
How to stop hospitals from killing us - bmahmood
http://online.wsj.com/article/SB10000872396390444620104578008263334441352.html?mod=googlenews_wsj
======
greenyoda
"A few years ago, Long Island's North Shore University Hospital had a dismal
compliance rate with hand washing—under 10%. After installing cameras at hand-
washing stations, compliance rose to over 90% and stayed there."

There's something seriously wrong with the medical profession if doctors only
wash their hands 90% of the time, even if they know they're being watched. The
words "reckless disregard for human life" spring to mind. How many deaths from
infections per year could be prevented if hospitals just fired any doctors who
didn't wash their hands? (Hospitals are a breeding ground for antibiotic-
resistant pathogens like MRSA.)

Another interesting article is Atul Gawande's "The Checklist" [1] (later
expanded into a book), which describes how the use of simple checklists,
similar to those that pilots use, can prevent medical errors like operating on
the wrong body part.

[1]
[http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_...](http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=all)

~~~
bryanlarsen
"There's something seriously wrong with the medical profession if doctors only
wash their hands 90% of the time"

It's not that they're failing to wash their hands 10% of the time, it's that
they're not washing their hands properly 10% of the time. We don't know if the
incompleteness is significant or insignificant.

~~~
konstruktor
If that's what they actually checked, I can see doctors avoiding washing at
the washing stations to not get caught with errors, which is even worse than
getting it wrong. Talk about bad incentives...

However, I would consider bad hand washing almost as neglegient. It's really
not rocket science

~~~
mcmatterson
Actually, it is. This is a classic example of blaming the offender and not the
process. Many hospitals (and this is borne out by research conducted by
colleagues of mine; I'm not making this up) don't even have soap dispensers
near sinks. Some hospitals mistakenly cross-label hand sanitizer and soap.
Things are simple as housekeeping being late refilling paper towel dispensers
cause drops in adherence rates. Can you carry a coffee cup from room to room,
or is that an infection vector as well? What about chart updating? Do you wash
your hands before or after touching a shared computer keyboard at the nursing
station (answer: both, but many nursing stations don't have sinks).

Blaming healthcare providers for not washing their hands is like blaming John
Q Public for the housing crisis. The reality is much, much more complicated,
and solutions to the problem are equally so. Healthcare is an _incredibly_
complicated ecosystem, and even things are simple as hand washing are affected
by dozens of factors, many of which are non-obvious at first. Root cause
analysis and a judicious application of process change can help greatly, but
the reality is that even simple things such as this do not change overnight in
healthcare. It's harder than you think.

------
anigbrowl
The US is rated worst among developed nations for this sort of thing:
[http://www.commonwealthfund.org/News/News-
Releases/2005/Nov/...](http://www.commonwealthfund.org/News/News-
Releases/2005/Nov/International-Survey--U-S--Leads-in-Medical-Errors.aspx)

I was in hospital following an accident last year. When I was discharged from
the ICU the following day, the nurse gave me the paperwork for the patient in
the next room. I didn't notice, being still rather beaten up by the whole
episode - it was my wife who spotted it. For a 12 hour stay I ended up paying
over $15,000, and then I hard to fork over an extra $90 to get copies of the
medical record. On paper.

I'll take socialized medicine any day of the week. the private sector does a
terrible job of healthcare.

~~~
larrywright
"I'll take socialized medicine any day of the week. the private sector does a
terrible job of healthcare."

Go find the nearest veteran and ask them about their experience with
government-provided healthcare.

EDIT: I don't mean to say that this is true everywhere, but in the US it
definitely seems to be the case.

~~~
zach
Uh, okay. My dad has been delighted with his VHA healthcare, if you demand
anecdotal evidence. Statistically speaking, the Veterans' Health
Administration routinely outscores private hospitals for satisfaction and is
more cost-effective as well.

[http://www.biomoda.com/presidents-column/june-presidents-
col...](http://www.biomoda.com/presidents-column/june-presidents-column/)

Certainly, the Department of Veterans Affairs itself is poor, and the
facilities are dealing with a massive influx of new veterans, but the quality
of healthcare in the VHA remains quite good.

