How twitter helped a technology consultant escape from an evil hospital
inmantechnologyit.blogspot.com
inmantechnologyit.blogspot.com
A rural surgeon is going to be professionally offended if their patient calls up an egghead at Harvard from their pre-op hospital bed and then tells him she doesn't trust his judgement and instead wants to be medivac airlifted back to Boston. It's like when you watch a detective show when the FBI takes over and the local cops are all bent out of shape. The hospital staff may have been thinking about health insurance and losing their accreditation but I doubt it was a sinister plot to meet their spinal surgery quotas. It was probably more along these lines: "a crazy lady from Boston just broke her back jumping off a bridge with some 13 year olds. Now she's telling us to schedule a chopper to Boston because she's Facebook buddies with some prick neurology prof at Harvard. Quick, give her some morphine and get her under the knife before her spinal column collapses and she's paralyzed and we get slapped with a half billion dollar malpractice suit... "
Note that I'm not defending that sort of attitude. That's just what I think they would be thinking, rather than some nefarious conspiracy to maximize insurance profits, which is what the article and most commenters on this post seem to be suggesting.
The other thing is that I don't think the doctors were necessarily wrong in their diagnosis. The higher you go up in the spine, there's a lot more danger of paralysis or other severe spinal cord problem. If you're over 30 and shatter your T12, there's a 50% chance you're going to end up with a serious neurological problem. The odds for recovery are far better the sooner you have surgery, if the surgery is necessary.
Timing of surgery is also an important issue in the treatment of thoracic spine fractures. ... Some studies suggest that patients with thoracic spine fractures treated within 72 hours, irrespective of concomitant injuries, do much better physiologically postoperatively than those in whom stabilization is delayed.
http://emedicine.medscape.com/article/1267029-treatment
Lastly, I don't think a patient requested 370 mile helicopter flight for a treatment which could be performed locally could possibly be covered under any insurance plan, no matter how good the coverage is.
The same thing happens in small town India as well where doctors are more interested in keeping you admitted above and beyond the needed duration and doctors in large cities are just better because they have a greater patient load to be well versed with complex surgeries if needed.
According to the Harvard neurosurgeon she made the less risky decision. Given the choice between believing a random poster to hacker news and someone with those qualifications, I'm going with the known expert every time. It is just icing on the cake that the expert's opinion fits with what I've been told about the risks of back surgery by multiple doctors, physical therapists, and even a panel appointed by the US government. (Admittedly the last is somewhat out of date.)
They may well have had a poor bedside manner, and they may well have tried to pressure him into having a surgery they thought necessary, but doctors disagree with treatment methods all the time. That doesn't mean that they were necessarily evil in disagreeing with the doctor in Boston.
It's also fairly standard practice for insurance companies to decline to pay a patient's hospital bill if that patient signs out against medical advice. So, if they said that he would have to pay out of pocket, they may well have been telling the truth. If he was signing out against medical advice, he may well have been responsible for the entire transfer bill, which would likely have been in the tens of thousands of dollars.
Also, if the hospital was the closest qualified trauma center, and if it was deemed by the Attending Neurosurgeon that he have surgery soon or risk permanent paralysis, it's understandable that they would have been reluctant to transfer the patient. And, if he was refusing emergency back surgery and if he was demanding transfer, he may well have been risking permantent paralysis as well as being financially liable for the hospitalization.
Perhaps this is exactly why health care costs have gone up so dramatically. We have insurance, so the doctors take advantage of it -- needlessly. We very well could be spending a lot less money for the same amount of health care.
I think the solution to the health care problem is for someone to start saying NO, like in that other article on the front page now. No to more test, no to unnecessary treatments and surgeries and non-generic drugs.
Say no!
... not to mention greater actual health.
When health care was the leading issue in Canada a few years ago and every politician was going around promising to expand it, I remember wondering if I was the only one thinking we need less of it, not more.
It might be helpful if we used a more accurate label than "health care" (perhaps "disease industry").
There are a couple of solutions to this, but no one really talks about them. (1) There are plenty of people that are qualified to be doctors, but because they did their medical school in India or China before immigrating to Canada, they aren't allowed to be certified as doctors. (2) Lots of doctors 'jump ship' to more profitable countries like the USA because they can just charge insurance and they aren't regulated from creating a 'factory practice' where no patient ever gets more than 5 minutes of the doctor's time.
In the US, a large number of people use the emergency room as a doctor's office because they have no other choice.
So, Canada: problematic. US: fail
But if Canada keeps using US logic, it might wind-up in our boat. Good luck to you...
How do you mean though? I'm saying that people with flu/colds/UTI/etc just go to the emergency room instead of a doctor's office (or even walk-in clinics at times) in Canada. I've been without healthcare, but I spent most of my life on a good healthcare plan through my parents. I don't have much experience with people that are off of the healthcare system (the only time I've had friends that were 'poor'[1] was in Canada where they were still covered for healthcare and social assistance).
