A Problem with Patient Safety?

Don't think I'm about to write that patient safety is the best thing that ever happened to medical care. I'm not. I think it might be useful sometimes, and is occasionally a reasonable addition to procedures in medicine, but the problem with "patient safety" is that there are NO LIMITS to its implementation.

All this patient safety began around the time of the publication of the book, To Err is Human. It was published by the Institute of Medicine in 1999. There had been rumblings about safety before that, but that book began the major onslaught of regulations. JACHO, CMS, state agencies, leap frog, medical board organizations, insurance companies and others, too many to count,began to apply their own regulations to support the growing idea that the doctors were dangerous and needed to be controlled! After all, doctors kill over 100,000 patients/yr. with mistakes.

First of all, I'm not certain that figure is accurate. I have been in medicine for over 30 years, and I can barely remember deaths caused by errors. Is giving the "wrong" antibiotic prior to culture results a mistake; is an incisional hernia a mistake; is an infection after surgery a mistake (even in a malnourished patient); is a heart attack after a below knee amputation a mistake? These numbers added up, and fed the final conclusion of 100,000. These numbers are based on research done in the 1980s to discover why there were so many malpractice suits, and I have questions about these statistics. It sounded good, and this conclusion opened the door to control and regulation of doctors with no limits. After all, who can speak up against "patient safety?" Not me!
But there is problem with this crusade. "Outsiders" have been given authority to manipulate and control all aspects of physician behavior to the extent that any semblance of professionalism is being decimated. Professionalism includes the concept of PROFESSIONAL FREEDOM, and this has disappeared in medical practice. CMS demands some of these rules because of payment constraints, but they all jumble together to control the day to day behavior of physicians. Do they really believe we are trying to make errors? It just happens decisions in medical care are difficult, and that's why we used to be paid well for our work.

The words we use in our "private patient charts," the details of behavior in the operating room, the "time out," the concept of patient consult versus evaluation, instrument and sponge counts on cases with incisions only 3 centimeters long; updating a physical exam prior to surgery, re-dating the operative request;signing verbal orders within 24hours, dictating operative notes within 24 hours, and not to mention the continued devaluation of our services through reimbursement reduction, are just a few examples of the ever increasing infringement on professional liberty that physicians are forced to endure. Are these checks useful? Maybe some of them, we don't truly know. One thing, however, is for sure: they are selecting a certain type of physician who will practice in the future in this oppressive environment. This "new" doctor will be the type who will not live a life for medicine or for the patients. Medicine will become a job, a supplement to a "lifestyle" which offers time off, reasonable payment, time for family, and time for other "more important" activities. As long as these doctors follow the RULES, and stay under the radar of the regulators, they can continue to work at their job. Fortunately, it was not a job in the past, it was a profession.

Surgeons are now required to do a "time out" prior to operation. I have never operated on the wrong patient or wrong side in 30 years. But we are now required to mark the site prior to surgery, have the request signed before surgery, and discuss the site of surgery before we do it. I am surprised that we are not required to turn around three times after the "time out" and do it again to make sure we have the right patient!

If the specialty organizations-American College of Surgeons, American College of Physicians, American College of Cardiology, etc.- do not begin to speak up against the continued oppression of physicians, and begin to demand some reasonable limits to these oppressive regulations, I fear the patients of the future will be treated by physicians who are not particularly concerned or motivated to get the best for each patient. These new physicians will be a "physician bureaucrat" who is enforcing the RULES of "the system." I do not believe this is a bargain society wants. There can be no profession without "professional liberty." Professional behavior and motivation depends upon it.

James P. Weaver, M.D.

The Smoker's Choice: addiction

Apparently, there was a recent settlement for 8 million dollars in another "smokers" case. "They made me do it!" The plaintiff was the wife of a smoker who died at age 55 after years of smoking- he was ADDICTED. He died in 1997, at the age of 55. How long does it take for someone to hear the message? Smoking causes disease and death.

I used to smoke myself, and I knew in 1970, that smoking was dangerous for my health. I used to joke that the cigarettes I smoked were keeping the cancer cells quiet, and if I stopped, they would wake up and kill me. The above case is just another nail in the coffin of accepting personal responsibility for our behavior.

As a thoracic and vascular surgeon, I have thirty years of experience watching my patients smoke and struggle to stop. I have heard all the excuses in the world, "I've smoked for 50 years" and, "I'm addicted" are the most common. It's the "I'm addicted" that deserves further comment.

I think the people who make the "products" to help smokers stop want them to believe they are ADDICTED. Believing you are addicted means that you cannot stop WITHOUT buying their product to stop. That is what they want smokers to believe because it means money for them, but what they do not want smokers to consider is that addiction comes in different flavors. Their are addictions to narcotics, or alcohol, and these are serious. If you stop these drugs suddenly, you can die. Seizures, vomiting, and diarrhea are the consequences. But smoking is a special type of addiction that I call a "situational addiction."


As a previous smoker, I know what a situational addiction is. It's one that comes on under certain situations: up in the morning, read the newspaper, a cup of coffee, and a cigarette; an important telephone conversation and a cigarette; after dinner, a cup of coffee and a cigarette. All of these situations NEED a cigarette. I used to get up in the middle of the night, think about a problem that was bothering me, and have a cigarette. When I finally quit, it was the SITUATIONS that I had to deal with to stay away from cigs.

