The Vietnam-era adage “war is unhealthy for children and other living things” remains truer today than ever, but it is reassuring to realize that the knowledge gained and the techniques perfected in battlefield care are ultimately applied to civilian medicine and especially to today’s trauma units. While far preferable to the alternative of “toe tags and body bags,” lifesaving medical advances result in greater numbers of unfortunate soldiers surviving with severe brain injuries, paralyzing spinal cord damage, or overwhelming psychological trauma. These harrowing sequelae of combat must be addressed, not only by the medical community but also by society at large. And ultimately, no matter what the political outcome of war, all Americans benefit from the sacrifice of our valiant men and women.
III
HOSPITALS AND HOSPITAL PRACTICES: THE TWILIGHT ZONE
22
HOSPITALS: SCARY PLACES
EVEN FOR DOCTORS
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Even top caliber hospitals cannot escape medical mistakes that sometimes result in irreparable damage to patients.
—SENATOR CARL LEVIN
THE MAN HAD BEEN VOMITING, was incoherent, and reeked of alcohol. Believing it to be a routine “drunk call,” the ambulance drivers took their time transporting him to the emergency room. Once at the hospital, he lay on a stretcher for some time, unattended, because the medical staff too believed he was just one more guy who’d had one too many. It happens almost every night in the emergency room to some poor John Doe. Except that the man wasn’t drunk. He had been beaten and robbed on his way home from dinner. His medical evaluation was delayed for several critical hours before the staff realized their error, and he died two days later as a result of blunt trauma to the head, neck, and torso.
Cases like that don’t happen often, but one of the more common emergency room errors is mistaking a medically ill patient for one who is merely drunk. Most patients who smell of alcohol or have a high blood alcohol content are merely intoxicated and will be fine in several hours as the alcohol is metabolized. But in a small number of those patients, alcohol masks other conditions—trauma, infections, diabetic coma—that must be treated immediately. A delay of several hours is often the difference between life and death.
One of the startling things about this case was this John Doe victim turned out to be a reporter for the New York Times. Several years before that, another highly publicized medical error occurred when the medical reporter for the Boston Globe died after receiving the wrong dose of chemotherapy. Errors or near errors have occurred involving family members of some of the most well-known physicians in the country, including the wives of Donald Berwick, the president of the Institute of Healthcare Improvement, and Albert Wu, one of the country’s leading internists from Johns Hopkins. If it can happen to these people, it can happen to anybody. So far every doctor I have talked to has shuddered and agreed with that basic premise.
Physicians are familiar with the errors, both trivial and serious, endemic to hospitals. Yet even with their medical expertise, hospital connections, and familiarity with the inner workings of the system, physicians are often powerless to prevent hospital danger and indignity. Wrong medications dispensed, miscommunications at shift changes, and tests continually rescheduled are all common screwups. In addition hospital care is increasingly dictated by specialists. Patients may benefit from doctors who are better informed, but a lack of coordinated effort between specialists sometimes results in confusing and contradictory treatment plans.
The people running hospitals have only now begun to remedy these problems. Today hospital marketing arms have photogenic doctors striding confidently around the “campus” (the current pretentious term) describing the wonderful things going on all around them. On its best days, that’s what the hospital is like: effective care, compassion, and the occasional miracle. When you’re sick, you hope that’s what you get. Of course when you go to Wrigley Field (unless you’re a White Sox fan), you hope the Cubs play errorless ball, hit home runs, and pitch shutouts. But ultimately at the hospital and the ballpark, hope and reality don’t always jibe. Hospitals can be wonderful places, but they can also be bastions of miscommunication, inefficiency, indifference, and bureaucracy that would make a Third World post office look impressive.
There are some things a smart patient can do:
Bring someone who can stay with you. The hospital can be a lonely and frightening place. A trusted family member or friend can be invaluable, especially on weekends and holidays.
Ask questions. Not in a way that questions authority (the staff is human, they don’t like that) but in a way that shows interest and concern with your health. Contrary to popular opinion, most doctors and nurses like it when patients ask questions. It gives them a chance to involve you in your care, bond with you, and show off their knowledge a little bit (the staff is human, they do like that).
Also, a box of candy never hurts. Make it two, one for the doctors and one for the nurses.
In 2002 the Harvard School of Public Health reported over one-third of the doctors surveyed reported errors in either their own care or that of family members. The hospital can be as oblivious to the patient concerns of connected reporters or informed physicians as it is to everyone else. It recalls a joke comedian Richard Belzer once told: “When I hear Mick Jagger sing he can’t get no satisfaction, I think if that’s true, what chance does a poor guy like me have?”
23
ER OVERLOAD
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People have access to health care in America.
After all, you just go to an emergency room.
