FRINK Linked Data Fragments server

Matches in SemOpenAlex for { <https://semopenalex.org/work/W2006133732> ?p ?o ?g. }

• W2006133732 endingPage "511" @default.
• W2006133732 startingPage "506" @default.
• W2006133732 abstract "Our specialty has never been more stressed than at present. Obstetrics and gynecology (Ob-Gyn) has traditionally been a specialty of immense emotional rewards tempered by very long hours and a difficult call schedule. Recently our specialty has become a battleground buffeted by the forces of consumerism and tort liability.1ACOG Red Alert, 8/26/2004.Google Scholar Unfortunately, the economics of Ob-Gyn practice reflect this situation and are also deteriorating. My practice reflects the economic reality of obstetrics and gynecology in Florida. This is graphically presented in Figures 1 and 2. Reimbursement for hysterectomy is at the same level as 1980. Total obstetric care rose from $620 to $2000 in the 10 years between 1980 and 1990 because of the malpractice crisis of the late 1980s. In the past 14 years, reimbursement for obstetric care has declined slightly to $1900. On the cost side, however, the increase in liability insurance from $8900 for $1M/3M in 1980 to $142,000 per year in 2004 is exponential but with substantial variability related to the insurance cycle. Certainly, obstetric care reimbursement lags costs by a considerable margin.Figure 2Typical reimbursement for obstetric care and TAH.View Large Image Figure ViewerDownload (PPT) As the economics of obstetric care have deteriorated, obstetricians have attempted to maintain income by reducing liability coverage.2Internal Data North Florida Women's Physicians.Google Scholar At present FPIC—by far the largest insurer in the state—insures 344 Ob-Gyn physicians and reports the following:$1M/$3M 6 policies$500/$1.5M 20 policies$250/$750 318 policies They report they cover only 1 physician in Dade County (the states most populous county that includes Miami) and 5 physicians in Broward (Fort Lauderdale and the second most populous county). Dade and Broward reached the levels of 2004 in the late 1980s and exited the insurance market at that time. The rest of Florida is now in the process of exiting the insurance market (personal communication, Mr Ellis, FPIC Insurance Co.). ACOG reports that the number of United States medical graduates entering Ob-Gyn residencies is down significantly in 2004. Further, an informal survey of some major medical school departments in Florida suggests the decrease in Florida medical school graduates going into Ob-Gyn is much more than 50%. They are quick to point out that the reasons are multifactorial with gender preference issues also important. When faced with the above, the Florida Legislature decided that no meaningful change was necessary. This decision made despite a concerted effort by a popular Republican governor and with Republicans controlling both chambers of the legislature. Significant change in our present liability system was opposed by the Trial Bar, along with the majority of major newspapers in the state and consumer groups. A subsequent Constitutional initiative produced very mixed result that will almost certainly be more negative than positive. The obstetricians of Florida have chosen to go bare rather than fight so there has been no job action or meaningful protest. Our specialty's problem is a level of maloccurrence and risk that we are presently unable to manage financially. On the one side of this equation is a steadily diminishing level of bad outcomes, but on the opposite side is a substantial rise in both the percentage of bad outcomes litigated and the awards. Mostly the potential size of the awards is the big issue as the total number of litigated occurrences has actually diminished slightly. The rapid increase in the price of liability insurance confirms that the financial balance has tipped away from us. In the short term, our only potential salvation is to accelerate the decrease in maloccurrences and make that decreasing number of maloccurrences more difficult to successfully litigate. This leads us to human performance and human error. Can we “safety” our way out of this situation. Dr James Reason3Reason J. Human error. Cambridge University Press, Cambridge1990Crossref Google Scholar wrote the definitive book on human error and I would commend it to anyone interested in this subject. Dr Reason traces the history of research into the cognitive sciences and notes that until the early 1970s most psychologists believed in “Bayes Theorem” or “Subjective Expected Utility Theory.” In 1967 Peterson and Beach4Peterson C.R. Beach L.R. Man as an intuitive statistician.Psychol Bull. 1967; 68: 29-46Crossref PubMed Scopus (550) Google Scholar stated “In general [our] results indicate that probability theory and statistics can be used as the basis for psychological models that integrate and account for human performance in a wide range of inferential tasks.” Unfortunately, subsequent research by cognitive scientists has disproved this theorem. Simon5Simon H.A. Reason in human affairs. Basil Blackwell, London1983Google Scholar in 1975 dubbed our thinking “Bounded Rationality” and stated the following: “the capacity of the human mind for formulating and solving complex problems is very small compared with the size of the problems whose solution is required for objectively rational behaviors in the real world- or even for a reasonable approximation of such objective rationality.” This leads to “satisficing behavior.” And, not only is our rationality bounded, it is also imperfect. Wason et al6Wason P.C. Johnson-Laird P.N. Psychology of reasoning: structure and content. Batsford, London1972Google Scholar in the 1960s and 1970s demonstrated in a series of experiments