er·ror
/ˈɛrər/ Show Spelled[er-er] Show IPA
–noun
1. a deviation from accuracy or correctness; a mistake, as in action or speech: His speech contained several factual errors.
2. belief in something untrue; the holding of mistaken opinions.
3. the condition of believing what is not true: in error about the date.
4. a moral offense; wrongdoing; sin.
A contextual error occurs when a physician overlooks elements of a patient’s environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care.
The above appears in a work by Weiner, et al in the Annals of Internal Medicine last month. I’m terribly poorly read on healthcare QA and medical errors but it appears to be a relatively novel concept. A search by title or keyword for “contextual error” in Medline reveals a total of three articles. The two other than Weiner’s have nothing to do with the idea as his group defines it.
I like the idea; I think it raises important considerations.
I don’t like the way Weiner’s group designed a study to document the prevalence of contextual errors.
He sent undercover patients into doctor’s offices with regular complaints: a diabetic with blood sugar out of control. Raging asthma. Need for a hip replacement. They functioned as the “secret shoppers” of health care.)
In each case the actors could present a standard version of the problem, or versions where they offered a clue to an extra fact, something all physicians would agree should change the plan of care, if it were known. For the patient with raging asthma, one clue was “it’s been worse since I lost my job.”
A smart doctor would ask if new financial problems meant the patient could not pay for medicines. With that information in hand, the doctor could readily change to cheaper medications or identify a source of support. If a doctor fails to pick up on that clue, however, then they are likely to add new prescriptions. That would be the wrong decision.
Physicians only asked follow-up questions about those clues to good care about half the time. When there was a problem in the patient’s life situation, like inability to afford medicines, doctors only came up with an appropriate plan of care one time in five. Four times out of five, the patient left the office without receiving good care.
I’m not sure the example given represents a mistake on the part of the physician. Not in full. Not enough to claim,
That error rate is unacceptable.
Patient non-compliance with therapy is a failure of the medical system, but it is largely a patient side error. I’m not denying the responsibility of providers to promote social health and situations that facilitate patient compliance. But a patient who presents to a physician with worsening of his symptoms and doesn’t offer the fact that he’s been non-compliant with the recommended therapy because he can’t afford it, well, that is fully on the patient.
Telling physicians they’ve made a mistake for not ferreting out the complex situations in which patients aren’t compliant during a fifteen minute office visit is bollocks.
The primary care-specialist pay gap is a popular target for those eager for reform. The gap is hailed independently as an example of and a cause of the lack of focus on primary care and prevention in the United States.
There is no doubt that the United States treats primary care, preventative care and triage much differently than most of the rest of the developed world. The distribution of primary care to specialists, especially procedure based specialists, favors the specialists much more here than in any other health care system, at least that I’m familiar with.
But I’ve expressed serious doubts about how payment reform might reshape the distribution of primary care versus specialists considering the per capita primary care population has grown just as fast that of the specialist, if for no other reason than the ever increasing influx of foreign medical graduates. FMGs who have picked up whatever slack was left by U.S. doctor’s perceived abandonment of primary care. We haven’t lost ground on primary care, in terms of the numbers, as the inequality between the earnings of the general practitioner and the specialist have grown.
And amongst the editorials and blog posts that focus on leveling the pay scale, sometimes, the very reasons originally articulated for paying more for a CABG as compared to an office visit are ignored.
And so I want to make the argument for why the orthopaedist, the cardiologist, the neurosurgeon deserves to earn more, and considerably more, than the primary care physician. And to make the argument that maybe we’re not so far off the mark with out current reimbursement structure.
I would lay out the argument for the specialist’s pay like this: the training is longer and more difficult, there is a disparity in early earnings and the assumed risk is something much more.
I’m going into a specialty with better earning potential than just about anything else in medicine. I’m also perhaps more intimately aware of differences in training amongst the specialties than most. I’m currently a neurosurgical resident, previously I started a general surgery residency, I watched my mother go through a pediatrics residency and a critical care fellowship as a single parent, and I’ve watched my fiancee through her internal medicine training at two different programs. Not bad breadth and more familiar and substantial than just observation of the day to day doings of various residents, in various specialties that anyone at a teaching hospital sees. Enough to speak on I feel.
My residency training is as long as it gets. The seven years I will put in are more than double what a family medicine resident will. More importantly, and controversially, I would argue that it’s more difficult as well. Even in the age of work hour restrictions, I would argue wholeheartedly that each 80 hour work week is not created equally.
