Tuesday, October 12, 2010

The Ant and the Grasshopper

So are you an ant or a grasshopper? It seems an odd question, but when you talk about the housing crisis and its governmental solutions, homeowners are clearly divided into ants and grasshoppers. And if you’ve been reading my articles, you know that I root for the ants.

Aesop’s fable, “The Ant and the Grasshopper” is well known. It goes something like this. There is a grasshopper that spends the warm months singing and dancing with the ant works diligently to store up food for the winter. When the cold winter finally arrives, the grasshopper finds itself dying of hunger. The grasshopper goes to the ant to beg for food, but is rebuked. While there is little variation of the story, the ending has many variations. Some end with the grasshopper starving to death, others with the ant offering help, and some leave the ending ambiguous. The moral of the story remains the same, which, if you could not guess, is idleness brings want.

The fable offers a fairly good allegory for the housing crisis. You begin with homeowners. At this point you should know if each homeowner is an ant or a grasshopper based on the amount he has borrowed and his ability to keep up with payments. But as this is the mortgage crisis, both the lenders and lendees were either ignorant of the fact or disregarded that fact. And so over the warm months, or the growth period of the housing bubble, you had homeowners that dutifully salted away money to build equity in their home. You also had homeowners who believed their home values could only increase and make up for impending ballooning payments in the future. So you have the ants and the grasshoppers, respectively.

Then the housing bubble burst, and home values plummeted. The majority of home values went underwater, with values less than the mortgage owed. This was complicated by the banking crisis as well, and homeowners saw their retirement savings plummet as well. Many people lost their jobs. Suddenly there was a population of homeowners that could not make their mortgage payments. And while many of these instances resulted from unfortunate circumstances such as unemployment, the majority of defaults resulted from homeowners simply taking mortgages too large for their financial situation. The remainder of homeowners also suffered from loss of home value and even underwater mortgages, but were still able to keep up with their mortgage payments.

So now here we are in the dead of winter. You have homeowners that were responsible enough to take on mortgages they could handle, and homeowners that cannot keep up with their payments because they wanted a bigger house than they could afford. How will this story end? Well, it ends with the ant being forced to help the grasshopper. The government has set up programs to help defaulted homeowners keep their homes by magically reducing their interest rates. In essence, banks are coerced to refinance, in one form or another, defaulted mortgages to give the miscreant homeowners lower mortgage payments. All the while, homeowners that are keeping up with their underwater mortgages are eligible for nothing. They must maintain their current interest rate, unless they have enough equity or cash to refinance. And on top of that, their taxes are used to help the defaulted homeowners refinance.

So much for the moral of the story. For me there is only minimal comfort in knowing that a swarm of ants could take apart a grasshopper as it stands there in under a minute.

Monday, October 4, 2010

Medical Errors

To err is human, but to forgive is divine. That is the common Alexander Pope saying. It essentially means that it should not be surprising if you screw up, but expect to be crucified if you do. This is no more true than in medicine. Medical errors accounted for about 195,000 deaths a year nationwide in 2002. That number seems to be holding steady even in recent years. There are numerous ways in which a medical error may result or contribute to a patient’s death, including incorrect medication selection and dosing, incorrect surgical site and retained surgical instruments, missed medications, and errors or complications during procedures. Now 190,000 is not a tremendous number when you consider the number of people who pass through hospitals each year, including admissions, ER visits, same day surgery procedures, and infusion room visits. But who wants to be one of the 190,000?

So every year someone comes up with another bright idea to eradicate the medical error problem. It would seem logical that you should have a hospital that has no medical errors, right? So you simply have to remove all the factors that make errors more likely to occur.

First were the abbreviations. Since there is a lot of Latin in medicine, many dosing frequencies are abbreviated using the Latin instruction—“qd” for daily, “qod” for every other day, “ or “qid” for four times a day. Also, non Latin abbreviations, such as, “u” for units, “MSO4” for morphine sulfate, “MgSO4” for magnesium sulfate, and so on. There were also issues with numbers and where the decimal point and places after the decimal point were concerned, such as, “.1” instead of “0.1”, or “1.0” instead of “1”. You can see how each of these instances could result in a medication error. So they were done away with, and everything had to be written out. There was little aftermath from this change because the electronic medical record and computerized physician order entry came later, and described below.

Second was the fatigue factor. Researchers took volunteer subjects and kept them awake for thirty plus hours and then asked them questions to see how many they would get incorrect. When compared to subjects that were not sleep deprived, the sleep deprived subject made more mistakes. So it then had to follow that if you had a resident on call, he or she would have been up that morning, up that night, and up the next morning until at least 5pm. The propensity for medical errors should be enormous. So the edict was sent out that no resident on call should work no more than 80 hours a week, *and* no shift should exceed 30 hours, *and* there should be 10 hours off between shifts. And while it was state that this would be a voluntary recommendation, no program would be allowed to remain accredited unless it complied.

There are, however, some things to take into account. Since work hour limitations have been implemented, there has yet to be shown a clear decrease in hospital mortality rates. The other issue that will be difficult to determine is that if you reduce a medical trainee’s work hours, you reduce his or her exposure to the medical field. Without an increase in duration of training, you will be left with more undertrained physicians over time. This coupled with the fact that patients are sicker and carry more medical comordities these days results in a precarious healthcare scenario.

Third it was the handwritten medical record. It used to be that everything was written—notes, prescriptions, orders, medication records. But with the classic joke of a doctor’s poor penmanship, this was an easy target. The medication records were the first to be digitized for the pharmacists and nurses. Then physician orders were digitized. Now the remainder of the medical record is set to be digitized. The only problem with the electronic medical record (EMR), is that there is no standard. As a result, innumerable software companies have developed their own EMR system to hawk to healthcare facilities everywhere. None of the EMRs are compatible with each other, so in order to import information from one system to another you end up with a PDF file of the printout from the other EMR. So while some errors from poor penmanship are avoided, you now are left with lost information that may otherwise impact care.

Fourth, the Centers for Medicare and Medicaid Services (CMMS) require hospitals to report medical errors. These reports are reviewed and compensation is linked to the error rate of a hospital. Not a bad idea, right? What is not advertised is that CMMS *expects* a minimum error rate, and if the hospital is below that rate CMMS assumes there is underreporting. Of course, it could not be because the hospital actually has a lower rate of medical error. The hypocrisy of Medicare continues. And the fact that there is a minimum error rate tells you that it is there only to look for potential underreporters of medical errors.

So to summarize, medical errors account for about 200,000 deaths a year, and costs about $8 billion a year. Look at the time and money we have thrown into medical errors, with legislation, lawsuits, and wasted money on nonstandard software. On the other hand, tobacco use results in 440,000 deaths a year and costs about $97 billion a year.

But then again, smokers make up 21% of eligible voters, and physicians only 0.1% of eligible voters. And do not think I will not make a Venn diagram to account for physicians that smoke, because I will.