Friday, November 30, 2012

Samuel Shem: What I've learned from speaking out against the brutality of medical training

Samuel Shem, 34 Years After 'The House of God'
What I've learned from speaking out against the brutality of medical training, in advocacy of quality connection -- and four additional "laws" for good doctors
By Samuel Shem
The Atlantic
Nov 28 2012

For better or worse, except in real danger, I don't seem to run on fear. Guilt, yes; fear, no.

It's a good thing, because my book The House of God enraged many among the older generation of doctors. I was maligned and disliked. The book was censored by medical school deans, who often kept me from speaking at their schools. None of it really bothered me, though. I was secure in the understanding that all I had done was tell the truth about medical training.

I took this pseudonym because I was just starting my psychiatric practice and wanted to protect my patients from knowing that their therapist had written such an irreverent novel. (They all found out, and didn't care -- but "Shem" had arrived, and refused to depart.) I also felt that real writers had no place in going out and publicizing their novels. I refused all invitations. And then one day I got a letter forwarded from my publisher, which included the line:

"I'm on call in a V.A. Hospital in Tulsa, and if weren't for your book I'd kill myself."

I realized that I could be helpful to doctors who were going through the brutality of training. And so I began what has turned out to be a 35-year odyssey of speaking out, around the world, about resisting the inhumanity of medical training. The title of my talk is almost always the same: "Staying Human in Health Care."

The theme of my speaking out is simple: the danger of isolation, the healing power of good connection. And any good connection is mutual.

I base a lot of my talks on what I've learned from The House of God. About how I've come to see it, and all my novels, as a "fiction of resistance," a way of resisting the injustices of a system.

It wasn't until years into my journey that I realized the importance of the fact that I and my fellow interns were products of the 1960s. We grew up in that unique lost period of American history -- beginning with FDR and ending with Reagan -- when we learned that if we saw an injustice, and got together and took action, we could bring about change. During my college years, we helped put the Civil Rights laws on the books and ended the Vietnam War. When we entered our internships we were a generation idealistic young docs. We soon were caught in the clash between the received wisdom of the medical system, and the call of the human heart. Our patients, and we, were being treated inhumanely. As Chuck the intern put it:

"How can we care for our patients, man, if nobody cares for us?"

If we decide to walk through suffering alone -- "stand tall, draw a line in the sand, tough it out" -- we will suffer more, and spread more suffering around.

And so we took action. The novel can be read as a model of nonviolent resistance. Big hospitals, like all large hierarchies, are "power-over" systems. The pressure comes down on the ones at the bottom, and they become isolated. Not only do they get isolated from each other, but each gets isolated from his or her authentic experience of the system itself. You start to think "I'm crazy," instead of "This is crazy." In The House one of the interns does go crazy, and another commits suicide.

The crucial question is how to find mutuality -- or "power-with" -- in a "power-over" system. Historically, the only threat to the dominant group -- whether of race, gender, class, sexual preference, ethnicity -- is the quality of the connection among the subordinate group.


In The House of God there were 13 "Laws." I would now add these four:

Law 14 : Connection comes first. This applies not only in medicine, but in any of your significant relationships. If you are connected, you can talk about anything, and deal with anything; if you're not connected, you can't talk about anything, or deal with anything. Isolation is deadly, connection heals.

One of the worries in how the new generation of doctors practice medicine is their use of computers. If you have a laptop or smart phone between you and your patient, you are much less likely to create a good, mutual connection. You will miss the subtle signs of the history, of the person. With a screen between you, there is no chance for mutuality, and the connection has qualities of distance, coolness, rank, authority, and even disinterest. The "smart" digital appendages can make you, in human-connection terms, a "dumb" doctor.

This, as more and more studies suggest, can lead -- hand in hand with the tyranny of algorithms and other "quality/efficiency/cost-containers" -- to more tests, more errors and medical mistakes, lower quality care, and higher costs to all.

Law 15 : Learn empathy. Put yourself in the other person's shoes, feelingly. When you find someone who shows empathy, follow, watch, and learn.

