Boreal B[l]og

Twenty years ago, medical director of a hospital, I took a call from a woman who wanted to know how many Abdominal Aortic Aneurysms (AAA) her husband’s surgeon had repaired the prior year at our facility.  She asked a good question, because the surgery is difficult, fraught with risk, even when done electively, which in this instance it would be.  Too often, it is done after the aorta ruptures.  My cousin’s husband died of a ruptured AAA; I have dealt with the issue emergently, and it is difficult to control the bleeding while simultaneously repairing the vessel.

I didn’t know the answer.  Therefore, I had no idea her husband’s chances of survival, how long he would likely be hospitalized, or his condition six months later.  We didn’t track that.  It took me four years to get the hospital to track outcomes from cardiac surgery, after I exploded one night in the ICU saying that I had been consulted 26 times in 270 open heart cases in one year.  Consulting a neurologist after a heart case usually doesn’t bode well.

I mention this, because AAA is one of the outcome measurements Leapfrog uses in determining how well a hospital performs.  So is Aortic Valvular Replacement.  The Tucson hospitals that used Leapfrog scored no better than “C”; one scored “D”.  Some of these hospitals had marketed themselves as being “one of America’s top 100 hospitals.”  It seemed that they were not quite as good as they thought they were.

Leapfrog tracked drug errors, too, and no hospital in Tucson scored better than “C”.  On 2 May 2002, I met with administrators at University Hospital in Tucson to outline my reporting program to reduce medical errors.  A year earlier, I had met with their cardiac surgery program to help track outcomes better.  I can’t believe I was so naive to think that I, who had practiced, been an administrator, had a Master’s in statistics, and 2 months earlier had written an op-ed on an error reporting system we needed in medicine would take on Big Hospitals.  Capitals mine.

Both groups wanted to know, in an unfriendly tone, who I was.  Being from the same city was a minus; had I been from outside, I might have had more credibility.  It would have helped if I were good-looking, exuded charisma, and showed glossy paper with colorful bar graphs, rather than having sound ideas and a quiet demeanor.

Needless to say, the cardiac surgery program wasn’t interested, and I was assured, that second of May, that University Hospital had “one of the best safety records in the country.”  They gave me no data.  They wanted to know what software I would use. I didn’t need software; I needed reports of errors in order to understand them better.  Unfortunately, computers and charisma mattered more to them.

Leapfrog was initiated by a group who had the smarts, the looks, the networking ability, and the leadership skills I lacked.  My ideas were ahead of theirs.  In 1974, I was counting outcomes in medicine when I was an intern.  I was selecting my surgeon to do carotid surgery in the mid-1980s, based upon his outcomes.  I raised concerns about our cardiac surgery program in 1990.  I wasn’t surprised that hospitals were graded “C.”

Every member of my immediate, now small family, has suffered from a medical error.  People make mistakes.  I accept that.  People should learn from them, too, which they often don’t.  For years, we had lousy data and lousy tracking systems.  No, we had no data and no tracking systems.  We hadn’t a clue, and we let Big Medicine, called the Joint Commission, dictate what hospital quality was.  I met with the Joint Commission, too, on 14 August 2001, in Chicago, at my expense.  They were quite interested, so they said, but I never heard again from them.  No e-mails, no calls, no response to my written requests, nothing.

It takes 30 seconds to compose and send an e-mail saying one is not interested.  They weren’t  too busy.  They were rude, arrogant, and wrong, as wrong as Condoleezza Rice had been 8 days earlier and the Bush administration would be four weeks later.  The only difference is a lot more people die from medical errors every year than died on 9/11.  We just don’t know how many.  Our estimates are bad, and the margin of error of those estimates is seldom given.  That violates a basic rule of statistics.

We should be tracking outcomes of common procedures in medicine.  When I broke my hip in an accident, the surgeon had no idea I had done well until I wrote him.  I fractured my fifth metacarpal, had a cast for four weeks, and told that alcoholics often took off their casts with no sequelae.  When I was told I needed two additional weeks of the cast (which did not change the angulation of my metacarpal), the comment my father made was “that is what your doctor learned to do where he trained.”

