The American Medical Establishment Is On the Wrong Track in Its Efforts to Reduce Medical Errors

Editorial Comment:
As a member of a self-regulating legal society, I can empathize entirely with Dr Levitt's concerns about bad actors in the medical system. While he is in the United States and I'm in Canada, he'll no doubt not be surprised to hear that medical outcomes here are similar to his experience. This is a significant problem that arises from self-regulation - although we (medical and legal professionals) are all required to carry practice insurance, it is clearly designed to protect us and not our patients/clients.

The reference in Dr Levitt's piece to the intravenous lines is one example of system improvement, as was the surgical checklist designed to work like the system used by commercial pilots. But there is no question that in the medical world - as in mine - system improvements can only help mitigate so far. Removal of substandard practitioners is essential, and neither medical nor legal societies are inclined to do that.

-prh
Axis of Logic editor

This is a commentary about health care. It tells why we are losing the battle to prevent over 100,000 unnecessary deaths in America's hospitals each year. My opinion is that physicians are primarily responsible for the deaths. A recent poll of Swedish doctors showed that a sizable minority felt that physicians were the source of most patient mishaps. That doesn't prove anything, of course. But I will stand by the facts in the body of my commentary below.

I’m a retired neurosurgeon who served as a chief of staff and governing board member of two separate 400 bed community hospitals over a five year period. I learned where most of the skeletons were hidden. I was a reformer who tried to remove doctors who repeatedly hurt their patients. There were several of them at each hospital. Their sins included refusing to show up in an emergency, lying to patients and other doctors, missing diagnoses, getting poor operative results, doing unnecessary surgeries and extracting sexual favors from patients. My efforts were opposed by my colleagues, the hospital administrators and the hospital lawyers. I sensed that protecting bad doctors was a significant cause of the unnecessary loss of 98,000 lives a year from harmful adverse events. To Err is Human, a book by the Institute of Medicine revealed that stark figure to a shocked public in 2000.

I had to do some lifting and probing before I could turn my intuition into arguments. My research into why my experience was nearly universal led me to someone who mined the National Practitioner Data Bank, Dr. Robert Oshel, who worked for the data bank before he retired. That repository was established by Congress in 1986 and put into effect at the end of 1990. It lists for the public, by a number only, those physicians who have been sued successfully or have lost their license to practice. Here’s what he found over a period of 20 years:

There is a hard core of 2% of the physicians whose misdeeds result in half of the money paid out in malpractice cases.
The average hospital drops only one doctor from its staff every twenty years.
About 250 doctors lose their licenses each year, or 0.04% of the total. At that rate it would take 50 years to remove the hard core 2% from practice.

There is an insidious cause of undue leniency to doctors who repeatedly hurt patients in To Err is Human itself. The authors had turned the interpretation of the original data of their own published findings, the Harvard Medical Practice Studies, their primary source, on its head based on theoretical, not empirical grounds. No new studies were done so that no new data were gathered to contradict the original. The original numbers showed that at least 61% of adverse events in hospitals were the result of blunders by individual physicians and that systems errors were responsible for only 6%. I questioned the chief author of both studies, Dr. Lucian Leape of Harvard, in a series of e-mails, and found his explanations for his monumental reversal inadequate and unscientific.

To Err Is Human had famously blamed bad health care delivery systems, not bad doctors. It emphasized “creating safety systems inside health care organizations through the implementation of safe practices at the delivery level. This level is the ultimate target of all the recommendations.” As a result, all of the efforts to save the lives of the 98,000 per year have been systems based. The licensing boards of all the states, the main bulwarks against bad doctors, have bought into this and made a joint statement to that effect in 2008. They said, “Systemic sources of risk significantly eclipse professional incompetence as the dominant cause of harm to patients.” The evidence from the Harvard Medical Practice Studies was otherwise.

Documentation that the systems correction approach was not working came in two devastating reports that came out in November, 2010, one from the Inspector General of HHS, based on data gathered on Medicare patients and the other from Harvard Medical School based on outcomes in several North Carolina hospitals. That state was chosen because its hospitals had the reputation of rigorously following systems error prevention methods. Both reports said that in the first decade of this century, the period following the publication of To Err is Human, the number of deaths from adverse events was unchanged from the 15 years preceding, perhaps greater, and had stalled at 120,000 per year. According to the facts, we are getting almost nowhere in our efforts to reduce hospital mishaps.

It boils down to this: The most reasonable interpretation of the Harvard Medical Practice Studies is that the greatest share of responsibility for harmful errors falls on individual physicians, not bad systems. The systems approach, while it was a huge and rapid success in preventing airline mishaps and poorly manufactured cars, has made only a small dent in the number of unnecessary deaths in American hospitals. That tiny inroad came in avoiding three to six thousand deaths a year from infected intravenous lines, thanks to Dr. Peter Pronovost of Hopkins, an accomplishment which got swallowed up by the number of deaths from other sources. Over a million will die in the next decade. We have no time to lose. We must rid the profession of repeatedly erring doctors on a much larger scale than the minute fraction that we remove now.