—GEORGE W. BUSH
THE SHOCKING RECORDING of the 911 call suggested the dispatcher had no idea what to do when she received a call from the boyfriend of Edith Isabel Rodriguez. As he pleaded with the dispatcher to send paramedics to her aid, Rodriguez lay on the floor, in pain, throwing up blood. The dispatcher was flummoxed, though, because the policy of “take the patient to the closest hospital” didn’t apply. Rodriguez was already in the emergency room lobby of Los Angeles’ inner-city Martin Luther King Jr.–Harbor Hospital.
Shortly after another bystander made a second futile 911 call imploring paramedics to take Rodriguez to another hospital, she died of a perforated bowel. A security videotape was said to show her writhing on the hospital floor unattended for forty-five minutes. At one point the tape reportedly showed a janitor going about his business mopping the floor around her. A number of staff were merely reprimanded over the incident.
Her death became the center of a controversy in Los Angeles, typifying the bureaucratic indifference of a public hospital that treats primarily indigent and minority patients. This case involving King-Harbor prompted federal inspection of the medical center even as politicians and physicians pointed fingers at each other. Ultimately, in large part because of the Rodriguez case, the hospital closed and reopened as a smaller facility nearly a decade later.
Edith Rodriguez’s death struck a special nerve throughout Southern California, where even the wealthy often endure interminable waits in the emergency room. For the poor, the situation is worse because the emergency room is often the only place they can go to see a doctor. In Rodriguez’s case, she died with nurses and doctors literally in the next room. The Rodriguez case exemplifies our public health care system at its worst. Similar tragedies have occurred at public hospitals in other cities, but this problem is not confined to the public sector: in 1998, a boy bled to death after being shot right outside the emergency room of one of Chicago’s North Side private hospitals.
The media that profess shock at public hospital ineptitude often fail to mention the complicity of bureaucrats, politicians, and the private hospital system, all of which contribute to the big picture. After the controversy over the Rodriguez case, Los Angeles was the scene of another scandal when certain private hospitals were discovered to have arranged for ambulances to discharge indigent and disabled patients to a skid row area.
Unfortunately, there
are no simple solutions to tragedies such as that of Edith Isabel Rodriguez. Deaths such as hers are usually the result of a combination of administrative incompetence, medical and nursing negligence, bureaucratic indifference, and emergency room overcrowding. The last is a particularly vexing problem across the country. Emergency room overcrowding is usually a result of a dysfunctional primary care system, a problem not unique to Los Angeles. Too many people forced to visit the emergency room for primary care renders the emergency room not only inconvenient but also occasionally dangerous. It may be worse in the public sector, but patients often have to wait a long time in fancy private emergency rooms too.
Without a fundamental restructuring of primary care, emergency rooms will continue to serve as the clinic of last resort, a situation that benefits no one. It is ironic that for decades the American public hospital system represented the best and worst of our society. The best because it took care of those the system otherwise ignored. The worst because of the incompetence and indifference that cost the lives of Edith Isabel Rodriguez and so many others like her.
24
PROTECT PATIENTS’ MEDICAL RECORDS FROM PRYING EYES
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Progress is man’s ability to complicate simplicity.
—THOR HEYERDAHL
IN TODAY’S MODERN WORLD, certain developments demand a wellspring of public outrage. A case in point should be the results of a study published in JAMA: The Journal of the American Medical Association that went virtually unnoticed. The study found that between 2009 and 2013, more than twenty-nine million medical records were hacked, stolen, or otherwise compromised. Most of these were criminal breaches, with five states—California, Florida, Illinois, New York, and Texas—accounting for 34 percent of all breaches.
The study’s lead author, Dr. Vincent Liu, estimated the actual number was likely even larger. He believes the trend of medical record theft will continue unabated in the future. “Our study demonstrates that data breaches have been and will continue to be a persistent threat to patients, clinicians and health care systems,” Liu said.
In the last twenty years, the electronic medical record has been promoted by the government and health care industry as a way to improve care, save money, and, not surprisingly, process payment. As the JAMA study indicated, an unforeseen consequence of the transition from paper to computerized records means that even with passwords, firewalls, and encryption software, your medical file can be accessed anywhere in the world. This means not just your diagnoses, test results, and insurance information but your home address, social security number, employment data, genetic profile, and other confidential personal information.
Since the time of Hippocrates, about twenty-five hundred years ago, medical confidentiality has been the cornerstone ensuring patients could communicate freely with their caregivers. Confidentiality guaranteed that the interests of patients and caregivers were aligned, so patients could receive care and doctors could render it without fear of divulging information publicly.