that a group of highly intelligent people would almost invariably get certain deductive problems wrong, and the mistakes were usually of a similar kind. Again this is not new. Sir Francis Bacon in “Idols of the Tribe” written in 1620 stated: “it is the peculiar and perpetual error of the human intellect to be more moved and excited by affirmatives than by negatives.” He went on to say: “The human understanding when it has once adopted an opinion draws all things else to support and agree with it.” This is called “confirmation bias.” Cognitive scientists have demonstrated in a number of ways that reasoning is governed more by “similarity matching” than by logic. Similarity matching can be paraphrased in the following statement: “Whenever 2 different items or classes can be matched in a 1-to-1 fashion, then the process of inference is readily made be it logical or not.”7Johnson-Laird P.N. Wason P.C. Thinking: readings in cognitive science. Cambridge University Press, Cambridge1977Google Scholar The rational physician might say “Well, that is probably true for most people but not for physicians.” Twersky and Kahneman8Tversky A. Kahneman D. Judgment under uncertainty: heurisitics and biases.Science. 1974; 185: 1124-1131Crossref PubMed Scopus (18909) Google Scholar used the interpretation of mammograms and the evaluation of breast lumps to evaluate rational or Bayesian thinking. Their conclusion: “In his evaluation of evidence man is apparently not a conservative Bayesian: he is not a Bayesian at all.” Instead they argued that man uses a few methods of discovery (heuristics). Two heuristics are most prominent: “Like cause like” and “things are judged more frequent the more easily they come to mind.” So it turns out our thinking is not completely rational but bounded and imperfect—even flawed. And, it gets worse. We are reluctantly rational as we seek to avoid “cognitive strain.” The most common imperfect but useful strategy is titled “persistence-forecasting.” Similar to bounded rationality and imperfect rationality it serves to direct our thoughts down common pathways and restricts the size of the problem-solving space. For the typical and predictable, this is a useful tool. For the unusual or different it will fail and perhaps fail spectacularly. Given the above how do we manage, for we do manage rather well? Rasmussen9Rasmussen J. Skills, rules, knowledge: signals, signs and symbols and other distinctions in human performance models. IEEE Trans: Systems, Man Cybernetics. 1983, SMC-13, 257-67.Google Scholar approached this problem from the standpoint of explaining our errors as well as our successes and his model remains the dominant one. According to Rasmussen our cognitive toolbox is composed of skills, rules, and knowledge. We apply these singly or in combination to solve the problems of our daily life as well as occupations. Skill-based and rule-based decisions are the hallmark of expertise. Errors occur quite infrequently at the skill- and rule-based level but because the vast majority of decision and actions are at that level they still account for most of the errors. Knowledge-based decisions and plans are by far the least frequent and we are far more likely to err at this level. The above led cognitive scientists to a generic error-modeling system or (GEMS). It is not my purpose nor am I able to explore this entire subject in depth but some superficial conclusions are reasonable. At the skill-based levels, omissions and slips dominate and they are usually related to interruptions, reduced intentionality, and interference. At the rule-based level (RB) there is the misapplication of good rules and the application of flawed or bad rules. At the knowledge-based level (KB), the errors can become much more varied but a few obvious examples are overconfidence, biased reviewing, out-of-sight out-of-mind, and workspace limitations. Through all of this, our limited memory workspace remains our enemy and will be a problem and source of error. A very important feature of GEMS is the prediction that when confronted with a problem, human beings are strongly biased to find a prepackaged solution at the RB level before moving to the KB level. This means we are prone to ignore inconsistent facts as we look for a rule-based solution that is close or frequent—“strong but wrong.” GEMS is based on a recurrent theme in the psychological literature, “humans, if given a choice, would prefer to act as context-specific pattern recognizers rather than attempting to calculate or optimize.”10Rouse WB. Models of human problem solving: detection, diagnosis and compensation for system failure. Proceedings of IFAC Conference on Analysis, Design and Evaluation of Man-Machine systems. Baden-Baden, FRG, September, 1981.Google Scholar Dietrich Doerner in his book “The Logic of Failure” examines more complex KB problem-solving and identified 3 particular areas where intelligent subjects had difficulty.11Dietrich D. The logic of failure. Metropolitan Books, New York1996Google Scholar They were “insufficient consideration of processes in time,” “difficulties in dealing with exponential development,” and “thinking in causal series instead of in causal nets.” Among poor performers 2 maladaptive styles were very common: thematic vagabonding and encysting. Thematic vagabonding is a flitting from one topic or area of a problem to another without sufficient time or effort being expended to resolve the problem. Encysting is well known as “paralysis by analysis,” but is more than that as the same part of a problem is turned over time and time again with only the most minimal of changes. And there is one more problem with human thinking—“hindsight bias.” Toward the end of his seminal book on Human Error Dr Reason devoted a