[1] By poor I mean, barely making any money and living off of welfare and/or living in subsidized housing. I don't mean starving/homeless, though I was a couple of 'degrees' away from people that were homeless.
> But if Canada keeps using US logic, it might wind-up in our boat.
How do you mean?
> Good luck to you...
I'm currently living in the US, but I was living in Ontario for a time. It just irks me when people start talking about the 'problems with the Canadian system' when it's not a unified system as I understand it. The same when people start talking about 'socialized medicine,' since every country that has such a system has a different take on it.
http://www.amazon.com/Crisis-Abundance-Rethinking-Health-Car...
Except for a few blockbuster interventions (antibiotics for bacterial infection, orthopedics, reading glasses), the expected return of many health care interventions is negative; they cost so much, and have the potential to do so much harm, for such uncertain good, that we're better off avoiding them. The only reason individual consumers subject themselves to so many negative-expected-value treatments is that they do not bear their full costs, sharing the financial part of them with their insurers.
Finding the right balance between cost and heath is hard, but blaming everything but the blockbusters is the wrong place to start. Two years ago my father went from fine to dead in one week in part because the doctor failed to ask for a single test. He had health inshurance, went to a doctor who liked to avoid extra tests and died. A hundred years ago, dieing at 62, could have been seen as living a long life, but today a simple test and a quick surgery and he could have lived another 20 years in good heath.
PS: If you really want to look for waste in heath care figure out where the money goes. Starting with the payments to your heath insurgence company and how little get's back to actual treatments.
This is why in the mid-90s the Agency for Health Care Policy Research (AHCPR) looked at the subject and concluded that back surgery was inadvisable if any other options were available. Unfortunately for the AHCPR back surgeons are a fairly well off group, got the AMA on their side, and the result was that Congress nearly destroyed the AHCPR. The remnants have learned not to issue politically controversial opinions, no matter how well-founded in fact they may be. Thus a well-meaning attempt to actually evaluate expensive medical treatments for effectiveness ended.
Incidentally experts claim that the vast majority of the gains in life expectancy over the last 150 years have been due to improvements in public health, not medicine. Each of vaccination, sanitation and clean water supplies has done more to contribute to longevity than any medical advance you care to name, including antibiotics. Yet people are unaware of the contribution of public health. I find this odd.
In any case the original article was about a woman who went through a nightmare to get a hospital to not perform unwanted, unneeded and dangerous spinal surgery. So to my eyes I was bringing the discussion back to the example under discussion. And pointing out that it has been well known for over a decade that spinal surgery is a generally bad idea to me underscores the horror of what happened to her.
You don't specify what missed test killed your father.
There are, however, many symptoms where, given the uncertainty of all technology today, giving an operation or a drug prescription to might save X lives whereas NOT taking action would save Y lives, where X and Y are very uncertain.
The harder thing, though, the lives that are lost through giving the operation or the drug tend to be even harder to measure - people die through being prescribed 4,5,6...X drugs up to the point that interaction fry them without any one drug being "to blame". People die from complications of many surgeries, yet if the surgery is possibly necessary, people don't think to blame the decision to operate (the New Yorker figure that surgical accidents kill more than auto accidents is remarkable - auto accidents were once the 4th leading cause of death in the US). And there is a hidden if you test everyone for everything. False positives can kill people - false positives do kill many people today.
And as the New Yorker article mentions, physician incentives to make tests (or in other circumstances, to avoid them) can make a big difference.
[edit] Anticoagulation is the more common treatment because it has better long term odds. But, that assumes fairly early detection.
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_...
Atul Gawande argues that the problem with healthcare in the US is overutilization.
The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. If there aren’t any complications—and there usually aren’t—the pain goes away on its own or with pain medication. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder.
Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.
I am sure the pain will come back some day and then we will have to make another decision, but meanwhile we have avoided an invasive surgery.
If you're interested in this, read up on the PSA (Prostate-Specific Antigen) test: it's the main test used to check for prostate cancer in males. You'd think that doctors would issue it to all males of a certain age annually, and up until recently most doctors did that. But there's been an interesting change of thinking in the past few years: someone noticed (and importantly, some insurance companies agreed) that the combination of an increase in the power of drugs/surgical techniques available to treat the disease and a stabilization of the relatively-high false-positive rate in the PSA test (and the dangers of what happens with a false-positive) means that unless someone has a predisposition to prostate cancer, it's often better not to test for it. The net result when the options are getting prostate cancer and taking the treatment vs. getting screened early and undergoing the invasive diagnostics needed to confirm a PSA test at that stage, it's usually a better choice just to get prostate cancer.
Note that this math goes out the window, however, if you have a family predisposition to prostate cancer. In that case, the risk of option #1 goes up (since it's predicated on the relatively low incidence rate of prostate cancer), and the dowsides of option #2 go down (since the probability of a false-positive is much lower).
This discourages doctors from overworking themselves and offering shoddy care (instead choosing to move patients through like a cattle farm), and also discourages the sort of unnecessary treatment this article talks about.
