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> the doctors or hospitals are not necessarily held liable (unless it's gross negligence) I've had friends who have worked retained surgical instruments cases.

> the doctors or hospitals are not necessarily held liable (unless it's gross negligence) I've had friends who have worked retained surgical instruments cases. Meet one or two of those victims and you will never support tort reform again. If this were a problem of gross negligence, then I would agree with you that we should focus there. But the problem isn't gross negligence, it's a problem of "business as usual." It's a thousand doctors following procedures with a 0.1% error rate and 999 thinking, "nothing bad's happened to me so I must be doing everything fine," even though they could each reduce that to a 0.001% error rate with a simple checklist or by actually washing their hands. Put another way, if you put someone's life in your hands and you're not focusing a significant percentage of your efforts on procedures designed to radically reduce risk, then you're engaged in gross negligence. There's another area where we all have that philosophy. We send a million people hurtling through the air each day in incredibly complex machines. Airlines focus on safety because (a) they are actually responsible for their passengers and can't just call a mulligan because, hey, people make mistakes; and additionally, (b) they suffer massive reputational costs for safety errors. So my medical malpractice reform would make medicine more like other industries with far better safety records. It would include a requirement that hospitals post their mistakes on their front door as people walk in.

eru 10y ago
> It's a thousand doctors following procedures with a 0.1% error rate and 999 thinking, "nothing bad's happened to me so I must be doing everything fine," even though they could each reduce that to a 0.001% error rate with a simple checklist or by actually washing their hands. Seems like that's an argument for a very discerning insurance company. Following the checklist should reduce their insurance premiums 10 times. And that's noticeable. (Of course, the ideal insurance company in question needs to collect the information how doctors behave, and needs to be legally able to act on it.)
- studentrob 10y ago
  > Seems like that's an argument for a very discerning insurance company. It's an argument based on a made up or uncited statistic.
  - eru 10y ago
    Forget the example---it's only for illustration. The argument is: An insurance policy transforms a spiky stream of obligations into a steady stream. If priced correctly, this will make people directly pay for the risks they take, removing the element of good or bad luck. Thus giving us a much more direct link between risky behaviour and consequences.
    - studentrob 10y ago
      Malpractice insurance already exists
      - eru 10y ago
        Yes. Do you know if the existing malpractice insurance takes into account whether a doctor follows eg checklists and stuff? Might not be on an individual level, but perhaps if you work for a hospital that has these procedures, one might pay less? In order for insurance to transmit the incentives right---and not create a moral hazard at worst---they have to have access to a lot of information.
        studentrob 10y ago
        > Do you know if the existing malpractice insurance takes into account whether a doctor follows eg checklists and stuff? It does not. The checklist research hasn't been sufficiently replicated, and checklists do not guarantee focus and awareness. There is not a one-size-fits-all solution for increasing people's focus. The solution is not simple. The checklist researcher admits this. I wrote more in a reply to brownbat [1] > Might not be on an individual level, but perhaps if you work for a hospital that has these procedures, one might pay less? I suppose that'd be up to the insurer to decide whether it's profitable or not to offer an option that includes such a clause. > In order for insurance to transmit the incentives right---and not create a moral hazard at worst---they have to have access to a lot of information. Absolutely. As a data science guy, I'm a huge fan of more data. I also believe in the observer effect and that in the case of doctors their stress level needs to be balanced with the additional obligations we impose. Asking hospitals for more data does not necessarily translate into better care. "Doctors need to be able to work one-on-one with their patients, without the added pressure of survey scores and ratings that have little insight into the entire patient experience" [2] Convincing doctors to provide more data is critical in the process of data collection. That process is probably best begun by a significant effort to understand the doctors' hardships and workflows. I suspect people have tried but do not have time to interview every doctor. Even then, you will never get everyone to agree. So it's a matter of working with whatever data we have, supporting good doctors and practices, and crossing our fingers that we haven't overlooked some practice that worked better in the past. [1] https://news.ycombinator.com/item?id=11635532 https://news.ycombinator.com/item?id=11635532 [2] http://observer.com/2015/06/the-supreme-court-obamacare-rx-leaves-doctors-and-patients-confused/ http://observer.com/2015/06/the-supreme-court-obamacare-rx-l...
dan_quixote 10y ago
It's actually common for retired pilots to teach risk mitigation classes for doctors and nurses. Something as simple as a small checklist can make a huge difference.