“Why?” I asked, “don’t we know whether somebody with a broken metacarpal even needs a cast?  Why don’t we know the optimal time? Do metacarpals heal depending upon geography?”  This is not a rare injury.  If we don’t need a cast, wouldn’t that save money and time?  How many other conditions don’t we know the results?  Perhaps some shouldn’t do certain procedures, like colonoscopy, lumbar punctures, bronchoscopy or angioplasty.  How many of these have you done, doctor?  And what happened to the patients?

We physicians like to say we are scientifically trained, and non-physicians don’t have data to show they make a difference.  Where are the numbers?  What should they be?  And what are we doing to achieve those numbers?   Too many ideologues argue using rhetorical questions, which I find annoying.  A statistician’s job is to ask questions.  Ours are good questions, answered with data, uncertainty and appropriate inferences.

We don’t need high speed computers to measure outcomes.  Pen and paper work just fine, with a lot of curiosity, and an open mind.

“Dr. Smith, lay to the bridge.”

John, my hall mate back aft on the O3 level, cringed, and then let loose with a few epithets.  He and I had the two aft staterooms separated from the rest of “Officer’s Country” by a door.  It was colder there when it was cold, like off Korea in March, and it was hotter there when it was hot, like in the Philippines in June.  But we were mostly left alone, had an exit door aft, with a good view of the ship’s wake, when we weren’t working.

The numbering system for decks started with the Main Deck, then 2,3,4 going below or down.  Going topside or up, it was O1, O2, O3, to the uppermost deck, our bridge on the O4 level.

John cringed, because “lay to the xxx,” was used only to call enlisted personnel. “Your presence is requested to xxx”  was for officers.  Put succinctly, it was a breach of etiquette. The Navy was polite.  As coarse as the day-to-day language was, contributing to my current curse word vocabulary well into three figures, there was politeness.  I had to salute senior officers once a day on board, but only if I were covered, or wore a hat.  At sea, hats were not required, although most of us wore ball caps.  Navy men never salute uncovered.  Covers were not allowed in sick bay; they were required on the bridge.  In port, in uniform, one was always covered outside.  I learned these rules fast; I had to.

Coming aboard, one saluted twice, once aft, where the colors (flag) flew, and once to the officer of the deck, concomitantly saying, “request permission to come aboard.”  The procedure was reversed when one disembarked.  One needed an ID ready, too.  Ashore, one saluted any senior officer, holding it until the salute was returned. We called senior officers “Sir,” but on board, the executive officer was “XO,” the Captain was “Captain,” or plain “Cap’n”.  He didn’t mind.  When the Captain appeared, the first person spotting him said, “Attention on deck,” and we all jumped up.  The Captain would say “at ease,” and we would sit down.  This was formal stuff.  When the XO appeared in Sick Bay, I stood up.  It showed respect.

In correspondence with junior officers or enlisted men, we wrote, “Your attention is directed to xxx.”  To senior officers, we wrote, “Your attention is invited to xxx.” To this day, I take that and three other things with me from the Navy: short hair, my shirt buttons lined up with my pants zipper, and use of the word “Sir.”

I mention all of this, because the other day at the local pharmacy, where I get my medications, I stood inside the privacy line, painted on the floor.  Privacy is a big deal these days, except everybody knows everything about me, so I don’t really believe in it.  I may not see a prescription, but even with bad ears I hear what people are getting.  In any case, I was chided with a “Get back behind the privacy line.”

Gee, sorry that I am old, new in town, and honestly didn’t see the line, since the letters were faded.  I got half my medicines, since one was still not ready, five days after I dropped off the prescription, another problem with today’s “just in time inventory.”   I decided to return the next day.  As I left, I heard , “Thank you, Michael,” and cringed.

I don’t like strangers, especially the young, calling me by my first name, and I don’t like it when people on the phone with whom I speak ask me how I want to be called.  You call people Mr., Mrs., Dr., or Ms.  It is default.  You don’t ask, you do it, and you ought to know that.  I still call the former head of neurology where I trained “Doctor.”  He is in his 80s, and he has always been “Doctor” to me.  The past Executive Director of the Medical Society always called me “Doctor,” although we spoke on a lot of issues as friends.  It’s a sign of respect.