Law 16 : Speak up. If you see a wrong in the medical system, speak out and up. It is not only important to call attention the wrongs in the system, it is essential for your survival as a human being.

Law 17 : Learn your trade, in the world. Your patient is never only the patient, but the family, friends, community, history, the climate, where the water comes from and where the garbage goes. Your patient is the world.

Some have said that The House of God is cynical. And yet in rereading, it has a constant message that I was dimly conscious of in writing: being with the patient. In the words of the hero of the novel, the Fat Man, "I make them feel that they're still part of life, part of some grand nutty scheme, instead of alone with their diseases. With me, they still feel part of the human race." And as the narrator Roy Basch realized, "What these patients wanted was what anyone wanted: the hand in their hand, the sense that their doctor could care."

And so in 1974 I came away from The House of God aware of at least one thing: The essence of medical care, and life, is connection.


Fast forward 30 years.

I have published two more novels -- Fine and Mount Misery. Also, with my wife, co-wrote the play Bill W and Dr. Bob about the founding of Alcoholics Anonymous, and a nonfiction book We Have to Talk: Healing Dialogues Between Women and Men.

Love and death. How lucky we are.

During this time, as they say, life happened. There were many life struggles, and walks through the suffering. Luckily, at the right times, I was accompanied by others.

From Mount Misery, and also from conducting gender dialogues all over the world while writing We Have to Talk, I learned the importance of shifting focus from a center on "I" or "You", to "We." As in, for physicians, "We've got all the information; let's talk about what we can." The patient will say, "I think maybe we should .. " Suddenly there is a concreteness in your approach to treatment, that you are in this together.

From Bill W. and Dr. Bob, I learned that, in Bill's words: "The only thing that can keep a drunk sober is telling his story to another drunk." Alone, an alcoholic cannot resist alcohol. The self alone -- self-will or self-discipline -- will not work. What works is asking for help from a non-self-centered perspective. AA is an astonishing mutual-help organization, because alcohol and drugs are diseases of isolation.


My latest novel, The Spirit of the Place, took me in a new direction. I had always wanted to go back to my small town on the Hudson River and join my old mentor, a family doctor, in practice. Life had taken me elsewhere, but the beauty of fiction is that you can do in a novel what you haven't in the world.

At a point toward the end of the novel, the fraught protagonist has to make a choice. He struggles with it until he hears a kind of voice in his head:

"Don't spread more suffering around. Whatever you do, don't spread more suffering around." ...

--Samuel Shem, MD, PhD, is a doctor, novelist, and playwright. He is the author of books including The House of God and The Spirit of the Place.

Kaiser Employee Reported Illicit Patient Charges, Fired

Most Kaiser Permanente management employees, including doctors, understand what is required of them: they must go along with whatever is needed to increase profits. This woman didn't understand how Kaiser and other healthcare entities do business.

Woman: Reported Illicit Patient Charges, Fired
Courthouse News
November 29, 2012

PORTLAND (CN) - Kaiser fired its director of patient access business services for reporting what she believed was patient fraud, the director says in a complaint filed in Multnomah County Court.

Aimee Mansell sued Kaiser and her boss Lisa Morrison for wrongful termination and whistle blowing.

Mansell says in her complaint that she blew the whistle on Morrison, who had "devised a policy where Emergency Department employees, including Ms. Mansell, would collect an additional 'triage' charge from Emergency Department patients, or include the triage charge on that patient's invoice for services."

Because she believed the charges to be a violation of state and/or federal law, Mansell reported these violations to defendant's complaint hotline, the court complaint says.

"On numerous occasions Ms. Mansell complained to her supervisors, human resources department, and managers at Kaiser about what she believed in good faith were different work related violations which were being committed by defendant Ms. Morrison and other Kaiser employees," her court complaint continues.

"A substantial factor in Kaiser's decision to terminate Ms. Mansell's employment was due to her fulfilling the societal obligation of reporting what she believed in good faith was patient fraud, and by protesting these triage charges which defendant Ms. Morrison had imposed or planned to impose on patient accounts," Mansell says in her complaint.

