The idea for a checklist in clinical settings was originally conceived by Peter Pronovost at Johns Hopkins. Last year, Gawande wrote an awesome essay for the New Yorker about the ICU checklists that were attempted in the US (saving hundreds of lives) but eventually cancelled by regulatory authorities-- "If you're changing the way things are done, you need to perform controlled FDA-approved studies."
Also, you should read his book Better, which is just page after page of interesting stuff; Atul Gawande is the Malcom Gladwell of medicine, but I think his stuff is far more engaging.
As a pilot, I've often contemplated this myself with some sense of sick wonder. Flying a plane is trivial compared to surgery but overlooking something important has equally dire consequences, so all pilots everywhere are taught to always use checklists. It works wonderfully. I just can't imagine going into something so life and death with a "I'm pretty good at remembering everything" attitude!
This combined with How Doctors Think made me realize that our doctors in the US are really no better than witch doctors. In fact in some ways going to a shaman is probably better. They are less likely to cure you, but they are also vastly less likely to kill you by accident. A pretty good tradeoff, considering that medical accidents are the leading cause of death in the US.
And this isn't even counting the fact that none of our antibiotics are working anymore because our medical system sees fit to use over 70% of our total antibiotics produced each year in animal feed.
While your stats are nonsensical and incorrect, I agree there is a big problem with Witch Doctor, M.D. An experience I once had:
Me: I have nerve pain in my pinky and right side of the forearm. [Shows the doctor where it hurts.]
Dr: You are a programmer. I think you have carpal tunnel syndrome.
Me: I've got pain in my forearm. Also, the ulnar nerve is what connects to the pinky, and that doesn't pass through the carpal tunnel. Are you sure about that?
Dr: Are you questioning my judgement?
I'm happy to say I have found a doctor who does practice the scientific method. Unfortunately, not all do.
"I'm happy to say I have found a doctor who does practice the scientific method. Unfortunately, not all do."
In the book How Doctors Think, they show a statistic that the vast majority of doctors make up their minds about what's wrong with you in the first thirty seconds and then never reconsider no matter what you say or the evidence suggests. This is one of the advantages of going to see a naturopathic doctor in addition to an allopathic doctor. They will actually sit down with you for a 45 minutes and discuss your health, diet, exercise, etc. This would be unthinkable for 99% of normal doctors. While it's true that allopathic doctors should be trained to take your diet and such into account when trying to figure out how to cure you, the fact is that none do. So you could have depression that's caused by a lack of magnesium and your doctor will give your powerful SSRIs, when in reality it could just as easily be cured with a little guacamole. A lot of people will quibble because the example I just gave falls under the myth of what doctors are supposed to do, but if you look at what doctors actually do do then it becomes clear that allopathic medicine is a disaster. Never judge an organization by its mission statement; medicine is no exception.
A doctor may try and fail to deliver science-based medicine.
Some doctors are even intellectually incapable of doing this, and practice cargo cult medicine (compare to cargo cult programmers). They vaguely follow some science-based procedures without really understanding what they are doing.
A naturopathic "doctor" does not even attempt to use science, at least not consistently. Naturopathic medicine is feel-good mumbo jumbo. Some of it works (your guacamole example), some of it is utterly wrong (homeopathy) but still used. Naturopathic medicine does not, even in principle, attempt to use science-based medicine.
Science-based medicine, like most human endeavors, is flawed. It doesn't always do what it should do. The solution is more science, not the complete abandonment of science in favor of new-age nature-worshipping religion.
As for your stats, just FAIL. One example:
There are 98,000 medical-mistake caused deaths. The 37,136 deaths due to unnecessary procedures and the 32,000 surgery related deaths are a subset of the 98,000 medical errors. You just can't add them, which your source does.
I'll illustrate the mistake with cows:
I have 98,000 cows. In particular, I have 37,136 black cows and 32,000 white cows. Therefore, I have at least 167,136 cows.
