How to Do No Harm

How leaders can minimize harm in health care, in other industries, and in all areas of life.

“How can we change this process to prevent this error from happening again?” the senior ward nurse asked the group. It is a common question, one that I have heard thousands of times from experienced and dedicated health care professionals of all stripes.

I have worked in health care for many years, serving in positions from volunteer to emergency medical technician to senior attending physician to chief of staff at a hospital to chief medical officer of a large network. In every position, “do no harm” is a fundamental theme. This famous statement from the writings of Hippocrates encapsulates quality improvement, patient safety, access to care, and many other goals in modern medicine.

“Do no harm” can be thought of as eliminating risks that could lead to a bad outcome, such as injury or death. Occupational and Environmental Medicine physicians learn that there are four ways to decrease risk in the workplace and in the environment:

  1. Eliminate the risk entirely. We have two inverter generators to use at home and church rather than traditional ones. They are quieter and generate less carbon monoxide, thus eliminating two risks. Taking the lead out of gasoline and paint decreases the chance of lead poisoning, and using nitrile rather than latex gloves helps avoid latex allergies.
  2. Separate the risk from the people. Modern automotive engineers have designed and built cars which nearly the whole car can be destroyed in a crash, but the passenger compartment can stay nearly intact, thus saving the people inside. Hospitals sometimes use devices that automatically retract used needles to avoid needlestick injuries.
  3. Develop administrative controls; processes to minimize risk. “Tickets to ride” ensure the patients are protected before patient transport and “time outs” before procedures minimize the chance of operating on the wrong site, or even on the wrong patient.  
  4. Use personal protective equipment (PPE). Lead aprons in radiology protect patients and staff from radiation exposure. Gloves and mask decrease the chance of infections. In the fire fighting world, bunker gear enables humans to survive and even work in otherwise fatal environments.

The surest way to “do not harm” is to engineer the risk out, and second is to separate people from risk. Neither of these methods require people to do anything, and therefore remove the single biggest point of failure in many safety processes…human error. Techniques 3 and 4 are less reliable precisely because people have to be trained to follow administrative controls and use PPE. Further, people have to follow these controls and use these practices every time and under every condition.

Manufacturing is far more amenable to engineering controls than health care. Producing tires or peanut butter can be broken down into a discrete series of steps which must be done in sequence and in which the production machinery, the rubber, the peanuts, and the other parts of the process can be trusted to behave in reliable ways. In health care, neither the staff nor the treatments nor the patients are equally predictable. That is why health care relies on administrative controls and personal protective equipment, and why we have so many failures…so much risk to patients and staff.

There is, however, another way to minimize the risk of harm, and that is to improve the people. If hazard is thought of as having three components – danger (what can do the damage, like a hepatitis A virus), person (who is at risk), and vector (food and water contaminated with hepatitis A), those who wish to minimize the risk of hepatitis A can attack at any of these points. The Smallpox Eradication Program of the World Health Organization in the 1960s and 1970s, and the modern polio eradication program are examples of attacking the pathogen directly. Purifying the food and water, which commonly transmit hepatitis A, eliminates the vector. Immunization strengthens the person, making them immune to the disease. Simple interventions such as improving diet, exercise, sleep, and mental health improve the person and make disease and injury less likely. Education helps leaders and workers know why they are doing something, and training helps them do it right again and again. Cognitive aids such as checklists minimize reliance on human memory and other sources of failure.

In summary, “do no harm” applies to medicine, but also applies to every other area of life. We can and should engineer harm away, for it is the most effective way to minimize risk to life and health. Vaccines may be considered as a means of engineering harm away. We will attack dangers, block vectors, and strengthen individuals. To “do no harm”, health care professionals will use every tool in the shed, and will use them in a comprehensive and coordinated system. Our patients and our staff depend on it.  

Health Care Foibles – A Personal Tale

An example of the stupid things even doctors do when it comes to health care. 

In March of 2013 I wrote Healing the Health Care Cost Conundrum. Four years later, in March of 2017, I have retired from the US Army and am practicing medicine in Memphis, TN. My practice is in the inner city, and our focus is serving the Medicaid population. Our patients are impoverished and often very sick, with chronic diseases frequently showing up 20 years earlier than in their more affluent counterparts. Many live in dangerous communities, have no reliable transportation, and have unhealthy food. Obesity is the norm, violence is taken for granted, and serious mental illness is widespread. It comes as no surprise that many patients abuse drugs, citing chronic pain that may or may not be real. Some come to the clinic for no other reason than to feed their drug habit, and try to get narcotics to generate a little extra income. It is the toughest medical environment I have encountered since my combat tour in Iraq.

