X-Message-Number: 5053 Date: Oct 95 19:04:10 EDT From: Mike Darwin <> Subject: The state of medicine Several people have recently sent private messages to me asking if what they are hearing about the state of medicine in the US and Canada in books and press are true; in particular relating to loss of physician and patient autonomy, degradation od the doctor-patient relationship, overwork to the point of life threatening complications in treated patients, chronic understaffing and arbitrary decisions to use NON equivalent drugs which result in severe management problems, inadequate control of pain and life threatening agitation. I have responded privately to these people saying that it IS true that these problems are widespread and giving a personal (seat of the pants) estimate that they effect about 60-70% of US hospitals. Many more in Canada. I think this post is of some relevance to this list for the following reasons: 1) TWO of the cryonics cases I have done in the last year involved gross incompetence beyond anything in my experience. In one case a child who could have expected at least 6 months more of quality life was killed right in front of her parents when and undertrained (and no doubt overworked) resident gave her an IV dose of morphine which would have been appropriate for a LARGE adult, not once but twice during a minor procedure. 2) The second case involved a mother in her early 30's who died intraoperatively from a procedure that carries a less than 1% mortality from misdiagnosis and surgical-medical mismangement of a pretty coarse nature. 3) A friend and colleague of mine, in my considered opinion, died an iatrogenic death which was again, in my opinion (and other independent 3rd parties with good medical credentials who reviewed the case) due to gross neglience and lack of proper post operative follow-up and care. This case should be of more relevance to YOU on this list because the individual was a cryonicist with many years of productive life left. 4) I am in contact with some of the best medical people in the country and participate in a number of medical forums on the Internet. Just in the last year these usually highly technical forums have shifted emphasis such at a good 20 to 50% of all traffic involves issues of istrogenic problems, anger over bureaucrats, horror stories on cost control, and so on. 5) Two of the four terminal cryonics cases I have now have involved horrible (1 case) to poor (second case) medical care which was corrected by our Medical Director Dr. Harris and in one case by Dr. Harris in consultation with one of the best critical care and pain management experts in the country who flew out at his own expense to consult on the case. Leaving aside the question of whether the profession as a whole DESERVES these problems from their prior bad behavior, there remains the issuse of whether YOU and I deserve them and of far more relevance, whether we are aware they even exist. Herewith I pass along this post from a place where what The following appeared recently in a magazine called Australian Doctor and graces the walls of many Australian hospitals. You may recognize some of it. A CALL TO ARMS One hears these dreadful tales of the effects of turning health care management over to the bean counters. Medicine lives in the marketplace and cost is a preferable driver to quality. A few good tales of the effects of this have come my way from the States recently. In a large hospital a doctor went to prescribe a drug and was told it was no longer available. The pharmacist had withdrawn it as it was too expensive. "Use brand X" he was told. He was cross and told the pharmacist brand X was unsuitable. It was. The next day he was summoned to his boss as the result of a complaint from the Director of Pharmacy via the CEO. His boss had been instructed to tell him that if he was not prepared to co-operate with the hospital's efficiency programme his tenure was unlikely to be continued. The New York Times of 1st August carried another cautionary tale. It told of the cost saving efforts of the Long Island Jewish Hospital. The hospital had five major catastrophes in 10 weeks. All anaesthetic related. And many doctors, according to the paper, said this was related to the hospital getting rid of the private practitioners who cost $300,000 a year and replacing them with less experienced salaried lads at $100,000 a year. The hospital is confident that the five cases were isolated and show no pattern of negligence. The replacement of the private guys with salaried guys led to the American Board of Anaesthesiology placing the training programme on probation. This meant the quality of residents fell. A hospital director lauded the current staff and said they were excellent and even provided an obstetric anaesthesia service. And the paper noted many hospitals had similar revenue generating fund saving programmes. Bob in Houston is not a man to be trifled with. His patient was a sixteen year old male from a car accident. He had expert major life saving surgery and made it to ICU. And his HMO wanted him transferred to their "preferred" hospital. He deteriorated. The local HMO medical director by now was refusing to pay any expenses and sending the patient's primary care GP to the hospital to review the charts. One lawyer suggested transfer before his emergency condition was stabilised