Et tu Dr. Gupta?

As well intentioned and thoughtful as he is, Sanjay Gupta nonetheless misses the point in his recent New York Times op-ed “More treatment, more mistakes.”  The theme of the chief medical correspondent for the Health, Medical & Wellness unit at CNN is:

Certainly many procedures, tests and prescriptions are based on legitimate need. But many are not…. This kind of treatment is a form of defensive medicine, meant less to protect the patient than to protect the doctor or hospital against potential lawsuits.

Herein lies a stunning irony. Defensive medicine is rooted in the goal of avoiding mistakes. But each additional procedure or test, no matter how cautiously performed, injects a fresh possibility of error.

With a quick aside in admiration of Peter Pronovost’s approach to harm reduction and some other process improvements, he then says:

What may be even more important is remembering the limits of our power. More — more procedures, more testing, more treatment — is not always better.

And then, remarkably, he presents M&M conferences as a remedy:

One place where I have seen these issues addressed is in Morbidity and Mortality, or M and M — a weekly gathering of doctors, off limits to the public, which serves in most hospitals as a forum for the discussion of mistakes, complications, deaths and unusual cases. It is a sort of quality-assurance conference where doctors hold one another accountable and learn from one another’s mistakes. They are some of the most candid and indelible meetings I have ever attended.

Having a consistent gathering to talk about the mistakes goes a long way toward that goal, and just about any institution, public or private, could benefit from a tradition like M and M.

OMG.  Dr. Gupta has inadvertently given us a wonderful exposition about a lack of understanding of the nature of quality and safety process improvement in hospitals. Most harm is not caused by a doctor making an error of commission, i.e., an extra test or an unnecessarily executed procedure. The number of reported adverse events from such instances is dwarfed by other forms of harm — hospital acquired infections, falls, failure to rescue, pre-39 week induced labor.  Many of these are not even reportable as harm.

Dr. Gupta’s presentation reflects no knowledge about the science of process improvement.  Peter Pronovost’s check list is not just a good idea.  Brent James’ introduction of clinical protocols is not just a good idea.  These are approaches that introduce the use of the scientific method into the clinical setting.  In contrast, M&M conferences are essentially anecdotal reviews of an incredibly small number of adverse events.  I would not understate their importance as teaching tools (when they are conducted in a pedagogically appropriate manner), but they do not deal with systemic problems, with near misses, with the manner in which communication fails.

As Lucien Leape and others have stated, and as Dr. Gupta makes clear in a way he certainly did not intend, the medical profession needs to have dramatically improved training in the science of process improvement as part of the undergraduate and graduate medical education curricula.

Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston, where he blogged for several years about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.

8 replies »

  1. Sanjay ought to be covering more important matters of safety, like the massive dangers patients face when their medical records disappear for hours as what happened because of Cerner’s “huiman error”. It was a Cerner trained employee who apparently took down dozens of hospitals at once.

    I am shocked, literally shocked, that this failure of nationwide medical care infrastructure has been ignored by this blog and its bloggers:


    It matters not how these devices satisfy meaningfully useless guidelines when thousands of patients are put at risk at once.

  2. Could you send my comment back to me to finish please. Sorry I hit the wrong button.

  3. Where there are financial incentives and revenue opportunities, there will be treatment, some of it unnecessary. Sure, more care introduces more opportunity for errors, but we must create a system that truly incentives the right care (protocols, checklists, etc) and penalizes the avoidable errors and inappropriate care. Combine science of process improvement and a big chunk of evidenced care and we will moving towards better healthcare.

  4. I have worked in hospital risk management for three decades. I understand that people make mistakes and I have a good understanding of patient safety and performance improvement. But the most heartbreaking situations I have had to deal with (and there were way too many) involved a “defensible” or “unavoidable” complication in a completely unnecessary treatment situation. The highly marginal cardiac surgery patient who dies from sepsis. The prostate biopsy that leads to sepsis. We don’t have to understand all the nuances of sepsis and its treatment and prevention to eliminate these poor outcomes. We just don’t do the procedure. I’m with Dr. Gupta. Until medicine recognizes this problem, costs will remain high and too many people will suffer the consequences.

  5. Overtreatment sets the stage for medical errors.

    We know that a signficiant number of surgeries are unnecessary
    –back surgery comes to mind–but it’s just one example.The patient who
    undergoes unnecessary surgery undergoes all of the risks of being
    hospitalized (hospital acquired infections, medication mixups, etc. etc)– with no benefit.

    I entirely agree that processs improvement lies at the heart of patient safety.

    But if we didn’t overtreat so many patients, nurses would not find themselves
    reponsible for more patients than they can handle. Residents would not be forced to work 30-hour shifts. Chaotic working environments make co-ordinated care difficult. And we know that fatigue leads to mistakes.

    I don’t think M&M conferences are the answer to overtreatment–(not sure how Gupta makes that leap.) But the fact that we do too much to too many people is an enormous problem not only because it’s costly, but beause patietns are subjected to risk without benefit. Every medical treatment carries a risk, even a test.

    Finally, while process improvement is central to safety,Bob Wachter
    made an important point in June when he wrote that individual accountability
    should be part of improving safety in our hospitals:

    “our early focus was on improving systems of care and creating a “no blame” culture. This focus was not only scientifically correct (based on what we know about errors in other industries) but also politically astute. Particularly for U.S. physicians – long conditioned to hearing the term “error” and reflexively thinking “medical malpractice” – the systems approach generated a level of goodwill and buy-in that would have been impossible with a more clinician-centered focus.

    “Perhaps the greatest change in my own thinking between 2007 and today is my greater appreciation of the need to balance a “no blame” approach (for the innocent slips and mistakes for which it is appropriate) with an accountability approach (including blame and penalties as needed) for caregivers who are habitually careless, disruptive, unmotivated, or fail to heed reasonable quality and safety rules. Fine-tuning this balance may well be the most challenging and important issue facing our field over the next 5-10 years ”

    I agree. Hospital administrators should encourage nurses, residents and
    techicians to speak out when inidividual caregivers are causing harm.
    Whistleblowers need to be protected. Finally, doctors who attempt to do
    “too much” (too many surgeries, back to back) are more likely to make mistakes.

  6. It is all so sad and true, yet Doctors are still proud of it, you only have to read this book to see how blinkered we are to improving quality. It is not just a confession it is an expose of our complete failure to understand that we are are arrogant, slow to learn, stubborn and impotent. The place for the public would be in our M&M meetings to see how inadequate we are about correcting our imperfect behaviors.

    Confessions of a Surgeon
    Dr. Paul A. Ruggier

  7. OMG pretty much sums it up. Not to be rude or petty, but this is what happens when a part-time neurosurgeon and part-time celebrity anchor talks about quality improvement and process change in hospitals.

    Totally agree with you, Paul. M&M abosolutely has a role in creating change and holding people accountable, but as someone who has sat through enough of them AND been involved on the quality side, M&M does incredibly little to create process change. I think that part of the challenge is for physicians to understand that although, they/we as individuals are responsible at the end of the day for outcomes, that we must also acknowledge how the overall system is actually much more accountable for broader level results than we may, from an ego perspective, may want to given credit.