Medical Errors – The Third Leading Cause of Death in America
The Third Leading Cause of Death in America
Many of you have read the recent study by Johns Hopkins researchers that showed medical errors are now the third leading cause of death in America. Deaths from medical mistakes – some 251,000 people per year – are outnumbered only by deaths from heart disease and cancer. Medical mistakes have become a national epidemic.
Reasons for medical errors: I am going to explore some of the factors that have led to so many medical errors. But before I do so, you will need to understand the differences between private medicine and academic medicine. Most of your exposure to doctors has likely been in private medicine. And it is private medicine that has suffered the greatest damage from the changes in our healthcare system. This means that we will all need to rely increasingly on academic medicine to get the specialty care that we need.
Academic Medicine vs. Private Medicine: When many of you were children, you had a General Practitioner (GP) or local doctor who took care of your family. Your doctor was likely a kind and dedicated person, but his level of training was relatively limited compared with doctors who had trained at modern academic medical centers. The old GPs were, in effect, the pioneers of private medicine.
Over time, as medical education improved, the number of well-trained doctors in the country increased. Good internists and specialists who trained at the best medical schools left the academic world and opened private practices in the community. These doctors, however, practiced with an academic mindset and set a standard of care, which was on par with many university medical centers. For example in the 1980s, cities like Tucson had an excellent group of private internists and specialists. These doctors took care of their patients from the office to the ICU. The quality of care was superb. There were few medical problems that required a patient to leave Tucson for a higher level of care in another city.
Attacks on Private Medicine: One of the laws of nature is that as soon as you have something worth having, someone or something is going to try to take it from you. To opportunists in the insurance industry, and to politicians looking to centralize the control of medicine, private medicine was a big target. Controlling private medicine, where most people got their care, represented an opportunity to siphon off huge amounts of money for insurers. For politicians, it represented a way to buy votes from people who believed that the government could do things better and that the system was intrinsically “unfair.”
With the rise of healthcare costs to businesses, the HMO executives offered to take control of medicine and lower costs. Of course, this turned out to be a ruse. The real motive of the HMO middleman was to ration care for profit. By paying doctors less and limiting the choices of patients, there was a lot of extra money in the pot, which created windfall profits for the HMOs. HMOs never did anything to improve medical care. To the contrary, they damaged it. Though the HMO industry was unsuccessful in its ultimate goal to takeover medicine in the 1990s, private doctors and local hospitals were severely weakened by their battles with this industry.
Additional attacks on private medicine came in the form of powerful oligopolies; namely, the large insurance companies and large national hospital corporations. The trial lawyers did not help either. By the time Washington created the Affordable Care Act, many private doctors were already so demoralized and weakened that they finally gave up on private practice. Many of the new rules and regulations of the ACA made it financially impossible for private doctors to stay in business. The cards were stacked against them by the government. For example, hospital-employed doctors were allowed to charge more for the same tests done by private doctors.
As national hospital corporations consolidated their control over hundreds of community hospitals, they began controlling medical practice itself. They set policy and even determined the composition of the medical staff. For example, administrators hired out-of-town-doctors through national physician staffing organizations to take the place of private doctors in the community. Local ER doctors and hospital doctors who had practiced in Tucson hospitals for years were suddenly told that they’d been replaced.
Doctors Used to Control Medical Quality in Hospitals: Private doctors used to be responsible for maintaining the quality of medical care in community hospitals. I know this because I held leadership positions in Tucson hospitals. As a private doctor, I was elected by my colleagues to serve as the Chairman of the Department of Internal Medicine, Director of the ICU and Chief of Medicine at St. Mary’s Hospital, a 400 bed community hospital. I led committees that examined medical errors in the hospital and investigated what went wrong and why. In those days, the administrators at St. Mary’s had nothing to do with medical practice. They were not allowed to make decisions that directly impacted patient care. It was the administrator’s job to keep the lights on and to run the facility. Medicine was the doctors’ turf.
