Still Demanding Medical Excellence

Forget for a moment the familiar scenes of action and outraged reaction that are playing out in our long-running national debate over how best to provide access to health care for every American. Instead, ask one simple question: what happens in the doctor’s office or hospital once access is achieved.

I set out to write a book addressing that question almost twenty years ago. I thought myself well qualified: I’d written about health care for a decade for the Chicago Tribune while receiving various awards and other recognition. But it didn’t take long for a painful realization to set in of how naïve I really was.

Digging through hundreds of studies, articles and other first-hand sources stretching back for decades, I was stunned to discover that repeated evidence of unsafe, ineffective, wasteful and downright random care had had no effect whatsoever on how doctors treated patients. Literally none. Moreover, the few professionals who understood this truth couldn’t talk about it in public without endangering their careers or engendering vitriol from peers.

Fortunately, I had no academic or clinical career to imperil. In the conclusion to Demanding Medical Excellence: Doctors and Accountability in the Information Age, I gave vent to anger and indignation. I wrote:

From ulcers to urinary tract infections, tonsils to organ transplants, back pain to breast cancer, asthma to arteriosclerosis, the evidence is irrefutable. Tens of thousands of patients have died or been injured year after year because readily available information was not used ­– and is not being used today – to guide their care. If one counts the lives lost to preventable medical mistakes, the toll reaches the hundreds of thousands.

The only barrier to saving these lives is the willingness of doctors and hospital administrators to change.

Demanding Medical Excellence came out in October, 1997. What progress has been made since then, and where we have fallen short? I address that question in a short article, “The Long Wait for Medical Excellence,” in the October, 2013 issue of Health Affairs. The purpose of this blog entry is to recap some of what’s said there (for you non-subscribers) and to add a few impolite observations that don’t jibe with the rules of a peer-reviewed journal.

Demanding Medical Excellence shone a spotlight on medical error, evidence-based medicine, health information technology, population health and patient empowerment well before those topics achieved their current prominence. A few labels have changed since then. “Managed care,” for instance, has morphed into “accountable health care” (with a few twists), while the plea to employers and insurers to “buy right” has been repackaged as “value-based purchasing.”

Far more importantly, conversations about quality of care problems that were once suspect or even taboo have become open and officially approved. Still, a tendency towards “little white lies” persists in a shying away from confronting head-on the agonizingly slow pace of our progress. I think the tendency shows up in all areas of health care, but it is particularly evident with medical error. I confess that I’ve been among the guilty.

That paragraph I just cited about the toll on patients (“From ulcers to urinary tract infections…”)? My editors didn’t spot it, but I deliberately made the total smaller than it should have been. Elsewhere in Demanding Medical Excellence, I had written that there were “about 180,000 deaths and 1.3 million injuries each year owing to medical treatment” in hospitals. That was based on my extrapolation of studies from the late 1970s and early 1990s. However, in the book’s conclusion, I lumped in deaths from a lack of evidence-based care and low-balled the whole thing.

In my defense, I was writing at a time when the Institute of Medicine (IOM) had not yet not breathed a word about “overuse, underuse and misuse,” much less pronounced a nearly six-figure death toll from mistakes. Although I was no longer a reporter, I was worried about being portrayed as a sensation-seeking journalist.

Yet even today, many in the quality field hesitate to stare directly into the face of the grim statistics on the persistence of the medical error problem. Recall that I used data from decades ago to calculate 180,000 preventable inpatient deaths annually. In 2004, HealthGrades ended up with 195,000 deaths, about the same number. In 2009, an investigation by Hearst journalists found 200,000 deaths. Most recently, a September, 2013 study in the Journal of Patient Safety put the toll at 210,000 to 400,000 deaths per year.

By way of comparison, the 1998 report on errors from the IOM estimated that 44,000 to 98,000 patients die each year in hospitals from preventable mistakes. The Agency for Healthcare Research and Quality (AHRQ), using a different methodology, recently estimated the number to be 97,000.