~~~
larrywright
My dad had the exact opposite experience. They were excruciatingly slow, quite
literally almost causing him to die as a result of their bureaucracy. Private
healthcare (Mayo, specifically) saved his life. Throughout my dad's final
years I saw both kinds of healthcare at work, and there was a massive
difference.

~~~
zach
That's a good insight, thanks. The bureaucracy of providing care, especially
where it involves the VA (which as mentioned is a different story than the VHA
itself), can indeed screw up all the other benefits in the system. Definitely
a cautionary tale to keep in mind.

By the way, as long as we're all here, this article by a fellow I used to work
for is a remarkably insightful view of the problems involved with our current
healthcare system:

[http://www.theatlantic.com/magazine/archive/2009/09/how-
amer...](http://www.theatlantic.com/magazine/archive/2009/09/how-american-
health-care-killed-my-father/307617/)

------
tokenadult
From the submitted article:

"Nothing makes hospitals shape up more quickly than this kind of public
reporting. In 1989, the first year that New York's hospitals were required to
report heart-surgery death rates, the death rate by hospital ranged from 1% to
18%—a huge gap. Consumers were finally armed with useful data. They could ask:
"Why have a coronary artery bypass graft operation at a place where you have a
1-in-6 chance of dying compared with a hospital with a 1-in-100 chance of
dying?"

"Instantly, New York heart hospitals with high mortality rates scrambled to
improve; death rates declined by 83% in six years. Management at these
hospitals finally asked staff what they had to do to make care safer. At some
hospitals, the surgeons said they needed anesthesiologists who specialized in
heart surgery; at others, nurse practitioners were brought in. At one
hospital, the staff reported that a particular surgeon simply wasn't fit to be
operating. His mortality rate was so high that it was skewing the hospital's
average. Administrators ordered him to stop doing heart surgery. Goodbye, Dr.
Hodad."

So we have a known model that improves results. Let the patients who decide
which hospitals to visit know beforehand how hospitals compare in getting good
results for patients. Give patients power to shop. That provides incentives
for hospitals to do better, and nudges hospital managers to do what is
necessary to win the trust of informed patients.

This kind of reform would be very good to apply to schools as well. Already,
one state in the United States that is conspicuous among all fifty states in
educational achievement (the state I live in) allows all residents of the
state to enroll in the public schools of ANY school district anywhere in the
state. (The school district I live in has inbound open-enrollment students
from the geographical territories of forty-one other school districts.) In
general, the power to shop is the incentive factor to bolster by government
regulation, letting each consumer decide what trade-offs are important. That
works considerably better in driving improvement than regulating outcome
goals, and better still than regulating inputs into the provision of the
important service being regulated.

~~~
makomk
Reporting death rates does give hospitals an opportunity to reduce them, yes,
and one way they might that is to get rid of unsafe surgeons and fix unsafe
practices. Unfortunately that can only reduce death rates so far - they're
also affected by the number of high-risk cases the hospital takes on. So it
turns out that reporting these statistics gives hospitals a financial
incentive to turn down, drive away, or otherwise prevent and discourage high-
risk patients from obtaining medical help.

~~~
konstruktor
That's how home births get their low mortality rate: Midwives (luckily) just
send all the high risk cases to hospital, and even a cancelled home birth
where the actual birthing happens in the hospital would count towards the
hospital's mortality rate.

------
bryans
It's amazing how easy it is for tiny mistakes to result in serious
consequences.

I have a medical condition that took over two years to officially diagnose.
During one of my hospital stays toward the beginning of that ordeal, a doctor
had decided that my issue required major surgery involving the removal of an
organ. Less than one day before the scheduled surgery, the doctor decided to
do "one more test" for an easily treatable condition. As it turned out, he had
misread a previous doctor's note suggesting a possible diagnosis, as a
dismissal of the diagnosis.

I'll never know whether the confusion was due to poor handwriting or poor
attention to detail, but I feel lucky that the error was caught in time. I met
multiple people during my numerous, lengthy visits whom I suspect were not as
lucky.

------
Alex3917
"If medical errors were a disease, they would be the sixth leading cause of
death in America—just behind accidents and ahead of Alzheimer's."

This is wrong, it's _at least_ the third leading cause of death. And
realistically if you don't smoke and you exercise once in a while, medical
'oopsy daisies' are probably your #1 risk of death:

C.f. The IOM's report To Err is Human:
[http://wps.pearsoneducation.nl/wps/media/objects/13902/14236...](http://wps.pearsoneducation.nl/wps/media/objects/13902/14236351/H%2007_To%20Err%20Is%20Human.pdf)

And then also read Lucian Leape's commentary in JAMA on why it is probably a
huge underestimate:
<http://jama.jamanetwork.com/article.aspx?articleid=192842>

(Leape is one of the authors of the original IOM report, and the report cites
a lot of his own research, including his study estimating that only 5% of
medical errors are ever discovered.)

C.f. also Barbara Starfield's estimate in JAMA:
[http://jama.jamanetwork.com/article.aspx?articleid=192908#RE...](http://jama.jamanetwork.com/article.aspx?articleid=192908#REF-
JCO00061-1)

Realistically, all of these estimates are at the low end. In fact most of them
only count deaths in hospitals (and severely undercount them), when at least
half of all medical errors are thought to happen at local doctors offices,
plastic surgery clinics, nursing homes, etc.

C.f. also the CDC figures for Hospital Acquired Infections, which IIRC the IOM
report doesn't count as being medical errors:

<http://www.cdc.gov/HAI/pdfs/hai/infections_deaths.pdf>

My personal rule of thumb is to avoid taking any drugs or getting any non-
trivial medical procedure unless I've read at least three books about it. The
problem is that all the papers published in medical journals are basically
complete bullshit (except the occasional well-done NIH ones), which means if
you want real information about a given drug then the only way to get it is to
subpoena the FDA, or read a book written by someone who has.

The way drug approval works is that you need 2 tests demonstrating that the
drug is better than a placebo, but you're allowed infinite tries to get there.
So often a drug will be better than a placebo in only 2 out of 10 trials, but
it will still get approved and only those two trials will get published in
medical journals. And then those journal articles will have very little in
common with the actual data from the FDA trials because the pharma companies
completely spin it, which is why the vast majority of the most popularly
prescribed drugs are not only no more effective than placebos, but in fact
significantly worse when you look at the total quality/length of life.