Meanwhile at the policy level, Obamacare is proving too expensive to sustain, and just yesterday Republicans in the House of Representatives failed to pass a bill with their plan to reform health care. While the survival of Obamacare causes rejoicing in some and consternation in others, the simple truth is that neither the Patient Protection and Affordable Care Art (Obamacare) nor the American Health Care Act (Republican bill) are health care reform, they are health insurance reform. Both pieces of legislation regulate how health care is paid for, not how it is delivered. With all due respect to our legislative leaders, they cannot improve health care delivery. Only health care professionals can make health care all that it needs to be. This is what those in my practice are trying to do – build a system that can provide quality, affordable, medical care to the poorest Americans. If we can do that, in conjunction with others around the nation striving for the same goal, American health care will be transformed.

Revolutionizing medical care, rather than merely medical insurance, may be a noble goal, but achieving it is like walking from Cairo to New Delhi; long, arduous, and dangerous. One reason for this difficulty is that no matter the education, resources, or social support, humans will be humans.

My Personal Tale

This past week I developed an eyelid infection. I ignored it for a few days, and one evening after a long day at work I decided to do something. Since most medical facilities were closed, and we had no other antibiotics in the house, I took some long-expired antibiotics that had been prescribed for someone else. Taking expired medications can be dangerous, or at least ineffective, and expired antibiotics can increase resistance. I regularly tell patients not to use expired meds or those given to someone else. In this case, I opted for short term convenience, and hypocrisy.

After unsuccessfully trying home care, I went to the Emergency Department at a local hospital. This infection could have been treated more effectively, and far more cheaply, at a local primary care practice. But it was only 6:30 in the morning, too early to call for an appointment. Most practices that we found opened at 8 or even 9, while I had to be at work at 8, and I could not be guaranteed to be seen. So again, I violated my own standards and took a my eyelid infection to an emergency department, costing my insurance about $1,000 instead of about $50.

I tried to be a patient instead of a doctor in this setting, but my secret came out when the nurse asked my occupation. It would have leaked anyway, because medical people talk differently about medical conditions than lay people do. My description of my eyelid as red, swollen, and tender but not painful, was a dead give-away. When the physician’s assistant (PA) came in to examine me, he suggested that Vigamox eye drops would be the best to cure this infection. Even though I thought an oral antibiotic would be a better choice, I was still trying hard to be a patient and not a doctor, so I agreed.

My wife later called from the pharmacy. Vigamox, with a generic name of moxi-floxacin, cost $200 for three milliliters. I was more than a little annoyed; a similar ophthalmic solution of ciprofloxacin would cost $15. Why had the PA prescribed as his first choice something so ridiculously expensive? Word of mouth? Pharmaceutical company marketing? Ignorance of the cost? All of the above? How would this affect others such as the uninsured or the underinsured?

A day later, my eyelid got worse. The Vigamox was not controlling the infection, because it was more widespread than the PA realized. We made an appointment with optometry, and I worked from home. The optometrist prescribed oral Bactrim, which cost $2 at the pharmacy. The infection gradually improved.

The Lessons Learned

This tale of minor misjudgment, multiplied hundreds of thousands of times, is much of the story of health care in America, and around the world. Patients do things that they should not, even when they know better, and do not do things that they should. We opt for convenient care instead of cost-effective care. Had I been faced with the whole bill, I never would have gone to the ED instead of a clinic; I simply would have called in late to work.

Well-meaning but hurried providers make poor diagnoses and prescribe dauntingly overpriced treatments. Because of mistakes in primary care, specialists get involved unnecessarily. Drug companies tout their latest miracle cures, but make no mention of comparative pricing. In fact, no one knows the real price of anything in health care. The ED did not provide a clear statement of the total cost, nor did the optometrist. Further, the prices for me, someone with commercial health insurance, are different than the prices for a Medicare patient, a Medicaid patient, or an uninsured patient.

Quality is an issue. Was the ED that I visited a high-quality ED or not? How did they measure quality? How would I know what the scores were? The PA was a pleasant chap, but the quality of care that I received was lacking. In the absence of metrics, word of mouth rather than clinical outcomes becomes the main quality measure. I went to the optometrist that my mother had recommended because when she saw him, “he was nice”.

An eyelid infection is a relatively minor medical problem. Imagine how much mischief the same combination of human laziness, misjudgment, opacity, and inconvenience causes for more serious diagnoses. Imagine how much these factors contribute to unnecessary expense, and to human suffering.