Put it all together and this is what you’ve got: for the past decade (or, maybe, for several decades), 100,000 Americans (or maybe upwards of 200,000 Americans) have lost their lives each year in hospitals through preventable medical mistakes. Add it up: a million preventable deaths? Two million? Plus preventable injuries? Pick your time frame and your toll.

Now, consider that 15 years after the IOM error report there is no reliable estimate at all of the death and injury toll in the outpatient environment. Why? And why no outrage?

In a 2010 Health Affairs blog, “Why We Still Kill Patients,” I bluntly blamed the lack of progress on a combination of errors’ invisible consequences, professional inertia and the income hospitals quietly reap from substandard care. I believe that new standards of transparency, in addition to government and private sector financial incentives, are making care safer (I’ve written about a personal experience with my wife.) But we’ll have to wait and see what the data show.

Also on the bright side, there is certainly evidence that care is getting more evidence-based. So much so that clinicians with short memories are kvetching about process of care measures. They forget that years of studies and even hectoring by the American Medical Association (AMA) couldn’t get doctors to consistently do something as simple as administering beta blockers to appropriate heart attack patients. However, after Medicare made this a publicly reportable “core measure,” the rate soared. “What gets measured gets managed” is a piece of business world wisdom that has helped prompt dramatic improvement in health care.

The current debates about which measures to keep and use are a sign of progress. Not long ago, measurement itself was suspect, and the AMA considered the very word “guideline” an implicit insult to physician judgment. Its preferred term was “practice parameter.”

In just the last few years, there have also been enormous strides in adopting health information technology (HIT), enabling care to be measured, managed and improved. I wrote of an information revolution “owing more to laptops than to lab coats” at a time when Web browsers were a new technology, and mobile computing was the watch worn by Dick Tracy in a comic strip. Today, thanks to payments of billions of federal dollars to doctors and hospitals through the HITECH Act, most providers are rapidly catching up to the 20th century and some are in the 21st.

In the health IT realm, clinical pioneers began using computerized decision support in the mid-1950s. I admit it never occurred to me that bribery (“Take this money for computers, but promise you’ll provide ‘meaningful use’ in return”) would prove the key a half century later to unlocking its acceptance. Still, money has always been a powerful motivator, and the Affordable Care Act is filled with similar motivating provisions.

There’s one other change that doesn’t get talked about much, but is quietly crucial. “People are policy,” the saying goes. Some who were leaders in quality and safety back then are still leaders today: see, “Intermountain Health Care.” Elsewhere, in hospitals, medical groups and other institutions, there are now leaders who built careers on an embrace of quality improvement when it was far from a wise decision to do so.

Take, for example, the two clinicians writing about medical error in the Annals of Internal Medicine in 2000 who called Demanding Medical Excellence “required reading for physicians.” Both were young Harvard docs with a passion for patient safety despite substantial pushback within their own institution. One, Dr. David Bates, now directs the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital and holds senior posts in the Harvard system. His co-author, Dr. Atul Gawande, has made patient safety, practice variation and evidence-based medicine the stuff of everyday conversation through compelling articles in The New Yorker and best-selling books.

The Robert Wood Johnson Foundation, which provided the grant enabling me to write my book, is headed by Dr. Risa Lavizzo-Mourey, the former deputy administrator of what is now called AHRQ. The president of the Commonwealth Fund, Dr. David Blumenthal, is a pioneering quality and safety researcher who early on hailed the potential of HIT to improve the “moral pillars” of medicine. At Thomas Jefferson University in Philadelphia, the nation’s first School of Population Health was begun by Dr. David Nash, who pushed transparency and accountability years before it was politic to do so. There are others like them.

Demanding Medical Excellence also profiled Dr. Donald Berwick, who had founded a small non-profit with the mission of spreading quality improvement practices. Berwick went on to lead the Centers for Medicare & Medicaid Services, one of the biggest purchasers of health care in the world, and focused it on the “triple aim” of better care, better health and lower cost. Berwick is now running for governor of Massachusetts. The Institute for Healthcare Improvement that he founded most recently reported revenues of almost $43 million.

