Josef Stalin famously said: one death is a tragedy; one million is a statistic. Perhaps 250, 000 preventable deaths from medical errors, according to an analysis by Makary and Daniel in the BMJ, maketh a Stalin.
The problem with Makary’s analysis, which also concluded that medical errors are the third leading cause of death, isn’t the method. Yes, the method is shaky. It projects medical errors from a series of thirty five patients to a country of 320 million, which is like deciding national spice tolerance on what my family eats for dinner.
The problem with Makary’s analysis isn’t that it is full of assumptions. Assumptions are inevitable in biomedical research, and abundant in health services research. Researchers of medical errors must determine whether a bad patient outcome, such as death, was avoidable. Bad outcomes lie in a spectrum between inevitability and preventability. If every death is inevitable doctors are rendered impotent, and if every death is avoidable doctors are rendered omnipotent (FWIW, I prefer omnipotence).
Researchers of medical errors don’t have perfect information. They don’t know the clinical context. How can they? They were not there. They must assume and set their default assumption – which means that the researchers must choose between erring towards calling a bad medical outcome avoidable or inevitable. Err they will. But if they must err in their adjudicating error they must err systematically, because the scientific method, the measuring instrument, demands consistency. Even though reality is arbitrary, stuck between reality and science, the researchers are compelled to choose science.
Systematic erring by a measuring instrument scales the error it makes. Yet, the problem with Makary’s analysis isn’t the estimation of deaths attributable to medical errors. Yes, 250,000 deaths a year from medical errors is alarming – that is 28 deaths an hour, or a death every two minutes. At their most murderous, ISIS decapitated 28 Ethiopian Christians along a beach in Libya in one morning.
I’m not attempting dark humor by conflating ISIS and medical errors. I would not jest without observing that patients are not flocking to Palmyra in the arms of ISIS – the lesser of the two quantitative evils – to escape hospitals. I’m pointing out – I hope successfully to the satirically challenged – the absurdity of using morally relativistic hyperbole to convey the gravity of medical errors.
If it wasn’t emotive enough comparing the toll of medical errors to a jumbo jet crashing daily after the Institute of Medicine (IOM) report, To Err is Human, medical errors have been likened to serial urban genocide, and even the holocaust. Metaphors and similes can literally be dangerous with people who are literal. And it’s unclear that those who resort to hyperbole aren’t being literal.
Unmoored quantitative reasoning places rationality absurdly close to stupidity leading to egalitarianism of death – stripping death of context – giving a resident who ruptures the aorta from a misguided intra-aortic balloon pump insertion the same moral vector as Jihadi John making snuff movies.
Hyperbole is seldom helpful. Hyperbole creates resentment in patients who have been harmed, which surely isn’t the intent. But hyperbole also tunes out doctors because the comparisons are so egregious that they becomes parody. Medical errors lose gravity precisely because overzealous safety advocates elevate them to a frightening level of quantitative seriousness, even though the intent of hyperbole may be to receive more funding from the public purse, rather than to demonize physicians.
Makary’s numbers may well be very bad numbers, but if the number of preventable deaths is 25, 000 a year – how would things be done differently? Would you say – “that’s a preventable death every twenty not two minutes. Thank God”? Which takes me to the problem with Makary’s analysis. The analysis is problematic not because it is wrong. In a sense it is not even wrong. It is problematic because of what it implies.
Makary’s analysis, indeed other analyses of medical errors, implies that death is an anomaly. That once the doctor intervenes, death is optional. At what point death ceases to be deferrable is anyone’s guess. So when physicians fight death until the patient’s last breath – the cause of much indignity in people’s last week on this planet – it is because we (doctors and patients) think death is abnormal.
The authors narrate a case in which the patient post-transplant died from a bleeding hepatic pseudoaneurysm because of a pericardiocentesis which breached the liver. Was not this an error? Should the cause of death not be medical error? The answer is yes, in a Newtonian sense. But the structural assumptions and corollaries of this conclusion lie in a Twilight Zone where profundity and parody coexist.
If medical errors are causative, if medical errors are a disease, if the American hospital is the most dangerous place on earth after Hotel Rwanda, then it follows that a sensible precautionary measure to avert this dangerous entity is to abstain from it and let nature take its course. Contradictions are replete in the Twilight Zone.
The IOM estimated that 98, 000 deaths were attributable to medical errors – Makary’s estimate is over twice that, one analysis says it may be ten times. What is going on, Have doctors become more ten times more incompetent? Given the billions spent on quality and safety how is it we suck even more today? Were hospitals safer in 1950 than 2016? Is the intensive care unit the greatest scourge on mankind since syphilis? Is the balloon pump a proxy of danger – like a Kalashnikov – or does it signal something else?