"A naturopathic "doctor" does not even attempt to use science, at least not consistently. Naturopathic medicine is feel-good mumbo jumbo. Some of it works (your guacamole example), some of it is utterly wrong (homeopathy) but still used. Naturopathic medicine does not, even in principle, attempt to use science-based medicine."
First of all, naturopathy and homeopathy have nothing in common except for that they sound kind of similar. Kind of like java and javascript.
Second, naturopathic medicine is science based. Of the four naturopathic schools in the country, two rely almost entirely on the same set of peer reviewed literature that traditional medicine relies on. The only difference is they are primarily interested in the effect of plants, not specific chemicals from plants.
Also, you may well be right on the stats, I haven't studied them closely.
Incidentally, the effect of plants is the result of the interaction of the chemicals inside the plants with the chemicals in the body. Willow bark reduces pain because it has aspirin in it.
If, as you say, naturopaths are just practicing scientific medicine but using plants rather than chemicals, all they are doing is adding a new source of errors to traditional medicine. Rather than giving a patient 200mg of aspirin, you give them a plant which is likely to have about 200mg of aspirin in it (more or less).
"If, as you say, naturopaths are just practicing scientific medicine but using plants rather than chemicals, all they are doing is adding a new source of errors to traditional medicine."
The theory is that when plants have powerful drugs in them, they usually also have other mechanisms to prevent those drugs from being toxic. The idea being that eating the whole plant is often less harmful than taking a massive dose of one specific chemical. For example, people die every year by OD'ing on Red Bull or caffeine pills, but hardly anyone ever dies by drinking too much green tea. Why? Green tea has lots of acid and other stuff that'll make you throw up long before you can drink enough to kill yourself.
There are many other things that traditional doctors won't tell you take because they are illegal. For example, coca tea is far less likely to have nasty side effects than the altitude pills your doctor prescribes you, but your doctor isn't allowed to prescribe you coca tea because it's illegal.
And of course most doctors also accept bribes from the pharmaceutical industry. Every few months we see huge articles in the NY Times to this effect. Think of how many times your traditional doctor has advised you to take a plant-- probably never. Because plants aren't patentable and the pharma industry isn't there giving your doctor free trips to hawaii if he tells you to smoke weed for your bone cancer instead of taking some dangerous chemical compound.
Of course the dosages are a lot more variable than if you just got a pill, but that's why you go back to your naturopathic doctor every week or so instead of just taking a fixed dosage and going back if it gets worse. The whole idea is that the medicine is based around what makes you feel better, not what works for the average person as compared to a placebo.
Is there conclusive evidence that in general, it is better to eat the whole plant rather than just a controlled dose of the active chemical?
As for the illegality of various drugs (coca tea, pot), I agree our legal system is fucked up. Not sure how naturopathy helps here, unless naturopaths routinely break the law.
"Of course the dosages are a lot more variable than if you just got a pill, but that's why you go back to your naturopathic doctor every week or so..."
How does that help? More frequent control does not reduce the noise in the inputs. The naturopathic shaman doesn't know what he gave you. He has no way to know if he should give you two plants vs one, or if the plant he gave you just has an abnormally low dose of the chemical.
"The whole idea is that the medicine is based around what makes you feel better, not what works for the average person as compared to a placebo."
And that's why it is unscientific. All you know is how you felt before, and how you feel now. You can't know the cause of your change in feeling, except in a randomized trial.
"Is there conclusive evidence that in general, it is better to eat the whole plant rather than just a controlled dose of the active chemical?"
It's different for every problem. If you want to take aspirin then it's better just to take aspirin because the compound alone causes less stomach irritation. However if you want to take resveretrol then it's (probably) better to take the pill with a glass of red wine. The problem is that allopathic doctors are will NEVER prescribe taking the whole plant, even if peer reviewed research has shown it to be clearly better than a synthetic alternative.
"The naturopathic shaman doesn't know what he gave you."