Now, decisions like selecting an electronic medical record system for physicians is the sole decision of hospital administrators. Decisions that very much affect the quality of medical care in our local hospitals, or the way that doctors work, are made by business people with no medical expertise, located thousands of miles from Tucson.
External Pressures on Private Medical Offices: In the outpatient setting, the private doctors who have decided to stick it out have been burdened with an increasing load of new clerical duties; things that take precious time away from practicing medicine. Doctors have been forced to participate in a new and complex billing system, which has been mandated by the federal government and insurance companies. There are now 70,000 diagnostic codes that doctors must sift through just to get paid for their services. Doctors must type their own electronic medical records, as opposed to using a more efficient transcription service. This is why some of your specialists have their noses buried in a laptop when you see them. Time previously spent caring for patients and reading medical journals is eaten up doing meaningless clerical work.
Studies have shown that on average, the electronic medical record has added an additional 2 hours of clerical work to every doctor’s day. Instead of leaving the office at 6 PM, the doctor now leaves at 8 PM or he takes his computer work home with him. Think about the impact of adding 2 extra hours of uncompensated clerical work to every doctor’s day. Said another way, this mandate has added an additional 10 hours to every doctor’s work week or an additional 40 hour work week to every month of his life. Where is this time supposed to come from? In many cases, that time has come from the hours that a doctor previously spent reading and doing continuing medical education. Reading is the most important activity for any doctor. It is the only way for him/her to remain competent and current.
Learning from Medical Errors: All people make mistakes and there is no way to create a mistake-proof system. However, physicians used to have forums in which to learn from their collective mistakes. During my training at Cornell, we had weekly morbidity and mortality conferences. Cases were presented in which medical errors resulted in a bad outcomes or death. The doctors who made these errors stood up and presented their cases to dozens of other physicians. Colleagues would ask questions and make judgments about how those errors could have been prevented. This was painful for the doctors who made the mistakes, but this process improved patient care. It made us all more vigilant. With the malpractice crisis, those conferences disappeared. Mistakes are no longer discussed.
Loss of doctors: As a result of the ACA, many doctors have retired early, quit medicine or sold their practices to become employees of national hospital corporations. As you’ve no doubt read, Dr. Peter Rhee, the esteemed chief trauma surgeon at UMC, just announced that he is leaving the University after the hospital was taken over by Banner Health, stating publicly the hospital is “no longer a positive environment for me.” I’ve stopped counting all of the excellent specialists that have already left Tucson, both in private practice and from the University. And each time we lose a gifted physician, each time we lose a great doctor, there is a void that cannot be filled. The entire community suffers.
Non-physicians practicing medicine: Once you have devalued doctors and have taken away their professional decision making authority; once you have defined them as just another part of the labor force, it is a very short step to decide that they can be replaced with a cheaper form of labor. You can then start replacing doctors with nurse practitioners or physician assistants at a lower cost. Many Tucsonans who end up in the local ERs are now seen by nurse practitioners instead of doctors. The ER staffing companies do this because it is cheaper to hire nurse practitioners than it is to hire doctors. The Veterans Administration just announced that they plan to allow nurses to treat veterans instead of doctors. I’m sure this will go a long way to improve the already disastrous medical care that has become the hallmark of VA medicine.
The result of using lesser trained individuals to do the work of physicians will necessarily result in more medical mistakes. How could it be otherwise? There are certain roles in which a nurse practitioner is helpful. However, nurse practitioners and medical assistants are not doctors – anymore than paralegals are attorneys. And as the physician shortage worsens, you will see more and more nurse practitioners and physician assistants doing the work of doctors.
The Biggest Problem of All
You now understand that there are many external forces that have adversely affected medicine and have made patient care, especially in private medicine, more dangerous. However, there is an unrecognized epidemic that has infected many doctors. This disease has paralyzed doctors and allowed private medicine to be destroyed with barely a whimper.
