An op-ed by Sanjay Gupta, MD, the Atlanta neurosurgeon and
CNN medical correspondent, appeared in the New
York Times on August 1, 2012. “More
treatment, more mistakes” makes the case that medical errors are common and
that they are largely due to the pressure to “do more”, to do more tests, to do
more x-rays, to do more surgery. This is not news in itself; the Institute of
Medicine (IOM) of the National Academy of Sciences published its study “To
Err is Human” in September 1999, observing that between 44,000 and 98,000
deaths occurred per year as a result of medical errors (full text available at http://www.nap.edu/openbook.php?isbn=0309068371).
To Err is Human itself was not the beginning of the
study of medical errors. It uses a taxonomy dividing errors into “Diagnostic”,
“Treatment”, “Preventive” and “Other”, published 6 years earlier in a study by Lucian
Leape, et al., in the Quality Review
Bulletin.[1]
To Err is Human detailed the variety of types of medical errors that
could occur, the relative frequency with which they occurred, and the reasons
why they occurred, and provided suggestions as to how to prevent them from
occurring. The Institute for Healthcare
Improvement (IHI), founded by Leape and former CMS director Don Berwick (who
were among the authors of the IOM report) has been working on this issue for
more than 25 years. Its “100,000 lives campaign” sought to save that many lives
by having hospitals sign on to implementation of certain strategies that had
been shown to reduce errors. These included “timeouts” in surgery to be certain
that everything was correct (right patient, right part of the body, etc.)
before beginning, particular ways of managing people on breathing machines in
intensive care units to prevent “ventilator associated pneumonia”, and the
like.
A key point is that very few of these errors are intentional
– they are not malpractice in the traditional sense, they are rarely the result
of physicians being “bad doctors” – and yet people, avoidably, die from them. A
key part of the strategies promulgated by people like Berwick and Leape, IHI,
by the IOM report, and others working in the field is to employ the systematic
approach to error reduction developed in other industries, such as airlines. (A
common trope is that if airlines had errors as frequently as medicine, a jumbo
jet full of people would be crashing several times a day.) Continuing
follow-ups have looked a “how we are doing”, such as in “Five years after ‘To
err is human’: what have we learned?” by Leape and Berwick in JAMA in 2005[2]
and the summary of it by the Commonwealth
Fund.
It is in the context of this history that Gupta’s article
appears. Its main significance is that it brings to public (New York Times) attention the fact that
these problems still exist, and that despite progress (and there has been much)
there is much that still needs to be addressed. It is a balanced presentation,
but does emphasize the point in the title – that more treatment leads to more
errors, or, to put it another way, that more
is certainly not always better. He cites “Rule #13” from the novel “House of
God”, written by Stephen Bergman, MD (under the pseudonym Samuel Shem) in 1979:
“The delivery of medical care is to do as much nothing as possible,” a
restatement of the dictum primum non
nocere, first do no harm.
An interesting series of letters responding Gupta’s paper
appeared under the heading “Taking
steps to reduce medical errors” in the Times
on August 4. One of them is from Bergman, who echoes Gupta’s concept that
fear of malpractice suits (the “whining motor behind doctors’ ordering
unnecessary, pricey tests,”) is the cause of many errors, and applauds
interventions such as surgical time outs. However, another letter, from Niall
O’Dowd, the uncle of Rory Staunton, the 12-year old boy who died after being
treated for a “minor” scrape in the NYU Hospital emergency department (see Jim
Dwyer, “An
infection, unnoticed, turns unstoppable”, NY Times July 10, 2012 and many follow-up articles including a
column by Maureen Dowd “The
boy who wanted to fly”, 3 days later), points out that there are also
dangers, as in his nephew’s case, from doing too little.
Mr. O’Dowd focuses, naturally, on the emergency department,
which is where his nephew was treated, inadequately as it turns out. Emergency
departments are seeing more and more patients, and are responsible for a very
large and increasing number of admissions to hospitals, as detailed in a recent
New England Journal of Medicine article
by Schuur and Venkatesh, “The growing role of emergency departments in hospital
admissions”.[3] They identify a number of trends that tend to
increase the use of the emergency room as a source of care, particularly for
acute conditions. These include the lack of availability of acute-care
appointments in primary care practices, and the lack of the high-tech
instruments such as CT scanners that permit EDs to rapidly diagnose and admit –
or rule out and then discharge – conditions such as heart attack and
stroke. They also include public education
campaigns that urge people to go to the ED when they have symptoms that could
be heart attack or stroke, and, of course, the fact that lack of insurance
prevents people from accessing health care in most other settings (federal law
requires EDs to assess anyone who presents there). While the fact that the
increase in admissions from the ED may have something to do with their “lower
threshold” (“…emergency physicians are
trained to assume the worst and are more likely to admit patients with
uncertain diagnoses and with whom they don't have an ongoing relationship, and
that they are unwilling to discharge patients when they cannot guarantee
outpatient follow-up,”) it is also possible that in their pressure to
diagnose and admit the most sick, they could possibly undertreat some, like
Rory Staunton, who do not appear to be so ill.
Mr. Staunton may have benefited from antibiotics he did not
get. Other letter writers speak of both the dangers of underusing antibiotics
and overusing them; however, the settings they describe (critical care units in
the first case, treating viral syndromes in the second) are very different. Doing
a lot is not necessarily wrong, or right. Doing little is not necessarily
wrong, or right. Both can cause errors, and both can save lives. Yet a fifth
letter writer suggests “our mission is clear: if it’s right for the patient,
it’s the right thing to do.”
This is true as far as it goes; the difficulty is in
ensuring what is right for the patient. But systems, checklists, timeouts, and
consistent rules can go a long way to making this be the case. And if people
with non-acute, non-emergent conditions can get in to see their doctors, and as
important, have doctors and can have
the health insurance that allows them to be seen, it would help even more.
This is something that we must not lose sight of; as Schiff,
Bindman, Brennan et al note in a 1994 JAMA article, denial of care is the
“gravest of all quality defects.”[4]
[1] Leape L; Lawthers A, Brennan, T, et al. ,“Preventing
Medical Injury”. Qual Rev Bull.
19(5):144–149, 1993.
[2] Leape L, Berwick D,
“Five years after to err is human: what have we learned?” JAMA. 2005;293(19):2384-2390
[3]
Schuur JD, Venkatesh AK, “The growing role of emergency departments in hospital
admission”, NEJM 2Aug2012;367(5):391-3.
[4]
Schiff G, Bindman A, Brennan T, et al., “A Better-Quality Alternative: A
Single-Payer National Health System Reform”, JAMA. 1994;272(10):803-808.
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