You lost me right there. I’ve been a software developer for nearly 2 decades, and I’ve spent more than the average time in a doctor’s office. My own experience with doctors is of course anecdotal, but I’ve worked in maybe a dozen different software shops, large and small, so I know that end pretty well. It’s a very, very large thing to say that doctors are broadly sloppier than software developers. When I joined my current shop, there was no versioning, no source control, and no system of any kind for backing things up. Each system that went out the door had its own code base. There were no standards of any kind in place for coding, design, or pretty much anything else. There was cursory unit testing and no system testing before code hit the customer.

Much of this has been rectified in the intervening 3 years, but this shop, in my experience, was just a tad below average when I got here in the realm of sloppiness.

If a patient comes in with lower abdominal pain, the differential diagnosis is huge. Appednicitis, diverticulitis, kidney stone, genitourinary infection, musculoskeletal injury or strain, an undiagnosed malignancy, neurologic disorder such as shingles, or a ruptured aortic aneuryusm are just some of the things to consider. It’s possible to rule out a bunch of those, if you have the time. If it happens to be a rupturing AAA, then you most likely don’t have the time to work the process out and the patient is likely to die. Even at the beginning, the unknowns include how much time you have to get to the right answer.

Therefore “not being able to know it all” is a given, and not only that but a lot of what we know is probably wrong, too. The thinking when I was in medical school was that estrogen replacement for postmenopausal women was pretty much all good. It was supposed to be good for the heart and bones, and may help stave off dementia. In the last 10 years, all of that has been proven wrong. It’s worse for the heart, the phosphonates are better drugs for the bones with fewer side effects, there is no effect on dementia and it probably worsens breast cancer risk in some patients. Anyone who says “the science is settled” is overgeneralizing or wrong, particularly in medicine. The example of peptic ulcer disease being primarily caused by bacteria is yet another world-shaking discovery that proved nearly everything wrong that other authoritative people built their careers around.

If this weren’t bad enough, there is a couple of trainloads worth of new data coming toward medicine in the form of genomics. It will probably end up being a two to three-year fellowship after a full three-year internal medicine residency. We’re learning so much more everyday that keeping up is getting to be not just difficult but impossible.

Most docs don’t feel the need to protect the incompetent though what happens most often is that they are shunned. Nobody wants to get involved in their cases because they don’t want to end up named in a suit. It becomes difficult for them to practice, and so they leave some location and head elsewhere. Often the proximate cause of their departure is threatening of their hospital privileges, and since that is a reportable event to the National Practitioner Data Bank (and often to state medical boards) most docs in that situation would rather resign than have the black mark against them, and most hospitals would rather they leave instead of pursuing something likely to land them in court. I get worried when a physician has a career comprised of 2-3 year stints in multiple states.

We are told by medical malpractice insurers that bad outcomes don’t generate suits, angry people do. Particularly if a physician doesn’t communicate well, or angers patients or their families. The hole in the whole bad doctor problem is that if a physician is personable and incompetent, it can be very difficult for accusations of their incompetence to be seen by the public as anything other than professional jealousy. Their patients love them, they talk to their patients, they listen to their patients, and the patients will raise a stink, particularly in small towns. A physician who demonstrates that they care in a convincing fashion and yet lacks clinical skills commensurate with their perceived competence is very hard to dislodge.

Too bad we’re not back in the 1950s, or 1850s, when there was virtually no real medicine to know, so almost any doctor (or barber) was “qualified”. But, what about 2050? This is where the problem is (sort of) similar to the case of software developers. The public – and management – tends to have faith in “the technology” or “the science” and doesn’t believe the virtue of the individuals involved is nearly as important. And in this they are very wrong.

Obama seems to be case in point, believes all he has to do is ask for a solution, and voila, it will appear. He said this almost exactly as part of his campaign rhetoric. Seems to believe that’s all it would take to get the bill written and passed, too.

Science is difficult, is what I’m trying to say. The idea of calling medicine “practice” I find a horrible anachronism and a large part of the problem. I suppose computers will improve things over the next ten, twenty, fifty years. Yes, I know the debate about that, from back in the AI expert system days. The AI mostly sucked, and who has faith in cold Bayesian statistics? And yet, the computer can know all that is known, or apparently a lot more than your average practitioner.

So, I actually support a lot of what Obama is suggesting, but I wonder if it doesn’t leave out some critical items. That is, I’m certain it does.

The problem of inept physicians is a real and difficult problem, for at least three reasons:
1–About 40 years ago a study was published in the American Sociological Review entitled ‘The Protection of the Inept’. It discussed the wide-spread phenomenon, across all societies and groups within societies, in which the inept members of a group are protected by the group, even when it would seem to the group’s disadvantage. For example, it was observed that members of professional sports teams would try to hide from the coaches the mistakes that the more inept team members made. It is only when there is a wide gap between the most inept and the next member of a group that the group is likely to withdraw this protection. The hypothesis is that members of a group fear a domino effect: if the most inept is removed, then who is next and when will it end up being me?
2–Physicians on professional standards committees in hospitals, chosen because their knowledge is respected, accept that role from a sense of responsibility to patients and to their profession (not a paid position) but they also fear it. The process of removing a physician from a hospital staff is likely to result in a ruinous lawsuit against the physician on the professional standards committee by the inept physician.
3–It turns out that there is little or no correlation between the competence of a physician and the likelihood of being sued. Often the best physicians are referred the most difficult cases–cases with the greatest chances for mistakes and bad outcomes. And so when physicians see other physicians make mistakes, there is a knowledge often of ‘there but for the grace of God go I’.