Yes, they do. They look up what could be causing your health problems in peer reviewed journals and then try different things. With the depression example, there are five or six different underlying things that can cause a serotonin imbalance that creates depression. With allopathic medicine they just give you SSRIs, which fix the serotonin problem without ever fixing what's causing it. With naturopathic doctors they will actually do blood tests and thyroid tests to see if you have too much or too little of something. Even though thyroid problems are extremely common, allopathic doctors will almost never do a thyroid test unless you explicitly ask for one.
"And that's why it is unscientific. All you know is how you felt before, and how you feel now. You can't know the cause of your change in feeling, except in a randomized trial."
Except they are starting with drugs that have been clinically proven in randomized trials. They are just going back and adjusting the dosage afterward, unlike allopathic doctors who will just keep you on the dose that has been shown to be most effective for the "average" person. In many ways this is even better than the process used by allopathic medicine.
But does a naturopath actually give you some willow bark to chew on? From my experience, it is just a plant derived active ingredient. Kinda like the difference between "Natural Flavors" and "Artificial Flavors" in foods. The active chemical is identical, but one comes from a plant, and one was derived in a lab. In the end it doesn't matter too much because they both end up pretty much as identical chemicals in a test tube.
I mostly know of "naturopaths" who are into the homeopathic "mumbo jumbo" so I'm surprised to find out that naturopathic schools attempt to follow the journals.
I kinda think that there are good "doctors" (be it traditional or not) who are up on their science and listen past the 30 seconds they meet you. And then there are regular doctors who don't listen enough and misdiagnose on a regular basis and naturopaths who are into a lot of hand-wavy "medicine" that wouldn't hold much salt if properly tested, but because of the placebo effect find themselves still employed and even convinced of their skills.
"I kinda think that there are good "doctors" (be it traditional or not) who are up on their science and listen past the 30 seconds they meet you."
The best naturopathic doctors are only doing what an allopathic doctor would do if they were more competent. As it stands, the vast majority of allopathic doctors can't name a single medical journal article published in the last year-- not surprising considering how low job satisfaction among doctors is. Certainly not all naturopathic doctors are good, most are basically quacks. But the best naturopathic doctors, the ones who are super intelligent and intrinsically motivated, tend to be better than the allopathic alternative only because they don't have this huge bureaucracy telling them how to do their jobs and killing their intrinsic motivation to do a good job.
The best "doctor" I ever saw was a physical therapist.
I sprained both my ankles at one point. One of them was really, really bad, just this side of needing surgery.
I told my orthopedist, "My toe looks wrong. And I feel shorter when I stand on one foot." He said "Your toe is fine. You are a hypochondriac. I'm going to offload you to a physical therapist." (essentially).
My physical therapist said, "Oh, your toe is too far off to the side because of swelling in this cross-ligament here. And you ARE shorter on one foot! Your pelvis has tilted from limping."
And he made me better.
It was so good I could have cried.
Also, turns out I had $40k of invasive and destructiev sinus surgery when a $15 immune system treatment called Broncho Vaxom could have made me better.
But it's not available in the US, just Europe and third world nations.
Just from informally talking to a few people, it seems like sinus surgeries have basically a 100% rate of leaving you messed up for life. I'd be interested in seeing actual data though.
I had a really good surgeon and didn't really suffer any permanent ill-effects. But, aside from fixing my deviated septum, no long-term positive effects either.
I still got sick, til my mother-in-law (a Viennese neurologist) put me on Broncho Vaxom.
I'm going to be as nice and polite as I can be here.
Medical science has had a long history, at least a few hundred years and performs studies/experiments/etc. to make sure that things work.
Witch doctors try random shit and see what sticks to the wall even if it means the patient dies.
Do you see the difference?
If doctors were killing a lot of people, I'm sure journalists would have jumped all over it by now and a lot of doctors would have malpractice suits filed against them.
Antibiotics do work. There have been studies to prove that. This isn't the small-time, this isn't the minor leagues, these pharma-companies are paying a big chunk of change to make sure something useful happens when you take those pills.