Conclusion

When I told my daughter, a student in Public Health, my story, she was disgusted. She called it “a personal problem”, but unfortunately the effects are more than just personal. Rather than getting an inexpensive prescription at a primary care office, spending less than $100, I got ED care, an expensive prescription, and specialty care, likely costing well over $1,500. Rather than taking two days to get better, it took five, including time off work and lost productivity.

My foibles are obvious, but they are not unique. I have met few doctors who have never used higher priced care when a cheaper care would do. I have met even fewer doctors who have never taken someone else’ medicine or used expired medicines. Nurses and other health care professionals do the same, and we all know better. Little wonder that patients, who often don’t know better, follow our example.

How then do we revolutionize health care, my stated goal at the beginning of this article?

  1. By engineering hazards out, including mistakes, misjudgments, and misunderstandings.
  2. By transparency in quality and pricing.
  3. By better rewarding good behavior.
  4. By practicing evidence-based medicine.
  5. By intentionally using low cost medications and other interventions when the outcomes are similar.
  6. By making the patient more responsible for costs and outcomes, having “more skin in the game”.

Please also see Healing the Health Care Cost Conundrum for more ideas.

Republicans and Democrats at all levels, local, state, and federal, will continue to fiddle with American health care. Their work is important, but can only address a small part of the problem. We as health care professionals must figure out how to provide quality, affordable, and accessible care to everyone. Using lessons learned from stories like this, we can do it.

How to Improve your Health and Health Care

Throughout Central Asia, the Middle East, and much of the developing world, people have told me that they cannot get good medical care. In some cases good care is too expensive, in other cases medical care is affordable but poor quality, and in still other cases medical care, good or bad, does not exist. Some friends with significant health care problems labor in austere conditions never knowing when a medical emergency will strike, and if they will be able to get help when and where they need.

Some people have similar problems in the developed world, even including the United States. America has been swept by debates about health care, especially about how to make quality health care available to all Americans. Medicare is a government single payer program for the elderly and Medicaid is the same for the poor, but these programs pay providers too little and yet are unsustainably expensive for the nation. The Affordable Care Act (ACA) was the most recent Federal attempt to improve Americans’ health, but the results have been mixed. Fundamentally the ACA was health insurance reform, not health care reform, and providing someone with an insurance card is not the same as providing them with health care. Hence we have millions who lost their insurance, millions who got new insurance, and millions waving their new insurance cards in the air who cannot get care because it doesn’t exist in their area, wait times are too long, or the system pays so little that providers cannot afford to take these patients.

Britain’s National Health Service, and single provider or single payer systems in Canada and Europe, also attempt to get health care to everyone in their population. While some of their outcomes are good, these systems ration care by long waits and care denials. Despite sometimes draconian cost saving measures such as denying cancer and heart disease treatments to the very old, these systems are still increasingly unaffordable.

Everyone needs health care, at least at home, in their lives, and most people need professional health care, such as that provided in clinics and hospitals, at some point. Professional health care must be affordable to the patient and family. Most people have neglected seeing the doctor, getting medications, or getting a blood test because in their perception the cost was greater than the benefit.

In some cases the needed professional health care is simply not available. As noted above, many Western expatriates in the developing world have no way to get Western quality medical care. Some people in rural areas throughout America and the world must travel hours or days to get to clinics or hospitals, and many don’t go as a result. This article will describe things that people can do to improve their health and health care.

How to Improve your Health

Historically, most medical care has been nursing care and has occurred in the home. The human body has a remarkable ability to heal itself, as long as it is well fed, sheltered and clean. The vast majority of routine illnesses and injuries will heal on their own without any intervention by the medical system.

Healthy bodies heal better and faster than unhealthy bodies. Volumes have been written about getting healthy, including the value of a good diet, exercise, and sleep, and the importance of avoiding tobacco, alcohol, and other unhealthy behaviors. This article will not revisit these messages. Clearly the most important way to improve your health care is to improve your health.

Having a healthy home is the second most important part of good health. Homes that are clean, safe and harmonious are generally homes with healthy people. When a parent smokes, the whole family is harmed by the smoke. When a parent uses alcohol, the whole family is more likely to suffer because of alcohol. When a home is dirty and unsafe and food is poor, everyone has a greater risk of illness and injury.

Another important factor in health is having a healthy and safe neighborhood. Accidents are the most common cause of death in children, and injuries afflict all ages. Yards, sidewalks, homes and schools should be safe and neighborhoods clean and well lit. More than governments, residents are responsible for the safety and health of their neighborhoods.