The greatest paradox of medicine is that the more lives it saves the more responsible it becomes for not saving lives. The sicker and frailer the patient, the more invasive lines and tubes they have, the more likely they are to benefit from the intensity of treatment, and the more at-risk they are to medical error. You’re at greatest risk from medical error when you have most to lose from no medical care. At death’s door medicine is both your friend and foe. Antibiotics can save you from death from sepsis or kill you from toxic megacolon from pseudomembranous colitis. The antibiotic is both Florence Nightingale and Chengiz Khan. It is our failure that we have not articulated this paradox to the public at large.
The goals of the safety movement are noble. There are serious medical errors and seriously incompetent doctors. But collapsing all errors, regardless of the degree of seriousness or preventability, to integers to enable easy arithmetic is injustice to those who have truly been harmed. Doctors should certainly strive to be better. But better is an aspiration. And to make doctors better, and healthcare safer, it surely is better encouraging professional pride than inducing professional guilt.
To be fair, I can’t single out the safety movement for moral relativism of death. Egalitarianism of death is the zeitgeist – after all, a death is a death, isn’t it? The excess deaths from flecainide post myocardial infarction, before CAST put that practice to rest, has been quantitatively likened to the Vietnam War.
“Dying” and “saving lives” have lost all meaning. Republican Governors were accused of causing death by not expanding Medicaid. By which logic, the FDA are mass murderers every day they delay approval of life-saving drugs, and 20 % (i.e. the relative risk reduction of screening) of women who die from breast cancer for skipping mammograms because they listened to the USPSTF’s recommendations should put cause of death: USPSTF. And denying statins to an expanded constituency of 33 million Americans, assuming an NNT of 100, kills 37 people an hour, putting ISIS to quantitative shame.
There’s no moral distinction between death from action and death from inaction. Chengiz Khan stared at his victims before chopping their heads. With statistical deaths neither the murderers nor their victims know each other.
I’ll leave future anthropologists to explain how Homo sapiens at the zenith of rationality lost the plot. For now I must my express my strongest objection to Makary’s analysis. He says that medical errors are the third leading cause of death. I disagree. Given the optionality of death, the inevitability of death, and the omnipotence of physicians, medical errors are surely the number one cause of death.
About the author:
Saurabh Jha is a radiologist and a contributing editor of Healthcare Blog. He can be reached on Twitter @RogueRad
You have misinterpreted the data in that article completely. The number you quote is a base statistic. There were at least 180,000 deaths in 2016 from Medicare patients alone; and you are not extrapolating accurately. The actual number of deaths from preventable medical error is approximately 440,000; and the number of patients that suffer “serious harm” due to preventable medical error is between 4.5 and 9 million. Get your facts right. But there’s little else I can expect from a physician.
And the lesson is:
Stay away from doctors and hospitals.
These scolds need to get some attorney friends. The law has been dealing with this negligence problem for hundreds of years. It has come up with the concept of “proximate cause”.
[my dad was a judge]. To find the proximate cause is the law’s way of assigning guilt or accountability when negligent or other wrongful actions are litigated. There may be other ways too.
There are two parts: 1. You say “if not, but for ____( the action is put in here)______, this would not have happened.”
2. Then you say “given ____(this set of facts)___, we can predict a likelyhood that this (bad result) would happen.”
Eg. 1. ” If not but for Mr. Smith’s car going through the stop light against the signal at a high speed, his vehicle would not have struck and killed the officer.”
And 2. “we can predict that Mr Smith, whose blood alcohol level was .2 mg% and who was not wearing his corrective eyeglasses would get into some problem drivng his vehicle.”
“These scolds need to get some attorney friends.”
Not sure which side you’re on?
Typical erudite but somewhat confusing takedown. Well done.
We visited this issue last fall before Makary tortured these data, again. That post and the discussion that followed remains highly relevant:
I agree that the subtext of the study is that death is optional, and that we are incompetent idiots who can’t manage a single patient without killing them–esp. a volume overloaded kidney transplant patient in rejection who is alive by the very interventions that can easily cause death. The patient would have died on Serengeti centuries ago.
The problem is that as a society, we don’t know when to stop with the interventions. The more interventions, the more chance for an inadvertent error. “Do everything you can doctor to save the life!!!”. I asked the chief cardiologist “why are we doing this,” once in a CCU setting w/a cardiac transplant patient on a balloon pump, dialysis and finally a bypass machine to keep him going until some miracle would occur–tubing and machines everywhere–obstructing the path to actually examine the patient. I was summarily scolded that the discussion wasn’t appropriate for us to be holding with the family. Predictably, the patient started bleeding from all mucous membranes and expired within 48 hrs. Of course, it was all that heparin! A medical error!!
