I doubt anyone reading this will contest that assertion, although members of the plaintiff’s bar almost certainly would.  The adversarial nature of the process prods both sides to exploit the ambiguities of clinical medicine, its nuances and the quirks of biology and documentation style, to either demonize or exonerate.  The judicial system requires that qualified “experts” present testimony to a lay jury without acknowledging those nuances and uncertainties, because any such even-handedness will not be reciprocated by the opposition.  Some doctors, a very small but particularly vicious minority, sell their credentials to whichever side might employ them, bringing discredit to those who testify in good faith and to the profession as a whole.

I thought it might be liberating to get these things off my chest, but it isn’t.  These are serious matters that threaten the profession and the people we serve.  Perhaps no one should be allowed to post such a list without suggestions for cure, but I am not that clever.  If you have some ideas, I’d really like to hear them.

For the sake of symmetry at least, I’ll try to come up with the five best things in healthcare, but that must await another day.