If you want lies and deceit, I suggest you go to a "natural" "organic" pharmacy that sells homeopathic garbage.
these pharma-companies are paying a big chunk of change to make sure something useful happens when you take those pills.
Unfortunately, it's not always clear that those drugs do work. The problem isn't in the scientific process, but how it's often carried out and reported by the companies, who know exactly what it takes to get FDA approval (this is BIG business). I'm interested in how this process can be improved.
The "alternative/complementary" medicine thing is a red herring, to be polite.
Here's an interesting article that discusses some of the less than ideal ways that pharmacy companies report the science behind the drugs they develop, among other things.
You are correct of course. I remember reading about some pill right after WW2 that caused many birth defects but was approved for the public. It is a big business which is precisely why there needs to be an overseeing body.
Alternative medicines isn't a red herring, it relates directly to witch doctors. None of these alternative medicines are tested properly in an objective matter to prove that they do in fact work. These people still haven't gotten to step 1 on the stairs of science, while pharma companies are at step 123901823091283 though still need to climb a few more.
"None of these alternative medicines are tested properly in an objective matter to prove that they do in fact work."
Many have been tested and proven to work. The only reason they are "alternative" is that doctors only prescribe medicines that the pharma companies promote. So they will prescribe people statins to lower their cholesterol, but they would never advise someone to take red rice even though it does the exact same thing with less risk of complications.
Yes, but I'm not an ND or MD so I don't know which journals are reputable and which are not. I get the feeling that research on botanical medicine mostly gets published in the same journals that publish normal pharmaceutical research, it's just that doctors only prescribe things that come in pill form.
"Medical science has had a long history, at least a few hundred years and performs studies/experiments/etc. to make sure that things work."
And when push comes to shove, there's a simple procedure that can cut your risk of dying from surgery in half, and it's illegal for your doctor to use it in the US. As in if they do, they lose their medical license and go to jail. Why? It's insane.
"One of the sad realities of ignoring history is that almost every American is ignorant of the fact that medical freedom was tragically left out of the American Constitution. In 1776, Dr. Benjamin Rush, Surgeon General and the only American doctor to sign the Declaration of Independence, tried strenuously, but failed, to have "medical freedom" enshrined in the Constitution. He stated "The constitution of this Republic should make special provisions for Medical Freedom. To restrict the art of healing to one class of men and deny equal privileges to others will constitute the Bastille of medical science. All such laws are un-American and despotic."
If this amendment were actually enacted then probably your risk of dying in surgery would be 50% of what it actually is today.
There is a problem, in that a medical doctor will often prescribe you expensive irritable bowel syndrome drugs when eating live culture yogurt or swallowing some culture pills (from those "natural" "organic" pharmacies) will solve the problem faster and cheaper.
The "natural" stuff is about half real and half hokum.
Unfortunately, it seems like regular medicine is, too.
This is where the problem is. How does one properly filter the real from the fake? I find myself quite annoyed with the whole thing. (especially homeopathy)
"I thought it was obesity? Or smoking? Or drinking and driving?"
Obesity isn't as dangerous as was previously thought, not that many people smoke anymore, and the dangers of driving after a drink or two are vastly overstated.
"I don't know, they worked great both when I had lyme disease and when I had bronchitis..."
That chart is worldwide, not US. And iatrogenic deaths wouldn't be in the chart anyway because there are ten or fifteen different types, most of which would fall under another category.
Fine, here's the US data for 2005 from the CDC. I don't think you can ascribe deaths from heart disease, cancer, stroke, lung disease, diabetes, and Alzheimer's to doctor error. Most come from lifestyle choices. Cigarettes, junk food, and no exercise make Homer something something (DIE EARLY).
You might strengthen your argument for me if you talk about proximate vs underlying causes of death. We're all going to die.
I understand that iatrogenic deaths aren't in the table. And I do think the 800,000 figure the site I linked to may be too high. But almost certainly medical errors are the number three cause of death.