I want to know who paid for that transplant, the post op care and management, the pharmacology–all of it. I want to know how much cocaine the victim snorted first. I’m not joking here. If we’re going to inject moral relativism, we need to know the background of each story, and this is impossible. The millions spent on futile end of life care–or past the expiration date–would fund free statins or vaccines for decades to entire continents. The choice is here, no longer because there’s a financial pie to divide, but it’s now a cookie.
“The problem is that as a society, we don’t know when to stop with the interventions.”
Pesto, what criteria would you tell “society” to follow?
I would tell U.S. “society” to replicate the Western European cultural mentality of not imposing unreasonable costs and expectations on their fellow citizens especially with respect to end of life care. For good measure, their less litigious tort environment would be worth emulating as well if we want to lower healthcare costs or at least slow its growth rate.
“I would tell U.S. “society”…”
U.S. society doesn’t like to be told.
No society should ever be “told”, the author starts out with a quote by Stalin, and look how well that went…I have observed that economics more than anything else shapes behavior. The insane spending during the last few months of life, by Medicare, is what I’ll stick to since it’s what I see as a physician. Everybody gets the full court press at death unless there are living will witnesses, DNR/DNI orders, and/or intelligent communication. No, your 96 year old demented mom is dying and she will not get dialysis for life ( 1 week). The baby boomers’ parents are living longer and longer and the boomers are used to getting what they want, when they want it, especially in the guilt ridden scenario of what to do for Mom.
Obama, though I loathe him, in his defense tried to broach the issue and got shot down by Palin with the death panels’ meme. I say, we sorely need end of life, SANE discussions on this topic.
I would offer that each beneficiary must be owner of their own Medicare funds, and they would direct their own care according to their means. If we’re going to inevitably compare to France, let’s go there. First, immediate tort immunity to every physician treating Medicare patients on the Medicare dime. Medicare savings accounts, with the patient in charge, with lifetime spending caps–and what he/she puts is what she gets, plus a match from employer taxes or a catch up phase, the actuaries and such can work on this. Truly tax free until death, and passed on to heirs’ tax free. End Stark rules–doctors can own the lab and the hospital, and treat whomever they want, or whoever wants to be seen, as they are the truly at that point the patient and the consumer. A rheumatology hospital? Done. A cardiac only hospital? Done. Open the friggin’ market! And end the paternalistic, only-we-know-best attitudes from hospitals, tertiary care academics, and the central planners in government.
“and they would direct their own care according to their means.”
So wealthy people get the full court press and poor people are told they don’t have the money to prolong care?
“immediate tort immunity”
Interesting comment in a topic on medical errors.
“I say, we sorely need end of life, SANE discussions on this topic.”
Yes, but convince the “christian reich” on that. How about an economic incentive to create a living will. What if the will says – “spare no money to keep me alive”?
A will can say “spare no expense”, but the procedure party would go on until the money runs out. No heir will go bankrupt caring for Mom.
The more interventions, the more chance for errors, it’s a cumulative add-on effect. And it’s a situation of damned if you DO (to cover the legal ass) and damned if you DON’T (to cover the legal ass again) so tort immunity in caring for government insured persons would eliminate a substantial chunk of cash. Make no mistake, the defensive medicine costs are huge and never discussed because the attorneys themselves wrote PPACA, so fuhgeddaboutit.
There is already a double standard in our country. You can have an outpatient surgery at a plush center with excellent service and hushed tones, and be offered a warm blanket upon awakening from anesthesia–if you pay the facility up front and have a PPO that at great cost covers such service. Or you can go to the county hospital where you’re at risk for MRSA and see vomit stains on the curtain separating you from the other (combative) patient. It’s here right now.
Do “the poor” own Bentleys? Do “the poor” have any incentive to keep their health care costs down, i.e. not running to the ER for every sore throat? No. Do you have a limitless credit card when you enter a store? No. We need established government cost limits, right now it’s a limitless buffet where Americans gorge on pills and interventions, and cigarettes and illegal drugs–no doubt we can prolong a heartbeat, but in the end, the outcome is death. Again, we all die. This is verboten to address. These heroic procedures at the end of life–and doctors can tell when it’s the end–are inhumane and futile and I will even venture to say, experimental in nature to have researchers and residents learn on the poor (at teaching hsopitals, for example, where Medicaid is the credit card esp at Johns Hopkins). And if you’re too poor and you can’t afford a transplant, society and government funds cannot foot your bill. This has to be the only way. Economics will ration care.
