[IMPROVEDX] variations in variability

Phillip Benton pgbentonmd at AOL.COM
Sun Nov 13 01:16:42 UTC 2016

Dr. Robert Bell, et al,

I am a retired orthopedic spinal surgeon after 30 years (plus 10 years as a GP before that) who attended Emory Law School while waiting for the residency I wanted. While actively practicing spinal surgery I taught Adjunct at Emory Law, including Medical Malpractice for 20+ yrs.

Since retirement I will dedicate my time (and passion) to reducing medical error. These are a few ideas, for which efforts I welcome volunteers and suggestions:

1.)  Having the resolution of each medical error lawsuit that is mediated or settled include identification of root cause(s) and a binding contract to make changes that correct systems or conduct errors to prevent/reduce recurrence of that or similar errors. To achieve this:
      A. Enlist state Commissioners of Public Health to push for specific enabling legislation by consumer-minded state legislators and governors (non-partisan).
      B. Convince the Plaintiff's Bar organizations (state and national) to encourage strongly its membership to go the extra step and include such stipulations in voluntary settlements or  meditations, and to publicize proudly that they are doing this.
      C. Prevent 'Confidentiality Clauses' that keep secret errors made and corrective measures taken, but instead create a de-identified State Medical Error Registry for such crucial data.
      D. Convince the Defense Bar organizations to cooperate in these efforts.

2.) Organize a RWJ (or other) grant funded Medical Error Study Group, with a CME Medical Error Newsletter distributed through each medical specialty's parent organization tabulating, analyzing and making evidence-based recommendations based upon all of the above data. I would ask Jim Weinstein and Sohail Mirza at Dartmouth to help lead this.

Phillip Benton, MD, JD
Atlanta, GA
pgbentonmd at aol.com

-----Original Message-----
From: robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>
Sent: Fri, Nov 11, 2016 9:32 pm
Subject: Re: [IMPROVEDX] [IMPROVEDX] variations in variability

Dear Yskert,

Thanks you so much for your erudite thinking.

When you say "So, to reduce diagnostic error, we need people to get involved in really doing something about the problem:” I agree with you whole heartedly. In my article last year entitled, Errors in Medicine: Do Something Now. I appealed for ACTION and laid out one approach. however, I feel that there are many ways to move forward. Please drop me a line if you would like a copy of the Do Something Now article.

We have been talking about moving forward for some 50 years or more and essentially nothing happens.

I appeal to the powers that be to just tell me or my family, if I am not here, when there is hard data that says that the first patient has been saved from death by a program introduced into a hospital by the efforts of this organization. And I fully acknowledge that Mark Graber and his colleagues have done more than many to bring the issues to the forefront.

But to do anything significant in a world driven by money and conflict needs some new approaches since “nothing"  has worked so far. Many people working in the Safety industry even believe that the situation is getting worse day by day.

I have suggested triaging the situation and identifying the obstacles to progress.

So let me talk aloud and suggest one or two things. Others may have better ideas. And I acknowledge that many because of conflict issues will be hindered in speaking up. 

Lets analyze the politics of the situation with the importance of the bottom line, and conflict issues being first. From here work down.

And conflict is pervasive. Right now it seems that the only non-conflicted people are those that are retired and not earning from the health industry. Could they be used more often - they have the hidden “talent" of usually being non-conflicted?!

Where are we going now with the new administration. Is there a chance for change or do we have to wait 4 to 8 years?

If there is still further stalemate, then what to do?

I was impressed With Dr. Peter Pronovost’s work in the US and how his recommendations in catheter sterility so quickly spread around the world.

Could we fund something like that and do an improve diagnosis study in the US? If not could we do the study overseas (Australia, Iceland or some other country)? It is a global issue. Would single payer healthcare countries be intersted in partenring with us?

Perhaps that is something the new Johns Hopkins Arms could  undertake.