Think about it this way. If your chance of getting MRSA during surgery drops from 4% to 0% if your doctor uses a simple 6-item checklist, imagine all the other ways that doctors are hurting people. Plus, heart attacks are usually the cause of death when your doctor prescribes either the wrong medicine or the wrong dosage, or prescribes the right medicine but gives it to the wrong person.
And why shouldn't they do a controlled FDA-approved study? Medicine is a /science/ which means we need to test things, rather than relying on "common-knowledge". If it is as effective as you say, a study should be fairly easy to set up.
They did set up a study, informally, like you would do in most sciences for an exploratory experiment.
But it was shut down by the FDA. And to comply with FDA rules (which are designed specifically for drug testing and exploring new surgical processes) it would have taken six years and been too expensive for their budget. So they went to the UK and completed the study in six months for free. The US lost out on that.
You're conflating "scientific studies" with "FDA-approved studies". The former proceed at whatever pace makes sense for medicine and for patients; the latter proceed at the speed of molasses.
It's great to do a study, but in the meantime can anyone explain how a checklist could be dangerous? If you can't give any ways, then it's silly to ban it for now. This isn't a new medicine with potential unknown effects.
Imagine you're operating on a person and you accidentally leave a sponge deep inside their abdomen. The nurse, following the checklist, tells you and you go back in and remove it. In the process, you cut an artery and kill the patient. The patient's family claims the hospital was performing an "experiment" on the patient because without the checklist they would not have gone back in to remove the sponge and the patient would have lived.
Obviously, this is stupid. But cases have been won on this principle, which shows legal precedence. When the FDA came knocking, the hospitals, afraid of lawsuits, complied.
That's what OR nurses generally do, count sponges, needles and instruments. They also have to be willing to nose to nose with a crabby surgeon and tell him to re-open the patient and try to find the missing sponge when the count is off
As a member of the general public, I do find it hard to believe this sort of thing isn't done already.
As a victim of a minor surgical mishap myself (general anaesthesia applied when it shouldn't have been), I can definitely believe "incidents" happen all the time.
"I do find it hard to believe this sort of thing isn't done already."
I showed a similar article to my wife (has worked in healthcare for 20+ years) and she said "Oh yes, we do that all the time. Everything has a check-list." So if it makes a difference, I guess it is either mandated for higher-level staff (surgeons and consultants who are often a law unto themselves) or rigidly enforced at all levels.
Also, the study might show bias because people will do the lists if they know it's being assessed for an experiment, but might ignore it on a day-to-day basis.
Any doctor who reads the study and sees the 50% reduction in death rate in surgeries and 90% reduction in accidental deaths in the ICU would be negligent to ignore checklists.
If this surgery checklist and the ICU checklist were to be implemented in every hospital, they would save more lives than all new medications introduced in the last five years, combined. Ignoring results like that is just asinine.
"Any doctor who reads the study and sees the 50% reduction in death rate in surgeries and 90% reduction in accidental deaths in the ICU would be negligent to ignore checklists."
Although I've only had non-trivial procedures done on me once or twice, I've never seen a checklist used.
As for ignoring checklists on a day to day basis, this could be solved by making them a required part of a patient's medical record. That way, doctors are constantly being assessed on the basis of completing a checklist. You could even publish stats on it.
"No checklist, no payment" would also be a good way to enforce it.
I'm a med student and a programmer. I think there are a lot of similarities between these two disciplines.
The body is an incredibly complex system that you or a pathological process can perturb in a variety of ways, just like any other system. The results of those perturbations may be evident immediately or may take a long time to present themselves. The results are output in the form of physical signs and symptoms. The way this particular system works is that there are more potential pathologies than there are physical signs and symptoms, so sometimes you end up with collisions in the pathology to sign/symptom mapping. In these cases you can use instruments like labs, radiological tests, and sometimes invasive methods like surgery to further investigate. These tests are imperfect and are themselves perturbations to the system.
