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President Obama wants to change the U.S. health care system, with the government taking the lead role. Some have used the Veteran's Administration (V.A.) as an example of a successfully run government health care operation. Yet, there are signs that the V.A. may not be the best model for public health, especially where highly specialized treatments, and supervision are indicated.
According to The New York Times, a V.A. cancer unit allegedly committed malpractice on a regular basis when dealing with prostate cancer patients. The government was aware of the problem, yet the physician committing the errors continued to practice and the evidence of his negligence was ignored. At the center of the controversy was the fact that the doctor "changed" his surgical plan after the complication occurred, a practice that in the eyes of the V.A. made the complication not existent.
It is this kind of loophole that makes the phrase "close enough for government work" frightening.
At the Philadelphia V.A. Hospital, one physician, Dr. Gary Kao incorrectly implanted radiation seeds aimed at treating cancer in 92 of 116 cases over several years, according to The Times. Patients often suffered life altering side effects, such as loss of bladder and bowel control as a consequence. Yet, even after he was investigated "Dr. Kao, with (the government's) consent, made his mistake all but disappear."
According to The Times: "Had the government responded more aggressively, it might have uncovered a rogue cancer unit at the hospital, one that operated with virtually no outside scrutiny and botched 92 of 116 cancer treatments over a span of more than six years — and then kept quiet about it, according to interviews with investigators, government officials and public records." In fact "The team continued implants for a year even though the equipment that measured whether patients received the proper radiation dose was broken. The radiation safety committee at the Veterans Affairs hospital knew of this problem but took no action, records show."
Indeed, as the Times succinctly reports: "The 92 implant errors resulted from a systemwide failure in which none of the safeguards that were supposed to protect veterans from poor medical care worked." The Times further notes that "a staple of every good hospital, in which colleagues examine one another’s work, did not exist in the unit. The V.A.’s radiation safety program; the Nuclear Regulatory Commission, which regulates the use of all nuclear materials; and the Joint Commission, a group that accredited the hospital, all failed to intervene; either their inspections had been limited or they had not acted decisively upon finding problems."
Dr. Kao was contracted from the University of Pennsylvania and "had a medical degree from Johns Hopkins and a Ph.D. from Penn. He is also on a team from Penn that won a contract this year from a NASA-financed consortium to study radiation in space." Dr. Kao was trained in radiation oncology, but had little experience in brachytherapy, the implantation of small metal seeds into the prostate to deliver the treatment. Yet, as the Times points out, "the unit had no peer review," which means that no one was supervising Dr. Kao, or reviewing his results, good or bad. According to The Times, the V.A.'s view was that because Dr. Kao came from Penn, it qualified him as an "expert," thus not requiring stringent review and observation of his techniques or his results.
And the problems started early. According to The Times: "On Feb. 3, Dr. Kao mistakenly implanted more than half the seeds in a patient’s bladder. With the patient still under anesthesia, a urologist had to thread a small tube through the man’s penis to retrieve the 40 errant seeds. Because they were bloody and contaminated with urine, the seeds could not be reused, and no more were available."
The problems were discovered after a clerical error, where the wrong strength of seeds were ordered led to an audit of the program. As the auditors reviewed records, they found more and more evidence suggesting that the program was flawed.
Dr. Kao's lawyer called the report "false." Dr. Kao continues to do research at Penn, but "voluntarily" gave up his clinical privileges. The V.A. brachytherapy program in Philadelphia is no longer operating. Other similar programs have also been stopped, although no evidence of wrongdoing has been linked them, according to The Times.
Conclusion
Dr. Kao's tale is of concern on many levels. To be sure, he is innocent until proven guilty. And one New York Times article is not a conviction or proof of negligence.
Yet, the article points to yet another potential set of bad outcomes from lax controls at government run facilities, where lack of attention to detail, and a general lack of supervision can lead to bad outcomes.
And yest, there are plenty of people in government who do an honest day's work. A perfect example are those who finally audited the program and took the proper actions to shut it down.
Yet, waste, fraud, and a general disdain for public safety are clear in this situation, if it is proven to be true in a court of law or malpractice. You have to wonder what caused the difference in outcomes from Dr. Kao's work at Penn, and his allegedly dismal record at the V.A. Was it faulty equipment at the V.A.? Was it that Dr. Kao had more supervision at Penn?
Was it patient selection? Or was it just bad luck?
It really doesn't matter, though, if you're one of the patients who had a bad outcome.
What's our point? Health care is not something for bureaucrats to run. It's a Chaotic entity which is full of risk and which cannot be pigeon holed into artificially constructed classifications and categories created just for bean counting. It requires a thorough review process at multiple levels, which is evident in most private hospitals, where the fear of being sued, along with professional pride guides most physicians to do the right thing.
Health care is about constant vigilance, regardless of the "expert" status of practitioners. It's about performing procedures only when they are clearly indicated, and when the equipment and drugs needed are both available, in the correct dosages, calibrations, and in their full operating capacity.
And it requires the ethical commitment of all involved, which seems to have been sorely lacking in this case.
Much remains to be discovered about this alleged case of malpractice. But it does offer a window into what goes wrong when the system loses the ability to police itself because of the "expert" status of its practitioners.
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