postscript on “being wise after the event.” I believe it is worthy of repeating for emphasis. “For those who pick over the bones of other people disasters, it often seems incredible that these warning and human failures, seemingly so obvious in retrospect, should have gone unnoticed at the time. Being blessed with both uninvolvement and hindsight, it is a great temptation for retrospective observes to slip into a censorious frame of mind and to wonder at how these people could have been so blind, stupid, arrogant, ignorant, or reckless.” One purpose of this concluding section is to caution strongly against adopting such a judgmental stance. No less than the accident-producing errors themselves, the apparent clarity of retrospection springs in part from the shortcomings of human cognition. The perceptual biases and strong but wrong beliefs that make incipient disaster so hard to detect by those on the spot also make it difficult for accident analysts to be truly wise after the event. Unless we appreciate the potency of these retroactive distortions we will never truly understand the realities of the past nor learn the appropriate remedial lessons. As Baruch Fishcoff and his colleagues have shown, possession of outcome knowledge profoundly influences the way we survey past events. This phenomenon is called hindsight bias and has two aspects:(a)The knew-it-all-along effect (or creeping determinism), whereby observers of past events exaggerate what other people should have been able to anticipate in foresight. If they were involved in these events, they tend to exaggerate what they themselves actually knew in foresight.(b)Historical judges are largely unaware of the degree to which outcome knowledge influences their perception of the past. As a result they overestimate what they would have known had they not possessed this knowledge. The idea of personal responsibility is deeply rooted in western cultures. The occurrence of a man-made disaster leads inevitable to a search for human culprits. Given the ease with which the contributing human failures can subsequently be identified such scapegoats are not hard to find. But before we rush to judgement, there are some important points to be kept in mind. First most of the people involved in serious accidents are neither stupid nor reckless, though they may well have been blind to the consequences of their actions. Second, we must beware of falling prey to the fundamental attribution error (ie, blaming people and ignoring situational factors). As Perroe (1984) argued it is in the nature of complex, tightly coupled systems to suffer unforeseeable socio-technical breakdowns. Finally, before beholding the mote in his brother's eye, the retrospective observer needs to be aware of the beam of hindsight in his own.”3Reason J. Human error. Cambridge University Press, Cambridge1990Crossref Google Scholar Looking back on the above it is easy to understand why a jury trial is a “stacked deck” with strike 1 being “similarity matching” and strike 2 hindsight bias. It is also easy to understand the puzzling views of the news media and government. However, it is essential that our colleagues in Ob-Gyn are aware of these errors of human cognition. We are not truly competent unless we understand the weaknesses of human cognition, the inevitability of human error, and the distortions of hindsight. When we try to make our case to these people, we must keep this problem in mind. Instead of having systems where only the brightest can succeed and then view the rest with contempt, we need a system where the average doctor will succeed almost invariably and we support one another. Given the insurance/malpractice system, at the end of the day we will all pay for each other's mistakes and the best of us can and will fail disastrously given the right set of circumstances. In 2000 the Institutes of Medicine published, “To Err is Human.”12Institute of Medicine To err is human. NIH, Bethesda (Md)2000Google Scholar The recommendations contained in this report lay out a 4-tiered approach:•Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety;•Identifying and learning from errors through immediate and strong mandatory reporting efforts, as well as the encouragement of voluntary efforts, both with the aim of making sure the system continues to be made safer for patients;•Raising standards and expectations for improvements in safety through the actions of oversight organizations, group purchasers, and professional groups; and•Creating safety systems inside health care organizations through the implementation of safe practices at the delivery level. This level is the ultimate target of all the recommendations. Obviously, the first 3 recommendations seek to apply pressure to obtain the last behavior change. Frankly, this is a goal that we have already embraced in obstetrics. I think we can improve but the question is how much. As always, “bad doctors” muddy the water and the committee addressed this. This is the legal system's bugaboo that is so quickly embraced by the press and politicians. While recognizing that “incompetent physicians” were not the problem, the committee thought that we can and should do much better in this area. They thought that proper safety systems would permit the identification and removal of unsafe practitioners “before they harmed patients.” This is not credible as some errors are inevitable and reminds one of the quote by Ernst Mach in 1905: “Knowledge and error flow from the same mental sources. Only success can tell the one from the other.” How many errors (patients harmed) does it take before one can conclude that a practitioner is incompetent. Nonetheless, we should do a better job of limiting the injuries these people cause by identifying and dealing