A few months before she was fired, Mansell was presented an award "In recognition of many achievements and contributions throughout the year," signed by her direct supervisor and defendant Morrison, the Patient Access Business Services Director, according to the complaint.

Plaintiff is represented by Patrick D. Angel of Portland.

Thursday, November 22, 2012

Cancer Survivor or Victim of Overdiagnosis?

It appears that over a million women who didn't have breast cancer were diagnosed with it and treated for it.

Cancer Survivor or Victim of Overdiagnosis?
New York Times
November 21, 2012

FOR decades women have been told that one of the most important things they can do to protect their health is to have regular mammograms. But over the past few years, it’s become increasingly clear that these screenings are not all they’re cracked up to be. The latest piece of evidence appears in a study in Wednesday’s New England Journal of Medicine, conducted by the oncologist Archie Bleyer and me.

The study looks at the big picture, the effect of three decades of mammography screening in the United States. After correcting for underlying trends and the use of hormone replacement therapy, we found that the introduction of screening has been associated with about 1.5 million additional women receiving a diagnosis of early stage breast cancer.

That would be a good thing if it meant that 1.5 million fewer women had gotten a diagnosis of late-stage breast cancer. Then we could say that screening had advanced the time of diagnosis and provided the opportunity of reduced mortality for 1.5 million women.

But instead, we found that there were only around 0.1 million fewer women with a diagnosis of late-stage breast cancer. This discrepancy means there was a lot of overdiagnosis: more than a million women who were told they had early stage cancer — most of whom underwent surgery, chemotherapy or radiation — for a “cancer” that was never going to make them sick. Although it’s impossible to know which women these are, that’s some pretty serious harm.

But even more damaging is what these data suggest about the benefit of screening. If it does not advance the time of diagnosis of late-stage cancer, it won’t reduce mortality. In fact, we found no change in the number of women with life-threatening metastatic breast cancer.

The harm of overdiagnosis shouldn’t come as a surprise. Six years ago, a long-term follow-up of a randomized trial showed that about one-quarter of cancers detected by screening were overdiagnosed. And this study reflected mammograms as used in the 1980s. Newer digital mammograms detect a lot more abnormalities, and the estimates of overdiagnosis have risen commensurately: now somewhere between a third and half of screen-detected cancers.

The news on the benefits of screening isn’t any better. Some of the original trials from back in the ’80s suggested that mammography reduced breast cancer mortality by as much as 25 percent. This figure became the conventional wisdom. In the last two years, however, three investigations in Europe came to a radically different conclusion: mammography has either a limited impact on breast cancer mortality (reducing it by less than 10 percent) or none at all.

Feeling depressed? Don’t be. There’s good news here, too: breast cancer mortality has fallen substantially in the United States and Europe. But it’s not about screening. It’s about treatment. Our therapies for breast cancer are simply better than they were 30 years ago.

As treatment improves, the benefit of screening diminishes. Think about it: because we can treat most patients who develop pneumonia, there’s little benefit to trying to detect pneumonia early. That’s why we don’t screen for pneumonia.

So here is what we now know: the mortality benefit of mammography is much smaller, and the harm of overdiagnosis much larger, than has been previously recognized.

But to be honest, that general message has been around for more than a decade. Why isn’t it getting more traction?

The reason is that no other medical test has been as aggressively promoted as mammograms — efforts that have gone beyond persuasion to guilt and even coercion (“I can’t be your doctor if you don’t get one”). And proponents have used the most misleading screening statistic there is: survival rates. A recent Komen foundation campaign typifies the approach: “Early detection saves lives. The five-year survival rate for breast cancer when caught early is 98 percent. When it’s not? It decreases to 23 percent.”

Survival rates always go up with early diagnosis: people who get a diagnosis earlier in life will live longer with their diagnosis, even if it doesn’t change their time of death by one iota. And diagnosing cancer in people whose “cancer” was never destined to kill them will inflate survival rates — even if the number of deaths stays exactly the same. In short, tell everyone they have cancer, and survival will skyrocket.