I don’t push the issue, but maybe it’s time to.  If you are too polite, you will be given an honor (yes, it is) to call someone people by his or her first name.  One should not put people in an uncomfortable position of asking how they want to be called, which happened with me with AARP.  How about “Mr. Smith”?  It is always in style, never wrong.

Thirty years ago, I flew over to San Diego to attend my Chief’s retirement.  I stayed in my stateroom one last time. I could have called both the Captain and the XO by their first names, for I was a civilian.  I could have called my chief by his first name, too.  But I didn’t.  I never had.  These people were “Captain,” “XO”, and “Chief”.  They were, and they always would be.

I discovered in civilian life that “Sir” is a powerful word showing respect for the office or age, but properly pronounced may be used to show distaste for the individual or task.  I learned the last to more than one lawyer’s chagrin, when he thought he was dealing with an arrogant doctor: my use of “Sir” with the appropriate tone was devastating.

“Sir, could you please step behind the privacy line?  Thank you.”

“Thank you, Mr. Smith. Good-by.”

“Mr. Smith, may I outline the benefits of our program?”

Notice the “Sir,” “please”, “Thank you,” “Mr.” and “may I”. These seven words exude politeness.

Many gun owners have told me that gun ownership will create a polite society.  I disagree.  I didn’t think the 19th century was so polite, the 20th or especially this one, while gun ownership has increased rapidly.  People must be scared of something.  Congress won’t even fund the CDC to find out why.  If we had 25,000 people dying from a new virus every year, you bet the CDC would get money.

Ironically, one of the most polite places where I worked was one where rifles were locked up, we enforced the Uniform Code of Military Justice with Captain’s Mast (non-judicial) more than courts martial, and fights were almost always with fists, even in liberty ports.   I treated a lot of STDs; I honestly can’t remember treating even a knife wound.

But please, dear reader, bear with me, for my memory is no longer good.  I might be mistaken.  But not about gun violence.

April 15, 1994, was a memorable day:  The executives of tobacco companies stood before a congressional hearing, under oath (Italics mine), and said these words, among others:

“Cigarettes may cause lung cancer, heart disease and other health problems, but the evidence is not conclusive.”

At one point during the hearing, Rep. (now Sen.) Wyden presented data from medical groups and a 1989 Surgeon General’s report on the health consequences of smoking, asking each executive if he believed that cigarettes were addictive. Each answered no.  I saw that on TV. (Italics mine.)

“What the anti-tobacco industry wants is prohibition,” said one. “We hear about the addiction and the threat. If cigarettes are too dangerous to be sold, then ban them. Some smokers will obey the law, but many will not. People will be selling cigarettes out of the trunks of cars, cigarettes made by who knows who, made of who knows what.”

I know what: carcinogenic and addictive substances, same as now.

Despite earlier denials, a Philip Morris study that suggested that animals could become addicted to nicotine was suppressed in 1983 and 1985.

Wow, if cigarettes are banned, only outlaws will have cigarettes, and as bad as firearm lack of regulation in our society is, the magnitude of deaths is at least 20-fold more in the case of cigarettes. (Italics mine.)

The executives stated that tobacco companies could control the amount of nicotine in cigarettes, using these blends for flavor.

Or to addict people.  Turns out smoking is not a character flaw, but is an addiction, like high fructose corn syrup, but the latter is for another time.

Pressed by the subcommittee’s chairman, Mr. Waxman, and Representatives Wyden and Synar, (all Democrats), the companies agreed to supply many private company papers, including all the research done by the Philip Morris researcher whose scientific paper on addiction was blocked from publication by company executives.  (Italics mine.)

When one executive said that all products, from cola to Twinkies, had risks associated with them, Mr. Waxman replied, “Yes, but the difference between cigarettes and Twinkies is death.”

“How many smokers die each year from cancer?” Mr. Waxman then asked.

“I do not know how many,” was the reply, adding that estimates of death are “generated by computers and are only statistical.”