constituted an 1867 (OBCA) violation. Whatever that is. Another disagreed as the case was in Texas and OBCA does not apply. Finally Bob told the HMO man to meet him behind the car park to discuss ethics, legal issues and economics. The HMO declined. Many doctors believe that in all this madness of economic drivers for medicine the doctors are being beaten without a fight. This is in part because they know they have been the bad guys and in part because the don"t agree amongst themselves about cost abd benefit issues.. But there are fighters left. I read one diatribe the other day from a man known as Fearless Leader,a shadowy figure who lurks on the Information Superhighway. And Fearless Leader wrote "I grew up in an era when we really thought we could change the world. Our music, clothes,lifestyles and general attitudes radicalised society. Whether or not we really made a difference is often debated but our heart was in it. I was in Washington DC in June 1970 when the streets filled to the brim with Vietnam Vets against the war. The single most heart wrenching scene I have ever witnessed in my entire life was a three block line of medal winners, many in wheelchairs, tossing combat medals for valor over the white house wall in a big pile one by one. Silver Stars, Bronze Stars, Purple Hearts.... Visions of what was right and wrong were fairly straightforward. Identification of who was responsible for societal injustice was also very clear. The redress of injustice seemed worth the potential for personal loss; seemed worth fighting for. We were willing to have our collective heads busted open by nightsticks in order to "do the right thing". We also came away with a deep and abiding fear and distrust of traditional authority that has permeated many of our lives since. Authority figures also learned a lesson from the 60s. They learned that the way to defuse dissent is to raise the stakes of personal loss for potential dissenters. Kids in jeans and sweatshirts have little to lose by bucking the system and are more likely to throw their bodies in front of tanks for an abstract principle. Full grown adults with wives, kids, mortgages and responsibilities are much less likely to shoot themselves in the foot while their foot is in their mouth. So the answer to the problem is to put them in positions where they have infinitely more to lose by bucking the system than by simply going along. So in our world, physicians who, by their nature tend to be advocates of patient rights, are the enemy. They tend to demand expensive things that providers don't want to pay for. How does the establishment (whose major incentive is to make money and increase influence) deal with them? If they remain free agents they cannot be effectively controlled. So make them dependent on the establishment for their livelihood. Hire them. Then explain the rules and then explain the consequences for bucking the rules. Allow them to get used to a nice living standard. Then remind them that that standard could disappear if the game is not played. Enter the 90s. Administration suits looking to maximise their personal interests have learned to simply buy and sell those in positions to further those goals. Need to save money on drugs.? No problem..simply hire a PharmD and tell him / her that their job and livelihood depends on doing establishment bidding. If that interferes with the best patient care-not a problem. You are hired to do what we say,.not what is the "right thing". Hire a medical director and insure that his livelihood depends on doing the hardline. If that interferes with the best thing for sick patients, that is not really a consideration. Call a meeting and discuss their salary eventualities: that is the end of that problem. If these people buck the hard line, they have more to lose than to gain. I remain a child of the 60s. I learned my lessons well. I never ever thought I would have gotten as far as I have. I'll go up against an authority in the blink of an eye and for the smallest of ideals. My wife pays cash for everything because she knows I could be out on my ear in a heartbeat for some esoteric philosophical principle dear to my heart. So far it hasn't happened but the sword is always there, twisting in the wind. If some pharmacist sends me a memo telling me that they are directed by the hospital suits to cut back to Valium as the only drug I can use for sedation, I am going to come out like a chain saw,and if it means that my job is threatened, so be it. The right thing to do is the right thing to do..and that is the end of it." Every hospital in Australia has one Fearless Leader. Bean Counters refer to them as "Loose cannons. And even if this Fearless Leader's musings are seen as his idealistic naivety by some of my colleagues, they work for me. Imagine 10 or even 50 FLs. We could, to quote the sage,start a movement. And maybe the public might learn what the Bean Counters are doing and react. Got to be worth a try, because what we are doing now just isn"t working. "Retractor" Malcolm Fisher Intensive Care Unit PH 61/2/98656 Royal North Shore Hospital of Sydney Fax 61/2/4398418 St Leonards,NSW,2065 Australia Shake me,wake me,tell me it's a dream I got a B52 on my TV screen And a man in a tie, Pointing to the sky Where you gonna run to now. Redgum Rate This Message: http://www.cryonet.org/cgi-bin/rate.cgi?msg=5053