Now to be fair, there is much intraspecialty variation. I’m sure if I was training somewhere else my work load would be something different. Even so, I am daring to argue that on the average a surgical subspecialists training will be more work, hour for hour, than a general practitioners. Sometimes substantially more.
This year, through 2 months, is poised to be exceptionally more work than my time in general surgery and, I will say, at my own peril with my family, exceptionally more work than what I’ve seen of medicine or pediatrics training. And I face seven years of such.
Granted, there are some reprieves in terms of the rotations (bless you neurology) but I would argue, as a percentage of my training, those “good” months are less than what is generally found in primary care training.
Specialists are poised to do, in my case, more than twice the years of training of primary care physicians and those years promise to be more difficult; even if it all adds up to 80 every week.
The trial of Nadja Benaissa has begun. She is a German based pop-singer who is accused of having unprotected sex with multiple partners while knowing she was HIV+ and not disclosing that fact. At least one partner claims to have been infected by her.
I’ve commented on this ‘trend’ before, of criminalizing risky behavior. Despite my earlier post on the issue, I’m pretty adamant that this shouldn’t be a criminal matter. It’s not that I’m concerned with the shadowing consequences such a trial and potential verdict will have on those who are HIV+, it is merely that there is shared responsibility here enough. Unless the trial brings to light some form of actual deceit, for instance if she lied about her HIV status, then I’m not sure unprotected sex with a person of unknown HIV status in the modern risk environment doesn’t exculpate the accuse somewhat.
But there should be penalties and if not in a criminal court then in civil opportunities for those she’s put at risk. I guess we’ll see just how aggressive this German court wants to be over the coming weeks.
Merritt Hawkins posted a survey of 114 hospitals on the revenue physicians generate for the hospital through their activities. No surprise but surgeons and proceduralists generate the most. Topping the list are neurosurgeons.
Are the big pharmaceuticals too big to fail? Is that a necessary characteristic for successful, expensive drug development?
Usually so opinionated I’ve got mixed feelings on big pharma. Consider those feelings doubly mixed after reading this CNN special investigation concerning the COX-2 inhibitor Bextra which Pfizer (or at least, controversially, it’s subsidiaries) was accussed of marketing illegally.
By April 2005, when Bextra was taken off the market, more than half of its $1.7 billion in profits had come from prescriptions written for uses the FDA had rejected.
But when it came to prosecuting Pfizer for its fraudulent marketing, the pharmaceutical giant had a trump card: Just as the giant banks on Wall Street were deemed too big to fail, Pfizer was considered too big to nail.
Why? Because any company convicted of a major health care fraud is automatically excluded from Medicare and Medicaid. Convicting Pfizer on Bextra would prevent the company from billing federal health programs for any of its products. It would be a corporate death sentence.
Prosecutors said that excluding Pfizer would most likely lead to Pfizer’s collapse, with collateral consequences: disrupting the flow of Pfizer products to Medicare and Medicaid recipients, causing the loss of jobs including those of Pfizer employees who were not involved in the fraud, and causing significant losses for Pfizer shareholders.
[...]
So Pfizer and the feds cut a deal. Instead of charging Pfizer with a crime, prosecutors would charge a Pfizer subsidiary, Pharmacia & Upjohn Co. Inc.
The CNN Special Investigation found that the subsidiary is nothing more than a shell company whose only function is to plead guilty.
I suppose I can’t support the break up of big pharma for both practical and philosophical reasons. But this kind’ve three card monty prosecution game seems beyond the verge.
There’s been a lot of dissatisfaction in surgical training with work hour restrictions. Perhaps I shouldn’t limit it to surgical residencies, merely to say, instead, that they’ve been the most vocal for my experience.
The 80 hour work week and the 30 hour work shift restrictions have been bemoaned by academic surgeons. Fears that resident’s hand offs of patients would harm continuity of care and thus patient outcomes were front and center, and voiced by all specialties. Fears that resident surgeons would get less hands on surgical experience were unique to surgery but no less concerning.
Talk that further restrictions on how much residents can work are coming brings the issue front and center again. A not too distant IOM report commissioned by the AHRQ recommended such further limitations on resident work hours. And decried by surgical specialists and others alike. I’ve heard prominent individuals from within organized surgery, of course being explicit that they’re voicing their opinions as individuals, decry any further attempt to limit the surgical resident experience.