with them as soon as possible. Respected authorities should do a better job of avoiding unrealistic though politically correct opinions. The committee strongly encouraged the development of a culture of patient safety. They described this culture in part as: “requiring at a minimum that members of the organization believe that safety is really a priority in their organization, that reporting will really be non-punitive, and that improving patient safety requires fixing the system, not fixing blame.” In the mid 1990s my large private practice group decided to develop such a culture. I think we called it quality but we knew we had to do everything possible to manage liability risk. A group of our size is sued with some frequency. The human and organizational costs of these suits are enormous and as noted before the risk cannot be managed financially. All the physicians were in agreement and anxious to proceed. Safety thus became an explicit overriding goal. Safety has always been a goal of all our practices but an implicit one. When faced with the realization that we were “betting the practice on every delivery” our group practice did the following things. We decided to meet regularly to consider our systems of care and safety issues. This would include our office and the hospital and issues primarily effecting Physicians as well as issues primarily about the organization of care processes. We hired a Nurse Supervisor who understood explicitly that her primary duty was quality and safety. She would help develop and refine our systems of care to maximize patient safety. She would set the agenda for these meetings with the input of the physicians. She would supervise our “error recovery system.” She was the supervisor of the nurses in our office and would carry the message and systems of safe care to them. She would also be our liaison with the Hospital. The managing partner of the group would be her direct supervisor and she reported directly to him. Over the years the following has become clear to me.1.Safety is not a disciplinary function.2.Safety is a prospective and continuous function. It is a journey not a destination.3.Discipline is secondary to safety though it may be a byproduct of safety considerations.4.Discipline is a retrospective, episodic function.5.Safety thrives in an atmosphere of fellowship and good will.6.Judgmental attitudes are to be avoided.7.To err is human but more importantly inevitable. I am certain we would all tend to come up with similar lists of latent errors in our practice. We must see a large number of patients over a prolonged period with minimal rest breaks. The substantial majority of these patients are normal. There are constant interruptions with pseudo-emergencies and rarely emergencies. Prolonged hours and sleeplessness are almost certainly our most dangerous enemy. Figures 3, 4, and 5 amply document this.13Mittler M.M. Carskadon M.A. Czeisler C.A. Dement W.C. Dinges D.F. Graeber R.C. et al.Catastrophes, sleep and public policy: consensus report.Sleep. 1988; 11: 100-109PubMed Google Scholar, 14University of Virginia Center for Biological Timing. Available at http:/www.cbt.virginia.edu/tutorial/HUMANCLOCK.html. Accessed on May 24, 2005.Google Scholar We can not avoid working at night and losing sleep but we can recognize the dangers of this situation and move to mitigate the dangers. Technologic change is an issue. Human technology interface problems are increasingly recognized as a major potential source of error. Implementation of EMR will need to be carried out with great care. The transition will be dangerous. Finally, shifting paradigms or changes in practice patterns are major problems. Advances in medical knowledge lead to shifting paradigms and the misapplication of rules. Best described in the great quote by 19th century humorist Artemis Ward: “It ain't the things you don't know that get you, it's the things you think you know that ain't so.” This can lead to one-error disasters. The above are an unavoidable part of an obstetrician's life but careful thought needs to be devoted as to how these problems are mitigated. Use your office nurse, operating room nurses, and labor and delivery nurses as “error recovery” agents. In my experience, overconfidence is the error most to be feared. Very “competent” physicians are at risk here because they forego “error recovery” and are at risk for a one-error disaster.Figure 4Vehicle accident data.View Large Image Figure ViewerDownload (PPT)Figure 5Performance errors.View Large Image Figure ViewerDownload (PPT) All this said, we still must ultimately have tort reform. Although my group has done this for nearly 8 years, we have no metrics to tell us it is better. These events occur infrequently so, it is impossible to establish statistical trends. Although this is an inaccurate measure, the number of low Apgar infants remains the same at about 1 per every 200 deliveries. The anecdotes seem less frequent and severe and we have gone more “physician years” between law suits but adverse results continue to occur and the tort system being what it is, malpractice is unnecessary for a successful tort action. Ultimately, the problem is the jury system and the size of potential awards. To paraphrase “it's the awards stupid.” In the meantime we need to pursue safety as our public duty while our political system tries to remember its duty to the pregnant women of this country as opposed to the medico-legal industry. Safety should be an explicit and primary goal not an implicit one. Vigilance and focus are essential but they are not enough, Plan for safety. Simplify and standardize your practice. Adopt technology carefully and beware of paradigm shifts. Finally, be humble. “There but for the grace of God go I.”" @default.