I do see more hospice advocacy locally, the very sick or old, are realizing that they will be tortured on ventilators and pumps near the end and if they choose to go peaceably with their loved ones at home, they can. But they have to declare this when they’re of sound mind and somewhat healthy. And some poor souls move to Oregon so they can choose suicide without being harassed by the anti Dr Kevorkians.
I believe private charitably run hospitals should flourish, like Shriners or St Jude’s if there no government maw to constantly feed. I believe “free” care can exist if there is no JCAHO, MOC, EHR, ACO, MIPS, etc to distract from the role of true healing.
“Or you can go to the county hospital where you’re at risk for MRSA and see vomit stains on the curtain separating you from the other (combative) patient.”
Is that where you’d want your mother to go?
“I do see more hospice advocacy locally”
Medicare pays for hospice.
“and doctors can tell when it’s the end–are inhumane”
Do you prompt your other docs to have the end-of-life talk? Does your hospital have a policy on this? How do you fight for this? At my wife’s hospital the docs DO have the reality talk to parents of hopeless premies.
I don’t think health care should be determined by your wealth. The wealthy eating up unending care is just as wasteful as anyone else. But I always chuckle when I see Republicans bitching about government support while they belly up to the Medicare/SS subsidy.
Some hospitals “encourage” end-of -life talks, most don’t because the more procedures, the more they make from Medicare and Medicaid, hence a big conflict of interest.
As a private individual of course I discuss with colleagues, some agree, some don’t. I can’t force others what to do or say, no more than you.
The wealthy eat up more of everything, simply because they have money. Accept that and you’ll be able to engage in debate, no matter what your belief is. I’m offering creative ideas to the tangled mess of excessive interventions, excessive errors, waste of money, OUR money, federal funds–everywhere. Read: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2862687/
Something like 25-30% of Medicare spending is on the last few weeks of life–what a gigantic waste.
“The wealthy eat up more of everything, simply because they have money. Accept that and you’ll be able to engage in debate”
Health care is not cars, houses or gourmet restaurants. As soon as you separate the richer folks from the health care system the poorer folks get ever increasing marginalized, underfunded care. If we can unify on something it should be health care.
I’m not arguing that EOL care is expensive and usually unnecessary, it is also for the wealthy. I just think we need a better way to get people to create living wills, if you can fight the hysteria of the obsessed faithful.
Peter — Maybe suggest is a better word that told.
Pesto Sauce — In your experience, what percentage of Medicare patients get the full court press at the end of life and has it changed any over the last 5-10 years? Do you think it will change in the future in the absence of other changes in the system?
It isn’t just the deaths. The #1 primary coded ICD9 has been “sepsis.” By a considerable margin over #2. Obviously, not all sepsis originates in the hospital, by a longshot–but there are also plenty of sepsis cases that are not primary-coded if they are coded at all, and plenty of errors that are not sepsis.
Still for sepsis to be #1 and no one has commented on this, is huge. Obviously this is a big problem.
You’re missing Makary’s larger point if you focus on the numbers to discredit him.
“Currently, deaths caused by errors are unmeasured and discussions about prevention occur in limited and confidential forums, such as a hospital’s internal root cause analysis committee or a department’s morbidity and mortality conference. These forums review only a fraction of detected adverse events and the lessons learnt are not disseminated beyond the institution or department.”
Nurse accidentally kicked the respirator cord out of the socket – cause of death on death certificate was respiratory failure. Not listed as a medical error.
I listened to a discussion on this “study” and the least of the discussion were the numbers. Just because death is inevitable does not mean it wasn’t hastened by the medical care of lack of. Perpetrator’s defense – “Your honor, he would have died eventually.”
But now we really don’t know as most of the “errors” are hidden in the medical fog of cleaver reporting.
Respirators are very difficult to accidentally unplug with your foot–have you done this with your TV when it’s on? Or washing machine? Same gigantic machine with the rear to the wall and all the digital setting in front where they can be seen.
Also, that would be a NURSING error, not a medical error. Whoever makes the mistake owns it.
But isn’t someone on a respirator, by definition, being kept alive artificially? We have legions of people living longer but with zero quality of life. Facilities full of demented vegetables. In France they start the sublingual morphine when the shortness of breath has no end in sight in a COPD patient, there is no respirator for them. You will never see an octogenarian rolling around Rheims with their scooter and nasal cannula/canister of oxygen. They’ve long shuffled off the mortal coil. And less admissions to hospital means less medical error reporting all around. Win-win for France.