- retbull 10y ago
  :D I have a friend who does this. Great guy loves procedures.
- click170 10y ago
  BBC Horizon actually did a show on the importance of checklists and how they save lives in medical settings, and because of that I'm trying to start using checklists at work as well when practicable. The episode is called How To Avoid Mistakes In Surgery for those interested. Available at torrent sites near you!
- alanh 10y ago
  These can help in software development, too. Everyone is so obsessed with speed, but often the thinking is short-term. Slow down a little bit and use a checklist when deploying. Use a checklist when reviewing code. Iterate so you aren’t wasting time or limiting your thinking.
  - gnaritas 10y ago
    Developers have something superior to a checklist much of the time, automation. Deployment should be fully automated, no checklist necessary. But yes on non-automatable things like code review, a checklist is certainly a plus.
    - retbull 10y ago
      Also unit tests provide a type of checklist.
    - cmdkeen 10y ago
      Not all parts of a deployment can be automated in every case. I've helped craft a checklist we use on our releases based on lessons learned over several years, an awful lot of it is about communication to end users / other teams. Especially if the release is one that involves downtime it's important to have consistent practices and clarity about who is going communicate what and when. Checklists are a good way to capture the "what could have gone better" outputs of retrospectives.
studentrob 10y ago
Speaking as someone whose father was a physician, I feel a few of your comments are unfounded. Generally, I think there must be a way to hold most problematic doctors accountable while not causing excessive burdens for most good doctors. Also, any system will not be perfect, and the goal should be to maximize the health of most patients. > it's a problem of "business as usual." It's a thousand doctors following procedures with a 0.1% error rate and 999 thinking, "nothing bad's happened to me so I must be doing everything fine," I see no evidence of this, and I doubt you have the audacity to say this in the presence of your own physicians. > they could each reduce that to a 0.001% error rate with a simple checklist or by actually washing their hands I'm not sure where you live where doctors do not wash their hands, or how you know that they do not, but wherever I have been, doctors wash their hands vigorously. Infection in hospitals is common. Everything needs to be super sterile. It's more than just washing hands. Everything needs to be packaged air tight and used once in one part of the body, and then thrown away. It's already much more involved than you're suggesting. Doctors complete between 11 and 16 years of training [1] Doctors spend an average of 60 hours working per week. They work on average 1.5 times more than the average American [2] Doctors have too many patients and too little time. They are already well educated and don't have time for checklists to remind them of every little detail they learned during their 10-year long training program. They don't sleep much and don't get paid very well for the debt that they incur. Many doctors got into the field because they want to help people. My father was a physician until 2004ish, and the stress induced by bureaucracy nearly killed him. He was a great doctor. You're suggesting making the system more complex. I'm saying, that's going to make patient care worse, not better. If you choose to look only at court cases and do not read medical research, then trust is required in this system. Any procedural changes should be vetted by researchers using the scientific method, not bureaucrats who seek to make unscientific sweeping changes based on anecdotes to further their own political careers. > Put another way, if you put someone's life in your hands and you're not focusing a significant percentage of your efforts on procedures designed to radically reduce risk, then you're engaged in gross negligence. This is the job of a doctor. They focus on reducing risks to your health. The solution isn't to add arbitrary checklists and make doctors more busy. The solution is to use the scientific method to add doctors, make our population healthier and capable of maintaining their own health, and reduce the load of patients per doctor. > So my medical malpractice reform would make medicine more like other industries with far better safety records. It would include a requirement that hospitals post their mistakes on their front door as people walk in. At first you argue against tort reform and then you argue for it. I think things like Zocdoc will help good doctors be recognized and allow patients to self select their level of care. Reviews are just one thing. It's a complicated system that needs to balance many factors in order to maximize patient health. [1] https://www.google.com/search?client=ubuntu&channel=fs&q=how+long+do+doctors+go+to+school&ie=utf-8&oe=utf-8 https://www.google.com/search?client=ubuntu&channel=fs&q=how... [2] https://www.google.com/search?safe=off&client=ubuntu&hs=o9p&channel=fs&q=how+many+hours+do+doctors+work&oq=how+many+hours+do+doctors+work https://www.google.com/search?safe=off&client=ubuntu&hs=o9p&...
ultrasandwich 10y ago