To be sure, many patients and doctors still believe that “more” care is “better” care. Their numbers, though, are likely dwindling due to the efforts of professional and consumer groups alike. Moreover, patients are being brought into economic and clinical decisions in health care in ways that seemed inconceivable in the 1990s.

When I wrote Demanding Medical Excellence, I thought the new world of quality measurement and management lay just over the horizon, but culture change can be stubbornly slow. It was nearly a century ago that Dr. Ray Lyman Wilbur, former president of the AMA and chairman of the blue-ribbon Committee on the Costs of Medical Care, wrote this: “The quality of medical care is an index of a civilization.”

It is a benchmark we’d do well to keep in mind today.

Michael L. Millenson is president of Health Quality Advisors LLC in Highland Park, IL and the Mervin Shalowitz, MD Visiting Scholar at the Kellogg School of Management.

21 replies »

  1. This is a wonderful article and if you have not read it,Michael Millenson’s The Silence is also worth your time. I have been a student of the quality movement for some time and have followed his writing as well as the IOM reports etc. People often end up in the hospital because they did not receive the appropriate care in the outpatient setting. Women with repeated chest pain may die or have a heart attack even if their arteries are not blocked. If their heart cath is normal they are told that it is esophageal reflux or gas-or “go home and take your prozac. Everything is going to be fine.” Then that same woman will be admitted because she did not receive best medical treatment for her angina. Men with stable angina will receive a stent although hard evidence shows that a stent adds nothing to best medical treatment. Medical treatment relieves the pain in 70% of these patients completely within a year. Most stents in patients with stable angina are not needed and most patients do not receive best medical treatment. The effects on cost and health are enormous.
    I have worked with others in my group to create an advanced medical home that reliably provides optimal medical therapy for patients with high cardiovascular risk. Hard evidence says that in some populations you only have to treat three patients in this manner to prevent a major cardiovascular event and 5 to prevent a death. Still, efforts to scale the model have been frustrating and extremely slow.
    I was naive enough to think that reason would prevail and that if you built a better mousetrap it would be adopted. All innovation is a threat to the old order -the winners under the current system. Innovation in medicine struggles against tremendous push-back. We just need to develop enough push to overcome it.

  2. I am familiar with and an admirer of Dr. Starr’s work. Just to be clear, “unnecessary surgeries” is typically not included in medical error tallies; error refers to not doing what you wanted to do. Flawlessly performing surgery on someone who doesn’t need it could be fraud or unintentional overuse, but it is not in the same category as, say, infections. Similarly, when we go to ‘preventable” errors, there are adverse drug reactions that could be foreseen by clinicians and those that could not be.

  3. Interesting blog! While the number of deaths due to preventable errors may differ dependent on data and methods used, there is no doubt that the harms due to medical treatment is alarming and deserves urgent attention by all. Consumers and patients have the rights to quality of care and to be free of harm.

    By the way, among all the discussions, few mentioned another significant report, “Is US Healthcare Really the Best in the World?”, by Dr. Barbara Starfield (a well respected scholar on heathcare at Johns Hopkins School of Public Health). This article was published in 2000 JAMA, just one year after the To Err is Human:


    So as early as in 2000, Dr. Starfield’s findings had already placed the medical care as the third leading cause of death in the US:

    • 12,000 deaths from unnecessary surgeries;
    • 7,000 deaths from medication errors in hospitals;
    • 20,000 deaths from other errors in hospitals;
    • 80,000 deaths from infections acquired in hospitals;
    • 106,000 deaths from FDA-approved correctly prescribed medicines.

  4. Similar content? Threads build off each other. AND, as you may have noticed, folks can be notified when a comment is posted. Therefore, a “dying” thread is revivified. Sometimes. Be the topic medical error or needlepoint, bursts of comments likely come about that way.

    And, of course, let’s not forget randomness.

    Yeah, not as much fun as conspiracy theories, but there you go.

  5. So in case you have not seen any of these exchanges before (really?), they go something like this:

    Doctors: We need tort reform
    Lawyers: You need to stop injuring patients, the IOM study showed that …..