• W2006133732 created "2016-06-24" @default.
• W2006133732 creator A5074342284 @default.
• W2006133732 date "2005-08-01" @default.
• W2006133732 modified "2023-09-25" @default.
• W2006133732 title "Presidential address: Human error, patient safety and the tort liability crisis: The perfect storm" @default.
• W2006133732 cites W1528211185 @default.
• W2006133732 cites W1698505133 @default.
• W2006133732 cites W1879307016 @default.
• W2006133732 cites W1937795883 @default.
• W2006133732 cites W1993766096 @default.
• W2006133732 cites W1994851532 @default.
• W2006133732 cites W1995950839 @default.
• W2006133732 cites W2174896420 @default.
• W2006133732 cites W3141978889 @default.
• W2006133732 doi "https://doi.org/10.1016/j.ajog.2005.03.051" @default.
• W2006133732 hasPubMedId "https://pubmed.ncbi.nlm.nih.gov/16098878" @default.
• W2006133732 hasPublicationYear "2005" @default.
• W2006133732 type Work @default.
• W2006133732 sameAs 2006133732 @default.
• W2006133732 citedByCount "6" @default.
• W2006133732 crossrefType "journal-article" @default.
• W2006133732 hasAuthorship W2006133732A5074342284 @default.
• W2006133732 hasBestOaLocation W20061337321 @default.
• W2006133732 hasConcept C105306849 @default.
• W2006133732 hasConcept C121332964 @default.
• W2006133732 hasConcept C153294291 @default.
• W2006133732 hasConcept C17744445 @default.
• W2006133732 hasConcept C197487636 @default.
• W2006133732 hasConcept C199539241 @default.
• W2006133732 hasConcept C200635333 @default.
• W2006133732 hasConcept C2777834853 @default.
• W2006133732 hasConcept C71924100 @default.
• W2006133732 hasConcept C94625758 @default.
• W2006133732 hasConceptScore W2006133732C105306849 @default.
• W2006133732 hasConceptScore W2006133732C121332964 @default.
• W2006133732 hasConceptScore W2006133732C153294291 @default.
• W2006133732 hasConceptScore W2006133732C17744445 @default.
• W2006133732 hasConceptScore W2006133732C197487636 @default.
• W2006133732 hasConceptScore W2006133732C199539241 @default.
• W2006133732 hasConceptScore W2006133732C200635333 @default.
• W2006133732 hasConceptScore W2006133732C2777834853 @default.
• W2006133732 hasConceptScore W2006133732C71924100 @default.
• W2006133732 hasConceptScore W2006133732C94625758 @default.
• W2006133732 hasIssue "2" @default.
• W2006133732 hasLocation W20061337321 @default.
• W2006133732 hasLocation W20061337322 @default.
• W2006133732 hasOpenAccess W2006133732 @default.
• W2006133732 hasPrimaryLocation W20061337321 @default.
• W2006133732 hasRelatedWork W2351968139 @default.
• W2006133732 hasRelatedWork W2353170299 @default.
• W2006133732 hasRelatedWork W2362552876 @default.
• W2006133732 hasRelatedWork W2363186901 @default.
• W2006133732 hasRelatedWork W2379688099 @default.
• W2006133732 hasRelatedWork W2383064164 @default.
• W2006133732 hasRelatedWork W2998552475 @default.
• W2006133732 hasRelatedWork W382946487 @default.
• W2006133732 hasRelatedWork W4250615360 @default.
• W2006133732 hasRelatedWork W570342859 @default.
• W2006133732 hasVolume "193" @default.
• W2006133732 isParatext "false" @default.
• W2006133732 isRetracted "false" @default.
• W2006133732 magId "2006133732" @default.
• W2006133732 workType "article" @default.