> Meet one or two of those victims and you will never support tort reform again. Remarks like this are really counterproductive and frankly bizarre. Were character assessments ever relevant in lawsuits against tobacco companies? It's not hard to find unlikeable plaintiffs. However it is increasingly hard to keep your rights to a _public trial_ in a courtroom when it's a tort case [0]. When doctors ask you to give up your right to a public trial, then the rest of society (in my view) demonstrably loses out. And in fact, per-capita, Americans file fewer law cases now than in the 1840s. [1] > If this were a problem of gross negligence, then I would agree with you that we should focus there. But the problem isn't gross negligence... Gross negligence is literally the problem in the medical industry. The Johns Hopkins study found "medical errors account for more than 9.5% of all fatalities in the US." I'm uncertain that any "business as usual" by doctors is really a problem, but rather the checks and balances once offered to patients is being severely eroded. [0] http://harpers.org/archive/2016/04/suing-for-justice/ http://harpers.org/archive/2016/04/suing-for-justice/ [1] http://harpers.org/archive/2016/04/suing-for-justice/6/ http://harpers.org/archive/2016/04/suing-for-justice/6/
- brownbat 10y ago
  > Remarks like this are really counterproductive and frankly bizarre. I think that's both untrue and unfair. Typical tort reform discussion focus on how doctors can have their lives ruined without ever mentioning how patients can have their lives ruined. You cannot make a fair cost benefit comparison without understanding both sides. Most people don't understand both sides. Judging by your point about unlikable plaintiffs, perhaps you misread me. I'm not trying to argue that anecdotal experiences should replace facts in our cost benefit calculation. What I see in this area, though, is that people intuitively know what it means to lose a business, but have no intuitive grasp of what the consequence of a common medical error is (perhaps because there's no typical medical error). I'm essentially just saying that "People should know more about the details of this issue, they commonly misunderstand the harms involved," which is just how careful decisions should work. > per-capita, Americans file fewer law cases now than in the 1840s. Exactly so, and another reason the need for tort reform is overstated. > Gross negligence is literally the problem in the medical industry. The Johns Hopkins study found "medical errors account for more than 9.5% of all fatalities in the US." Gross negligence is a term of art, it's not literally equivalent to any fatal mistake. Though I was saying, metaphorically, that we should treat it that way in this industry. I think we actually agree on most of these points... just in the most heated way possible.
visarga 10y ago
> my medical malpractice reform would make medicine more like other industries with far better safety records It's impossible in medicine because we're not at that level yet.
usrusr 10y ago
Airlines are good at safety not because liability charges are astronomical, they are good at safety because of an enormous set of not too unreasonable regulations. Liability is a very bad substitute for regulation when risks are comprised of high damage at low incidence. That's why you have speed limits instead of responsible self-determination and potentially rich surviving dependents.
- studentrob 10y ago
  > Airlines are good at safety not because liability charges are astronomical, they are good at safety because of an enormous set of not too unreasonable regulations. Agreed. Checklist proponents in this thread oversimplify the issue. In a 2007 article, Atul Gawande, author of the 2009 book Checklist Manifesto, discusses how Peter Pronovost trained his hospital to better follow known surgical procedures, > 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. [1] So, he didn't just use a checklist. He convinced staff they were making mistakes. The administration changed hospital rules. Then, Atul says, > They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs. He claims the checklist is what saved people's lives. He continues saying so for the rest of the article and in his book. It's an oversimplification and misleads the public into believing medicine is simple. The result is the comments you see in this thread. Training people is not simple. Everyone forgets things, even with checklists. Atul himself later says so, "It turns out to be much more complex that just having the checklist in hand." [2] People want to hear about simple solutions. They disengage when a problem is described as complex. [1] http://www.newyorker.com/magazine/2007/12/10/the-checklist http://www.newyorker.com/magazine/2007/12/10/the-checklist [2] http://www.nature.com/news/hospital-checklists-are-meant-to-save-lives-so-why-do-they-often-fail-1.18057 http://www.nature.com/news/hospital-checklists-are-meant-to-...
  - calinet6 10y ago
    This is why the Lean healthcare movement (and Lean in general) is so great. It takes procedures into account, like checklists and workflows and all that, but more importantly it takes into account the human psychological factors in the workplace that prevent success on even the simple solutions. However, this could not be more perfect an explanation: > People want to hear about simple solutions. They disengage when a problem is described as complex. This is where true leadership is required to breach the barrier of complexity and lead systems thinking across a (naturally) complex organization. Any organization. It's extremely difficult to get people to look outside their bubble or change the way they think, and that's required to manage any complex system with any success. This leadership is the main barrier to improvement in any org.

