Tuesday, July 13, 2010

Compromise

Glenn Greenwald has done a bang up job of exposing the cozy, compromising relationships that the elite press corps has developed with the very Washington DC politicians and insiders they are ostensibly supposed to be covering. In this era of blogging and open source media, the public doesn't necessarily have to seek political news and opinions from the old guard of mainstream media. The elites no longer have a monopoly on defining what is news and how the news ought to be interpreted. So they cling to the one thing that the bloggers will never be able to touch---their sources, connections, and inside contacts.

As a result we get travesties like the Joe Biden party where reporters engage in squirt gun fights with the Vice President and other White House staffers. You get Chris Wallace "interviewing" Dick Cheney without asking a single uncomfortable question about torture and waterboarding. You get Sarah Palin running for Vice President without having to endure a single unscripted press conference. The presentation of "news" becomes merely a propaganda show where journalists and reporters subserviently regurgitate what the politician wants them to say, unchallenged. Because if they don't, guess what? No more access! No more "private sit down" sessions with Mr. VIP! And so the journalist/reporter simply stops doing the job he/she was hired for, i.e. holding governmental persons in postions of power accountable. Getting at the truth isn't so important as maintaining an open relationship.

Similarly, in medicine we often compromise ourselves for nefarious purposes, especially financial. We bitch and moan about tort reform and the insidious malpractice situation but we refuse to hold one another accountable. When another doctor makes an error, no one says anything. It's "too awkward" to say anything or "it creates an antagonistic environment" will be the explanations you hear. And of course this is true to some extent. But a larger reason has to do with the way private practice is constructed. Referral patterns are based on relationships and habit. You refer to a certain surgeon because he seems nice and the patients like him. You refer to a certain endocrinologist because she went to your medical school. Rare does it have anything to do with the quality of care delivered. And as these referral patterns and relationships ossify, it becomes harder and harder to change them. One thing that will change a referral pattern mighty quick would be "tattling" on a referring doctor for providing substandard care. Or receiving a notice in the mail from your QA committee that another physician has submitted several examples of cases where you delayed an intervention.

We specialists don't want to disrupt our profitable and essential referral patterns. So we don't say anything when an internist puts a patient on full strength lovenox 24 hours after a colon surgery. At most we perhaps off-handedly mention to the physician that maybe it would be a better idea to allow the surgeon to decide when to re start anticoagulation. The GI doc doesn't report the surgeon who always calls him for his all too frequent post-lap chole bile leaks. We don't report the internist to QA who prescribes massive doses of IV steroids to a patient with a rash (probably from morphine reaction) who was admitted with diverticulitis, who then decompensates and becomes septic with peritonitis. We just kinda, sorta mention that altering the patient's immunity with corticosteroids maybe wasn't such a great idea. Or maybe we don't say anything at all. Because it would just create an awkward situation.

6 comments:

Frank Drackman said...

Bla Bla Bla, did you get that Trig Palin Drool I sent ya??? Might be able to harvest a few buccal mucosal cells, little DNA genotyping, and you can go on the lecture circuit..
Serioulsy, LeBron leaving Cleveland is Karma bitin ya, for that tasteless Sara Palin post. Next thing you know the Indians/Browns will leave although that might be a good thing...
"Los Angeles Browns"??? sounds pretty good...

Frank

Melly said...

Honest post. Thanks. And the analogy is right on. You scratch my back, in politics, press, medicine and a whole lot of other places, and I'll scratch yours, ignoring the truth as best we can.

Michael Kirsch, M.D. said...

Should we be healers and squealers?
http://goo.gl/qHUX

tom said...

Enabling behavior at its best; in my community the weak ones end up with lots of free time as their referrals dry up. Now if I am the only (fill in the blank) in town, my "bad luck" will probably be tolerated (supported?)

Anonymous said...

Very true. I once happened to see a letter from a specialist to the doc who referred me.

The doc referring me made a mistake in putting me on a particular kind of (non-useful) medication.

The specialist gently alluded to this in his letter, saying, "As you know, x medication has no effect on this condition..."

I think it is all litigation related. I have had docs make mistakes with me, but as yet I have no inclination to sue. It's true that a heartfelt apology by the offending doc and seeing that he/she is working hard to make up for it is all most patients need.

Aidian said...

I would suggest that the rise of non mainstream media outlets is actually the cause of the lack of media-generated accountability for elected officials. Sarah Palin can't actually sit down with any credible reporter and not answer some real, challenging, and skeptical questions. She can sit down with an ideologically-friendly blogger, or talk radio host, or any of the Fox News on-air talent, and get nothing but friendly softballs.

The fact that a few of the D.C. press corp are just access whores isn't that big a deal except in as much as they tend to be among the big names. But once you get beyond your Woodwards and Gregories and Ambinders, there are a significant number of serious journalists who take the watchdog role seriously. For an example of D.C. reportage done right read the work of McClatchy's D.C. bureau.

As a proud card-carrying member of the dreaded main-stream media I feel a duty to get the facts out to the public I serve. Everything else is gravy. I wouldn't go to the Biden's cookout, but even if I did I'd make damn sure that didn't stop me from holding him accountable to the voters. That's what we do. It's more important than making nice with Joe Biden or any other official. It's more important than keeping a source or avoiding a pissed off phone call to my editor from some big wig. It's more important than my job. It's more important than my career. It's what we do, and sacrificing that commitment is not negotiable.

Hopefully, you've never acted like the doctors you describe in the post. Because if a doctor is not willing to snitch out a fellow doctor over these sort of serious repeated errors then he or she is ethically as bankrupt as those access whores in the D.C. press corp. Morally, the culpability is higher, because of the potential harm being even greater.

Anyone who fails to be a watchdog for the public because of fears over losing access doesn't belong in journalism; anyone who lets a patient be harmed because of concerns about referrals or alienating colleagues or whatever has no business practicing medicine.