If you can come to a final diagnosis of the underlying pathology using the tools at your disposal (history, physical exam, labs, tests, and procedures) you can then engage in a therapy. The more precise your diagnosis, the more precise your therapy can be. Again, therapies are also perturbations to the system. Ideally these perturbations move the system back into its normal functioning state though they may also cause undesired results that must then be diagnosed and treated.
This entire process takes place within the context of a social interaction that can itself help or hinder. Both doctors and patients have their own social idiosyncrasies that may or may not match up well with each other.
I believe that most physicians operate by generating a gigantic hash table. Essentially they know several patterns of physical signs/symptoms that act as the key. The value is whatever knowledge they have of that disease process. As medical knowledge progresses some physicians update their hash table keys/values with new information, most don't. Almost all physicians update their hash table (i.e. learn) using information gathered in the process of seeing their own patients and recognizing the difference between the predicted outcome and the actual outcome. This is often a subjective process. I think it is because of this approach that most physicians find it hard to believe that medical diagnosis and treatment can be highly systematized and is at least partially such an obvious idea even needs a study to support its use.
There are three columns on the checklist. Here is the first column:
SIGN IN
□ PATIENT HAS CONFIRMED
• IDENTITY
• SITE
• PROCEDURE
• CONSENT
□ SITE MARKED/NOT APPLICABLE
□ ANAESTHESIA SAFETY CHECK COMPLETED
□ PULSE OXIMETER ON PATIENT AND FUNCTIONING
DOES PATIENT HAVE A:
KNOWN ALLERGY?
□ NO
□ YES
DIFFICULT AIRWAY/ASPIRATION RISK?
□ NO
□ YES, AND EQUIPMENT/ASSISTANCE AVAILABLE
RISK OF >500ML BLOOD LOSS
(7ML/KG IN CHILDREN)?
□ NO
□ YES, AND ADEQUATE INTRAVENOUS ACCESS
AND FLUIDS PLANNED
TIME OUT
□ CONFIRM ALL TEAM MEMBERS HAVE
INTRODUCED THEMSELVES BY NAME AND
ROLE
□ SURGEON, ANAESTHESIA PROFESSIONAL
AND NURSE VERBALLY CONFIRM
• PATIENT
• SITE
• PROCEDURE
ANTICIPATED CRITICAL EVENTS
□ SURGEON REVIEWS: WHAT ARE THE
CRITICAL OR UNEXPECTED STEPS,
OPERATIVE DURATION, ANTICIPATED
BLOOD LOSS?
□ ANAESTHESIA TEAM REVIEWS: ARE THERE
ANY PATIENT-SPECIFIC CONCERNS?
□ NURSING TEAM REVIEWS: HAS STERILITY
(INCLUDING INDICATOR RESULTS) BEEN
CONFIRMED? ARE THERE EQUIPMENT
ISSUES OR ANY CONCERNS?
HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN
WITHIN THE LAST 60 MINUTES?
□ YES
□ NOT APPLICABLE
IS ESSENTIAL IMAGING DISPLAYED?
□ YES
□ NOT APPLICABLE
The Surgeon/Anaesthesia/Nursing teams reviewing what has been/needs to be done out loud to each other is similar to a daily stand up and the initial sprint planning meeting in a scrum team.
Saying things out loud to each other makes a social bargain that they will/have been done.
I had v. minor "surgery" before Christmas and I got asked that many questions I started to think they were taking the piss. Based on that, it surprises me that they don't already have this checklist thing in place!
The idea for a checklist in clinical settings was originally conceived by Peter Pronovost at Johns Hopkins. Last year, Gawande wrote an awesome essay for the New Yorker about the ICU checklists that were attempted in the US (saving hundreds of lives) but eventually cancelled by regulatory authorities-- "If you're changing the way things are done, you need to perform controlled FDA-approved studies."
http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_...
Also, you should read his book Better, which is just page after page of interesting stuff; Atul Gawande is the Malcom Gladwell of medicine, but I think his stuff is far more engaging.