Hospital Accountability Is An Ideal (Not Always Reality)

I have spent as little time as possible on the staff of hospitals.  The interface between doctors and administrators has always seemed to be dominated by petty politics.  People are interested in money, and secondary to that, some vague sort of reputation or power.

A large and prestigious Midwestern hospital used to have a certain kind of meeting every few months.  This hospital had only the vaguest of University associations — just enough to make it look academic and research oriented.  I knew perfectly well it was neither.

It was a luncheon meeting of the medical staff and a few administrative types — uncommonly well-catered. There were about 25 folks, but only two other women who looked as uncomfortable as I was.

The meeting was to discuss certain hospital statistics, including some case details.  As the meeting agenda was passed around, the head of the hospital reminded us of the meeting “rules.”  We were gently reminded that no recordings were permitted and neither were extraneous notes.  We each received an agenda, which were carefully counted out as they were distributed.  We were told that at the end of the meeting they would be collected — and counted — before any of us could leave.

It felt like being in the first or second grade.  Scanning my memory, I could not remember having been to a meeting with this kind of rules.  And I have not been to another meeting with this kind of rules since.  I have not permitted myself to be on the medical staff of a hospital since, either.  I did not want any part of this thing.

These cases are among those I heard at that meeting.  They are all engraved in my mind — permanently.

1.  An older woman had all sorts of neuromuscular difficulties that seemed to be associated with low potassium.  A night nurse had given her some potassium intravenously.  This nurse was at the end of her shift and was coming off a tough night. She misread a decimal point, giving the woman one hundred times the amount of potassium salt the doctor had ordered.  The woman died immediately in cardiac arrest.

2.  There had been 11 deaths from hospital acquired infection in the period we were studying.  It was maybe 3 or 4 months, but I do not specifically remember that part.  Most of them were from “Pseudomonas aeruginosa.”  Others were from species I cannot specifically remember.  Most of these were patients who had been admitted to the hospital for pneumonia of various sorts.  In every case we reviewed, the person did not die from the infection they had when they came in — usually pneumonia.  In every case it was “hospital acquired.”  This means it was not the infection the person had when they came to the hospital.  Rather, it was something they contracted while they were in the hospital.

These infections are more resistant to antibiotics than the ones people bring in from the outside.  I was reminded of my professor of bacteriology.  She was a wise woman who fought tears as she told our class, “Every time you prescribe an antibiotic, you are treating the globe.”  What the prescribing doctor is doing is creating resistances among bacteria, so that antibiotics will not be as effective on them later.

Seven of these hospital acquired infection patients had died.  The Chief of Infectious Diseases was present, and his remarks were brief.  He said that this problem was everywhere and there was no good way to get around it.  He thought maybe things would be better when the hospital had a new building.

3.  There was a problem with surgical complication rate, most specifically post operative infection, with one particular surgeon.  The Chief of Infectious Diseases said he would speak with that person.  It was suggested there be some sort of report at the next meeting.  It struck me as strange that the other surgeons either could not – or would not? — review this older surgeon.

The USA Today recently reported that Marty Makary, a surgeon at Johns Hopkins Hospital in Baltimore, had written a book about transparency in hospitals and revolutionizing health care.  In the interview, he discusses how decisions are made, how incompetent doctors are allowed to keep practicing, and a whole bunch of other stuff I have generally seen elsewhere.

During my time in hospitals, I was always the junior in a position of weakness.  I will readily admit that I have generally avoided whistle-blowing in favor of self-preservation.  But it was part of the culture and I was never, ever alone.  The culture of physicians “protecting” each other has always been primordial throughout the places I have been.

I think Dr. Makary may be a tad idealistic.

His book got published and it is at least a little acclaimed because it was reviewed in USA Today.  He probably got that review because he’s a surgeon.  Idealists who never sat through medical school haven’t been able to achieve the same level of attention given to doctors.

From Catholic nuns to trained nurses, to university trained ethicists, many have bent my ear with tales of doctors’ over-sized egos.  I have told them that a doctor has to believe in him or herself.  Doctors have never really thought other professions to be their peers. Within this context, I fear that transparency shall easily slide into pseudo-transparency.

I mean, look at the speeches of the current presidential elections that are being dismantled by fact-checkers.  I have never known a surgeon I would trust not to at least slightly underestimate his post-operative infection rate.  I also have never known a hospital-acquired infection official who would not underestimate a bit for the whole hospital.  I do not know how much is conscious and how much is just survival.  I do know people in general are fairly subjective about things that impact their jobs and their pay. Physicians are human, all too often under inhuman pressure.

What if fact-checkers assaulted physicians at gunpoint, like they do presidential candidates?  For the latter, all “truth” — or its perception — seems to have something to do with a pre-existent belief.  No power is stronger than belief.

As for attitudes toward doctors, there is the ever popular “transference”– a complex Freudian phenomenon that is really quite simple.  Those who hate doctors will hear only the worst.  Those who view docs as loving and paternal might fall in love with them.  There are those who will not hear any good, as well as those who will hear no evil, and everything in between.

Assuming we can get past thoughts — and that is a wild assumption at best — then there is the public.  We are not the “enlightened” public Thomas Jefferson wanted for the United States.  If we were, we would have woken up long ago.

I think it would take a lot of “book-learning” for John Q. Public to interpret an apologia for a raised infection rate.  Such an idea is in the general ball park of people taking extra time to improve their knowledge, and subsequently, take responsibility for their own health.

The idea, the book, and hospital transparency are hard to make happen.  And harder still to use to achieve ends.  However, it just simply needs to happen.