The most common reason someone who has quit goes back, is that something happens that upsets them, and they say," I need a cigarette." This behavior is not a physical addition, as alcohol or narcotics are, this is a situational addiction. This type of addition cannot be handled with medicines or patches, or hypnosis, or needles. It can only be managed with reasoning and attitude, and understanding.

Simply being aware of this distinction can help the smoker understand and deal with the urge to smoke. Change in one's situation can help relieve the stress and the desire for another smoke.

When I quit, I was nervous for about three days. By then, all the nicotine (the "addictive" substance) is gone from the body. That's when an understanding of the situational part of the "addiction" becomes important. I actually wrote the Attorney General about this about one year ago; he never answered.

Success in quiting smoking is as dependent on being aware of the situational part of this process as it is using a patch or other devices to control the urge. I believe the reason so many of these devices fail is because of a misunderstanding of the causes of this addiction. Good luck.

James P. Weaver, M.D.,FACS

Doctor Ads

Physicians have been advertising ever since 1975, when the successful suit by the FTC against the AMA (Goldfarb v. Virginia State Bar) forced the AMA to remove the prohibition against advertising form its Code of Ethics. Since that time, physicians have used this tool to promote their practices. Unfortunately, physician advertising has placed doctors in the same venue as merchants, and degraded their previous status as one of the "learned professions."


In an article by Tomycz (N.D.Tomybz, Journal of Medical Ethics 2006;32:26-28),he explains that the leaders of the FTC believed that Medicine was mercantile, and needed to be regulated as a business. They believed that regulation would decrease the ever rising tide of medical costs. Didn't work did it!

The original AMA prohibition began in the 1800's, and was generated by the large amount of advertising put out by a multitude of potent makers and charlatans. Not wanting to be identified with this behavior, which was frequently deceptive, this medical organization forbade advertising by its members.

Today, physician's ads are ubiquitous. They are not false, or misleading most of the time. It is not unusual to see one next to a furniture store ad, or a restaurant ad, which places the physician firmly in the arena of the merchant. I have even seen a license plate cover with the name of an orthopedic practice in my town. How about identifying with a car dealership?

The real problem with advertising is that it threatens to dissolve the distinction between what is supposed to be the Profession of medicine, and business. Medicine, in the classical sense, is supposed to be a profession that carries an obligation of self sacrifice and self effacement towards the ultimate good for the patient. This characteristic of the profession is what generates the essential element of TRUST between the patient and the physician.

A merchants might want you to trust them, but they are not going to have any self effacement or sacrifice in their part of the relationship. If physicians are to be regarded as a profession, all of these elements-self sacrifice, self effacement, and trust-must be part of their ethic. By advertising, physicians place themselves in the venue of the merchants, dissolving a significant distinction and jeopardizing a trusting relationship with their patients. Is my doctor in it for the money?

I am aware, that in the current financial environment, doctors believe they must advertise to stay competitive. But they must be aware of the element of "professional suicide" that accompanies the road of self promotion. Medicine should remain a profession that is not interested in selling you anything. Our best advertisement is our reputation and our service.

James P. Weaver, M.D., FACS

Medical Care Oppression

I know most people think physicians have a pleasant professional life, but that is not true. The current atmosphere in the medical world is not a happy world. Most physicians do not advise there children to go into medical fields, and that is a tragedy. A practicing physician, around 40 years of age, should believe that practicing medicine is the best thing to do, and that nothing else would be better.

Doctors today feel oppressed, and Medicare is the major offender. Medicare tells doctors how much time to spend with patients; what they should write in the hospital and in their own private charts; who they can admit to the hospital; how much they will be paid for their labor; and all these directives are done with the constant threat of large fines and imprisonment if these "rules" are not followed. All of these rules apply even though the government promised that there was a "prohibition against any Federal interference" in the first paragraph of the original Medicare law.

Medicare has forced "Professionalism" out of medicine. It cannot pay for all the promises made to the people, and it continues to decrease reimbursement, and increase rules. Fifteen years ago, most doctors believed that they were being paid a reasonable wage for the work they were doing. Today, I and most other doctors believe we are not much more than controlled servants. We work hard for our wages, with difficult patients, taking risks that are not adequately reimbursed. Many services we deliver are "covered" under the "global" coverage of indentured servitude. Global coverage is a method that Medicare uses to force physicians into patient care situations that extract free work from physicians. It is all too common.

I have begun to wonder about the response of people that are forced into a system that they believe has no integrity. I think that doctors believe that Medicare has no integrity or honesty in its dealings with physicians. It continues to unilaterally cheat the providers with its many rules and restrictions. That cannot but encourage behavior in doctors which will not be helpful to patients.

I am searching the business literature for studies on this topic(how people behave in an environment that they believe is unjust), but have not found much yet. I intend to write about it later. How does someone behave when forced to work under a system that one believes has no justice? Why is it the malpractice rates keep going up, but reimbursement keeps decreasing? Are we doing something that is dangerous, but not worth much? I believe this system is not healthy or nurturing to the profession of medicine, and the social consequences have yet to be examined.

More to follow.

Dr. Weaver