Hell is Paved With Good Intentions

Human test subjects from the Tuskegee Syphilis...
Image via Wikipedia

Recently I worked in an occupational health setting, at a clinic for employees of a call-center: a warehouse of a building filled with rows of Dilbert-like low cubicles with people on telephones, fielding customer complaints. Women workers would come in to clinic with bladder infections from not wanting to take bathroom breaks. They have to clock out for bathroom breaks and they get penalty points if they take too many bathroom breaks during one shift. Too many points and they get fired. Taking a diuretic for high blood pressure, or being pregnant, can be bad for job security at this site. Not surprisingly, stress-related health problems like headaches, heart palpitations, and depression are commonly diagnosed at this employee clinic. The purpose of work-site clinics such as this one is to maximize the bottom line for the company—keep workers as healthy as possible, and then fire them when they aren’t healthy anymore. The clinic is also designed to reduce the overall health care cost to the company. The irony, of course, is that many of the employees say they have to keep their jobs to keep their health benefits so that they can get health care for job-induced health problems. These are all issues not unique to this particular company.

This is much different work for me than all the clinical work I’ve done within the health care safety net. Although there are overlaps. For one thing, many of my homeless young adult patients worked for call centers like this when they were transitioning out of homelessness. These are the sorts of low-wage, low-skill, entry-level jobs available to people without a college degree, without work experience. Working at the call center has increased my understanding of what my homeless young adult patients meant when they spoke about such work: it’s a job, it pays the bills, but it’s depressing work because almost everyone is angry at you on the phone and you have to be nice to them or you’ll get fired. It has given me a new appreciation for how stressful it can be for all of those anonymous help desk people I have to deal with at times.

Ours is the only country in the world to primarily tie health care to work. Blame Rosie the Riveter. Employer-sponsored health care started in our country during WWII, when the scarcity of workers, combined with a national wage freeze, made the benefit package—including health care—a way for companies to attract and retain employees. It continued even after the war—and wage freezes—ended. People came to expect it.

What started off as a good idea has turned into a bad one. Employer-sponsored health care drags down our national economy. It does this by limiting entrepreneurship—people are less likely to strike out on their own to start a small business if they can’t afford health insurance in the private market. It is also a drain on the national economy since we have more disgruntled—and therefore less efficient—workers staying in jobs they hate just to keep their health benefits. It contributes to the fracturing of the US health care system due to multiple health insurance companies vying for business with companies offering health plans—and drives up overall health care costs through increased insurance company administrative costs. Some of these problems are addressed in the Affordable Care Act, but since our health care system is a highly complex adaptive system, powerful interest groups such as insurance companies have already plotted ways to circumvent these changes and continue making huge profits.

To use another famous quote from George Bernard Shaw’s “Maxims for Revolutionists”: “Hell is paved with good intentions, not bad ones.” I am always wary of occupational health programs due to the complex ethical issues involved: role conflict, invasion of privacy, and paternalism/coercion related to health promotion activities. I also remember that the notorious Tuskegee Syphilis Study had its roots in an otherwise well-meaning occupational health program. It began in 1932 in Macon County, Alabama, still one of the poorest counties in the US. Funded by a Northern philanthropist family and operated through a local Agricultural Extension program, it provided comprehensive mobile health care—including screening and treatment for syphilis (commonly called ‘bad blood’)—to poor black farm workers. These men had access to very little health care. Well-planned and well intentioned, the occupational health program was a success until the Great Depression forced a major scale-back of the program.

The rest of this is perhaps a familiar story, but one worth repeating. The US Public Health Service, and subsequently the CDC, stepped in to take over the program, under the guise of a treatment and research project for syphilis. The doctors told the study participants, all poor and mostly illiterate black men, that they were receiving first-rate medical care—including treatment for bad blood—for free. Eunice Rivers, a black public health nurse from the area, helped recruit and retain participants. She did community-based outreach to black churches and schools. At her suggestion, the researchers offered the men free burial. This was highly valued since the greatest disgrace was to die so poor you couldn’t get a proper burial. The men were deceived and received no treatment for syphilis, even though penicillin was available as an easy cure. The study continued until 1972, when a San Francisco-based journalist—tipped off by an internal CDC whistleblower—persevered to bring the public’s attention to the awful facts of the study. Some of the white male doctors and researchers involved still see nothing unethical in what they did. Eunice Rivers needed a job and she sincerely thought she was providing good nursing care to “her men.”

“The hallmark of the Tuskegee Study, and a key to its 40 year life, was its culturally-sensitive, community-based approach,” wrote Stephen Thomas in his article “The Legacy of Tuskegee: AIDs and African-Americans” (Jan/Feb 2000, Body Positive Magazine.) This is a good reminder of how good intentions—and good approaches to health care—can go to hell.

I feel uneasy about working in an occupational health setting, and I doubt I’ll return to work at that employee clinic. I didn’t feel right patching the workers up to return to their high-stress, low-paying jobs, sitting in the endless rows of cubicles under flickering fluorescent lights. But this means that I am rapidly running out of morally acceptable (to me) places to work within the US health care system. Perhaps next I will try jail health.