The surgical specialties are poorly represented in the decision making process. The IOM committee which so recently commented on resident work hours had a single surgical subspecialists on it. The current ACGME Board of Directors has two surgeons sitting on it (and I’m explicitly excluding the ophthalmologists serving on it, and for reason I believe considering their training experience as compared to say that of an orthopedic surgeon). That is two representatives out of thirty or 6% of the vote on the body that will ultimately, at present, determine any further resident work hour restrictions.
With relatively broad coverage in the media of the issue, a decided bent in the public for support of work hour restrictions, and significant public advocacy money in play to influence the decision the whispers from within the ACGME are that further restrictions are inevitable in the next 2 years.
But what if the decision was taken out of the hands of the ACGME, at least for surgical residencies?
There is a growing movement amongst rather prominent academic surgeons for an Accreditation Council for Graduate Surgical Education. Organizing such would be no small feat. Getting the state boards, with public pressure in favor of restrictions, to recognize it may be even more of a hurdle. And that presumes that the inevitability of all of this mess isn’t Congress legislating resident work hours as say the Patient and Physician Protection and Safety Act [PDF] tried to do early last decade.
It’s true, work hour restrictions have worked the rest of the world over. European registars are limited to 48 hours a week and it is hard to demonstrate a qualitative difference between a CABG here and over there. And while the design of their health care system necessitates that many of them will spend years as SHOs (or even lower on the training pole) before a consultant spot opens up.
Drawing the analogy with other other surgical training experiences across the world would require a reimagining of how health care is organized in America. A more tertiary experience with fewer surgeons and lengthier training with further graduation of responsibility during it. That’s not something I’m personally willing to accept. As much as residents still bemoan their hours in the hospital, if push came to shove, and an ACGSE could postpone further reductions in my operative experience I am all for it.
I’ve made a big deal about access to physicians of recent. A little bit of a whiny deal. But there’s more to physician access than merely reimbursement. The media has picked up, with some gusto, the story that a surge in the insured and a ‘shortage’ of primary care physicians in the United States may severely limit access to care.
Primary care physicians already are in short supply in parts of the country, and the landmark health overhaul that will bring them millions more newly insured patients in the next few years promises extra strain.
The new law goes beyond offering coverage to the uninsured, with steps to improve the quality of care for the average person and help keep us well instead of today’s seek-care-after-you’re-sick culture. To benefit, you’ll need a regular health provider.
And other media, tell us as much. Now in general the United States has fewer physicians per capita than other western nations. And there are no doubt huge regional differences in physician supply. Parts of this country suffer from a severe deficiency in physicians in general, and primary care in particular.
But the fact is that, as much as we hear about the difficulty primary care has in attracting future physicians, the United States’ per capita primary care population compares pretty equatable to those of other nations. Other nations whose primary care delivery is generally considered more impressive.
Compare the primary care population to that of Australia and New Zealand or to the United Kingdom. Sure we trail two of the three, but not on the order of magnitudes.
Again, the anecdotes will be out there. No doubt incorporating a huge new patient population into the mess but a crisis is more difficult to believe.
I call home one of the largest cities in the country without a freestanding, full service children’s hospital. In the state of Texas my home is the only ‘major’ metropolitan area without such an institution.
The benefits of freestanding children’s hospitals and the problems pediatric care in my hometown faces should seem cognizant to even the layperson. While children’s hospitals certainly have higher charges they provide value for such, providing better care from everything in trauma to acute asthma exacerbation. The lack of a freestanding children’s hospital means tertiary pediatric care is fragmented. Pediatric services at hospitals around the city see fewer of each case of pediatric illness. Volume, as has long been shown, means quality. Concentrating tertiary care also promises to promote recruitment of everything from pediatric subspecialists to pediatric nurses.
The Beautiful Dell Children’s Hospital An Hour North Of San Antonio
I’ve always had a place in my heart for pediatrics. It represents unique challenges and at times can be tragic and gut wrenching caring for the young and critically ill. It is also incredibly rewarding. Your patients share no responsibility for their conditions and the promise they hold when you help heal them is virtually limitless. But of course, as easy as it is for pols to talk about children’s issues, they lack a constituency and children’s healthcare doesn’t exactly have the political will as, say, care for those over 65 does.
So I’m happy to see the movement for a new children’s hospital in San Antonio. A public-private venture the hurdles it faces are more than political but the backing of prominent politicians like Nelson Wolff is a very positive turn for pediatrics in this town. Amongst others in town, the former Mayor and long term head of Bexar County seems to have thrown his full weight behind a freestanding children’s hospital. That can only be a good thing.
