When my appendix burst, I went to a private hospital. Try telling nurses and doctors that you can't breathe, you must have your inhalers (which were NOT prescribed by THEIR doctors), I choked and coughed and tried to open up my airways. Then I got out of bed and within 45 minutes of coming out of anesthesia, I had checked out against doctor's advice (and with a pain medication with acetaminophen in it which I am grossly allergic to and THE DOCTOR refused to change the prescription).and was on a hell flight for 17 hours to where the doctors would listen to me. I was literally shitting blood when I got to Miami. I rolled up a torn up magazine, since it would be totally sanitary, and shoved it up my ass.

When I got back to my country of residence, I was in the best hospital in the capital within 45 minutes, I had the top teaching physicians for radiology, blood work, surgical work, and parasitology working on me. The nurse was drawing blood as I was going into the MRI. Another nurse helped to get a “stool sample” and almost fainted when I pulled out the magazine and the blood rushed out. She got the doctor immediately. Then I had a CT scan to see something that the MRI did not show clearly. Then they drew blood and ran a second blood examination to see if I had been infected in the us hospital.

Yes, my wife, her doctor friend and my interpreter were passing out twenty dollar bills by the fistful. Enough that the people in the hospital started saying it was too much. That since I had the courage to fly from the united states to get “their” opinions, that all anyone would take was their regular fee. The controlling physician told me the american doctors had done a good job.

Yes, they were proud. Yes I went through literal hell, but they listened to my wife and interpreter when they told them what I was allergic to and what they didn't know but I might be allergic to. And no one touched me without washing their hands with alcohol.

All of this happened after 2 AM. Trying getting top doctors out of bed in the united states at 2 AM.

As far as I am concerned, the medical system is totally fucked up beyond belief. Skip the damn analysis of everything and simply hire the Swiss to run the medical system. They know how to handle things when the country is run by an oligarchy, just like the US.

Sorry to use an improper term.

I remember my wife's first day at her new job at a Los Angeles medical center….

“Oh my god, the doctors and nurses wear their scrubs to lunch…and then they wear them home! This is illegal in my country.”

Researchers are even worse. They work with the really nasty stuff and don't bother wearing lab coats. You also wouldn't believe what gets dumped down a normal sink in some labs.

We have a lot of cultural problems….sadly, there are other countries that are far far worse in these areas.

I perhaps was too glib in my generalization about doctors. I do feel that the cultural focus on doctors as wunderkinds or genius specialists that need to be given free reign and have complete obedience by those beneath them leads to a lack of training that has nothing to do with doctor temperament. A lot of times (at least from what I hear from my friends that are nurses) it seems that the formal training about delivery consists of “do what the head nurse tells you, who in turn will be strongly influenced by how the doctors want it.” Because it's so informal, the rules are different in every unit and they came to loathe having to cover a shift in another unit simply because they spent their whole time with operational details.

I do feel that you have a point about the economic incentives and I didn't flesh that thought out clearly. What I meant was that the system has been thoroughly co-opted that business as usual is the way to do things. Thus, I don't believe that mere external pressure will lead to these reforms in particular…they must be targeted directly outside economic channels.

This is entirely analogous to the financial industry, where there is no institutional memory about things being any different than the way they are now. When the government imposed external measures they were fought against and lending efforts, etc. have been questioned because of the spreads…..when all the government stuff still allowed them to operate more freely and at greater profit than historically!!

No one (of power) inside the industry has said “hey I bet we can get a leg up if we use this as a chance to make all of these intrinsic reforms,” instead they just cut back programs wholesale that they have identified as less profitable or whatever. In the health industry this would cause an outrage and we'd just start pouring more money into it again (education is another perfect example).

I feel that the carrot of demonstrated efficiency will be more readily pushed through with the economic stick, but I simply meant that the methods won't be developed through economic pressures.

Although I did say geez louise when I read the part about how many of the ICUs didn't have Chlorhexidine scrub available. I don't practice veterinary medicine without it- I can't imagine being treated at a hospital critical care ward where the doctors and staff didn't have it available.

You've identified the cultural aspects (I think the doctor/nurse relationship is particularly key- although as the article mentions, some nurses have no problem figuring out how to give those nudges to doctors but by and large there's a reluctance to question them.)

Economically though, someone has to be accountable for the costs, and that someone has to actually understand what measures would be most cost effective. The article mentioned, for instance, that hospital administrators jumped on the bandwagon of using antibiotic coated lines even though they're costly and don't prevent infections as well as the sterile techniques do. Seems to me that those administrators heard what sounded good (and what was being pressed on them by manufacturers who have a vested economic interest) and went with it instead of having the training to learn what really works.

Ultimately, no matter how arrogant the doctors are, it's the administrators' responsibility to ensure high quality and efficiency in costs. And if our system held them more accountable for both, the economic pressures would work to push back against the perverse economic pressure of buying ineffective products and the perverse cultural pressure of letting doctors get away with unsafe and costly procedural shortcuts just because no one wants to ruffle their feathers.

There were a couple of other things in that article worth mentioning IMO. One is that in busy inner city hospital ICUs, the staff is constantly having to shift attention from one emergency to another and understanding this makes it a bit more understandable that people would have trouble with the checklist concept. When you have one critically ill or wounded person that you're trying to make life/death decisions for, and then have to change your focus to a second or third such patient, it would be nearly impossible to stop and mentally review a checklist on the procedures themselves, let alone handle paperwork to document that you've done so. Sometimes, if the choice is between getting a line in quickly or not getting a line in for the patient in the next bed in time, you're going to choose to cut some corners with sterility.

Also, Provnost made an interesting comment here:
“The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine.”

That's a separate cultural aspect that isn't associated with the arrogance of doctors- it reflects somewhat on their training as well. They recieve lots of training on understanding the diseases, diagnostics, and treatments, but very little on studying how to best deliver those treatments. I would think that would contribute greatly to their reluctance to believe or accept the importance of the checklist system.

And one final point- I'm not sure that we haven't actually started to address this on a national level. I came across this reference to funding that was enacted earlier this year to healthcare agencies (CDC, NIH, CMS, and others) to implement the recommendations made by the Provnost study nationally. I don't know if it's going far enough or not, or how successful they'll be, but it appears that the 2007 New Yorker article was about a problem that at least is starting to become addressed. Kudos to Obey and other Congressional reps who appear to have gotten the ball rolling at least.

The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.

And I pointed out of there that the usefulness of proper hygiene was established in the 1840's.