Op-Ed Contributor - Just Medicine - NYTimes.com

Waste in the health care system costs America upwards of $1 trillion per year. Much of this waste is generated or justified by the fear of legal consequences that infects almost every health care encounter. The good news is that it would be relatively easy to create a new system of reliable justice, one that could support broader reforms to contain costs.

The legal system terrorizes doctors. Fear of possible claims leads medical professionals to squander billions in unnecessary tests and procedures. "Defensive medicine" is so prevalent that it has become part of standard protocol — for example, mandatory pre-operative exams even where the patient record is current, and even for minor procedures.

Like a cancer, this legal anxiety corrodes relationships with patients. Doctors and nurses don't want to speak up for fear of assuming legal liability, and this causes unnecessary errors. Under instructions from lawyers, they don't apologize or offer explanations when things go wrong. They sometimes conceal errors in an effort to avoid a legal ordeal. Even in ordinary daily encounters, an invisible wall separates doctors from their patients. As one pediatrician told me, "You wouldn't want to say something off the cuff that might be used against you."

As the culture of health care disintegrates, costs rise further. In hospitals, self-protective bureaucracy multiplies. Patient encounters require witnesses, wasting professional time. Patients, sensing distrust, demand second opinions even on minor ailments. There are psychological costs as well: doctors no longer find professional fulfillment and drop out in their prime. Forget productivity — sometimes doctors avoid using e-mail so they don't have to put things in writing.

Restoring a foundation of trust requires a new system of medical justice. Medical cases are now decided jury by jury, without consistent application of medical standards. According to a 2006 study in the New England Journal of Medicine, around 25 percent of cases where there was no identifiable error resulted in malpractice payments. Nor is the system effective for injured patients — according to the same study, 54 cents of every dollar paid in malpractice cases goes to administrative expenses like lawyers, experts and courts.

America needs special health courts aimed not at stopping lawsuits but at delivering fair and reliable decisions. A special court would provide expedited proceedings with knowledgeable staff that would work to settle claims quickly. Trials would be conducted before a judge who is advised by a neutral expert, with written rulings on standards of care.

With a special health court, damages would consist of all lost income and medical costs, plus "pain and suffering" based on a set schedule depending on the severity of the injury. All information about each incident, including details learned in settlements, would be compiled and disseminated so that doctors and hospitals could learn from their errors. Proponents of special health courts have estimated that the total cost of such a new liability system would be about the same as the existing system — less than 2 percent of America's total health care costs. One benefit would be that the quicker, streamlined system would compensate far more people, with drastically lower legal costs. Most important, it would restore faith in the reliability of medical justice.

A court that freed doctors from worries about unnecessary and unreasonable malpractice claims would transform the culture of health care. Doctors could finally emerge from their defensive cocoons and start focusing on the health of the patient. Hospitals would concentrate on productivity and safety. Doctors could be more candid about decisions for terminally ill patients, and offer more guidance about high-risk procedures.

This country has a long tradition of courts and tribunals to deal with issues like bankruptcy that require special expertise. Nowhere is that expertise, along with the stability and trust it would bring, more needed than in health care.

Several prominent hospitals, including New York Presbyterian, have said they are interested in being part of a health court pilot project. Some large consumer and patient safety groups support the idea. The fastest way to do this would be for Congress to authorize and finance pilot courts around the country. These ideas already have some bipartisan support: Bills for alternative medical justice systems have been introduced in Congress.

Cutting back on the notorious inefficiency of American health care is essential to achieve universal care, as well as make the American economy more competitive. Part of the solution — overhauling the reimbursement model so that doctors get paid only for what is needed — is unavoidably complex. But restoring trust in law, the other essential reform, can be accomplished with the creation of reliable courts.

Philip K. Howard, a lawyer, is the chairman of Common Good, a legal reform coalition, and the author of "Life Without Lawyers: Liberating Americans From Too Much Law."

http://www.nytimes.com/2009/04/02/opinion/02howard.html?th=&emc=th&pagewanted=print

National Health Service (UK) - Health News

Behind the headlines provides an unbiased and evidence-based analysis of health stories that make the news.