~~~
grueful
I think one of the major turning points in the future will be to trigger a
"space race" which makes a grand project of developing substantive
improvements to medical care and quality of life.

There have been significant improvements here motivated by e.g. battlefield
medicine, and great results out of academic or humanitarian labs, but much of
our current work is stuck in a loop between patents and the FDA approval
process. Good intentions aside, the system acts to motivate certain patterns
of action in order to stay profitable and continue growing year-to-year which
aren't optimal for our long-range interests.

How one would go about motivating such a grand project - I have no idea.
Perhaps it's a matter of continuing to make such small improvements as we can
until the system is primed for one giant leap. The road of progress was never
a well-paved or straight one except in hindsight.

I think that small teams and open sharing of knowledge are both key
ingredients. The amount of resources currently in play in medicine is
staggering, but social systems tend to lose efficiency very quickly as they
scale. Perhaps startup culture will be a key piece in making this happen, but
the timescales involved in speculative medical research tend to be beyond the
scope of the typical VC-backed endeavor.

~~~
derleth
> a "space race" which makes a grand project of developing substantive
> improvements to medical care and quality of life.

How about a "space race" to destroy destructive nonsense like homeopathy,
anti-vaccine idiocy, reiki, and all of the other non-scientific crap people
try to use instead of real medicine.

Getting rid of quackademic medicine would be a good first step.

<http://en.wikipedia.org/wiki/Quackademic_medicine>

[http://www.sciencebasedmedicine.org/index.php/quackademic-
me...](http://www.sciencebasedmedicine.org/index.php/quackademic-medicine-
trickles-out-to-community/)

~~~
grueful
I'm all for that. The key problem is defining it. There exist historical
examples of quackery which wasn't, e.g. hand washing.

Stricter rules about null hypothesis testing would be a start, but the bigger
problem is one of education. We're still plagued by government that gives the
nod to creationism and horrifically distorted sex ed in public schools.

I'd like to say we've become empirical enough about what practices we place
belief in that we could just treat all cases of quackery as malicious fraud -
but the very prevalence of such issues tends to support the opposite
conclusion.

~~~
Alex3917
"There exist historical examples of quackery which wasn't, e.g. hand washing."

And homeopathy, which even James Randi admits was more effective than western
medicine in the 1800s. (In the video that was submitted to HN recently.)

~~~
carbocation
That's very misleading without providing proper context.

In Hahneman's time, medicine was actively harmful and virtually never actively
helpful. The risk benefit analysis would not come out in favor of getting
treatment.

In contrast, homeopathy does nothing. It's placebo. And giving placebo, it
turns out, is safer than actively sticking dirty instruments into your
patient's bloodstream and giving them bacteremia.

In that context, the statement makes sense, but is still obviously tongue in
cheek. Homeopathy never worked, but medicine at the time actively harmed.

~~~
Alex3917
"In contrast, homeopathy does nothing. It's placebo."

Well, yes and no. It is a placebo, but the research seems to show that
placebos do significantly more than nothing, at least for some diseases (pain,
depression, etc.).

The comment I was replying to was asking for examples of where things that
were once believed to be quackery were later vindicated. At the time
homeopathy was believed to be quackery. In fact the reason the AMA was
launched was to combat homeopathy because it was cutting into their profits;
one of their first acts was to launch a 'propaganda department' to scare
people off of homeopathy. (Essentially the AMA was founded to kill people.
They knew they were less effective than homeopathy at the time and they knew
they were killing people, but they just didn't care because they wanted the
money.)

The point is though that at the time homeopathy was actually significantly
better than western medicine. Now if the definition of something not being
quackery is if it's the best treatment available to us at the time, then
homeopathy couldn't have been quackery by definition, since it was in fact the
most scientifically advanced (or however you'd phrase it) form of medicine
available at the time.

