I got an interesting piece in my inbox from MedScape this morning (Who Believes That Medical Error Is the Third Leading Cause of Hospital Deaths? May 26, 2016)…
Readers may be aware of the absolute furor generated by a recent (2016) article in the British Medical Journal: Medical error-the third leading cause of death in the US.1
Using studies published since the 1999 IOM report, Makary and Daniel extrapolated annual inpatient death rates from those reports to the total number of US hospital admissions in 2013, publishing their findings in the British Medical Journal.1 They calculated that 251,454 inpatients (9.5%) die annually as a result of medical error. “If medical error was a disease,” they concluded, “it would rank as the third leading cause of death in the United States,” after heart disease and cancer.
While medical error is not a new topic, it is still a difficult one to address. Unfortunately, death certificates don’t have a checkbox for “medical error” as a cause or contributing factor in a patient’s death.
In 1999, the Institute of Medicine (IOM) published a landmark report2 on error in healthcare, concluding that medical care was responsible for 44,000-98,000 deaths annually in the United States. In the intervening years, several analyses have suggested that the IOM’s figures rather significantly underestimated the problem. Studies3-6 published after 1999 estimate that 130,000-575,000 annual inpatient deaths are attributable to medical error.
What Do We Really Mean By Medical Error?
Makary and Daniel wrote the piece, so they get to define what they meant by it:
- An unintended act (either of commission or omission)
- An act that does not achieve its intended outcome
- The failure of a planned action to be completed (an error of execution)
- The use of a wrong plan to achieve an aim (an error of planning) or
- Deviation from the process of care.
However, for this analysis, Makary and Daniel focused not on all medical error but on preventable lethal events.
To say some doctors were upset by this data is to understate things; many went absolutely ballistic and expressed their fury as irrational, aggressive and childish resistance.
Some of the objections were valid to a degree.
One of the common complaints was that the term “medical error” is misleading, because it implies “physician error.” They argue that a more appropriate term is “healthcare error,” because many different types of healthcare providers commit errors.
Several readers believe that the category of medical error should be expanded to include “patient error.” One physician wrote, “If medical error should be listed as a cause of death, then so too should patient error, or lifestyle error—namely, inhaled nicotine, overeating, sedentary living, and alcohol ingestion.”
Another doctor complained, “You will quickly learn that the main source of patient mortality is from the decisions and actions patients take that result in their own demise.”
So it’s all the patient’s fault? Doctors are guiltless?
An anesthesiologist asked, “If a patient presents with acute coronary syndrome in cardiogenic shock, immediately receives appropriate stenting, but because of the severity of the disease and limitations of current technology, the patient expires, is that considered a medical error?”
Yes! Because stenting has no lasting value. It is, factually, an error in itself, justified by shaky statistical analysis.
Relax! We have it easy these days. Or do we?
Antique French 19th Century Surgical Instrument
Amputation Set & Anesthesia Mask for sale on eBay.
Utter Nonsense
Among the (repeatable) words that were used to describe Makary and Daniel’s study findings were: “garbage,” “tripe,” “extrapolated hogwash,” and “bogus.” Still others described them as “outrageous,” “absurd,” “insulting,” and “a joke.”
An internist questioned both the credibility and the gravity of the findings, saying:
These numbers are total nonsense. It has been shown repeatedly (curiously left out of this article) that patients dying as a result of “error” are almost uniformly frail, weak patients whose life expectancies are short (ie, 6 months or less). These are not healthy individuals dropping dead from medical error. And the large majority would die from their conditions if it were not for major ongoing medical care.
It’s important to note he’s simply making this up, out of thin air. There is no evidence for what he is saying.
An oncologist criticized the study as “just another example of the endless ways to demean medical personnel. What a piece of hooey. I’ve seen plenty of people ‘saved’ from dying only to perpetuate their misery. Just walk through your local intensive care unit to witness it firsthand. The authors would have us believe that without medical errors, no deaths would occur—ever.”
So… let ‘em die, they’ll only suffer anyway? What planet was this guy born on?
Still others simply did not believe the results because they didn’t jive with personal experience. An emergency medicine physician wrote, “I have been in medicine for 45 years and have not seen this to be even remotely true.”
Are Doctors in Denial?
Although by far in the minority, some doctors believe that physicians who think this is all “hooey” are in denial about the scope of a real problem.
A pediatrician wrote:
Medical errors are hard to accurately quantify. They are hugely underreported and sometimes it’s very hard to tell whether an error caused significant harm. I do want to point out the Dunning-Kruger effect that plagues medicine in certain areas where people are practicing at the edge of their scope and not appropriately asking for guidance… [The Dunning–Kruger effect8 is a cognitive bias in which relatively unskilled persons suffer illusory superiority, mistakenly assessing their ability to be much higher than it really is].
A registered nurse was saddened reading some of the comments made about the study, saying, “Instead of asking what we can do about this problem, most are variations on exclamations of denial.” Another healthcare provider concurred, saying, “Errors and complications are frequently faced by patients, even if doctors refuse to admit it. Why do so many women die from heart attacks after being sent home from the emergency department with a proton pump inhibitor or an antianxiety medication after being seen for chest pain?”
