Collateral Damage

One December, when I was in high school, my grandfather passed away as the result of a physician’s error in judgment. To put it simply, the doctor gave him some medicine to slow down his racing heart and the medicine worked so well that it not only slowed his heart down, it stopped it completely. Efforts to resuscitate him were unsuccessful. My family certainly had a strong case against the doctor, but they chose not to pursue it–it was an accident, an honest mistake, and the doctor was a friend of the family.

These sorts of things happen every day in this country. In fact, chances are that you have at least one story of malpractice or medical error that has affected you, your family, or someone close to you. If nothing else, it is a reminder that medicine is as much an art as a science, and that physicians–despite whatever god complex some of them may possess–are wholly fallible. The truth is, some mistakes are unavoidable, while others are grossly negligent. In his book, Collateral Damage, author Dan Walter writes about the latter.

I mentioned Dan’s blog here a while back, and he has since turned the blog into a book. He was kind enough to send me a review copy, which I read quickly, and I promised him that I would review the book here on the blog.

The book tells of the horrible ordeal experienced by Dan’s wife, Pam, starting with what was supposed to be a simple cardiac catheterization to perform an ablation procedure that would put an end to her atrial fibrillation. With one simple mistake–turning the catheter counterclockwise instead of clockwise–the procedure goes horribly awry and is followed by emergency open heart surgery, weeks in intensive care, and a life forever changed for the worse. What’s more, the nightmare Dan describes took place at Johns Hopkins–America’s Best Hospital according to U.S. News–and no one there owned up to the truth of their mistakes, serving only to add insult to injury.

The book is thoroughly researched. In addition to his own eye-witness account of the situation, Dan digs up reports, journal articles, and medical records to make his case that academic medicine operates under some pretty unethical guidelines in attempts to get ahead, but then adopts a policy of complete denial of responsibility when the unethical approach backfires.

http://rcm.amazon.com/e/cm?t=wrighto-20&o=1&p=8&l=bpl&asins=B004EHZXAM&fc1=000000&IS2=1&lt1=_blank&m=amazon&lc1=0000FF&bc1=000000&bg1=FFFFFF&f=ifrCollateral Damage is a good, quick read. I must be honest though. It is a self-published book and would be made even better with the input of a good editor. There are a handful of typographical errors, some passages of text that are repeated throughout, and the text itself can feel “choppy” at times, rather than flowing naturally. In a weird way, though, these “flaws” make the text feel that much more raw and personal. As I read, I almost felt as though Dan and I were catching up over coffee while he told me about the terrible thing that had happened to Pam. It was clear, too, that the man remains rather bitter about the whole mess. In several places he levels personal attacks against certain physicians involved in his wife’s care. Of course, in light of the supporting evidence he provides, these attacks seem, if not justified, then at least understandable.

In the end, Collateral Damage doesn’t tell us much that we don’t already know about medical errors, their causes and consequences. What it does manage to do quite well, however, is tell us about those things in a very personal way. As Dan writes, “My larger purpose in writing this book is to tell Pam that she does matter, and that her life is important–and her story is important–and it deserves to be honestly told…” Dan Walter has unquestionably accomplished his purpose, and his gripping narrative is worth a read.

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Repeal and Some Housekeeping

The House is voting on the GOP’s bill to repeal health reform today. I, like most, think it is little more than a show vote at this point, because the Senate and the Presidency are still controlled by the Democrats. Still, it isn’t something to be ignored. How the moderates vote may be telling, and this of course is just the precursor to 2012. Unfortunately, I don’t have time these days to give you a more in-depth analysis, as I’m attending to more pressing matters, but the Kaiser Health News site has a lot of wonderful–even fun–information. Check it out here.

As for the housekeeping, I am, as I say, preoccupied with finishing my dissertation. There were large chunks of time (5 months to be exact) when I was waiting for the government to send me data, during which time I was able to blog prolifically. However, for some time now, I have been blogging less and “dissertating” more. As I enter what should be my final semester, that is ever more the case. So, in terms of the frequency of posts, the blog is going to be even more sporadic than it has been in recent weeks. What I would suggest you consider doing, if you don’t want to check back here all the time only to find no new entries, is to subscribe to my blog by email or using a feed service. This way, you will be notified if and when a new entry is posted. And, in the future, when I return to blogging more regularly, you can always discontinue that service if you wish (although I find it helpful). Okay, that’s all.