    No reasonable person would argue that we shouldn’t try to have the best medical care possible. Neither would any reasonable person argue that perfection is possible in any human endeavor.

    By using a unrealistic retrospective analysis of data, one can draw the conclusion that fits ones underlying biases.

    To give an analogy. On Sunday, I retrospectively analyzed the play calling of the Baltimore Ravens in their game with Green Bay Packers. I found that at least 30% of the plays called were the wrong play and that these negligent errors were the proximate cause of the loss. My expert opinion was confirmed by the other experts drinking at the bar with me.

    Now to answer your question: “Why didn’t I presume that the people talking urgently about the need to reduce medical harm must be doctors?”

    Because I have been paying attention to what different people are saying and focusing on. And I suspect you have too and know that your question is rhetorical.

    Now for my question: Why did 4 comments with such similar content pop up in a dying thread within such a short time?

  6. Sorry, legacyflyer, but you avoided the question: I do not know who and who is not a physician (I’m not), but the general discussion is not about malpractice or liability. Why do you want to make this a doctor vs. lawyer thing? Doctors and patients (and all of us end up as the latter, typically) share an interest here.

    No reason for polarization. Plenty of blogs you can go to for that.

  7. Gosh, legacyflyer, what an odd assumption that all these folks talking urgently about the need to reduce medical harm must be lawyers. Why didn’t you presume we were all doctors?

  8. Wow, what happened?

    – 5:50p James
    – 6:33p McGiffert
    – 6:43p Millenson
    – 6:59p O’Connell
    All saying pretty much the same thing on a dying post.

    Did the trial lawyers convention just get out?

  9. Many of the victims of Medical Harm that I have met were young,healthy, and wealthy.. going in for routine conditions. The harm that befell them was not unknown, complicated, clinical, flukes but simple, blatant, dumb, mistakes (aka Brain Cramps). A new term to consider “Clinical Atonement” = The fact that patients bear the full physical,emotional, and financial burdens for the sins of their Healthcare Providers.

  10. Even these few comments show the lack of methodological agreement about error. Should diagnostic error be included? What about “shortened life”? I just saw an article looking only at injectable drug errors, and it was thoughtful methodologically, horrific in its conclusions and included ramifications of the error that might show up months later. My own calculations were more primitive, but raise questions that should be addressed, as well.

    And, again, that’s without addressing errors that originate in the ambulatory setting. Since posting this, I saw an estimate in the July-Sept. Journal of Ambulatory Care Management based on a patient survey. But where’s the definitive estimate?

    What is most frustrating, as Lisa says, is the lack of popular support for this cause. The polling I’ve seen shows that the public doesn’t like to think about negative events, likes to think well of doctors, likes to think about cure. We also need to acknowledge that those most likely to be victims are older, poorer and SICK. That being said, it is time for those of us who are just plain impatient to figure out some new strategies. Too big a topic for this reply, but one worth thinking about and communicating about elsewhere.

    For, as one of my favorite quotes in Demanding Medical Excellence put it, an eminent Stanford physician once advised a sign above all operating rooms: There are some patients we cannot help, but none we cannot harm.

    Thanks to all,

  11. The most important point being made here is that medical harm is a persistent killer and mutilator in the US – as stated here, every single year 200,000 to 440,000 hospital patients die from it. Several recent studies estimated that at least 1 in 4 hospital patients are harmed, which I calculated to be about 9 million people using the latest available numbers of admitted patients from the hospital association; CDC estimates 2 million of those hospital patients got infections. Just pause for a moment and consider these statistics about hospital care alone. They are astounding. It is stunning that neither the American public – most of whom know someone who has been unnecessarily harmed by hospital care – nor our political leaders are up in arms about this. Our Safe Patient Project Network often discusses why there is no urgent call to action, no horror from political and societal leaders. We can’t come up with any reasonable answers other than the power and influence of the medical industry and the lack of accountability in our health care system – to the people who are harmed and to society. We know what needs to happen, but the resources always seem to be sent somewhere other than hiring more nurses, tracking infections, and implementing the many methods that experts know can prevent errors and infections? It is a shameful disgrace.