eru 10y ago

> It's a thousand doctors following procedures with a 0.1% error rate and 999 thinking, "nothing bad's happened to me so I must be doing everything fine," even though they could each reduce that to a 0.001% error rate with a simple checklist or by actually washing their hands. Seems like that's an argument for a very discerning insurance company. Following the checklist should reduce their insurance premiums 10 times. And that's noticeable. (Of course, the ideal insurance company in question needs to collect the information how doctors behave, and needs to be legally able to act on it.)

studentrob 10y ago
> Seems like that's an argument for a very discerning insurance company. It's an argument based on a made up or uncited statistic.
- eru 10y ago
  Forget the example---it's only for illustration. The argument is: An insurance policy transforms a spiky stream of obligations into a steady stream. If priced correctly, this will make people directly pay for the risks they take, removing the element of good or bad luck. Thus giving us a much more direct link between risky behaviour and consequences.
  - studentrob 10y ago
    Malpractice insurance already exists
    - eru 10y ago
      Yes. Do you know if the existing malpractice insurance takes into account whether a doctor follows eg checklists and stuff? Might not be on an individual level, but perhaps if you work for a hospital that has these procedures, one might pay less? In order for insurance to transmit the incentives right---and not create a moral hazard at worst---they have to have access to a lot of information.
      - studentrob 10y ago
        > Do you know if the existing malpractice insurance takes into account whether a doctor follows eg checklists and stuff? It does not. The checklist research hasn't been sufficiently replicated, and checklists do not guarantee focus and awareness. There is not a one-size-fits-all solution for increasing people's focus. The solution is not simple. The checklist researcher admits this. I wrote more in a reply to brownbat [1] > Might not be on an individual level, but perhaps if you work for a hospital that has these procedures, one might pay less? I suppose that'd be up to the insurer to decide whether it's profitable or not to offer an option that includes such a clause. > In order for insurance to transmit the incentives right---and not create a moral hazard at worst---they have to have access to a lot of information. Absolutely. As a data science guy, I'm a huge fan of more data. I also believe in the observer effect and that in the case of doctors their stress level needs to be balanced with the additional obligations we impose. Asking hospitals for more data does not necessarily translate into better care. "Doctors need to be able to work one-on-one with their patients, without the added pressure of survey scores and ratings that have little insight into the entire patient experience" [2] Convincing doctors to provide more data is critical in the process of data collection. That process is probably best begun by a significant effort to understand the doctors' hardships and workflows. I suspect people have tried but do not have time to interview every doctor. Even then, you will never get everyone to agree. So it's a matter of working with whatever data we have, supporting good doctors and practices, and crossing our fingers that we haven't overlooked some practice that worked better in the past. [1] https://news.ycombinator.com/item?id=11635532 https://news.ycombinator.com/item?id=11635532 [2] http://observer.com/2015/06/the-supreme-court-obamacare-rx-leaves-doctors-and-patients-confused/ http://observer.com/2015/06/the-supreme-court-obamacare-rx-l...

dan_quixote 10y ago

It's actually common for retired pilots to teach risk mitigation classes for doctors and nurses. Something as simple as a small checklist can make a huge difference.

