Since 1999, when a national panel of experts released a landmark report on the high number of medical errors, insurers, policy makers and regulatory groups have been piling onto the quality-improvement wagon with ever increasing gusto. As a result of their enthusiastic efforts, hospital accreditation procedures and standards have become more rigorous, physician duty hours have been trimmed, hand-sanitizing gel dispensers in hospitals have multiplied and physician reimbursement has been linked increasingly with quality goals and less with the number of CT scans ordered.

But few of these quality enthusiasts are actually caring for patients. And when a study in The New England Journal of Medicine last fall reported that despite all the efforts and new financial incentives, there was no significant decrease in patient injuries, these same enthusiasts were quick to point to the inertia and intractable attitudes of the medical “culture.” They noted that less than 2 percent of hospitals had installed comprehensive electronic medical records systems, doctors and nurses were routinely working in excess of limits on duty hours and few were paying attention to even simple hand-washing recommendations. It would take nothing short of an all-out legislative, financial and regulatory assault to change the system, many of them concluded.

But what these “experts” failed to take into account was the same thing that has led to the downfall of countless other groups’ efforts to create sustainable change: They ignored the contributions of the people within the system.

There have been a handful of grassroots endeavors, but most have focused on specific clinical dilemmas. Now that may be changing. Last week, nearly 1,000 surgeons, nurses and hospital administrators from across the country convened in Boston to discuss what is quickly becoming one of the most far-reaching of such efforts, the National Surgical Quality Improvement Program from the American College of Surgeons, the largest professional organization of surgeons. With the average American undergoing nine operations in his or her lifetime, the implications of a program that can improve how patients do after surgery are enormous.

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For almost three generations, debt has been a nearly inescapable part of becoming a doctor. Over 80 percent of each medical student class will graduate in debt; and while that percentage has remained unchanged for 25 years, the increase in the total amount owed has leapfrogged over all other economic reality checks, like inflation and the consumer price index. According to the Association of American Medical Colleges, which has been trying to address the problem for nearly a decade, young doctors who graduated from medicalschool last year had an average debt of $158,000, or $2.3 billion for the group as a whole. Almost a third of students owed more than $200,000, a number that will only increase with the addition of interest over payback periods of 25 to 30 years.

The skyrocketing costs are primarily due to the expansion and increasing complexity of universities and academic medical centers, and to the trend among university administrators to use tuition to support institutional projects that may be only indirectly linked to medical student education.

But while upgraded clinical facilities and spectacular research programs are obvious reasons, another key factor has gone largely unnoticed. It is our society’s assumption that individual indebtedness is required to obtain big-ticket items, whether they are cars, houses or higher education.

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Instead of letting precious time tick away as patients fill out forms and scramble around for health insurance cards, a New York City hospital is speeding up patient identification through palm reading – not the fortune-telling kind, but the type that uses a scanner to trace the unique web of veins in individual palms.

Administrators at New York University's Langone Medical Center hope that the new technology will make patient check-ins more efficient, as well as eliminate the hospital errors, some of them due to misidentification, that cause up to 98,000 deaths annually in the United States.

“The primary reason we actually got into this was patient safety,” the Center's vice dean and chief of hospital operations Bernard Bimbaum told Reuters on Wednesday. “The benefits so greatly outweighed the disadvantages it was a no-brainer to implement.”

One benefit -- patients do not need to be conscious when they are admitted to the hospital, which can speed patients emergency room patients receive urgent care. The scanners, made by technology services company Fujitsu, take a picture of an individual's palm veins using near-infrared waves. 

The process requires that patients have already included a palm scan in their medical records, and because we each have unique palm-vein configurations, software can then match these pictures with our records. For security, the palm scans are stored as numeric codes rather than as images. All of this takes only a minute to set up for new patients, with subsequent scans taking only a second.

“We can then just ask one question: Has your insurance changed?” Bimbaum told Reuters. “If ‘no,' you don't have to fill out a single form.”

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Rudeness and incivility among doctors, in particular in the operating room, can actually lead to poorer health outcomes and even higher death rates among patients.

Dr. Andrew Klein, director of comprehensive transplant center at Cedars Sinai in Los Angeles, and his colleague Pier Forni, founder of the Johns Hopkins Civility Project at Johns Hopkins University, collected data on previous studies of surgeons' behavior in the operating room and the subsequent outcomes of the patients on whom they performed procedures. They found that when doctors were more courteous to operating room staff, their patients were more likely to survive and avoid complications than the patients of docs who were O.R. boors.

And the legacy of incivility didn't stop in the operating arena. In studies of medication orders at hospital pharmacies, the researchers found that 75% of pharmacists and nurses prefer not to confront difficult physicians to ask about potential medication interactions or errors in the prescription. If a doctor who may be making a prescribing mistake goes unchallenged, patients may wind up getting the wrong type or amount of drug — with potentially disastrous consequences.

But it's the O.R. where manners are worst, and two particular features of the setting conspire to up the obnoxiousness ante. One is the stress of having a patient's life hang in the balance with every decision, and two, the anonymity of the surgical attire. “Everyone is wearing gowns, gloves, and masks, and it's a terrific camouflage,” says Klein, who as a surgeon admits to falling into the incivility trap. “Often you don't know the people you are working with, and you don't know their names. So if you ask for a clamp and what you get is a clip, the response in many cases is to throw the thing on the floor, maybe with an expletive, and say ‘I said clamp, not clip.' However, if you knew the person who had handed you the clip, or knew something about his or her family, you wouldn't act the same way.”

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New York State’s prestigious teaching hospitals could lose more than $1 billion a year as part of plans under negotiation in Washington to reduce the federal deficit that the hospitals say will lead to drastic service reductions.

The cuts would reduce the Medicare subsidy for training doctors and for providing intensive medical services like trauma centers and burn units and sophisticated equipment that the teaching hospitals offer. The plan would apply to teaching hospitals nationwide but would have its most profound impact in cities like New York and Boston, where medical schools and their affiliated hospitals have a significant presence.

Dating to the 1960s, the subsidy has helped make New York State the world capital of medical education, training about 16,000 doctors a year, or 14.5 percent of the nation’s total, more than any other state.

The benefits have been criticized for years by both conservatives and liberals who see them as a sweetheart deal for teaching hospitals in a few states. But now, with the pressure on the federal budget, they are being seriously considered in talks among the Obama administration and leaders of both parties in Congress.

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You can't control when health emergencies occur, but if you had to go to the hospital, you'd probably be better off avoiding the summer months.

At least that's been the conventional wisdom among doctors, who know that the most experienced medical residents graduate and leave hospitals in July, just as newly minted M.D.s (i.e., last year's medical students) arrive to start caring for their first patients. Now a new study confirms the trend, taking the first comprehensive look at death rates and complications occurring in hospitals throughout the year.

Reporting in the Annals of Internal Medicine, Dr. John Young of the University of California, San Francisco, and his team show that at teaching hospitals responsible for training new doctors, patient death rates increase while efficiency in patient care decreases during the month of July. In these hospitals, admitted patients serve as case studies used to educate future physicians on the best way to provide care; medical residents spend anywhere from three to six years as doctors-in-training, shadowing more experienced physicians as they learn how to diagnose and treat patients.

Young's study, which reviewed data from 39 previous studies that tracked health outcomes such as death and complications from medical procedures, found that death rates increased between 8% and 34% in July. That may be a wide range, but it's the result of the first study to focus specifically on better-quality trials; the studies included in Young's analysis controlled for other factors that may affect health outcomes, such as how sick patient populations were overall at the beginning of the studies.

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