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


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