  12. I’m the person who wrote the analysis in the Journal of Patient Safety. In fact my estimate was 440,000 lives significantly shortened each year because of preventable adverse events in hospitals. The life-shortening consequences of hospital care may not be manifested for many months or even years. I tried to make that clear. I reached a higher number than others (near 200,000) because I looked at weaknesses in the ability to detect medical errors from medical records. These weaknesses include: 1) inability to detect most errors of omission, 2) errors of commission that are not made evident in medical records, 3) limited detection of errors of context and communication, and 4) missing diagnostic errors. My estimate also includes death from hospital acquired infections. The magnitude of the estimate depends on knowing the limitations of the detection methods.

  13. Yes. Years ago not only did my primary care doc miss my thyroid cancer, once it had been “discovered” by my dentist when he saw a lump in my throat, my primary doc ordered archaic diagnostic testing instead of going immediately for an aspiration under ultrasound. By the time I had my surgery, I had had the tumor growing about 2 years. Lucky to be alive. And I continue to be disappointed in specialist who throw a few procedures at me but I get no symptom relief even though they have been given a hefty reimbursement for their procedures. I don’t think these doctors are careless or uncaring but our medical system is broke. We need to get rid of the health insurance companies who drain out almost 30% of all health care dollars into unnecessary costs (mostly to line a few executives pockets with outrageously high salaries and stock options). We need single payer national health insurance like the one proposed by HR 676. Switzerland is changing over from a Bismarck national health program to single payer. Sweden is beginning to swtich over from a VA or British style NHS to a single payer. It keeps the docs in private practice and just eliminates the unnecessary middlemen (insurers). Then we can have a saner system where people are more likely to get care that works instead of care that is covered by insurance so a doctor gets paid for it (whether it’s needed or not) and everybody can get care when they need it.

  14. I think it is important that we accept nothing less than excellence from our medical providers. The problem is that the level of ability in my Med School Class followed a bell shaped curve. There were some people in my class that I would have entrusted my life to without question, others well …

    And I think the strategies pioneered at Harvard and other prestigious colleges are key in our search for excellence. Apparently at Harvard (and other prestigious universities) the average grade is now a B+. If this continues, the average could become an A. In that case the students will have reached excellence!

    I would like to propose that doctors are graded in the same manner as Harvard (and other) students. By doing so, we will take a giant stride toward reaching the excellence we expect and deserve.

    As that great educational pioneer and reformer – the Wizard of OZ said to the Scarecrow:
    “I can’t give you a brain, but I can give you a diploma” (paraphrased)

    Yes, by demanding excellence, we can truly conquer the bell shaped curve of human ability. Just like Lake Woebegone, where: “All the men are strong, all the women are good looking and all the children are above average”

  15. Alas, unlike George W. Bush I did not go to Yale and Harvard

    But Atul Gawande (who is at Harvard) did call my book “required reading” for physicians. And, unlike platon20, he even spelled my name right. Of course, when you’re used to anonymous posts, the whole “name” thing might be rusty.

  16. Sounds like another blowhard post by an Ivy League academic “expert” who thinks he knows more about medicine than doctors do!

    True safety “experts” like Atul Gawande who is a real doctor who actually treats patients are people I take seriously. I dont take “experts” seriously who have never treated a patient.

    I love the story how Milliken “challenged” the nurses about antibiotic use when it was obvious he doesnt know the difference between a macrolide and a cephalosporin.

  17. When viewed from a change management perspective, this issue is about culture change. I reviewed social movements as models for the long-awaited change in our medical culture. I conclude that culture change is a complex and long-term endeavor that has political, economic, legal, organizational and behavioral components.

    Perhaps Medical Quality and Safety should be a new specialty with its own board certification. Then the knowledge base of evidence as well as the leadership skills will accumulate faster and the culture change can be sustained. Physicians are more easily led by other physicians; Quality and safety must be perceived as a core part of the culture of medicine and not as something added on.