Tuesday, May 11, 2010

Half full. Half empty.

At a recent presentation, a respected doctor expressed some frustration with the criticism that is sometimes directed towards the medical profession. He pointed out that the medical community has actually done a very good job taking care of serious illnesses in the population. He noted that this is because doctors really devote their lives to improving patient outcomes.

To support this point, he presented the chart above from the AHRQ Center for Delivery, Organizations and Markets (full study here) that demonstrates improvement in hospital risk-adjusted mortality for important diagnoses and procedures. Whether you have a heart attack or pneumonia, or whether you have an aneurysm repair or a hip replacement, your chance of dying in a hospital has gone down over the years. (I know this data ends in 2004, but I would be confident that the trends have held.)

I hope you, like I, am impressed with these numbers. They are a story worth telling and retelling.

But there is another story that has to be retold, too. It remains a bit of a paradox for me, one I discuss in my speeches. The paradox is how this group of extremely able and well intentioned clinicians, while accomplishing these great things, also constitute an important public health hazard, in terms of the number of people who are killed or otherwise harmed while in hospitals.

The famous Institute of Medicine Report, To Err is Human, was published in 2000. It documented, in a way that many people find uncomfortable, the number of unnecessary deaths that occur in hospitals. We now understand that much of this harm is caused by the systems of care, by how work is organized in hospitals, by excessive levels of variation, or, to put it another way, by insufficient levels of standardization based on process improvement principles. I summarized Brent James on this point in a post below:

We continue to rely on the "craft of medicine", in which each physician practices as an independent expert -- in the face of huge clinical uncertainty (lack of clinical knowledge; rapidly increasing amount of medical knowledge; continued reliance on subjective judgment; and limitations of the expert mind when making complex decisions.)

And, as noted below, we also often do not draw on our greatest resource, patients, in the design of care delivery. And finally, many hospitals and doctors are held back by a fear or reluctance to publish clinical outcomes in real time so that organizations can hold themselves accountable.

Is the glass half full, or half empty? As in such cases, probably both. Let's give tremendous credit to the medical profession for what it has accomplished. But let's hope that members of the profession also take to heart the fact that the job of reducing harm is not nearly done.


Anonymous said...

I think half-empty is more appropriate until there is a revolution in medical education and clinical administration that sets explicit expectations for quality improvement and accountability in performance. Otherwise, science is still second fiddle to the art of medicine. ('See one, do one, teach one' is not the scientific method!) The huge obstacle presented by the culture is exemplified in its very exclusion of empowered patients. Physicians may get tired of being pilloried, but they should look to their courageous colleagues who have been leading the quality and safety charge, with too few followers.

Anonymous said...

Thank you for writing this post.

Without making a comment to whether the frequent bashing of the medical industry as a whole is justified or not, I do think that improvements that it has made is too often overlooked.

The last thing we want to do is go so overboard in perpetuating the quality control problem as one that is overwhelming and incurable to the extent that it discourages people who have the ability to make life-saving changes from doing so.


76 Degrees in San Diego said...

The cited quotation exemplifies the usage of the royal "we" and literary exaggeration.

Anonymous said...

I do not believe there is an exaggeration.

Anonymous said...

Well I thought I was too tired to comment on this post tonight, but I can't pass up 76 degrees' comment.
Royal "we"; I don't know, Dr.James is an M.D. Explain please? Exaggeration; depends on how you define the phrases he uses in parentheses. Certainly I agree with the over reliance on the craft of medicine and individual expertise. We know most docs practice according to how it was done where they trained more than any other factor, particularly in surgery. Gary Kaplan from Virginia Mason in Seattle recently said that 80% of the time standard processes work in clinical care (I interpret this to mean standard clinical pathways),and the other 20% is when we use our professional judgment and individual expertise. I think that's a fair assessment.

nonlocal MD

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Anonymous said...

This link from Dr. Robert Wachter's blog, while tangentially related on its face, illustrates another source of patient harm from physicians - the sometimes-deliberate weakness of peer review systems.


I was stunned to read Dr. Wachter's statement that "a few teaching hospital" pathology groups and "foward-looking" radiologists review each other's work. In my community hospital system,such review was a matter of course for both pathology and radiology. . Accuracy of frozen section diagnoses, correlation of our diagnoses with second opinions, and random re-reading of selected cancer diagnoses were a routine, as well as other rotating monthly indicators. The radiologists routinely collected our breast biopsy diagnoses to correlate with how they had read the mammograms, and over-read each other's work. The data were verbally presented at each Medical Executive Committee meeting.

Why has this expectation of routine review of one's work not penetrated further into the clinical specialties? It would go far to standardize departmental practice and improve physicians' care. Dr. Wachter's own admission of surprise at the reporter's question is revealing - perhaps Paul is indeed correct to admonish us to "take to heart the fact that the job of reducing harm is not nearly done."

Marco Huesch said...

Hi Paul

I definitely appreciate your points which are well made in your speeches and here.

But I don't think "half" is the right fraction for the glass' emptyness.

That is, my recollection of the IOM report is that about 7% of all admissions experience an accident, of which 3% are adverse events, of which 13% are fatal. So we're looking at several basis points' (i.e. hundredths of a percent) worth of total fatal harm as a percentage of total admissions. Alternatively, if we take around 40m admissions and 40,000 medical error deaths a year, we get about 10 basis points of total fatal harm.

As you point out correctly and compassionately, each fatality due to harm is a loved relative.

However the table of improvements for a set of very common diagnoses and procedures are literally an order of magnitude higher. Each of these saved lives is a loved one too.

So I'd like to think the glass is almost full, not just half-full.

Kudos of course to your clinicians, nurses and staff team who try hard to make it a little fuller by reducing preventable harm.


Anonymous said...

Thank you, Marco. You present a thoughtful perspective on the issue.

Anonymous said...

Oops, anon 0840 is me, nonlocal,in case any rotten tomatoes are thrown.

Alyn Ford said...

Great article... complete with provocations. I would argue that the clinical effort of practitioners could be greatly ameliorated by logistical efficiencies. One of the encumbrances for our docs is all the effort expended to deal with the coordination of their efforts for multiple patients at a time. Perhaps the quantum efficiencies we seek are best sought from the white space amidst all the clinical activities.

Anonymous said...

The empty portion of the glass is mainly do to sporadic learning approaches rather than continuous learning. I recall a comment from a colleague when presented with a plan to adopt an EHR: "I didn't go to medical school to work on computers all day". It didn't help to state facts such as over 80% of today's med schools have adopted EMR's.