retbull 10y ago
:D I have a friend who does this. Great guy loves procedures.
click170 10y ago
BBC Horizon actually did a show on the importance of checklists and how they save lives in medical settings, and because of that I'm trying to start using checklists at work as well when practicable. The episode is called How To Avoid Mistakes In Surgery for those interested. Available at torrent sites near you!
alanh 10y ago
These can help in software development, too. Everyone is so obsessed with speed, but often the thinking is short-term. Slow down a little bit and use a checklist when deploying. Use a checklist when reviewing code. Iterate so you aren’t wasting time or limiting your thinking.
- gnaritas 10y ago
  Developers have something superior to a checklist much of the time, automation. Deployment should be fully automated, no checklist necessary. But yes on non-automatable things like code review, a checklist is certainly a plus.
  - retbull 10y ago
    Also unit tests provide a type of checklist.
  - cmdkeen 10y ago
    Not all parts of a deployment can be automated in every case. I've helped craft a checklist we use on our releases based on lessons learned over several years, an awful lot of it is about communication to end users / other teams. Especially if the release is one that involves downtime it's important to have consistent practices and clarity about who is going communicate what and when. Checklists are a good way to capture the "what could have gone better" outputs of retrospectives.

studentrob 10y ago

Speaking as someone whose father was a physician, I feel a few of your comments are unfounded. Generally, I think there must be a way to hold most problematic doctors accountable while not causing excessive burdens for most good doctors. Also, any system will not be perfect, and the goal should be to maximize the health of most patients. > it's a problem of "business as usual." It's a thousand doctors following procedures with a 0.1% error rate and 999 thinking, "nothing bad's happened to me so I must be doing everything fine," I see no evidence of this, and I doubt you have the audacity to say this in the presence of your own physicians. > they could each reduce that to a 0.001% error rate with a simple checklist or by actually washing their hands I'm not sure where you live where doctors do not wash their hands, or how you know that they do not, but wherever I have been, doctors wash their hands vigorously. Infection in hospitals is common. Everything needs to be super sterile. It's more than just washing hands. Everything needs to be packaged air tight and used once in one part of the body, and then thrown away. It's already much more involved than you're suggesting. Doctors complete between 11 and 16 years of training [1] Doctors spend an average of 60 hours working per week. They work on average 1.5 times more than the average American [2] Doctors have too many patients and too little time. They are already well educated and don't have time for checklists to remind them of every little detail they learned during their 10-year long training program. They don't sleep much and don't get paid very well for the debt that they incur. Many doctors got into the field because they want to help people. My father was a physician until 2004ish, and the stress induced by bureaucracy nearly killed him. He was a great doctor. You're suggesting making the system more complex. I'm saying, that's going to make patient care worse, not better. If you choose to look only at court cases and do not read medical research, then trust is required in this system. Any procedural changes should be vetted by researchers using the scientific method, not bureaucrats who seek to make unscientific sweeping changes based on anecdotes to further their own political careers. > Put another way, if you put someone's life in your hands and you're not focusing a significant percentage of your efforts on procedures designed to radically reduce risk, then you're engaged in gross negligence. This is the job of a doctor. They focus on reducing risks to your health. The solution isn't to add arbitrary checklists and make doctors more busy. The solution is to use the scientific method to add doctors, make our population healthier and capable of maintaining their own health, and reduce the load of patients per doctor. > So my medical malpractice reform would make medicine more like other industries with far better safety records. It would include a requirement that hospitals post their mistakes on their front door as people walk in. At first you argue against tort reform and then you argue for it. I think things like Zocdoc will help good doctors be recognized and allow patients to self select their level of care. Reviews are just one thing. It's a complicated system that needs to balance many factors in order to maximize patient health. [1] https://www.google.com/search?client=ubuntu&channel=fs&q=how+long+do+doctors+go+to+school&ie=utf-8&oe=utf-8 https://www.google.com/search?client=ubuntu&channel=fs&q=how... [2] https://www.google.com/search?safe=off&client=ubuntu&hs=o9p&channel=fs&q=how+many+hours+do+doctors+work&oq=how+many+hours+do+doctors+work https://www.google.com/search?safe=off&client=ubuntu&hs=o9p&...