The service is intended for both the public and health professionals and endeavours to:

• explain the facts behind the headlines and give a better understanding of the science that makes the news,
• provide an authoritative resource for GPs which they can rely on when talking to patients, and
• become a trusted resource for journalists and others involved in the dissemination of health news.

Behind the headlines is the brainchild of Sir Muir Gray, chief knowledge officer of the NHS and a lifelong advocate of patient empowerment.

"Scientists hate disease and want see it conquered," said Sir Muir. "But this can lead to them taking an overly optimistic view of their discoveries which is often reflected in newspaper headlines.

"Our service has more time to examine the science behind the stories. Independent experts check the findings and assess the research methods to provide a more considered view." 

http://www.nhs.uk/News/Pages/NewsIndex.aspx

A World of Hurt - Doctor Fights Doctor, Putting Workers’ Injuries in Dispute - NYTimes.com

Dr. Hershel Samuels, an orthopedic surgeon, put his hand on the worker's back. "Mild spasm bilaterally," he said softly. He pressed his fingers gingerly against the side of the man's neck. "The left cervical is tender," he said, "even to light palpation."

The worker, a driver for a plumbing company, told the doctor he had fallen, banging up his back, shoulder and ribs. He was seeking expanded workers' compensation benefits because he no longer felt he could do his job.

Dr. Samuels, an independent medical examiner in the state workers' compensation system, seemed to agree. As he moved about a scuffed Brooklyn office last April, he called out test results indicative of an injured man. His words were captured on videotape.

Yet the report Dr. Samuels later submitted to the New York State Workers' Compensation Board cleared the driver for work and told a far different story: no back spasms, no tender neck. In fact, no recent injury at all.

"If you did a truly pure report," he said later in an interview, "you'd be out on your ears and the insurers wouldn't pay for it. You have to give them what they want, or you're in Florida. That's the game, baby."

Independent medical exams are among the most disputed components of New York's troubled workers' compensation system. Under that system, workers with bona fide injuries are entitled to medical care and replacement wages, usually paid for by their employer's insurer.

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http://www.nytimes.com/2009/04/01/nyregion/01comp.html?th=&emc=th&pagewanted=all

Return to The House of God - Medical Resident Education 1978–2008 : Martin Kohn and Carol Donley

Reflections on Samuel Shem's The House of God and its impact on medical resident education

Samuel Shem's The House of God is widely regarded as one of the most influential novels about medical education in the twentieth century. Decades after being published, this satire still raises issues of how interns and residents are trained and how patients experience their treatment. Return to The House of God is a scholarly and creative response to the best-selling novel, exploring its impact on medical education, residency training, and the field of literature and medicine.

Among the contributors are some of the foremost scholars in medical humanities and the most highly respected physician- and nurse-writers. This collection responds to the surprises, challenges, and wit of The House of God. Some contributors point out constructive changes that the novel stimulated, while others see today's medical residency experiences as still in need of a cure. Some contributors appreciate the novel's black humor regarding overworked residents in hospitals, while others wince and deplore it. A few even take their cue from Shem and transform their experiences into literature. Final words of the volume come from Janet Surrey, Shem's wife, and Stephen Bergman himself, aka Sam Shem, reflecting on thirty years of doctoring and writing.

http://dept.kent.edu/upress/books/Kohn2.htm

Fourteen Stories - Doctors Patients and Other Strangers : Jay Baruch

"These edgy, heartfelt, wryly humorous stories, told from the authentic viewpoints of both young doctors and a wide canvas of patients, are wonderfully engrossing. They tell us what it's really like to doctor, to patient, to suffer and to redeem. A joy to read."
—Samuel Shem, author of The House of God, Mount Misery, and The Spirit of the Place

"Plunging into one of Jay Baruch's stories is like finding yourself in a busy Emergency Room at two in the morning—here you will meet characters whose lives are urgent and not always what they seem on the surface. Like his characters, Baruch's writing is vibrant and intense, and his vision is prismatic. He speaks in many voices, among them doctor, patient, family member, medical student, and even ER janitor, and so examines the world of health and illness from many points of view. I appreciate the way Baruch acknowledges the complexity of life, and then dissects it for us into so many planes of action and consequence."
—Cortney Davis, author of I Knew a Woman: Four Women Patients and Their Female Caregiver and Leopold's Maneuvers