I am not arguing against the importance of monitoring and enforcing the quality of medical care. It is just not easy.

Best wishes,

Jim

FWIW, the PCP was an excellent doctor, once upon a time, I believe suffering a little late-career burnout and simplifying his practice but still excellent, until his group was bought up by another group. I believe that is when his policies changed. But under ANYONE’s policies, it’s clear that he was grossly negligent in this case.

But, was his negligence any worse than the average care of the average physician, under the same guidelines? I have to wonder.

my Dad’s primary care physician was clearly negligent, repeatedly, and every other doctor in the chain knew it

This is interesting from a couple of standpoints.

First, the failure in your Dad’s case was with the primary care provider (PCP). One of the major flaws in both the managed care model and in the concepts embedded in the Obama Administration’s healthcare reform is to increase the importance of the role of the PCP. The idea is that the PCP can act as a gatekeeper (and cost controller) for the specialist system. They do this by effectively blocking access to specialists unless they are referred by a PCP.

This has the effect of limiting access to the specialist docs, and bottlenecking the system. The response for PCPs is then to turn care into an assembly-line, in an attempt to “process” patients as “efficiently” as possible. Less time per patient, both to visit and think. In my general experience, limiting the amount of brainpower applied to a problem is a bad strategy, and in medicine time and experience with patients are the two biggest drivers of brainpower.

What we should do is let specialists decide who they want to see, and let patients decide who they want to see. Some patients will prefer to see PCPs, so that they can establish a long-term care relationship that spans all of the health issues they may encounter during their lifetime. Others will want to “roll their own.” They should be allowed to do so, so long as they can find a doc, and are willing to pay for it. You know, a market of “buyers” and “sellers.”

Instead, we put a huge and unnecessary burden on the PCP, limit the customer pool for the specialists, and take the responsibility for the most important decision – who will treat me – from the patients.

The other interesting thing is how the other docs knew by whom the screw-up was made. This is not surprising; they’re the ones with the most data with which to do pattern matching. There is an argument to be made that the momentum for lawsuit abuse was created by the systematic refusal of physicians to “police their own” in an effective manner. This left people with no other choice than to go to court.

If you ask people why they sue for malpractice, the vast majority do so because they want to get an incompetent doctor out of the system. They know that winning will not bring their loved one back, but they feel a responsibility to get rid of a bad apple who might hurt others. And they have come to believe that docs simply won’t pursue one of their own. If docs really went after the “bad guys” in the system, a lot of malpractice would end, and a lot of the incentive to sue would go away.

At least for the victims and their families. The plaintiff lawyers, of course, are another matter…

Cheers,
L3

I understand what you are saying. Any single cell of the human body, is 1000x more complex than any computer system. But on the other hand, the body tends to take care of itself pretty well, doesn’t it? I’m afraid you put your finger on the sore point, when you say, “what is known is so vast that no physician can know it all.” But again, it’s soooo easy to use that as an excuse for shoddy work.

Something I did learn, watching my Dad’s last days, is the difficulty of being a physician in that environment, where you *will* lose a lot of patients no matter how hard you try.

But without going into the details, trust me, my Dad’s primary care physician was clearly negligent, repeatedly, and every other doctor in the chain knew it. My information is that the treatment recommended was inappropriate, we did not get even competent textbook decisions, even after I gently questioned it. And because of the weekend day and afternoon hour he went in, the proper tests and interpretations were done just a few hours too late.

The admitting ER doctor seemed sharp, and the critical care nurses seemed excellent, but the system, and priorities, and responsiveness, of the system certainly abused and lost a patient who should have had a much better outcome.

Not to mention, it would have saved the taxpayer probably six figures.

Josh, are you suggesting that the human body, including the brain, is no more complex a system than computers and their software? I suggest that a closer parallel to the complexity of the human system is the weather system, and with how much accuracy are we able to predict the weather a few days or weeks ahead–and sue the weather man if an error is made?

How many software developers live with a constant awareness that any keystroke may be irretrievable, may cause the death of a company, or may erase all that they have earned, maybe even before paying off the debts of 7 to 12 (or more) years of education after college?

Speaking as a physician, I think you have little concept of the thought that goes into making medical decisions and the soul searching that follows when treatment fails, either through error or just limitation of knowledge. Patients may not like this truth, but there is far more unknown than known in medicine. Also what is known is so vast that no physician can know it all. In fact, it is not even possible for any physician to know what he or she does not know–what other physicians might know that he or she does not know. But when things go wrong, most physicians, in their own mind, think “I should have known that”. This may be one reason that the incidence of depression and suicide is so high among physicians. Are physicians likely to admit publicly that “I should have known”? No, that is what the trial lawyer will drum into the jury.

Jim