For decades your medical records were reasonably secure. Hospitals, clinics, and doctors maintained the traditional presumption of confidentiality; records were usually kept as paper charts stored in an office or hospital basement. Insurance company billing required only a few pages, not a complete set of medical records. It was certainly possible for an unauthorized person to examine or steal a patient’s chart, but these were isolated occurrences. Those truly intent on mischief could do so only by surreptitiously removing a record and copying it. Even then, only a limited number of copies could be generated. The worst problems occurred due to the occasional improper disposal of paper medical records; in such incidents, at most several hundred records might be breached. Nothing on the scale of millions of records being compromised was conceivable, let alone possible.
Enter the electronic medical record. Its introduction has provided undeniable advantages to medical care, including making health records immediately accessible to providers, avoiding duplicated testing, allowing doctors at distant centers to see information instantaneously, and providing patients the ability to transfer their records to other providers easily. (These advantages unfortunately have not always included giving patients copies of their medical records without charging the patient exorbitant fees.) Yet as the medical community is painfully finding out, the electronic medical record has not been an unalloyed benefit.
Entering information into a computer while doing a medical interview has depersonalized the patient encounter to the detriment of the patient and the profession. It takes an exorbitant amount of the professional’s time. In addition reams of extraneous and duplicated information mean a simple hospital stay of several days now results in a virtually unreadable thousand-page chart printout.
But the most serious unintended problem of the computerized record has been the sacrifice of patient privacy and security of personal health information. Records have been breached on levels undreamed of only several years ago. With a little expertise, almost any computerized patient chart can be copied and distributed over the Internet to anyone in seconds. And even a single stolen laptop can contain thousands of patient files. It would be hard to conceive of a more inviting platform to identity theft.
Recently hackers targeted the health insurance giant Anthem and made the personal information of nearly eighty million Americans vulnerable, only one example of the massive security problem. An article in the blog Fast Company claims that on the dark web, hacked medical records go for four times the price of stolen social security numbers and twenty times the price of stolen credit cards.
There is no ready solution to this problem. Experts can devise new encryption systems to thwart hackers, but eventually the malefactors will beat any system. At the same time, the harder it is to access records, the more it bollixes up medical care, because consultants, nurses, and paraprofessionals must be able to access patient information. Our medical records are now perpetually vulnerable; it’s simply a question of how much inconvenience we are willing to tolerate to frustrate hackers temporarily.
By themselves, patients have little recourse. Both the medical and legal communities, including the American Medical Association and the American Civil Liberties Union, must take a much stronger stand on the behalf of patients and make the safety of personal health information a higher priority. More state and federal legislation is necessary, because there are major holes in the way current laws are written. As experts have pointed out, digital information companies such as Apple, Google, and Facebook, with the potential to access patients’ medical information, are not covered by most health care regulations. Further, computer outlaws, including offshore hackers, are hardly deterred by American law.
Welcome to the brave new world of health care. Computerized medical records have given your health care providers better access to your medical information than ever before, even while your medical history will never again be as secure as that of your grandparents. Most people in health care consider this progress. But as George Orwell once observed, progress is invariably disappointing.
25
RETRACING YOUR FOOTSTEPS
* * *
Do not follow where the path may lead.
—RALPH WALDO EMERSON
SOMETIMES WHEN YOU’RE HIKING, if you inadvertently stray too far into the forest, the best thing to do is just admit that you took the wrong trail. Likewise, after three decades of experimenting, it should be time for the medical community to concede that the adoption of the electronic medical record (EMR) was a mistake and has been more detrimental than beneficial to patient care.
Unfortunately, in this case, what’s done cannot be undone. It certainly seemed like a good idea in the early 1990s, at a time when patients began seeing many different doctors and frequenting many different hospitals, to develop a computerized system that would collect large amounts of information and make it available anywhere and anytime. When the government effectively mandated that all health care providers adopt EM
Rs, the plan was poorly conceived, with insufficient input by the professionals who would ultimately use digital records and without much forethought or actual evidence to support the benefit. This in the face of health care ombudsmen constantly criticizing medical practitioners for practicing without good evidence.
The thought was that medical records are similar to bank or other business records. They aren’t, and it’s much harder to develop workable digital systems. Different health care settings, specialties, and practitioners all require different types of records. A rural primary care clinic needs a different medical record than a university hospital ophthalmology department. This created a new multibillion-dollar nationwide industry for maintaining and updating medical records, so the toothpaste is out of the tube.
In fairness the new system has resulted in improvements in information retrieval and portability—at a huge cost. The government and the private sector spent billions of dollars and created a vast new bureaucracy to replace the paper medical record. Soon hospitals could not run without huge IT departments (the cost of which has become part of those egregious hospital bills).
What was the result of all this? Almost thirty years later, there is no single, universally accepted, user-friendly EMR system, and worse, no promise there will ever be one. The current systems usually cannot communicate with each other, and they all cost millions of dollars and require continual updating and maintenance (and once again, this becomes part of those hospital bills). Whether care is better is an unanswered question.
The Doctor Will See You Now Page 8