OP-ED

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.

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Bill BestermannYanling YulegacyflyerKerry O'ConnellLisa McGiffert Recent comment authors
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Bill Bestermann
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Bill Bestermann

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… Read more »

Michael Millenson
Guest

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.

Yanling Yu
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Yanling Yu

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… Read more »

legacyflyer
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legacyflyer

Good points

I remain curious (paranoid)

Michael Millenson
Guest

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.

legacyflyer
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legacyflyer

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… Read more »

Michael Millenson
Guest

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.

legacyflyer
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legacyflyer

Because they are all reading from the same script.

Are they?

Michael Millenson
Guest

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?

legacyflyer
Guest
legacyflyer

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?

Kerry O'Connell
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Kerry O'Connell

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.

Michael Millenson
Guest

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.… Read more »

Lisa McGiffert
Guest

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… Read more »

john t. james
Guest

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,… Read more »

Kyra
Guest

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… Read more »