Yskert, I believe we need to focus on the big hurdles stopping us getting to the finish line. And this means contact with the people at the top of the various health pyramids. With a break through here make the difference we need. Would studies setting best clinical practice be enough to create a wave of change globally?

Are there any litigation solutions that might work?

How to handle conflict in general. 

And on and on.


On Nov 3, 2016, at 1:14 PM, Kodolitsch von, Yskert <kodolitsch at UKE.DE> wrote:

Dear Rob,
Yes, clearly you aim primarily at avoiding diagnostic errors.
But, I am trying to promote a view that fighting diagnostic error should be embedded in a couple of issues that go far beyond the narrow description of the problem itself. 
The human cognition is always involved, but human communication, human motivation, team collaboration, labor environment, information technologies, and so on are also involved. To approach this, we need some kind of concept about how to address this system.
So, to reduce diagnostic error, we need people to get involved in really doing something about the problem:
You need to think about hospital (or other health) organizations. You need to address human behavior, not just of physicians, but also nurses, managers, transports, lab people, and so on. You need to think about leadership. Who is leader in a hospital. What do you ground leadership on. How important is it to leaders to promote patient safety, and so on. You may read the classic by Elliot Freidson, who explained in his seminal analysis of the organization of the medical profession, why the medical profession in his times (the book was published in 1970) was “structurally” unable to catch-up with its own professional ideals (see:http://press.uchicago.edu/ucp/books/book/chicago/P/bo3634980.html ). These issues are essential, I am deeply convinced.
Clearly, one can try to isolate the problem, and stick to “error” in a narrow sense. Clearly: Check-lists, IT-based solutions, supervision, checking-routines, and so on do have a definitive value. But these “narrow measures” will also not yield ground-braking results if not embedded in a commensurate organizational culture that respects the safety of patients. And again we are back to the organizational system, leadership, strategy. We do not come around a discussion of broader approaches. …
… I firmly believe … this may not be evidence-based (though Freidson indeed carried together impressive data to support this view).
You said that you thought that “making the right diagnosis was ethical within itself”. I do not think so. Making a correct diagnosis does not seem ethical as such. Only if it severs ethical purposes (which is usually but not necessarily does: The Nazi-medicine, for example, did this for criminal purposes). A correct diagnosis used as means to help a patient is ethical; striving vigorously and uncompromisingly to get to a correct diagnosis is ethical when motivated to help a patient; engaging in getting people to think about getting to better diagnostic results (like you do) is ethical, if you do this with the motivation of help patients, but it may also not be ethical in those who do it to increase their own prestige. Therefore, cultivating virtue among physicians in a hospital rather than cultivating prestige and money is important. Imagine a career-orientated physician, who only strives for avoiding diagnostic error to impress his boss rather than to help his patient. What will he do, when he is sure that sloppy work remains undiscovered by his superiors? …
We need a broader view of the problem. I insist.

Von: robert bell [mailto:rmsbell200 at yahoo.com] 
Gesendet: Mittwoch, 2. November 2016 18:40
An: Kodolitsch von, Yskert <kodolitsch at uke.de>
Betreff: Re: [IMPROVEDX] [IMPROVEDX] variations in variability

Thanks Yskert,


Not quite sure about the question. I would go with “What are the best ways to help our colleagues make less errors in diagnosis.” 


As an aside I would have thought that making the right diagnosis was ethical within itself.


Once we have clarified what we think are the best ways we can start making progress and doing something. And if  we do not get it right the first time we can change things.


And the "best ways” would include a discussion of conflicts. disclaimers, and litigation issues.


Will take a look at your link - thanks for sending.



On Nov 2, 2016, at 9:04 AM, Kodolitsch von, Yskert <kodolitsch at uke.de> wrote:


I understand your question in essence as the following: “How can we make people act in a desirable way?”

Or: How can we make people go from “is to ought” (David Hume), which may also be formulated as the question “how can we put ethical demands into medical practice?”


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