~~~
Alex3917
@carbocation

You can call it whatever you want, but the fact remains that if homeopathy was
quackery then western medicine was the whole duck.

Also, it's not really fair to say that homeopathy was better merely by
accident or that it wasn't scientific, since they're the ones who pioneered
evidence based medicine. It might have been completely wrong, but it _was_
scientific. They at least tested their ideas empirically unlike western
medicine at the time, which by any reasonable definition must make it more
scientifically advanced than the alternative.

~~~
carbocation
I am surprised to see that we disagree on the facts as well as the
interpretation of them.

I don't think the literature is nearly as scientific as you seem to think it
is, nor do I credit Hahnemann with the shift to empiricism in medicine, which
came later.

Again, just saying that medicine was harmful and that Hahnemann was observant
does not make homeopathy of the time scientific.

~~~
Alex3917
"I don't think the literature is nearly as scientific as you seem to think it
is, nor do I credit Hahnemann with the shift to empiricism in medicine, which
came later."

Well I should admit that I'm not an expert on this, but if you read the JAMA
book review of the book I mentioned above:

"By taking the homeopathy of that period seriously himself, Haller is able to
remind readers that 19th-century homeopaths pioneered systematic drug-testing
research, challenged the dangerously depleting procedures of mainstream
physicians at that time, established rigorous professional standards, and
valued advanced education at least as highly as their mainstream counterparts
did. It was not without reason that homeopaths considered the bases of their
approach to medical problems to be more logical and more promising than the
inherited tradition of the ancients, upon which mainstream physicians still
based their practices."

You have to remember also that 'scientific' is a relative term. Placebo
controlled trials weren't invented until the 50s. And doing properly
controlled placebo trials (with active placebos) is very rare even today.

Homeopathy of the 1860s and 1870s might not seem at all scientific by today's
standards, but that doesn't mean it wasn't a significant advance in science at
the time. (And by the way this was well after Hahnemann, who did most of his
work on homeopathy in the 1810s and was already long dead by this time.)

------
lostlogin
It would be interesting to see stats compared between 'socialized' systems (we
call it the public system) and private systems. When everyone has the same
boss (Minister of Health) and is working within the same rules and guidelines
it must do something to the stats. We do have a private healthcare service,
but its basically restricted to simpler day stay (or slightly longer stays)
surgery and less complex procedures. There are no private emergency healthcare
hospitals here that I know of. New Zealand is the country. The system is far
from perfect here, but I'm yet to learn of a system I'd prefer.

------
ivix
The NHS already provides this data:

<https://indicators.ic.nhs.uk/webview/>

The spreadsheet:

[http://indicators.ic.nhs.uk/download/SHMI/July_2012/Data/SHM...](http://indicators.ic.nhs.uk/download/SHMI/July_2012/Data/SHMI.xls)

Sadly, you can pretty much guess the results. Poorer areas = higher death
rates.

------
w1ntermute
In an industry as tightly regulated as medicine, it's not surprising that such
enormous inaccuracies have not been worked out. No matter what medical
professionals might say about wanting to save people's lives, the ubiquitous
motivator of economics is a much more powerful incentive. Unfortunately, since
the industry is not open to being influenced by the free market, it will be
very difficult to break into the industry and jump start that innovation.

It will be very interesting to see if developing countries manage to leapfrog
our current system and establish a medical industry that is less dependent on
people.

------
Riesling
The current state of medicine is extremely frightening.

Note 1: My comments here relate to the German health system, with which I am
most familiar with, but I assume that other systems work similar, if not less
efficiently.

In my opinion, there are many other problems in the broad field of medicine,
but the following two points could be resolved with the support of IT, so I
will confine my remarks to those.

1\. Plausibility checks

Virtually no plausibility checks will be carried out in todays hospitals.
Often conflicting drugs are prescribed, which produce uncomfortable side
effects. One should start to make all medications and treatment measures
subject to automatic (computer based) plausibility checks. This would also
lead to a cognitive relief of the clinical staff.