If computers are banned, then we won’t die, I guess.  (Italics mine.)

Mr. Waxman asked, “Does smoking cause heart disease?”

“It may,” Mr. Johnston said.

“Does it cause lung cancer?”

“It may.”

“Emphysema?

“It may.”

Could the world be flat?

It may.  (Italics mine).

The term “only statistical” underpins science. We stopped the study on the effectiveness of polio vaccination because of statistics proving the vaccine was effective.  I am polio-free today because of that.  I received the Salk vaccine when it was first available; I was in the first cohort who received the Sabin vaccine.  We have confidence intervals stating with high (not complete) confidence that global climate change is occurring.  I have never seen one CI saying that it isn’t.  (Italics mine.)

We didn’t regulate tobacco enough, allowing “market forces” and “getting government out of business” to handle such issues.  The result has been as many deaths from tobacco-related illnesses every year (Italics mine) as the number of Americans who died in World War II.  Stalin said that “One death is a tragedy, one million a statistic.”  Yes, it is a tragedy when it involves a death at 40, or 53, my father-in-law, or my brother.  This should be a national outrage.  Wow, I can make a case for anti-government being in line of Stalinist thinking.  (Italics mine, but reasoning probably faulty.)

The incredibly rich tobacco company executives lied in front of Congress, suppressing evidence that went back decades.

That, Mr. Boehner, and Mr. Cantor, and Mr. Joe Tea Party, is why we need federal regulation.  Without it, people DIE.  (Italics mine.)

We regulate, because left to their own devices, people make a mess of the world.  We learn that early in school when “today, on your break, you will stay quietly in your seats, because a few people abused the privilege by jumping on their desks and screaming.”  You can use whatever you want for what you couldn’t do, but the first seven words in the subordinate clause stay the same throughout our lives. (Italics mine.)

I unsuccessfully tried to regulate medicine.  With no regulations, doctors did piecework and expected to be paid for it.  I remember a few of these doctors.  Those were the “golden days” of medicine, when “Doctor” was “God,” surgeons threw instruments, people cowered, nurses and medical students abused.  I was verbally abused to the point of tears by many doctors and had a retractor slammed on my thumb once.  “The Giants” made mistakes, because they were human.  Their mistakes were covered up, not investigated so we could learn from them. because to rat on a colleague would result in ostracism and no referrals.

My colleagues operated on carotid arteries, with frighteningly bad results, worse than the natural history of the untreated disease.  I counted these and presented the statistics.  I was screamed at and told I had no business to interfere. I was unpopular; however, I did notice that 12 physicians who became my patients never referred their patients to me.  (Italics mine.)  I thought that interesting. We allowed rods and fusion for low back pain, without adequate evidence that they did any good, which with few clear exceptions, they didn’t.

We failed to do what was proven effective to decrease post-operative infections:  inject a specific antibiotic for clean case infections 30-120 minutes before incision.  Easy, right?  In my hospital, we did it 25% of the time, and physicians refused to change.  We couldn’t even mandate the right antibiotic, promoting resistance to stronger antibiotics that some surgeons insisted upon using.  (Italics mine.)

After many years, we finally mandated that only pulmonary physicians, not general internists, could manage ventilators, because the former had better results.  That was strongly resisted, but it was one powerful group against another, not a dweeby neurologist (Italics and individual mine.) trying to change the profession through data and outcomes.

Politically powerful physicians who brought money into the hospital had special treatment.  Facts, outcomes, right or wrong were too often subsidiary.  It had to do with money. (Italics mine.)

My point is simple:.  Every law, every regulation, came because of a reason.  Maybe the law could have been better written, but the fact that there is a law speaks to a reason.  Some person said, “There ought to be a law against…..”

Don’t like regulations?  Neither do I.  Then self-regulated your group, your peers, your city, your country.  Want government out of your life?  Then figure out how 310 million people can each do what he or she wants without upsetting somebody else.  (Italics mine.) Hear that, Mr. Boehner and Mr. Cantor?

I don’t miss second hand smoke.  Nor does my body.  

(Italics mine.)