A physician remarked about the obsession with the bottom line:
“You bring up a valid point that a lot of doctors are missing because they see this headline as a direct threat to them and their livelihood. Errors are not the fault of physicians but of systems. Human disease and top causes of death have changed from acute infections to chronic problems, but the mindset that drugs and interventions that worked so well in the past are also the solution in today’s world is wrong. It is a sign that medicine needs to change with the times.”
He’s absolutely right and I concur all the way: “Modern” medicine is so out of date, it’s turned primitive, along the lines of leeches and blood-letting! (Desperate measures with little or no rationale.)
We should be putting more emphasis on preventive medicine, holistic approaches, and physiological nutrition, because the drugs and interventions are doing nothing to stop the top killers.
Fear-Mongering & Unnecessary Panic
Some readers even attacked Medscape for DARING to report this bunk, which they said, would give ammunition to the uneducated public and personal injury lawyers.
An oncologist called the story “an irresponsible and provocative statement.” That sentiment was echoed by a cardiologist who wrote, “Another irresponsible article is going to create more panic and mistrust of the medical profession. There are no data; mere suppositions and extrapolations of extrapolations. But once you launch a figure like 200,000 deaths, it will be impossible to cancel it from public opinion.”
“Fear-mongering” and “dangerous sensationalism,” said another.
One or two even had the gall to claim this will cause “unnecessary panic.” I’m not sure in what sense they mean unnecessary panic. Or why publishing the findings should cause more panic than the fear of doctors and procedures which already exists in the mind of knowledgeable readers!
Plenty Agreed With These Findings
The real point that emerged is that not all Medscape readers considered that the findings of Makary and Daniel were invalid, and many were astonished at the dumb overreactions and comments made by their peers.
A pharmacist wrote:
It is appalling how cavalier many practitioners seem from their comments, instead of taking this deadly issue seriously. Grown men and women, with advanced medical and allied health degrees, are sniffing and discounting the reality of healthcare-induced harm when we all know it exists. Perhaps this study is not the Holy Grail, but don’t kill the messenger just because you don’t like the message.
A family physician concurred. “OK… let’s really study this. Healthcare is far from perfect. Instead of getting angry and dismissing the study, we need to take a good, hard look.”
A similar sentiment was expressed by another reader in response to the many comments from peers who dismissed the study out of hand. “One would hope that a study that exposes the high rate of medical error would generate a physician drive to investigate, confirm or deny the findings, and seek solutions. It is very disappointing to see an unwillingness to acknowledge a potentially serious problem.”
A family physician recounted some personal experiences in support of the study’s findings:
I recently sat at the bedside of friends who were hospitalized. It was a terrible, eye-opening experience. I saw equipment not working properly, arrhythmias and anoxia ignored, and delirium completely missed. I saw a large glass of juice given to a patient an hour before a surgical procedure, with the rationale that “It’s OK because the patient’s blood sugar is low.” I saw incompatible medications being given together, with the justification that “If the patient goes into [a heart attack] it’s OK; she’s in the hospital.” On and on it went. My friends are dead now. I just hope your loved ones don’t end up in the hospital so you can see for yourself just how bad it can get.
Nobody much commented on the squalor, the lack of hygiene, the lack of connectivity with patients or even simply comforting them that has made me very sad in recent years.
A family physician encourages reflection rather than fault-finding, saying: “As healthcare becomes more complex, the risk for error increases greatly. Physicians often overestimate the benefit of a treatment or test and underestimate the potential harm. This study should remind us to be better informed and more thoughtful.”
And finally, this insight came from a pathologist: “To measure the present value of the healthcare system, we would need to know the death rate from no medical care.”
Well, in a way we already know that, don’t we? Whenever doctors go on strike, the death rate drops! Seven peer reviewed studies looked at 5 strikes between 1976 and 2003. All concluded that the death rate fell or stayed the same. This is a paradox, to say the least!9
Thanks to Medscape for giving a wide airing of this “inflammatory” topic.
And remember my oft-repeated maxim: if you want to live long and stay healthy, keep away from doctors and hospitals!
References
1. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.
2. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC; National Academies Press; 1999.
3. HealthGrades. Patient safety in American hospitals. 2004. http://www.providersedge.com/ehdocs/ehr_articles/Patient_Safety_in_American_Hospitals-2004.pdf Accessed May 18, 2016.
4. Department of Health and Human Services. Adverse events in hospitals: national incidence among Medicare beneficiaries. 2010. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf Accessed May 18, 2016.
5. Classen D, Resar R, Griffin F, et al. Global “trigger tool” shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff. 2011;30:581-589.
6. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363:2124-2134.
7. McMains V. Johns Hopkins study suggests medical errors are third-leading cause of death in U.S. May 3, 2016. Johns Hopkins Magazine HUB. http://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death Accessed May 18, 2016.
8. Seidensticker B. The Dunning-Kruger effect: are the stupid too stupid to realize they’re stupid? Patheos. February 23, 2015. http://www.patheos.com/blogs/crossexamined/2015/02/the-dunning-kruger-effect-are-the-stupid-too-stupid-to-realize-theyre-stupid/ Accessed May 17, 2016.
9. Soc Sci Med. 2008 Dec;67(11):1784-8. doi: 10.1016/j.socscimed.2008.09.044. Epub 2008 Oct 10
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