To Err is Human: Medical Errors and the Consequences for Nurses

The Neonatal Intensive Care Unit.
Image via Wikipedia

That medical care can be harmful to your health or even deadly, is not necessarily news to many people. The extent of it within the US health care system and the impact of it on health care providers are not well known. The IOM Report To Err Is Human: Building a Safer Health System (2000) highlighted serious patient safety issues in our health care system and outlines approaches to patient safety improvement. This report emphasized that the vast majority of adverse patient events were the direct result of bad systems and not of bad health care providers. “The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system.” They pointed to the aviation industry as a model for safety design at the systems level. Root cause analysis was applied to understand and try to prevent adverse events. “Never events” were identified as sentinel patient safety events for monitoring purposes in hospitals (these include surgical removal of the wrong body part and inpatient suicides). National level patient safety monitoring databases were developed. Eleven years later where are we in terms of progress on patient safety?

In the April edition of the journal Health Affairs, indications are that we have not improved much and may actually have worsened. A study by Classen, et al reveals that serious preventable adverse events occur in one out of every three hospital admissions. Another study estimates a $17.1 billion annual cost of measurable medical errors in the US.  They point out that the risk of harmful errors in health care in the US is increasing due to the increasing complexity of care and of medical devices and medications. What to do about this? The Agency for Healthcare Research and Quality is putting an emphasis on educating patients on ways to advocate for their own patient safety (or parents of pediatric patients). But as Donald Berwick points out in the April 15th Health Affairs Health Policy Brief on improving quality and safety, “Commercial air travel didn’t get safer by exhorting pilots to please not crash. It got safer by designing planes and air travel systems that support pilots and others to succeed in a very, very complex environment. We can do that in healthcare, too.”

I have been thinking about the issue of patient safety and the consequences for nurses because of the recent news of the suicide of a respected local RN, Kimberly Hiatt. She died April 3rd at the age of 50. She had worked as a NICU nurse at Seattle Children’s Hospital for almost the past thirty years. I did not know her personally, but by all accounts she was a devoted and highly capable and compassionate nurse. In fact, Megan Moreno, a pediatrician who did her fellowship at Seattle Children’s Hospital and whose daughter Fiona died in the NICU of congenital health problems describes Kimberly Hiatt in an article published in the Archives of Pediatric and Adolescent Medicine (January 2006). She writes, “Our favorite nurse was assigned to us the next day, and she helped us through the difficult task of extubating Fiona.” At the end of the article she expresses particular gratitude to Kim Hiatt, RN, along with her neonatologist.

Kimberly Hiatt committed suicide because of a cascade of adverse events that happened to her in the aftermath of a medication error that resulted in an infant’s death in the NICU at Children’s. This happened in September, 2010 just months after a highly publicized death of a 15 year old autistic boy after routine dental surgery at Children’s, which resulted from an incorrect dose of a Fentanyl patch (a powerful narcotic) prescribed by the dentist. Children’s Hospital changed its policies on the prescribing of narcotics after this incident, but the dentist was not disciplined. Around the same time, an ER doctor at Children’s incorrectly administered a drug to a critically ill patient by IV instead of by an injection in the muscle, and the patient had to be transferred to another hospital because of the complications. The physician was not disciplined.

In contrast, Kimberly Hiatt was fired soon after the infant’s death. Also soon after the infant’s death, Children’s Hospital changed its policies to require stricter control and checks on the administration of the specific medication, calcium chloride, which is considered an especially dangerous drug  in medically fragile infants.  Dr. Hanson, the Medical Director of Children’s Hospital said that it was important that all staff feel safe to report mistakes. The Washington State Nursing Commission put restrictions on her nursing license with a four-year probationary period; with these restrictions no one would hire her to work as a nurse. According to a Seattle Times article (4-20-11), many hundreds of former patients and their family members, as well as nursing colleagues attended her funeral. In the Seattle Times Editorial and Opinion pages today, F. Norman Hamilton, a retired anesthesiologist writes, “The fact that the hospital changed its policies after the death implies that they realized that its policies were inadequate. Despite this, the hospital decided to fire the nurse for an arithmetic error. (…) If we fire every person in medicine who makes an error, we will soon have no providers. (…) It is my belief that if the nurse had been dealt with appropriately—with compassion and insight—that she, today, would be a valuable and happy nurse.”

So I am left with many questions. Why was the nurse treated so differently from the   dentist or physician at the same hospital for similarly serious medication errors? If one in three hospital patients in the US experiences serious preventable adverse events and we know that it’s “the system, stupid,” why are most of our efforts put into educating patients to advocate for safer care? If nurses are simultaneously being told by hospital administrators to report errors and then facing serious retribution for making honest unintentional mistakes—and usually due to unsafe staffing levels they have no control over—what do I teach my students to do? If the suicide of a hospital patient is considered a sentinel “never event,” shouldn’t the suicide of a nurse such as Kimberly Hiatt due to systems errors be considered a “never event?”