2\. Statistical evaluations (data mining)

The lack of inadequate statistical analysis is another concern. Germany has
begun to build a national cancer database only this year. One can only imagine
what valuable information is hidden in those statistics and have been missed
up to this day. Imagine an international database in which all patients who
are admitted as an emergency to the hospital are captured statistically. This
data could be stored completely anonymous. The only thing of importance would
be the provision of relevant laboratory values and the patient's symptoms
described in the context of the (verified) final diagnosis. Such a system
could support the finding of completely new knowledge (data mining) and
support the doctor in finding the right diagnosis.

And of course the hospitals need strong incentives to implement these
measures. Which is why I support the author's call for absolute transparency.

------
nancyhua
I feel sorry for everyone involved in this complex industry, no arena of which
is aligned with the goal of people's long term health.

The common sense suggestions in this article are a good step towards improving
things by increasing transparency and accountability via documentation but may
not address the root problems.

------
rayiner
But the malpractice lawyers are terrible! Tort reform!

~~~
mkopinsky
You joke (I think), but tort reform actually has the potential to
enable/encourage some of what is mentioned in this article - when mistakes are
something that we can't even talk about for fear of gazillion dollar
repercussions, it's hard to do anything to fix the problem.

------
marshallp
The only real solution to healthcare is to reduce costs by eliminating
hospitals/doctors altogether using big data/telerobotics/smartphones. Sadly,
because of the AMA and FDA this innovation will have to occur offshore first.

~~~
daeken
This seems deeply, deeply misguided. Let's say you eliminate hospitals --
where are you going to get surgery? Even if it's done by remotely controlled
robots, it's not exactly going to happen in your house, since it's not a
sterile environment. What about when you break your leg; do you expect a robot
ambulance to drive up an treat you in your driveway?

Hospitals and doctors alike have to change to make things better -- more
advanced technology, different business models, etc -- but throwing them away
entirely is just downright silly.

~~~
marshallp
Yes, the robots should drive to your driveway in a bubble of sterility.

I'm not suggesting this happen by tommorrow, just that it is technically
possible with the enough investment.

I'm just suggesting that when it comes to medical matters innovation is
happening at a snails pace.

The aerospace industry manages to lose almost no lives, while the medical
industry loses people left and right. There's something deeply wrong there.

Recently, Vinod Khosla suggested 80 percent of doctors are superfluous and
medicine still operates in a voodoo magic kind of way for the most part.

~~~
Gatsky
Despite the revelation on HN that there are high error rates in medicine, this
problem has been well known for a long time.

So here is the easy problem: using information technology to help doctors
deliver high quality healthcare.

Here is the hard problem: replacing the entire health system with
technofantasy buzzword medicine.

If no one can solve the easy problem, why should we listen to anyone who
thinks they can solve the hard problem? That's the voodoo magic.

If you want to get rid of 80% of doctors, then you would need to think of how
to replace the role of the doctor in the following situations, which crop up
every day in the hospital:

Making the decision to stop chemotherapy balancing the risks and benefits in a
patient with advanced cancer that has failed multiple lines of treatment.

Managing a patient with borderline personality disorder who tried to hang
herself early that day and needs to be observed medically who is demanding at
all costs to walk outside and smoke.

Managing a patient with chronic severe abdominal pain of unknown aetiology,
that has had all the tests known to man, multiple surgeries etc with no
result.

Managing a patient with severe emphysema who passes out at home from breathing
failure, comes to ED, gets resuscitated, then rips off the mask and drives
home on her scooter. Repeat this 150 times a year.

A woman has advanced cancer. She is dying, no treatment will benefit her. The
family decides to keep her comfortable. Her last son finally comes back from
overseas and starts demanding that everything be done to save her.

So this is the thing... Doctors do lots of things, they do tests, they think,
they prescribe drugs, they do surgery etc etc... all of those can be replaced
by other specialised practitioners and probably robots one day. But what they
actually, really do, most of the time, is take responsibility for a patient,
in the face of often great uncertainty and very imperfect science.

~~~
ippisl
The OP has got something right and something wrong. Yes replacing all of
healthcare with machines is not possible today. But we know that in order to
capture the full benefits of a technology, usually a new business needs to be
started, because old businesses are resistant to changes. That's true inside
and outside of healthcare.

And about the role of doctors: Pilots do also have huge responsibility. Part
of them being responsible is being able to defer themselves to checklists, to
algorithms and to machines when needed, which is practically always in their
profession.

Doctors resist that need. They resist checklists. They resist expert systems.
They resist evidence based medicine(why else is evidence based medicine so
slow ?).

How would healthcare looks if our the people who treated us stopped resisting
to those factors?

