'See no evil' butts up against learning curve

September 5, 2008

Hi, Roger. How are things at Memorial Hospital? What are you in line for?

Hi, Roger. How are things at Memorial Hospital? What are you in line for?"

"Things are fine at the hospital. I'm here getting a second mortgage for a ski lodge we're buying. And you?"

"I'm getting a third mortgage to pay Medicare."

"Medicare?"

"They did an audit of 100 radiology reports at our hospital, and they felt that 33% were either incorrect compared with pathology reports or had minor errors. Now they want to be reimbursed for 33% of all cases we read. This is just like when they would audit our practice over screening versus diagnostic mammograms."

"How is that?"

"They would audit 50 diagnostic mammogram cases and say most of the diagnostic ones were actually screening and then apply that number to all diagnostic cases we did over five years and expect to be repaid."

"Ouch!"

"Tell me about it. What with this and the HMOs squeezing us and the insurance companies trying every trick in the book not to pay claims, we're actually having to borrow money to stay in business."

"We don't have this problem at my hospital, since our x-ray, lab, and operative reports never conflict. We never have any errors."

"How can that be?"

"The administration has said so. 'No errors.' They don't want to lose any money either. We just don't allow disagreements in print, and we've stopped doing autopsies unless required by law. We also aggressively sell organs to get rid of evidence. With the new transplant techniques, the whole 'male enhancement' industry has been hugely profitable for us."

"Really? How much do you think I could get for my . . . ?"

What do the Chinese government, Wall Street, the Mafia, and most charities have in common with some hospital administrators? Omerta, the code of silence. It is often misattributed to the Mafia but is really a practice that arose in 16th-century Sicily in opposition to Spanish rule. We know, of course, what happens to those in the Mafia or in the White House (Scott McClellan, take note) who violate this rule. This applies equally to honest whistleblowers.

As reported in The New York Times, "Two and half hours after a huge earthquake struck [China] . . . an order went out from the powerful Central Propaganda Department. . . . No media is allowed to send reporters to the disaster zone."

Not only did the Chinese government try to censor coverage, but it also suppressed the fact that most schools collapsed due to substandard construction attributed to corruption. Parents and press were barred from school sites, and pictures of the faulty construction were seized and destroyed. This strategy proved about as successful as the government's handling of the SARS crisis.

Wall Street's code of silence often manifests itself as promotion of products traders themselves do not believe in. Bear Stearns hedge fund managers Matthew Tannin and Ralph Cioffi were arrested after losing $1.6 billion in a fund they thought was garbage. They were taking their own money out before it collapsed. Bear Stearns in public statements said everything was fine, even while in the executive suites, the company was crashing and burning.

Charities certainly could not be accused of such behavior, right? Wrong. A recent study based on data provided by the Association of Certified Fraud Examiners found that charities "lose on average 6% of their revenue to fraud every year." That is $40 billion a year out of the $665 billion a year they collect. How could none of us have ever heard of this astounding level of thievery? Because most charities keep it quiet for fear of bad press that would adversely affect future donations.

What does this have to do with doctors? Well, omerta seems to be no longer a shady unspoken practice but is now actually memorialized in medical staff bylaws. As part of the renewal of privileges at one hospital, staff are now required to sign a document saying that they will not discuss medical errors in any patient's chart or risk termination of privileges for "unprofessional behavior."

To quote Dr. Kelso, the testy administrator for the fictitious hospital on TV's "Scrubs," "At Sacred Heart, we do not make mistakes. If you don't look for mistakes, you can't find them."

Such attitudes would account for the dramatic drop in autopsies from 49% in 1955 to 5% today. Part of this decline is due to fear of lawsuits, since 24.4% of autopsies find major errors that would have altered treatment.

I can't help but think that this new rule not to document errors may just have something to do with the Centers for Medicare and Medicaid Service's decision to stop paying for preventable errors. Initially supposed to affect just six to eight conditions, this change is being expanded to 17, and we can surely expect more to come. CMS calculates that just nine of these categories cost them $25 billion a year. Other insurers have decided to follow their lead.

This decision is already changing how medicine is practiced, and not always in a good way. Several hospitals have started x-raying all patients at the end of surgery to make sure nothing is left behind even if the count is correct. Should we really be needlessly irradiating a 22-year-old woman after a C-section? Or do we want physicians having second thoughts about ordering tests for fear of finding something like a tiny PE/DVT that could result in nonpayment?

Many experts have questioned the ability to prevent many of these "preventable" errors: falls, PE/DVT, delirium, C. difficile infections. Even the authors of "The wisdom and justice of not paying for 'preventable complications,'" in the Journal of

the American Medical Asoociation (2008;299:2197) reported, "The ability to diagnose the remaining complications is error ridden, and there is limited to no evidence about their degree of preventability."

Just what you want-not getting paid for something that you cannot

prevent.

Errors are a fact of life, and trying to hide them makes it impossible to learn from them. We should not hide errors but instead make the public aware that errors are to be expected. Unfortunately, however, most people have the unrealistic expectation that medicine is perfect. Even some doctors think they are perfect until they have their own cases double-read, which does not happen as often as it should.

To avoid errors and unwanted scrutiny from outside sources, radiologists need to implement for themselves much more aggressive QA/QI programs. They should increase the number of overreads, along with doctor profiling, improved follow-up correlation with pathology reports, benchmarking, early adaptation of new techniques and technology, and more rigorous CME requirements.

If we don't do these things, others will impose them upon us, with painful monetary penalties attached, as we see from CMS. You may find yourself having to sell your own very private assets to make ends meet.

Dr. Trefelner is a radiologist

and cofounder of NightShift Radiology. He invites comments by e-mail at ericxray@pacbell.net or fax at 650/728-5099.