Certain lifestyle practices are associated with good health. We frequently hear that smoking and drinking alcohol are bad and exercise is good, but there are some more surprising changes that people can make to be healthier. Married people generally enjoy better health than unmarried ones, and people who attend religious services regularly are healthier than those who do not. Children also help people be healthier.

How to Improve your Professional Health Care

The Internet contains great information about health and health care, but it also contains misinformation. While proper use of the Internet can help people manage their care at home, misuse can cause anxiety, poor decisions, and bad health. The most important consideration in using the Internet for health care is to use reputable sites. The Virtual Medical Center at MDHarrisMD.com has reliable sites for patients, providers, health care administrators, and public health professionals.

Suppose your toddler has a fever and is fussy and you go to familydoctor.org. You click on the “symptoms” button and go to “fever in infants and children”. You then follow the algorithm. It tells you what to do for your child, when to seek care, and what kind of care to seek. These algorithms have been validated by many studies usually involving thousands of patients and you can rely on them.

For most people with a medical concern, their first reaction is to seek professional care; usually a visit with a provider. However there are many ways to get care without an appointment. Health care organizations often have telephonic Nurse Advice Lines where patients can get professional advice and care from registered nurses. Patients can often also call their primary care clinic to ask questions. Many medical practices have an online presence; websites that allow patients to check labs, renew prescriptions and ask questions in a secure web site. Many health care organizations allow patients to book appointments online. Some physicians even have online visits, in which patients can get an office visit from the comfort of their own home or office. Ask your doctor if he (or she) has an online presence and how you sign up for it.

For simple and short duration symptoms such as a cold, small retail clinics manned by midlevel practitioners such as physicians assistants and nurse practitioners provide reasonable service at bargain prices. They often also provide preventive health services such as sport physicals, but are not intended to manage complex medical conditions or long term care.

For most problems, go to a primary care clinic. Your primary care physician can handle over 90% of the most common concerns. Most patients do not need to see a dermatologist to remove a mole nor a gynecologist to perform a pap smear. Primary care physicians manage uncomplicated high blood pressure as well as cardiologists do, and early diabetes as well as endocrinologists. Neither uncomplicated acute back pain nor a sprained ankle requires a visit to an orthopedist. Insisting on a referral to a sub specialist wastes time and money for the patient, the practice, the community, and the health care system.

Take responsibility for your own health care. No one can coordinate your medical care better than you can, and no one will. Medicine is complicated but can be understood by anyone with the will to try. Those with genuine cognitive problems such as learning disabilities or early dementia may need family members or friends to help them, and communities, churches and other charitable groups can assist those truly alone. Medical practices, often caring for thousands of patients, can help, but no one can take the place of family and friends in assisting individuals in taking responsibility for their health.

At a visit, make sure that you fully understand your doctor’s instructions before you leave the office and understand how these instructions fit in with the overall plan of care. Shop for the best deal for ancillary studies like laboratory and radiology. If your doctor tells us that you need an MRI, ask him (or her) what vendors are available, what their quality is, and how much they charge. Just like you would do for any service, go to the place that best balances quality and price. If you are prescribed medications, ask your doctor to use generics and cheaper medicines when possible, as these are generally as effective as expensive, name brands. As a rule, do not ask for antibiotics; a competent physician will prescribe them when required. If not prescribed, they are probably not required.

Don’t neglect your preventive care. Immunizations are vital for good health, and vaccinations are generally safe. School and sports physicals are important for children, and prenatal care is indispensable for pregnant women and their not yet born children. Patients with chronic medical problems such as diabetes, high blood pressure, and high cholesterol need routine follow up.

Communicate with your professional health care team. Years ago I took my father to see his doctor. He had complained of fatigue and shortness of breath for months, but when his physician asked how he was doing, he replied “fine”. The doctor looked at him, undoubtedly wondering why he had scheduled the appointment. Unwilling to lose the opportunity, I listed dad’s real concerns and the visit became productive. Find a primary care practice that you like and stick with it, because consistent care is better and less expensive care. Many advisors tell patients to make a list of their health questions and worries and discuss them all with their doctor. While this may be reasonable, providers typically have no more 15-20 minutes with each patient and so may ask you which is the highest priority and handle only that one.

Unfortunately, some people have health care needs such as cancer which are beyond the ability of a primary care practice to manage alone. These patients should be managed jointly between their primary care provider and their subspecialty provider, like their oncologist. The need for routine primary care never goes away, so even patients with serious medical problems requiring specialty care need a primary care doctor. Medicine is more than a business, it is a relationship between a group of medical professionals, their patients and those patients’ families. Healing is physical, mental, social, and even spiritual. That is why for millennia and in every culture, the healer was often the priest, and the work of healing was associated with the transcendent power of God.