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Dave Barry on Health Reform

Dave Barry is one of the most hilarious syndicated humor columnists of which I am aware. He recently did a year-in-review piece for Slate. You can read the whole thing here. The part that made me chuckle the most–or at least the part that is most relevant to reproduce on this blog–was his take on health reform. Here it is:

“Let’s put this year into a full-body scanner and check out its junk, starting with …

JANUARY
… which begins grimly, with the pesky unemployment rate remaining high. Every poll shows that the major concerns of the American people are federal spending, the exploding deficit, and — above all — jobs. Jobs, jobs, jobs: This is what the public is worried about. In a word, the big issue is: jobs. So the Obama administration, displaying the keen awareness that has become its trademark, decides to focus like a laser on: health-care reform. The centerpiece of this effort is a historic bill that will either a) guarantee everybody excellent free health care, or b) permit federal bureaucrats to club old people to death. Nobody knows which, because nobody has read the bill, which in printed form has the same mass as a UPS truck.

The first indication that the health-care bill is not wildly popular comes when Republican Scott Brown, who opposes the bill, is elected to the U.S. Senate by Massachusetts voters, who in normal times would elect a crustacean before they would vote Republican. The vote shocks the Obama administration, which — recognizing that it is perceived as having its priorities wrong — decides that the president will make a series of high-profile speeches on the urgent need for: health-care reform…..

Speaking of celebrations in…

MARCH
… Democratic congressional leaders, responding to polls showing that the health-care bill is increasingly unpopular with the public, manage, with a frantic, last-minute effort, to pass the health-care bill, or, at least, a giant mass of paper that is assumed to be the health-care bill. This leads to a triumphant White House signing ceremony, the highlight of which is Vice President Joe “Joe” Biden dropping the f-bomb moments before being hustled off by aides to have an important meeting with somebody important.

Everyone at the ceremony agrees that the new law is historic and will become hugely popular with the American people once they have the opportunity to hear a few dozen more high-profile speeches about it from Obama. But opposition is “brewing” in the form of the Tea Party movement, consisting of regular Americans who are fed up with costly big-government programs except for Social Security, Medicare and Medicaid. These activists are determined to elect a new breed of representatives who are not career politicians or even necessarily sane…..

Getting back to reality: The 2010 election season enters its final days with polls showing that Congress enjoys the same overall level of voter popularity as hemorrhoids. Incumbents swarm out of Washington and head for their home districts to campaign on the theme of how much they hate Washington, in the desperate hope that the voters will return them to Washington. Obama, basking in the glow of the health-care reform act, offers to campaign for Democratic candidates, only to find that many of them have important dental appointments and are unable to join him on whatever day he is planning to visit. Adding zest to the Republican stew is the presence of many Tea Party candidates, including Delaware Senate hopeful Christine O’Donnell, who at one point in her campaign releases a TV commercial that begins with her stating, in a calm and reassuring tone, that she is not a witch….

The economy remains the big theme as the congressional elections enter the home stretch, with incumbents from both parties declaring their eagerness to go back to Washington and knock some sense into whatever incompetent morons are in charge. Polls show that the voters are in a very cranky mood, which tends to favor outsiders such as the Tea Party candidates, although O’Donnell definitely hurts her chances in Delaware when, during a televised debate, she turns her opponent into a toad….

Speaking of gory, in …

NOVEMBER
… the elections turn out to be a bloodbath for the Democrats, who lose the House of Representatives, a bunch of Senate seats, some governorships, some state legislatures and all of the key student council races. Also, a number of long-term Democratic incumbents are urinated on by their own dogs. Obama immediately departs for a nine-day trip to Asia to see if anybody over there wants to hear about the benefits of health-care reform.”