Supportive media coverage as well is a positive. The local newspaper has it here and here, saying,
Far from standing still, San Antonio is losing ground in pediatric care as other cities expand theirs, Austin moves closer to getting a medical school, and local military realignments reduce pediatric care resources.
In July, Texas Children’s Hospital bought full-page ads in the San Antonio Express-News promoting its services, evidence that this city is seen as a lucrative market for other cities’ children’s hospitals.
As has local television media. Hopefully that forecasts well for the future. San Antonio needs a children’s hospital.
I’ve repeated myself a lot over the years on reform. The frequency of me going in circles has increased as passage of reform neared. That’s boring. As all encompassing as health care reform has loomed I clearly am not in the loop enough, not able to blog enough to comment on the minutiae. My general thoughts are well layed out, and I need to stop repeating them ad nauseum.
Consider this a last all encompassing post. One intended to look at the arguments for why reform was necessary, what the current reform entails, what the current reform proposes to cost, how the current reform will fund itself, how the current reform succeeds and how it fails.
Reform Is Necessary
Or so the argument goes.
I don’t support reform, not reform that requires the further redistribution of wealth. I have sideline relativistic moral arguments for such. But arguments that either reform isn’t necessary or that progressive/redistributive reforms cannot improve the population’s access to care in all the quantifiable ways, well, I don’t buy them.
Now let me concede and give those who disagree with me their due that: 1) measuring ‘health’ is an incredibly difficult thing and 2) the United States’ failings in terms of health (if we grant they even exist) are multietiological.
Things like our genetic heterogeneity, our economic inequality (independent of how that effects access to care), even the way we measure health outcomes and a multitude of other factors play into why the United States appears to trail many of its western counterparts in measurements such as life expectancy, infant mortality, hospitalization rates for chronic conditions, etc.
Granting all those, it must also be granted that in this country insurance status effects access to care and that access to care effects overall health. Arguments that we enjoy an established safety net and that our health care resources are distributed with some sort of uniformity so that all have some sort of baseline, appropriate access to care are beyond the pale. They’re ridiculous. It is a settled issue that your insurance status, as an independent factor, influences your health. It effects lifetime mortality (pdf), it effects baseline functional measurements, it effects the stage at which cancer is found, it effects mortality related to a whole host of chronic diseases such as heart disease. Without a doubt lack of long term health insurance is an independent culprit behind excess deaths in this country.
I refuse to even have a further discussion on whether, in our current financing system, insurance effects access and thus health. It is settled.
We can debate the economics of the un- and under-insured and the census of such people, but the lay down is, whatever the measurements and whatever the causes, that the problem is real and far from insignificant.
Reform is necessary if your goal is to improve the ‘health’ of this country because one of the key components of improving such is improving access to care.
[T]here’s some critical mass of votes you need, short of a majority, at which point you start the doomsday countdown. Now that the count is underway, you can’t change the bill. So there’s no point in holding out for changing. And you “scale the bill down” or “start over” either. You have a victory, or you have a humiliating defeat. And everyone’s in the same boat. At that point, the votes will materialize.
Book this one, the House will pass the Senate’s bill tomorrow.
Pelosi told reporters there will be “no separate vote” on abortion or any other measure.
And Rep. Jan Schakowsky (D-IL), a leading pro-choice progressive, said they’re moving ahead without him. “There’s not going to be any deal made with Mr. Stupak…there’s been no deal whatsoever. He’s been told that his language is not going to be added to the legislation,” she told me this morning.
“We think we have the votes regardless, and we’re going to be moving forward,” Schakowsky said. “Yes. We do think we have the votes without him.”
According to reports, CBO estimates that the combined package will cost $940 billion over the first 10 years and reduce the deficit by $130 billion during that period. In the second 10 years, 2020 to 2029, it will reduce the deficit by $1.2 trillion. The legislation will cover 32 million Americans, or 95 percent of the legal population.
My pessimism on any sort of reform was ill placed. That’s not to give the Democratic leadership a full pat on the back. The reform they’ve mustered can hardly even be called such with a straight face. I continue to contend it’s long term prospects for expanding access to care enough to, say, do things like effect our broad health care metrics are dismal. My pessimism on this issue may however be tapered by the idea of this bill as a ‘building block’. It remains however that the progressive caucus has conceded the vast majority of semblance of cost control, and thus long term expansion of access to care, in this bill. The liberal Firedoglake bemoans the same and has a great table looking at what is promised with insurance reform and the realities of it.
The fact the democrats have struggled to pass even this bill is something less than impressive. But to be fair I didn’t even give them that much credit.