An emergency physician and faculty member at Brown Medical School, Jay Baruch has long been fascinated by how illness can make people strangers to their own bodies, how we all struggle to maintain control as the body decays and life slowly becomes unrecognizable, and how health professionals discove r and struggle with the limits of their own competence and compassion. In Fourteen Stories, Baruch doesn't present a series of clinically based essays but a rich collection of short fiction that gives voice to a variety of people who, faced with difficult moral choices, find themselves making disturbing self-discoveries.

http://dept.kent.edu/upress/books/Baruch_J.htm

Skin Deep - With a Buzz Cut, I Can Take On Anything - NYTimes.com

I GOT a buzz cut last July, four days before radical open surgery to remove my cancerous prostate. I told family and friends that I did it for reasons of ease and style: I wanted to avoid the heartbreak of hospital hair, that lank and greasy thatch that repels visitors.

But I was lying.

In a time of utter vulnerability — having already weathered three months of post-diagnosis ups-and-downs — I needed the primal ferocity that a buzz cut proclaims. I needed to look like a soccer thug or an extra from “Prison Break” to help get me through surgery, the physical indignities of post-op life, and my subsequent radiation and hormone therapy. I still do. My prostate cancer and its treatment have transformed me — in body and spirit — and the buzz cut has helped me cope with those changes.

I agree with the late Anatole Broyard, who wrote in his memoir “Intoxicated by My Illness,” “It seems to me that every seriously ill person needs to develop a style for his illness.” And the buzz is what I want to wear, what I need to wear, in this wicked waltz with cancer.

I’m an optimist, but not a day goes by in which I don’t wonder whether I’m going to die before I ever imagined. The buzz cut helps me scowl, glower and say “No!” to that thought.

Broyard, a New York Times literary critic who died of prostate cancer, also wrote, “Only by insisting on your style can you keep from falling out of love with yourself as the illness attempts to diminish or disfigure you.”

In some ways, I’ve already fallen out of love with my old self.

There’s a book-jacket photo taken of me early last year, before I learned that I had cancer, and I can’t stand to look at it. Can’t bear to look at my floppy mop of Glen Campbell hair, the innocent grin. I want to smack that cheery and naïve face and bellow: “Boy, you don’t know nothin’!”

That poor guy, at age 50, doesn’t yet know that he has cancer, that it will prove to be shockingly aggressive and that, among other indignities, his libido will take a sabbatical (on Ibiza, I hope).

For me, the buzz cut is a visible bulwark against the tide of emasculating side effects caused by the treatment for prostate cancer.

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http://www.nytimes.com/2009/03/26/fashion/26skin.html?src=sch

A World of Hurt - For Injured Workers, a Costly Legal Swamp

The hurt workers wait on benches at the Queens office of the New York State Workers’ Compensation Board.

People like Hopeton Watkis, 64, a laborer, who lost two teeth when he fell and hit a wheelbarrow.

Or Rajcoomar Jagan, 50, a construction worker, who injured a leg falling off a scaffold.

Or Vicki Marquez, 32, a retail sales associate, who hurt her elbow hauling clothes.

They come to the board seeking authorization for medical treatment and replacement wages — in short, a quick and fair resolution from a system set up to replace fractious court fights between employers and employees.

What they find instead is a subbasement of the legal world, a $5.5 billion-a-year state-run bureaucracy that, an examination by The New York Times found, struggles to treat workers with due speed, protect employers from fraud or mute tensions in the workplace.

These struggles are particularly evident each day in Queens, the state’s busiest hearing office, where The Times spent 18 months attending hearings, reviewing cases and interviewing participants, virtually none of whom defended the system as efficient.

