A Physician Responds to Organized Harm Stories

As a physician it is difficult to address the various issues brought up in various media or journal articles. As a family physician I feel caught between "sides." I see those truly harmed, those who may have been harmed, and those who blame others for their problems. I see a great deal of manipulation and confusion - and sorry. We do create our own realities as providers and as patients. But we often do not realize the major forces that are shaping outcomes - and not in ways that any of us want.

The patient story is one view of what is going on. For every story there are multiple viewpoints. Journalism typically does not explore much more than one viewpoint. A recent event brought home how patients can have expectations too high and experience "harm" where there is none.

Stories can be powerful. The internet has multiplied individual stories and opinions. Sometimes it is hard to find reality as adverse experiences dominate our thinking. Those who serve on the front lines such as public servants and health care professionals attract a great deal of attention. Ask yourself why were we so wrong about Vietnam veterans for so long? Could it be that other orchestrate our views and our biases - even for those serving because they feel that it is their job or duty? Teachers and nurses and others grow more frustrated with more to do with fewer of them and with less support and with higher complexity - and we help make it so. Where are their stories?

There are many problems in health care. Destroying confidence in health care is one more problem being added - as is also obvious in these stories.

What is most obvious from To Err is Human to the present is that social determinants, situations, resources, access, and relationships (or lack thereof) substantially shape health care events and outcomes. We fail to do simple things to protect ourselves. For example the people who prepare and serve our food are paid by minimum wage and do not have paid leave when sick - so they work when they have infections that can then spread throughout our families, homes, and communities. Some have set up paid leave as a priority. This is too few. Those that lobby against are more organized and more powerful - even more powerful that common sense.

We have lost sight of addressing public health and health infrastructure
in favor of more for fewer for substantially more cost.

Tinkering around with the tinsel has not been helping. Innovations and rearrangements fail largely because they are about not doing the hard work of delivering care or getting policy changes that matter. Cost cutting as the basis for payment design has made it worse (for 30 years). We fail to figure out where we can invest for efficiency and effectiveness and allow the accelerations of funding where care is least efficient or effective. We invest where it matters least.  Administrative cost accelerations insure that higher cost of delivery compromises care in many ways - within a nation, within a plan, within a system, within a practice. Meanwhile the cost goes up out of pocket and for premiums as dictated by insurance, government, and employers. 

Forcing Quality Fails for Quality and for Cost

Attempts to force quality have had no place in true quality improvement since the time of Deming, but we now have bandwagons of value based, pay for performance, and readmission penalties. New medical homes with new names actually cost more and can do less - also because quality is fixed in place.

Forced attempts at quality are not capable of addressing the factors important for quality determination and actually discriminate against patients in need of care and those who attempt to care for them. If it costs more to deliver care, practices can care for fewer patients and focus on patients with better income and insurance. Higher cost forces cuts in the support of the teams that deliver the care.

The real story of American health care
is the lack of a design that fits Americans.

Our design results in too little and too late for many and too much done for those with too much access. Care is concentrated in few locations involving few Americans. The research that we used to approve drugs and treatments ignores women, minorities, and those most typically receiving care. We do not even know if complicated treatments actually help complex patients with few resources as it is difficult for them to afford care or stop work or care for family members if they are disabled even temporarily for complex treatments.

What we have is health care that is a poor fit for most people when and where and how you can get care. In other words,

We are being led by people, institutions, and corporations
that do not understand the basics.

The leaders fail to understand the importance of a strong foundation of basic services and access and social fabric and other factors that truly contribute to better health and health care. 

We have a nation where access is lacking, where support for basic services is minimal, where technology is worshiped, where complexity is increasing, where basic nutrition and public health are compromised, where community resources are slashed, where child development is neglected in ways that will result in worsening health and health decisions, where corporate advocates successfully lobby for more testing and treatment or equipment, where advocates get legislation passed supporting treatments with little benefit and some harm, and where provider overload is accelerating. This is harm by design.

We are a nation of chaotic advocates adding more to the confusion on a daily basis. What health care needs is in many if not most ways, an entirely opposite design.

We need much better engineering with a focus on care for nearly all Americans.