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A Return Trip to McAllen, Texas

Unless you’ve been under a rock for the last year-and-a-half, you’ve read Atul Gawande’s now-famous New Yorker article about the highly disparate levels of Medicare spending in the Texas towns of El Paso and McAllen. It was an interesting, well-written article, and it made a compelling case for health reform, which is why everybody, including President Obama, referenced it often.

But Medicare isn’t exactly ideal for studying the entire population, because its beneficiaries are either elderly and/or disabled. While that’s a significant population, it leaves a lot of people out. So, some clever researchers went back and looked at El Paso and McAllen, focusing on spending among the non-Medicare population, and they found that the eye-popping differences Gawande originally reported almost completely disappeared. Younger, healthier people are different–or the way physicians treat them is different. Either way, something is different.

The Incidental Economist’s Aaron Carroll takes a look at the Gawande article and the new Health Affairs study in chart form, and tells you all you need to know. You should read it, just so that when you’re at a party and someone says, “Can you believe Gawande’s article in the New Yorker?! How can spending be so much higher in McAllen than El Paso?!” You can say, “Yes, I know, it’s striking, but did you know that the same spending differences between McAllen and El Paso don’t exist in the non-Medicare population?” At least, these are the kinds of parties to which I find myself going.

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If I Wrote the News (somewhat of a parody)….

Americans are willing to pay more to get less, according to a recent report from the Congressional Budget Office. This follows the results of the mid-term elections that adhered closely to historical precedent, as a majority of voting Americans proclaimed themselves the voice of the entire citizenry and declared that they were fed up with politics as usual, preferring instead to send members of the other of two parties that have defined American politics for the last two centuries back to Washington. Unusual politics, indeed.

The will of the people was defined not by their poor understanding of economic and social policy, nor by racism or xenophobia, but by their belief in the eternal wisdom that when things aren’t going well, one ought always to vote for the other of two parties. And that they did, which is how, as of Wednesday, the country now has a Republican majority in the House, and a Speaker by the name of Boehner.

The new majority wasted no time in pursuing its agenda, introducing legislation to repeal the comprehensive health reform legislation that Democrats worked for well over a year–and in some sense, decades–to pass. The title of the Republicans’ legislation is the Repealing the Job-Killing Health Care Law Act, which is quite notable according to a group of Norwegian social scientists at the Nojoke Institute in Oslo, who explain that marketing is very important, especially in politics. “Words mean things to people,” they say, “even if the people don’t understand what the words mean.”

According to Dr. Olaf Thatrufunnutjeenbutdajtruf, the leading expert on the semantics of semantics, the title of the new legislation is of great importance. “It would not make sense to have called the Republican bill the Repealing the Patient Protection and Affordable Care Act,” Thatrufunnutjeenbutdajtruf says. “After all, who would be in favor of repealing patient protections and making care unaffordable, as such a name suggests?”

Instead, the Republicans refer to the Democrats’ legislation as simply the “Health Care Law.” According to Terrance “T” Bagger, who dropped out of college to protest the unconstitutional role played by those whose political views differ from his own, the thing Americans are supposed to understand about the “Health Care Law”, is that it–and not reckless spending habits and poor economic policy from prior administrations–is to blame for the economic slump we’re in currently. “This Obamacare is destroying our country,” he says. “I used to have a nice house and a job, before I got fired. Six months later, Obama passed his Health Care Law. Coincidence? I don’t think so.”

Somehow, despite the fact that the beginning of the recession preceded the passage of the “Health Care Law” by years, not months, it is the “Health Care Law” that is responsible for the high unemployment rates facing the nation. And, Mr. Bagger says, it didn’t do this unintentionally. “They know the people needed jobs, but they went out and done this health care thing that nobody wanted, and ended up taking away even more jobs.” As he sees it, the law purposefully set out to kill jobs. He has a point. How else can it rightfully deserve the title of “Job-Killing?”