At some hearings, as judges looked on, lawyers chatted on cellphones, cracked bawdy jokes or read newspapers during testimony. Expert witnesses seemed biased to the point of caricature. Claims dragged on, but hearings seldom exceeded a few blurred minutes, rarely proved conclusive and were conducted in baffling shorthand.

Mr. Watkis waited two years to get his front teeth fixed. Ms. Marquez had to postpone elbow surgery for a year until the board allowed it. Mr. Jagan exhausted three years trying to get compensated, only to be denied all benefits, a decision that stunned even some insurance company lawyers.

“Comparing Supreme Court, say, to this is like comparing a hospital to a MASH unit,” said Anthony Pizza, a lawyer for insurance companies. “A lot of it is meatball justice.”

Workers’ compensation systems across the country are troubled, and reform efforts are under way here. But New York, a pioneer of the concept and home to the nation’s second-largest system, has some signature claims to dysfunction and is widely recognized as the most adversarial.

Though its commissioners largely function as a legal tribunal, most are not lawyers but relatives or allies of politicians, appointed usually without regard to experience in the field.

Though many cases turn on medical evaluations, the board has not had its own medical director for nearly a decade. Decisions are often driven by the opinions of doctors certified by the state as so-called independent medical examiners. Yet claimant lawyers and treating doctors say these examiners often understate workers’ ailments to win business from the insurers who pay them.

Fines for infractions are usually small, and some insurers ignore paying them for years without consequence. A few months ago, New York City agreed to produce $1.1 million in penalties, some years overdue.

Workers are known to fabricate claims, while employers can be equally uninhibited about pressuring injured workers against filing for compensation, or punishing them if they do.

And everywhere the system tolerates delays that can make the injured wait months or years for money and care. Statewide, in about one in six cases, insurers dispute that injuries are real or were suffered on the job. Until recently, these cases had averaged nearly nine months to resolve. And many of them remain unresolved years later.

Even unchallenged cases plod on. A.I.G., the insurance company, said a review of its 2007 New York cases found that those involving missed work took on average 802 days to reach a final stage, 30 percent longer than in the rest of the country.

A recent task force study found that when insurers reject a medical procedure, say, an operation, it takes more than three or four months for the board to settle the dispute. The delay can mean that injuries heal slowly or improperly, and in 75 percent of those cases, the worker’s need for the procedure is upheld.

Zachary S. Weiss, the chairman of the compensation board since late 2007, said that given the scope of what needs to be done, change must be incremental.

“There are millions of things I would like to correct and I’d like to correct them all immediately, and I can’t,” Mr. Weiss said.

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http://www.nytimes.com/2009/03/31/nyregion/31comp.html?src=sch

Depression Tests Urged for Teenagers - NYTimes.com

An influential government-appointed medical panel is urging doctors to perform routine screening on all American teenagers for depression, a step that acknowledges that nearly two million teenagers are affected by this debilitating condition.

Most are undiagnosed and untreated, said the panel, the United States Preventive Services Task Force, which sets guidelines for doctors on a host of health issues.

The task force recommendations appear in the April issue of the journal Pediatrics. And they go further than the American Academy of Pediatrics' own guidance for screening of teenage depression.

An estimated 6 percent of American teenagers are clinically depressed. Evidence shows that detailed but simple questionnaires can accurately diagnose depression in primary-care settings like a pediatrician's office.

The task force said that when followed by treatment, including psychotherapy, screening can help improve symptoms and help children cope. Because depression can lead to persistent sadness, social isolation, school problems and even suicide, screening to treat it early is crucial, the panel said.

The task force is an independent panel of experts convened by the federal government to establish guidelines for treatment in primary care. Its new guidance goes beyond the pediatrics academy, which advises pediatricians to ask teenage patients questions about depression. Other doctor groups advise screening only high-risk youngsters.

Because depression is so common, "you will miss a lot if you only screen high-risk groups," said Dr. Ned Calonge, task force chairman and chief medical officer for the Colorado Department of Public Health and Environment.

The group recommends research-tested screening even for children without symptoms. It cited two questionnaires that focus on depression tip-offs, like mood, anxiety, appetite and substance abuse.