ultrasandwich 10y ago

> Meet one or two of those victims and you will never support tort reform again. Remarks like this are really counterproductive and frankly bizarre. Were character assessments ever relevant in lawsuits against tobacco companies? It's not hard to find unlikeable plaintiffs. However it is increasingly hard to keep your rights to a _public trial_ in a courtroom when it's a tort case [0]. When doctors ask you to give up your right to a public trial, then the rest of society (in my view) demonstrably loses out. And in fact, per-capita, Americans file fewer law cases now than in the 1840s. [1] > If this were a problem of gross negligence, then I would agree with you that we should focus there. But the problem isn't gross negligence... Gross negligence is literally the problem in the medical industry. The Johns Hopkins study found "medical errors account for more than 9.5% of all fatalities in the US." I'm uncertain that any "business as usual" by doctors is really a problem, but rather the checks and balances once offered to patients is being severely eroded. [0] http://harpers.org/archive/2016/04/suing-for-justice/ http://harpers.org/archive/2016/04/suing-for-justice/ [1] http://harpers.org/archive/2016/04/suing-for-justice/6/ http://harpers.org/archive/2016/04/suing-for-justice/6/

brownbat 10y ago
> Remarks like this are really counterproductive and frankly bizarre. I think that's both untrue and unfair. Typical tort reform discussion focus on how doctors can have their lives ruined without ever mentioning how patients can have their lives ruined. You cannot make a fair cost benefit comparison without understanding both sides. Most people don't understand both sides. Judging by your point about unlikable plaintiffs, perhaps you misread me. I'm not trying to argue that anecdotal experiences should replace facts in our cost benefit calculation. What I see in this area, though, is that people intuitively know what it means to lose a business, but have no intuitive grasp of what the consequence of a common medical error is (perhaps because there's no typical medical error). I'm essentially just saying that "People should know more about the details of this issue, they commonly misunderstand the harms involved," which is just how careful decisions should work. > per-capita, Americans file fewer law cases now than in the 1840s. Exactly so, and another reason the need for tort reform is overstated. > Gross negligence is literally the problem in the medical industry. The Johns Hopkins study found "medical errors account for more than 9.5% of all fatalities in the US." Gross negligence is a term of art, it's not literally equivalent to any fatal mistake. Though I was saying, metaphorically, that we should treat it that way in this industry. I think we actually agree on most of these points... just in the most heated way possible.

visarga 10y ago

> my medical malpractice reform would make medicine more like other industries with far better safety records It's impossible in medicine because we're not at that level yet.

usrusr 10y ago

Airlines are good at safety not because liability charges are astronomical, they are good at safety because of an enormous set of not too unreasonable regulations. Liability is a very bad substitute for regulation when risks are comprised of high damage at low incidence. That's why you have speed limits instead of responsible self-determination and potentially rich surviving dependents.

studentrob 10y ago
> Airlines are good at safety not because liability charges are astronomical, they are good at safety because of an enormous set of not too unreasonable regulations. Agreed. Checklist proponents in this thread oversimplify the issue. In a 2007 article, Atul Gawande, author of the 2009 book Checklist Manifesto, discusses how Peter Pronovost trained his hospital to better follow known surgical procedures, > 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. [1] So, he didn't just use a checklist. He convinced staff they were making mistakes. The administration changed hospital rules. Then, Atul says, > They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs. He claims the checklist is what saved people's lives. He continues saying so for the rest of the article and in his book. It's an oversimplification and misleads the public into believing medicine is simple. The result is the comments you see in this thread. Training people is not simple. Everyone forgets things, even with checklists. Atul himself later says so, "It turns out to be much more complex that just having the checklist in hand." [2] People want to hear about simple solutions. They disengage when a problem is described as complex. [1] http://www.newyorker.com/magazine/2007/12/10/the-checklist http://www.newyorker.com/magazine/2007/12/10/the-checklist [2] http://www.nature.com/news/hospital-checklists-are-meant-to-save-lives-so-why-do-they-often-fail-1.18057 http://www.nature.com/news/hospital-checklists-are-meant-to-...
- calinet6 10y ago
  This is why the Lean healthcare movement (and Lean in general) is so great. It takes procedures into account, like checklists and workflows and all that, but more importantly it takes into account the human psychological factors in the workplace that prevent success on even the simple solutions. However, this could not be more perfect an explanation: > People want to hear about simple solutions. They disengage when a problem is described as complex. This is where true leadership is required to breach the barrier of complexity and lead systems thinking across a (naturally) complex organization. Any organization. It's extremely difficult to get people to look outside their bubble or change the way they think, and that's required to manage any complex system with any success. This leadership is the main barrier to improvement in any org.