Screening proponents have also encouraged the public to believe two things that are patently untrue.

First, that every woman who has a cancer diagnosed by mammography has had her life saved (consider those “Mammograms save lives. I’m the proof” T-shirts for breast cancer survivors). The truth is, those survivors are much more likely to have been victims of overdiagnosis.

Second, that a woman who died from breast cancer “could have been saved” had her cancer been detected early. The truth is, a few breast cancers are destined to kill no matter what we do.

What motivates proponents to use these tactics? Largely, it’s sincere faith in the virtue of early diagnosis, the belief that screening must be good for women. And 30 years ago, when we started down this road, they may have been right. In light of what we know now, it is wrong to continue down it. Let’s offer the proponents amnesty and move forward.

What should be done? First and foremost, tell the truth: woman really do have a choice. While no one can dismiss the possibility that screening may help a tiny number of women, there’s no doubt that it leads many, many more to be treated for breast cancer unnecessarily. Women have to decide for themselves about the benefit and harms...

Tuesday, November 20, 2012

Kaiser Permanente lays off 530 Calif. workers

Kaiser Permanente lays off 530 Calif. workers
By The Associated Press
Nov. 17, 2012

LOS ANGELES — Kaiser Permanente, one of the nation's largest HMOs, has laid off 530 employees in Southern California.

The Inland Valley Daily Bulletin reports ( ) the cutbacks are spread across the company's 60,000 staff members in offices and hospitals from Kern County south to San Diego County. Doctors are not affected.

Under certain contracts, the laid-off employees who are in unions will get income and benefits for a year. Many may also get their jobs back next year, when Kaiser expects membership levels to grow, after the federal Affordable Care Act is implemented.

At least 85 positions were eliminated at the Fontana and Ontario medical centers, according to the newspaper. Exact locations of the rest of the layoffs were not available.

Monday, November 19, 2012

Anthem Blue Cross Drops Cedars-Sinai, UCLA From Health Plan

Anthem Blue Cross Drops Cedars-Sinai, UCLA From Health Plan
Bob Herman
Becker Hospital Review
September 24, 2012

Anthem Blue Cross in California is shutting out two of the largest healthcare providers in the Los Angeles area — Cedars-Sinai Medical Center and UCLA Health System — from one of its health plans because the health systems are "too expensive," according to a Los Angeles Times report.

All physicians affiliated with Cedars-Sinai and UCLA will be eliminated from Anthem's Select health plan, effective Jan. 1, which is offered to roughly 60,000 employees and dependents in Los Angeles. The city said Anthem's plan would save $7.6 million in annual premiums. It is expected that roughly 2,200 city employees and family members will lose in-network access to their physicians, according to the report.

In response to the move, the health systems said their high costs are associated with their medical research and innovative treatments that "benefit the entire community," according to the report. Cedars-Sinai and UCLA also said Anthem's maneuver will only shift costs onto those who still receive care at the facilities.

Friday, November 2, 2012

Decapitation of baby during birth by irritated doctor--part two

This case is strikingly similar to the case of Dr. Hamid Safari at Kaiser Permanente. However, in the Kaiser case, the cover-up went all the way to the top. Instead of firing the doctor who killed the babies, Kaiser fired the Chief of the OB/GYN Department for complaining about Dr. Safari! At the same time, Kaiser offered $2 million to Dr. Safari to resign.

Dr. Gilbert Kenneth Moran's lawsuit says he was fired for complaining about "Dr. X," whose negligence resulted in three deaths at Kaiser in Fresno, which is where Dr. Hamid Safari worked when his notorious misbehavior occurred.

Missouri couple sues doctors for separating baby’s head during grisly botched birth, and trying to cover it up: reports
Arteisha Betts and Travis Ammonette claim in lawsuit that their OB-GYN refused to perform a planned C-section and then detached baby's spine while trying to yank him from the birth canal.
OCTOBER 12, 2012

Arteisha Betts and Travis Ammonette, of Florissant, Mo., claimed their son, Kaden Travis Ammonette, died during birth after the delivering doctor separated his head from his neck.