Upon reading the description of how the accident took place, my first thought was, "Really, is her insurance going to pay for that!?" And according to the last comment on her blog post, apparently the answer is, "No."
I would imagine either hospital would have to have enough familiarity with that type of accident to question whether her insurance would cover it as well.
I don't pretend to know much about this stuff. I did state that it was just a question I had. If insurance companies routinely cover people who have accidents while doing things significantly more dangerous than your typical day to day activities then that is great... I guess.
The first part of my comment still stands regardless. I wonder how much of the battle was over getting insurance money and how much of it might have been over the doctor's ego.
This aspect is hardly "the ultimate lesson of all this": if the post were merely about someone who jumped into a pond when they shouldn't have, no one would be discussing it.
I do agree though, that jumping or not wasn't the main issue here.
Here, let me repackage it for you so it's less topical: if people are doing something that you think is dangerous, don't do it just because they did it.
http://cornellalumnimagazine.com/index.php?option=com_conten...
That's evil. Unfortunately, it's a story repeated across the nation every day.
I can't believe you're making excuses for doctors who (if the story is true) tried to bully a woman against her will into having major spinal surgery that she clearly didn't need.
If they can't keep their accreditation then perhaps they could offer discounts to entice people to their hospital.
Rule systems and rule makers can't be held responsible for idiotic/selfish/malicious behavior by individuals. Yes rules and systems can be refined to improve them but ultimately it will always be up to the individual to exercise judgement and moral character. So I'm afraid I have to disagree with you. If you blame the system for being misused you miss the point.
The interesting characters in the story (again, assuming this is all true) are the sympathetic subordinates - nurses and so on - who supplied information about what was really going on.
IMO, this is the incentive of nearly all doctors in America - the dentists I've had span the entire spectrum of opinions about my wisdom teeth. From "if we don't take them out, you can die from a gum infection" to "do they hurt? no? do you eat meat? then you should keep them, they'll makes it easier to chew".
Sometimes these cases end up sounding to me like the people who try to decry the state laws requiring you to wear a seatbelt by pointing out the relatively few cases where not wearing a seatbelt did save (or could have saved) someone's life. They completely ignore the overwhelming number of cases where seatbelts do save people's lives. It's just a case of people trying to make the facts fit a conclusion that they've already come to and don't want to change.
Other than that, I would want to see the numbers on '% of people that need appendix removal' vs '% of people that need wisdom teeth removal.' My suspicion is that the latter is much higher than the former, but I could be wrong.
Something like "I will not authorize you to perform this procedure and have notified my physician and lawyer of this, if you perform anything that I have not authorized will result in an expensive lawsuit" or something.
Anyone know what the right terms to use are? It seems in other situations there are magic words that can be used to produce immediate results.
Hospital personnel will try to strongly discourage you from doing this -- not because they're evil, but because in most situations it's a really, really bad idea. But if you just keep saying "no, I don't want treatment, I want to leave, give me the forms to sign out AMA," and you're not clearly nuts or high on morphine or otherwise impaired, you can pretty much just leave.
However, unless you have a very specific reason for believing that the treatment protocol at work isn't correct or best for you, it's generally a bad idea.
Unsurprising. I think this is more about patients' rights than healthcare funding, though.
Pro: This wouldn't happen with government healthcare because there would be standards in place (i.e. the 'mobility test' would be standard everywhere not just in 'cutting edge' facilities)
Con: In government-run healthcare, she would have been forced to stay in that hospital so as to minimize the costs of treating her (i.e. no expensive transport from PA to Boston). The government would be taking away her individual rights to take ownership of her situation.
The healthcare debate is a lot more nuanced than the 'Arg! Socialism!' or 'Arg! Health insurance is evil!' crowds make it out to be.
The "con" would probably be that there would be no facility for spinal surgery in a rural area in the first place. She would not be able to choose to be treated there and she's getting on one of those helicopters.
If hospitals are still privately owned, but the government basically starts it's own 'insurance company' that covers everyone that isn't part of the private insurance company plan (similar to Germany) then it's possible that a rural area could still have spinal surgery experts. Even if the hospitals are all government-owned and run (similar to the UK method of healthcare), it's still possible to have spinal surgery experts in a rural area. It just would depend on what was cheaper. Is it cheaper to have a spinal surgery-trained staff at the rural hospital or to fly everyone 300 miles to another hospital? (Or the 3rd option of having staff at a different hospital, but making sure that it is less than 300 miles away -- i.e. spread out facilities that can handle such injuries so that there aren't hugely expensive transit costs for treatment)
Incidentally, her title references "social media" rather than Twitter, which I think is right; it's not hard to imagine, say, Facebook playing the same role. What's relevant is that she got word of her plight out to a network of people in a way that would be harder to do otherwise, and that feedback from this network led to a fundamentally different outcome than that experienced (I imagine) by most people with broken spines who are having unnecessary surgery and narcotics forced on them against their will.
And then yet back on the other hand, as you say, there is no friend requirement so those big personality types could really only amplify their voice in that way over Twitter.