Would These Physicians Do a Time Out Before a Procedure?

My wife, Cathy, is extremely knowledgeable in safety, quality and accreditation for the non-acute healthcare arena which can make for very interesting dinner conversation. Recently one evening, she shared that after entering “Medicare fraud” in the website search engine of her favorite journal, Outpatient Surgery, the site returned 1178 hits. 1178 hits? You mean 178 hits, I had replied–or maybe, hoped. Unfortunately, 1178 was the correct number. I had to go online and read a few of the stories returned in the search. Following are just two examples from their site:

Spine Surgeon Charged With Medicare Fraud …Atiq Durrani, MD, billed Medicare for $11 million worth of anterior lumbar fusion surgeries between February 2010 and January 2013. According to federal prosecutors, those cases were medically unnecessary for his patients. They’ve charged him with healthcare fraud and making false statements. According to published reports, he has been named as a defendant in 150 medical malpractice cases filed by former back and neck pain patients, and no longer has privileges at the 4 Cincinnati-area hospitals at which he performed surgery.

Oakland County Doctor and Owner of Michigan Hematology and Oncology Centers Charged in $35 Million Medicare Fraud Scheme Dr. Farid Fata, 48, of Oakland Township, MI, was arrested and charged in a criminal complaint for his role in a health care fraud scheme…submitting false claims to Medicare for services that were medically unnecessary, including chemotherapy treatments….positron emission tomograph (PET) scans, and a variety of cancer and hematology treatments for patients who did not need them…Fata falsified and directed others to falsify documents. MHO billed Medicare for approximately $35 million dollars over a two-year period, approximately $25 million of which is attributable to Dr. Fata…The complaint further alleges that Dr. Fata directed the administration of unnecessary chemotherapy to patients in remission; deliberate misdiagnosis of patients as having cancer to justify unnecessary cancer treatment; administration of chemotherapy to end-of-life patients who would not benefit from the treatment; deliberate misdiagnosis of patients without cancer to justify expensive testing; fabrication of other diagnoses such as anemia and fatigue to justify unnecessary hematology treatments; and distribution of controlled substances to patients without medical necessity or administered them at dangerous levels.

About two weeks ago, Paul Levy posted in Kill This Monster, that The time has come to drive a stake through the heart of an oft-repeated assertion. How often have you heard something like the following when those of us in healthcare who want to stimulate quality and safety improvements draw analogies to the airline industry?” Well, in an airplane, the pilot has an extra incentive to be safe, because he will go down with the ship. In contrast, when a doctor hurts a patient, he gets to go home safe and sound.

I felt compelled to respond to Paul in Pilots and Physicians…Skin in the Game, expressing that, if you don’t believe the reason physicians are slower to adopt proven safety tools than pilots are because pilots have more personal “skin in the game” than physicians do, than perhaps the difference between pilots and physicians might be one, or a combination of, three other reasons: (1) misaligned financial incentives, (2) physician autonomy, and (3) a lack of medical accountability and oversight.

Screen Shot 2013-09-01 at 8.33.40 AMI am, and have always been, a big believer in Just Culture. Be it James Reason or David Marx, the concept is critical to achieving any true culture of safety. Over the last few years, I have followed the work of Sidney Dekker, Professor of Humanities at Griffith University in Brisbane Australia where great quality and safety work originates from (See Living Mindfulness). Dr. Dekker has a PhD in Cognitive Systems Engineering and is the author of  Just Culture: Balancing Safety and Accountability, a book I highly recommend, as he encourages us to ask:

What is responsible, not who is responsible. The aim of safety work is not to judge people for not doing things safely, but to try to understand why it made sense for people to do what they did – against the background of their engineered and psychological work environment. If it made sense to them, it will for others too.

After reading about the two physicians via the Outpatient Surgery website, I really struggle to understand how these actions made sense to any physician. The only answers I can come up with are: 1) These physicians had little, if any, regard for the patients who put their trust in them, or; 2) Believed the chance of getting caught for the alleged crimes committed was very slim. The perceived risk-benefit profile was heavily weighted towards personal financial gain, versus the consequences of inflicting significant patient harm. And if these physicians (and the many others referenced in my search) seem to have no fear of the law and possible legal repercussions, what chance do we, as safety leaders, have in getting them to perform Universal Protocol or employ risk reductions strategies before any procedure?

Like Dr. Dekker I believe that a Just Culture is all about balancing safety and accountability. Accountability in healthcare should never be lost.  If we as physicians don’t take personal responsibility and hold others professionally accountable, who will?  When we don’t, we lose the most important element of any patient-physician relationship, which is trust. As Dr. Dekker says:

Calls for accountability themselves are, in essence, about trust.  Accountability is fundamental to human relationships. If we cannot be asked to explain why we did what we did, then we somehow break the pact that all people are locked into. Being able to offer an account for our actions is the basis for a decent, open, functioning society.

To this I say “Amen”.

And…that I am happy my pilot has similar “skin in the game” (aligned outcomes) as I do when I board his/her airplane.

2 Comments on “Would These Physicians Do a Time Out Before a Procedure?”

  1. Kathy Pischke-WInn says:

    Agree with Dr. Mayer’s post re: having “skin in the game” for provider accountability – which will lead towards greater trust with our patients

  2. Dave, I have also pondered this question and gave an answer in 2010 blog for Health Affairs: Why we still kill patients: Invisibility, inertia and income. Physicians have generally not seen the deaths, except in the most egregious cases, as preventable. Not true with airline crashes. There is inertia — taking on patient safety, until recently, was an utterly thankless task and career endangering. Dr. Dekker and others may ignore this past history, but it’s not far away and it’s important. Pilots? Being on the plane makes safety a lot “safer” topic of professional discussion. And, finally, there are what you politely call misaligned incentives.

    Again, some history physicians prefer to forget: BOTH major studies of errors in the 1970s and 1980s (the latter is the famous Harvard one) were done only because of rising malpractice costs and primarily to see whether lawyers or doctors were at fault. The finding: doctors, but not that many folks sue.

    In contrast to the patient safety threat, when there was a safety threat that did directly involve clinician lives, the AIDS epidemic, the response was swift and dramatic. The threat was visible, the professional consensus was there for action and the financial impetus not to act (cost of extra gloves, etc.) was minimal and certainly not much of a counterweight compared to an incurable disease afflicting highly trained professionals.

    What changed medicine? The visibility of cases like the Betsy Lehman one, a new generation of leaders who tried to change the professional culture through the Institute of Medicine and grassroots action and maybe even a dose of media and political pressure.

    It’s why David Bates of Harvard circa 1993 was viewed suspiciously by colleagues and warned he had no career, while David Bates circa 2013 has his own patient safety center and is a safely tenured faculty member. Oh: and why a system like MedStar actively recruited you.

    Culture, professional norms, money. Change those and we can do CQI and listen to reason/Reason. Which is what, finally, we’re starting to do.


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