A Missouri obstetrician separated a baby's head from his body during delivery and then shoved the newborn back into the mother and performed an emergency C-section to cover up the ghastly blunder, a couple claims in a lawsuit.

Arteisha Betts and Travis Ammonette, of Florissant, filed a 10-count complaint in St. Louis County Circuit Court last month claiming doctors wrongly pushed them to have a vaginal delivery, decapitated their son and then tried to cover it up, according to local Patch and Courthouse News Service.

The details of the couple's claim are horrifying.

During a February 2011 appointment, the couple claimed, Dr. Susan Moore told them their baby boy would have to be delivered by caesarian because his abdomen was too large for a normal birth, according the CNS report.

Betts went into labor on March 22, just 28 weeks into what is normally a 40-week pregnancy.

The delivering doctor at St. John's Mercy Medical Center, Dr. Gilbert Webb, refused to perform a C-section and "would only agree to deliver her baby by way of attempted trial of vaginal delivery," the complaint said, according to Patch.

Webb refused to allow them to go to a different hospital, and "Betts consented to a trial of vaginal delivery under duress and protest," the complaint said.

During the birth, the boy's head breached, but the rest of his body got stuck in the birth canal, the complaint said.

In an attempt to pull the boy loose, Webb applied traction to his head and "separated (the boy's) head from his cervical spine," the complaint said. Blood "shot out" from the newborn's neck in full view of his parents, the complaint said. Mercy Hospital in St. Louis, where Betts was brought to give birth in March 2011. The hosptial was not named in the couple's complaint. Webb then "pushed" the boy's head and body back into the birth canal and scrambled to perform a C-section, slicing into Betts before anesthesia kicked in, the complaint said.

During the procedure, Webb "surgically and completely removed" the boy's head from his body, the complaint said.

The doctor then tried to cover up the boy's wounds before handing him over to his parents — though the complaint doesn't say how he did this.

The suit, filed in late September, names Webb and Moore, along with Midwest Maternal & Fetal Medicine Services and Signature Medical Group as defendants.

The couple accused the group of wrongful death and negligence and is seeking unspecified damages...

Read more:

Asphyxia Brain Damaged Second Twin, Mom Says

Asphyxia Brain Damaged Second Twin, Mom Says
Courthouse News
November 02, 2012

SANTA ANA, Calif. (CN) - Kaiser Permanente's botched prenatal, labor, delivery and post-natal care for a pregnancy, leaving her baby brain damaged, says a newborn's mother in a complaint filed in Orange County Superior Court.

The minor plaintiff, born after his twin, who had died in utero, developed hypoxic ischemic encephalopathy, according to the complaint.

Kaiser botched "the examinations, ultrasounds, evaluations, diagnosis, care and treatment" of mother and son, her complaint says.

Kaiser also "failed to properly advise the plaintiff's mother of any possible alternative methods of diagnosis and treatment and the possible attendant risks or diagnosis or treatment thereby failing to obtain a free and informed consent," according to the complaint.

Because of his illness, the boy will need "past and future medical care, nursing care, attendant, rehabilitation, physical and occupational therapy, speech therapy, educational therapy and attendant expenses," according to the complaint. He also has lost earning capacity, and experienced severe pain and physical and emotional suffering, according to the complaint.

The woman claims in her complaint that defendants, Children's Hospital of Orange County and 10 doctors, were negligent in caring for her newborn's multiple injuries related to his hypoxic ischemic encephalopathy, including, his kidneys, his neurologic system and his heart. These defendants were negligent in failing to appropriately monitor and treat the baby's hypertension, which ultimately caused additional damage to his kidneys, heart and brain, according to the complaint.

Plaintiffs sue for medical malpractice and negligent infliction of emotional distress, and are represented by Marshall Silberberg of Irvine.