Medial Malpractice Claims - How Can They Be Reduced

Nicholas Bakalar (NY Times Science Section Apr 30) reports that a study published in the British Medical Journal Quality and Safety, concluded that diagnostic errors are the "most common cause of paid claims for malpractice."  Researchers reported that these claims resulted in 28.6 percent of malpractice payments, more than errors resulting from various forms of therapy, or the combined total of payments for errors in obstetrical care, medication error, monitoring mistakes, anesthesia complications combined.

I feel certain that some of these awards may have been made in cases where there, in fact, was no diagnostic error, or that the error played no significant role in the eventual outcome.  But I am also certain that there may have been other serious errors which never were brought to a lawyer's attention.  In any event, the number is what it is - and should be addressed.

Diagnosis is the result of algorithmic evaluation of data by the physician.  A physician begins his diagnostic journey with a detailed history and physical examination.  Progressing algorithmically, he then pursues additional data by requesting various diagnostic tests or procedures.  These may raise the possibility of a number of diagnostic probabilities leading to further, more involved diagnostic plans.  Eventually(and quickly one would hope) he arrives at the actual diagnosis, or the most likely diagnosis.

A computerized form of such appropriate diagnostic methodology will significantly reduce the possibility of physician diagnostic error.  Most physicians are not the "Dr. House," or some other amazing diagnostic genius, depicted of various TV dramas.  Physicians are human - they consistently make mistakes.  Development of this technology should significantly decrease diagnostic errors - especially where major diagnostic dilemmas exist.

But no technology will be able to correct improper input.  The physician who does not take an accurate history, or who does not detect an abnormal pulse, or who does not hear an abnormal heart sound, or who evaluates the size of a person's liver incorrectly will not input correct information.

 "Garbage in - Garbage out!"

Gender Attributes - Is There a Distinction?

In "The Tangle of the Sexes" (NY Times Sunday Review, Apr 21) Carothers and Reis argue that men and women are "less different than we like to think."  The implication is that  the sexes belong to the same taxon (sort of like "species") and any noticeable difference between the sexes such as in emotional reactions, scientific abilities, social support manifestations, or intimacy are really just "dimensional" and that there are no real gender differences. We are all basically from the same species-specific gene pool and any distinctions are not sex-related.

The authors evaluated 122 attributes from more than 13,000 individuals and found that "one conclusion stood out:  instead of dividing into two groups, men and women overlapped considerably on attributes" such as those given above as examples.

But wait a minute - what have we really learned here.  We have learned that there is more overlap than there is distinction.  This, however, proves nothing about whether significant distinction exists in areas that do not overlap.  If we were to compare the attributes of rocket scientists with those of ordinary workers, I feel certain there would be considerable overlap in most of them.  It's not the overlap - it's the distinction that matters!  It's the distinction we notice - not the commonality.

Men and women are genetically distinct.  It is not reasonable to believe that the only difference this yields is one of gender.  Though the overlap of similarities is obviously huge, both physically and attitudinally, one cannot conclude that no distinctions of significance exist at the non-overlapping points on the curve.

Remember - 90% of human DNA has commonality with that of a chimpanzee.  It's the differences that that make us distinct - not the similarities.

Aesop's Future

A quote  from a piece by Edward Hoagland which appeared in the Sunday Review Section of the March 24, 2013 edition of the New York Times.  Entitled "Pity Earth's Creatures" Hoagland bemoans the potential future loss of Aesop's animal metaphors as we, as Hoagland puts it, "shred our habitat."

Mostly that's over......The tortoise and the hare, the lion saved by the mouse, the monkey who would be king, the dog in the manger, the dog and his shadow, the country mouse and the city mouse, the wolf in sheep's clothing, the raven and the crow, the heron and the fish, the peacock and the crane.  From where will we draw replacement similes and language?.........Hogging the spotlight, playing possum, resembling a deer in the headlights, being buffaloed or played like a fish.  Will the clarity of what is said hold?  A "tiger, a "turtle," a "toad."  After the oceans have been vacuumed of protein and people are eating farmed tilapia and caked algae, will Aesop's platform of markers remain?

"Three Cheers for the Bloomberg Ban" - What??

In "Three Cheers for the Nanny State" (NY Times Mar 25) Sarah Conly argues for the Bloomberg Ban on large-size sugary drinks.  The argument is that the general public is just too uninformed or is just not able to fully research the data, or that we, as human beings, all suffer from the bias that bad things just won't happen to us.  In other words, we, as a species, are incapable of making proper, well analyzed decisions affecting our health and welfare.

One has to wonder if we are capable of deciding who to marry, what professions to pursue,  or when to seek medical help etc. - or are these decisions also best left in the hands of a more sophisticated and knowledgable party.    I am certain that such decisions may also affect the general health and welfare.

Though, admittedly, many drinkers of these large-sized sodas will remain quite healthy, Conly proceeds to equate a ban on these drinks to government-imposed bans on excessive highway speed.  After all, she says, many of us are capable of "safe driving" at 90 mph, so why should we "safe drivers" be limited.  It could also be argued that a ban on excessive alcohol intake, or a ban on cell phone use is a similar infringement on individual rights.  After all there are many who can drive very safely with excessive alcohol blood levels, and many who may drive with, perhaps, even greater caution when using a hand-held device.  Those bans are in place for the greater good, so why not ban large sugary drinks?