For people whose professional health care needs exceed the capability of their home and the local clinic, charitable and other private hospitals provide the best care. With some exceptions, such as combat casualty care and long distance medical evacuation, health care provided by governments is more expensive and less efficient than that provided in the private sector. Even for the sickest people, however, good health, home care, preventive care, and primary care are indispensable.

How to Save Money on Health Care (partly drawn from Kiplinger’s Personal Finance, Oct 2014)

Health Care and Ancillary Care Providers

  1. Pick a HCP in the network for your health plan. Your deductible and out of pocket expenses will be much lower.
  2. Find out which physicians are “super-preferred” providers in your health plan, usually because of high quality, cost efficient care. You may pay even less.
  3. Comparison shop between radiology centers. The stand-alone centers are often cheaper and have greater price transparency.
  4. If you need a surgery, ask your surgeon about which ones have the lowest cost while maintaining high quality.
  5. Investigate which hospitals and urgent care centers are in the network for your insurance when you first get the policy. That way you will know where to go when the urgent problem strikes.
  6. Independent labs, like independent radiology centers, often have greater price transparency and lower prices than hospital based ones while maintaining high quality.
  7. Consider telemedicine, which uses technology to produce virtual doctor visits and video visits, often at a lower price than going to a clinic.

Medications and pharmacies

  1. Compare costs for drugs just like you do (or should) for everything else.
  2. Use generic drugs whenever possible. Also, patents for brand name drugs expire and generics appear all the time. Watch for when your medications will become available as generics and switch as soon as you can. Finally, many generics cost less if you pay for them yourself rather than paying the copay and charging insurance. Some drug stores charge $4 for a 30 day supply of generics, while the copay alone might be $10 if you used insurance.
  3. Use therapeutic equivalent drugs, those with the same effects but lower costs, whenever possible.
  4. Use preferred pharmacies in your network, or order prescriptions through the mail.
  5. If your doctor agrees, cut your pills. If you can get a prescription for twice the strength and half the quantity, you can save money.
  6. Know the rules that your insurance company has in place for prescriptions. Some insurance companies require that for certain conditions, drug A must be tried before drug B. If your doctor doesn’t know this and prescribes drug B, you may pay an unnecessarily high price.
  7. Get prescriptions for expensive over the counter drugs. That way you may be able to get reimbursed from your health savings account and get a tax advantage.
  8. For people with rare or severe medical problems such as pulmonary hypertension and some types of cancer, special drug programs can help defray part or even all of the medication costs.

Preventive Care

  1. Get your preventive care with no out of pocket costs. Insurers must provide such programs under the Affordable Care Act.
  2. When a doctor orders a test at a preventive care visit, make sure that the test is covered under such a visit by your insurer.
  3. Large employers often have wellness programs that pay cash or provide reduced insurance premiums for employees that meet certain health goals like losing weight or stopping smoking. Participate in these programs whenever available.

Medical insurance

  1. Compare costs when buying health insurance and get only what you need. Be sure to consider your kids health needs, because they can stay on your policy until age 26. Research fair prices for the coverage that you need and comparison shop.
  2. Change to a high deductible policy, and make sure you get credit towards your deductible for all your care. Even if you pay for something out of pocket, file a claim so you get the rate negotiated by your insurer. Schedule procedures towards the end of your deductible year, and do so ahead of time so you can get them when you want them.
  3. If eligible, get a health savings account (HSA) with the highest contribution limit allowable. If possible, get contributions from their employer as part of your employee benefits. You can also save in your tax bill by making a one-time roll over from an individual retirement account (IRA) to an HSA. You can’t contribute to an HSA after signing up for Medicare, but you can use the money for deductibles, co-payments, vision and dental care, and long term care. Finally, if you are self-employed you can deduct health insurance premiums from your taxes.
  4. Negotiating care – Ask your doctor’s office for a discount if you pay cash. If your insurance company denies a test or procedure, reconfirm the need with your doctor and then appeal it. Also ask for an itemized bill when you are hospitalized and watch for common billing errors,

Conclusion

For the past two hundred years, people in Western nations have expected someone else, usually their government, to provide medical care for them. This has never worked well, and is working less as time passes. Health is never perfect, and death still happens, but the real key to having the best possible health lies first with the individual, then with the family, then with the church and community, and lastly with government. Each person is ultimately responsible for him or herself, but by doing what is listed above, we can all have our best possible health.