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http://www.nytimes.com/2009/03/30/health/30depression.html?em

Foreign Ways and War Scars Test Hospital

The man from Somalia sat nervously in an examining room at Hennepin County Medical Center, gingerly brushing his fingertips against the left side of his head.

"You're having surgery to remove shrapnel from your skull," Dr. Steven Hillson told him, pausing to let a Somali interpreter dressed in a black head scarf and a floor-length skirt translate.

The patient, Abdulqadir Jiirow, 31, nodded and explained that the shrapnel had been there since 1991, when he was 14 and civil war broke out in Somalia and an artillery shell smashed into his home. It had not bothered him much until recently, when he began to work at a meat-packing plant and the helmet and goggles needed for the job pressed on it painfully.

Mr. Jiirow said he worked in a small town several hours away and shared an apartment with other Somalis, while his wife and child lived in Minneapolis. He saw them on weekends.

"It's still astonishing," the doctor, shaking his head, said after Mr. Jiirow left. " 'Someone sent artillery into my home.' But it's common."

Hennepin County Medical Center, a sprawling complex in downtown Minneapolis near the Metrodome, offers an extraordinary vantage point on the ways immigrants are testing the American medical establishment. The new arrivals — many fleeing repression, war, genocide or grinding poverty — bring distinctive patterns of illness and injury and cultural beliefs about life, death, sickness and health.

In a city where Swedes and Norwegians once had separate hospitals, Hennepin spends $3 million a year on interpreters fluent in 50 languages to communicate effectively with its foreign-born patients.

Many arrive with health problems seldom seen in this country — vitamin deficiencies, intestinal parasites and infectious diseases like tuberculosis, for instance — and unusually high levels of emotional trauma and stress. Over time, as they pick up Western habits, some develop Western ailments, too, like obesity, diabetes and heart disease, and yet they often question the unfamiliar lifelong treatments these chronic diseases need.

Some also resist conventional medical wisdom or practices, forcing change on the hospital. The objections of Somali women to having babies delivered by male doctors has led Hennepin, gradually, to develop an obstetrical staff made up almost entirely of women.

Doctors here say that for many of these newcomers, the most common health problems, and the hardest to treat, lie at the blurry line between body and mind, where emotional scars from troubled pasts may surface as physical illness, pain and depression.

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http://www.nytimes.com/2009/03/29/health/29immig.html?em

The Difficulty of Treating Patients With Many Illnesses - NYTimes.com

Mazie Piccolo has so many health problems it's hard to keep track. Congestive heart failure makes her short of breath and causes her legs to swell. An abnormal heart rhythm raises her risk for stroke. Arthritis in her knees makes it hard for her to get around, and she can no longer drive.

Mrs. Piccolo, 84, of Rosedale, Md., also has osteoporosis, and she has fallen several times in the past few years, once breaking her pelvis. On top of all these medical ailments and others — high cholesterol, high blood pressure, gastric reflux — she has a history of depression, and it is sometimes hard for her to care for her husband, who is even frailer than she is.

Strictly by the book, Mrs. Piccolo should be taking 13 different medications — an expensive, confusing cocktail that has proved too much for her to manage. Other medications that might be advisable cause intolerable side effects, and the more drugs she takes, the greater the risk of dangerous drug interactions.

What is striking about her predicament is not how rare it is, but how common. Two-thirds of people over age 65, and almost three-quarters of people over 80, have multiple chronic health conditions, and 68 percent of Medicare spending goes to people who have five or more chronic diseases.

As a group, patients like Mrs. Piccolo fare poorly by any measure. They linger in hospitals longer, experience more serious preventable health complications and die younger than patients with less complex medical profiles.

Yet people with multiple health problems — a condition known as multimorbidity — are largely overlooked both in medical research and in the nation's clinics and hospitals. The default position is to treat complicated patients as collections of malfunctioning body parts rather than as whole human beings.

"Very often, there is nobody looking at the big picture or recognizing that what is best for the disease may not be best for the patient," said Dr. Mary E. Tinetti, a geriatrician at the Yale School of Medicine.

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http://www.nytimes.com/2009/03/31/health/31sick.html?ref=health