It sounds like a terrible thing, this “Health Care Law” that kills things. Of course, Congress must repeal it. To do otherwise would be irresponsible. And that’s just what the Republicans hope to do, but they face more than a few obstacles. Chief among them, the Affordable Care Act was deemed to reduce the deficit substantially over the next decade at the same time as it extended coverage to tens of millions of Americans.  Chief analyst at the CBO, Count Alda Mooney, expects that the repeal act, by contrast, will raise the deficit by a similar amount, while ensuring that these tens of millions continue to go without health insurance. Says Mooney, “If that’s not paying a whole lot more for a whole lot less, I don’t know what is.” But apparently, the American people want it that way.

(All jokes aside, the preliminary CBO analysis that repealing ACA will jack up the deficit and fail to cover the uninsured can be read here.)

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First Health Wonk Review of 2011

It’s up and running thanks to Avik Roy, who put together one of the best reviews I’ve seen yet, and not just because he included one of my posts in it. Let’s hope this sets the trajectory for the rest of this year and beyond. If you want to read it, and why wouldn’t you, head here.

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The Hurdles of 2011

The implementation of the Affordable Care Act has been underway for a while now, but we are still in the early stages, with full implementation not scheduled until 2014. But, as 2011 gets going, it’s worth taking a look at what lies ahead. Brookings’ Henry Aaron comes to the rescue with an excellent piece outlining the various obstacles health reform implementation faces going forward.

There will be continued activity in the courts, all of which lays the foundation for what is ultimately expected to be a ruling by the Supreme Court. On this issue, Timothy Jost writes a great column about the most recent decision out of the Commonwealth of Virginia, that finds the individual mandate to be unconstitutional. One thing I learned from it was just how many cases had already been dismissed by federal judges (the answer is 14). You don’t hear about most of those in the news, so I had no idea.

De-funding is also a serious threat, and one that Ezra Klein suggests may already have happened with the passage of a continuing resolution. I think it’s still too early to see what effect this may have, or how much of a fight over the budget we’ll see in March, but how that plays out will go a long way towards the successful implementation of reform, or the complete undermining of the effort. Tumultuous times await us. Here’s hoping that the right people rise to the occasion and help us navigate them in 2011.

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Crossing the Border

I hear it all the time: “All these illegals are coming over here and they don’t pay taxes, but they get all these government handouts and they’re clogging up our health care system and BLAH, BLAH, BLAH…..” I often point out that many undocumented immigrants actually do obtain a taxpayer identification number for the express purpose of paying taxes in hopes that if a path to citizenship ever becomes a reality for the undocumented in this country, they will have a record of their contributions into the system. I don’t think people believe me when I tell them this. But perhaps they’ll pay attention to the information I’m presenting today, which comes from a recently published study by Dejun Su and colleagues.

The study, “Cross-Border Utilization of Health Care: Evidence from a Population-Based Study in South Texas” appears in the latest issue of Health Services Research. While many of the people whose social circles overlap my own are of the opinion that all the immigrants are crossing over into the U.S. to take advantage of all our “widely available free care”–you know, the ER variety–this study showed the opposite: people are headed from the U.S. to Mexico for care.

Of course, that’s not the case generally. The study looked only at border towns, and specifically, found that those who were uninsured and/or in poor health were the most likely to head to Mexico for care. But the point is that about 50% of the residents of border towns do actually go to Mexico for care. Some of these are undocumented immigrants heading back to their homeland for care, but others are U.S. citizens who are finding it more cost-effective to head to a Mexican physician or pharmacy.

This study actually speaks volumes. Opponents of health reform claim that the U.S. has the best health care system in the world, and that the uninsured can get health care whenever they want it, by going to an emergency room. If this were truly the case, the flow of cross-border health care seeking behavior would be unidirectional, with everyone pouring into the U.S., but it isn’t. Instead, many people find it better to go to Mexico, where care is far more affordable, and I expect, absent improvements in our health care system, more and more people will choose to do so and will make the journey from farther away. After all, medical tourism is already a booming business far beyond Mexico. I just wonder if the people of Juarez are as disgusted with those of us crossing into Mexico to see their doctors as we are about them coming here. Something tells me they’re not.

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