Never-Never Land

December 14, 2009
Alan Berkenwald, MD

In 1904, the Scottish author Sir James Matthew Barrie sent Peter Pan off to Never-Never Land to escape growing up and to enjoy many-many adventures. As children, we all hoped it really existed. In truth, many of us fantasized, one day, to make the trip ourselves. Well, good news for physicians - that day has arrived!

...He intends only his own gain, and he is in this, as in many other cases,

led by an invisible hand to promote an end which was no part of his intention...

--Adam Smith, Wealth of Nations, 1776

Do you believe in fairies?...

If you believe, clap your hands!

--Peter Pan (1904)

In 1904, the Scottish author Sir James Matthew Barrie sent Peter Pan off to Never-Never Land to escape growing up and to enjoy many-many adventures. As children, we all hoped it really existed. In truth, many of us fantasized, one day, to make the trip ourselves. Well, good news for physicians - that day has arrived!

The Centers for Medicare and Medicaid Services, in a noble effort to improve patient safety - and reduce expenses - has outlawed the occurrence of hospital based 'never events,' which are defined as preventable illnesses or complications that occur in hospitals. Thus, with a stroke of the legislative pen, patients will no longer suffer falls, catheter associated UTI's, surgical site infections, DVTs or pulmonary embolism among other things. Should such an event occur there will be repercussions, so far limited to denying reimbursements for these events, and some elements of data collection and full disclosure on patient 'safety'.

In economics, this is called the "Rotten Apple Theory" - nothing is wrong with the system, it's just a handful of rotten apple physicians that prevents our having an affordable health care system. If we find those bad physicians and punish them, all our health care system's problems will go away. (For example, once we stop paying them, surgeons will stop amputating wrong legs.)

Thus, we have arrived at 'Never-Never Land.' And not a moment too soon. Forget statistics, forget the natural course of a disease, forget all about complications that do occur despite our best efforts. Henceforth, at institutions great and small, from Man's Greatest Hospital to the smallest community clinic, there will be no pulmonary embolisms or post op infections, no uncontrolled diabetes, no 'never events'.

Why didn't we think of this sooner?

These complications, and more, will soon go the way of Small Pox, another disease that disappeared. (I suppose it, too, was legislated away - but I need to fact check that.) Now, Medicare will use Adam Smith's invisible hand and the power of economic self interest to improve healthcare safety.

This presupposes physicians and hospitals are only in it for the money. Adam Smith proved long ago that altering compensation alters behavior. However, I guess I missed the study that proved paying physicians less decreased errors and misjudgments. Since cutting Wall Street salaries is now the cure for banking malfeasance, I guess cutting physician and hospital reimbursements will do the same.

The writer Sholom Aleichem, at the close of the 19th century, told humorous stories of the Wise Men of Chelm, the elder leaders of a small village in the Pale of Russia. As one holiday approached there was no sour cream for the traditional Blintzes (fried cheese pastries). So, the Wise Men of Chelm decreed that henceforth, all well water would be called sour cream, and all sour cream would be called well water. And so, the holiday was saved.

In Never-Never Land physicians will not make mistakes, our health care system will not run a deficit, and I can fly.

"So let it be written; So let it be done."

--Yule Brynner, as Pharaoh, in The Ten Commandments