But there is a great difference between banning acts that affect others and banning activities that affect only the concerned individual.  We do not ban individuals from smoking - only in places where it affects the health of others.   The limitations on drivers clearly affect the health and welfare of those who share their vehicles and their roadways.

Children comprise a separate category.  It is assumed that children cannot be aware of certain dangers and are unable to make appropriate judgements.  The government does have the right as well as the duty to protect them from undue injury in the event that the parents neglect to do so.  Government may ban the sale of cigarettes to children - and even the sale of large-size sugary drinks to children.

But not to an adult.  Unless a large number of purchasers are not just drinking these sodas themselves, but are forcing others to drink them, they should not be banned.

An afternote.  With the ban now in place,  it is the duty of the banning agency to scientifically evaluate the data to determine whether or not this ban has achieved the desired result.  This is not as easy as it sounds.  Controlling variables is such a study will be difficult.

Non-Indicated Medical Diagnostic Procedures - Who Should Pay?

A recent article in the Science Section of the New York Times examined a very prevalent and difficult problem for physicians, namely the right of a patient to "manage" his own diagnostic evaluation, in opposition to the opinions of his physician (Working Together on Costs, February 26.)   The article maintained that patients often "do not want their doctors to take cost into account.............even if those (more expensive) options were only slightly better than the cheaper alternatives."

The issue, unfortunately, frequently results in a physician complying with a patient's request and ordering a potentially expensive diagnostic procedure (e.g. MRI, ultrasound, etc.) even if he feels it is not indicated - "adjusting" the medical record accordingly.  Though, as the article maintains, it is the patient who bears major responsibility for this added cost to medical care, one cannot overlook the physician's complicity.  The doctor often rationalizes that if "I don't order the test, Mr. X will find another physician who will."

Medical insurance should not cover non-indicated procedures.  A patient, however, should not be denied the right to "purchase" a test.   If, in fact, he insists on a non-indicated MRI, he should have the freedom to "buy" one.  Perhaps there could be a new form of insurance policy, priced accordingly, for individuals who are interested in having the option of purchasing such highly-priced, non-indicated diagnostic procedures.

Faith and the Unknown

I find it extraordinary how god-believers use the absence of knowledge as an explanation for the presence of something.  All god arguments are eventually reduced to this principle - since we have no factual explanation, only the existence of a god can be the answer.  It is far more logical to conclude that what is unexplainable today may be explainable tomorrow.  If one uses well-documented history, one must accept this conclusion.  I won't even attempt to argue how far science has already brought us in the understanding of who we are, where we came from, and the universe in which we exist. 

Sure, we do not have all the answers - but what we should really be saying is that "we do not have all the answers yet." One can never logically conclude that the final explanation, for a lack of understanding, is a god - unless, of course, the term god is defined as the repository for what is presently unknown, but may very well be explained at some future time.  It would then follow that this repository is ever-modified, of course, as the knowns and unknowns change.

Faith (or god), some maintain, is necessary to "explain" human emotion and morality.  How else to understand the poetry of a flower, the exhilaration of love, or the human drive to "do the right thing."

Faith can explain nothing.

Faith is believing in something blindly - "blind faith" is a well accepted and, I should add, accurate term.  It is a "fall-back" position.  The fact that science has yet to completely understand the synapses and cells and transmitters and genes involved in certain emotive cerebral processes cannot mean that they do not exist!  In fact, logic demands that one must consider that they do exist and will, one day, be fully understood.  

Historically humans have always used god or faith to explain the unknown.  When we grow to doubt our faith or god-belief, it has been suggested we pay attention to the innocent faith expressed by children - that is how and where our faith may be restored.  Just remember that the vulnerable, innocent child may well believe that the moon is made of cheese.

One cannot logically conclude that what can't be explained is, in fact, explained by faith and god.  There is no answer to what is unknown - that is why it remains unknown!  

Health Care - Lets Face Some Realities

David Goldhill, in an op-ed article in today's NY Times (Feb. 17), has calculated that a 23-year old employee recently hired by his company at a starting salary of $35,000 will, over her lifetime, have borne a cost of $1.8 million in health care costs - assuming no growth beyond current estimates, that she never has a working spouse, and that she and her dependents never contract a serious illness.  (See full article for the details.)  His piece ends with yet another plan to mitigate this circumstance, suggesting that health insurance be limited to "truly rare, major and unpredictable illnesses."  "In other words," he goes on, "let's cover everyone but not everything."

Yet another potentially reasonable solution to a problem that will be ongoing as long as people demand "life at all costs."  If I were to offer you the choice of virtual poverty v. one more year of life, what would your choice be?  If I were to offer you the choice of virtual poverty v. one more year of your child's life, what would your choice be?  If I were to offer you the choice of virtual poverty v. one more year of life for your 80-year-old parent, what would your choice be?  Until we come to some sort of understanding as to what the actual problems are can we truly get a firm grip on a solution.

The marvels of medicine will continue to grow - new technology, new drugs, new techniques, new prostheses, new computer-activated appliances, the blind will see, the deaf will hear, the lame will walk - new hearts, new lungs, new livers, etc.  but at an extraordinary cost!  To provide all services to all people seems an improbable, if not, impossible achievement.  At some point soon we will have to face the reality of the cost of perpetual health and perpetual life.  At some point soon we will have to face the reality that this goal may be economically and societally unsustainable and that some limitation of services will be required.