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.