Learned Helplessness: One of the fundamental reasons that doctors have lost control over the medical profession, and hence lost control over their lives, is a behavior first described by psychologist Martin Seligman in the 1964. Dr. Seligman did a series of experiments on dogs, which examined how animals respond to uncontrollable stress in their environments.
Seligman placed dogs in cages and administered 5 second electrical shocks to their feet through a metal floor. Before each shock, a sound would be emitted as a warning to the animals. The dogs learned to associate this sound with an impending shock. One group of dogs had a lever they could push with their noses to stop the shocks. They learned to control their suffering. The other group of dogs had no stop-shock lever, so there was no way they could control their suffering. The sound would come, followed by a shock and there was nothing the dog could do about it.
The following day, a second experiment was conducted in which dogs from both groups were put into a different kind of cage. These new cages had a short wall, which all of the dogs were capable of jumping over to escape a shock. The experiment was designed so that when the dogs heard the sound signaling the impending shock, they could jump out over the short wall and avoid any suffering. Of the dogs that had learned to stop the shocks, all of them quickly jumped to safety as soon as they heard the sound. However, the dogs in the other group, which had not been able to control their pain, behaved helplessly. Two-thirds of those dogs just lay on the metal floor, accepted their shocks and whimpered – even though they could have jumped the short wall to safety. Seligman concluded that these dogs, through repeated painful experiences that they could not control, had learned to become helpless.
Learned helplessness is a well-described behavior in human beings. We see learned helplessness in battered women. We see it in abused children. And what human research shows is that when people are unable to control their suffering, they also become clinically depressed. They lose the energy to fight. They give up. They surrender.
Suffering Doctors are No Different than Suffering Dogs. In spite of all of the time, money and effort doctors have put into their education and careers, many have simply given up. Many survived the HMO movement, the abuse from insurance companies, the low reimbursement rates from Medicare and law suits. However, the final shock was the ACA, which has led to the complete surrender of most private doctors. What it surprising is that doctors’ relatively high IQs, their extensive education and their problem solving abilities have not inoculate them against the disease of learned helplessness. In this way, they have fared no better than the dogs.
There are now 12,000 doctors in the U.S. who have jumped the short wall of their insurance cages and have opted to practice concierge medicine. There is an escape route for private doctors, but most choose not to take it. This is classic learned helplessness.
How to Get Good Care in a Failing Private Medical System: So how are we to survive this unraveling of the private medical system? Where can we get the care that we need, while minimizing the risk of medical errors? The best you can do in the year 2016 is to try to establish care with a doctor in your community who is your diagnostician and your medical advocate. You should see this person promptly for medical problems, so that issues can be addressed before they become bigger problems. And when your doctor determines that you need a higher level of care than is available in the community, you may need to go to one of the academic medical centers in the country that has been able to insulate itself from the predatory third-party system. These are institutions like the Mayo Clinic, UCLA, and MD Anderson.
When my patients have a problem in an area where great specialists are in short supply, I do not hesitate to recommend that they travel elsewhere to get the best of care. I find the most experienced doctors in the appropriate specialty and I make the arrangements so that my patients can get what they need. Let’s hope that these facilities remain independent and that they do not fall under the control of large hospital corporations. Let’s hope that these centers of excellence have the leadership and the survival skills to continue to insulate themselves from the forces that have destroyed private medicine. Because if we lose these great institutions, if we lose the academic medicine centers, it will truly be the end of American medicine as we know it.
And one final word to the wise: If you want to maintain your sanity, do not wish for that which you want, but know you cannot have. We all wish that we could have back the excellent medical system we had 10 years ago in Tucson. Many communities across the nation feel the same way. But this is not going to happen. The system is not coming back. Accept this truth, do what you need to do to stay healthy and be thankful that you have the financial resources to travel to centers of excellence when the need arises. Comfort yourself with the knowledge that you are very fortunate indeed to understand the problem and to know how to solve it. Because most people who end up sick in a community hospital will not know what is happening to them. And even if they understood the problem, they do not have the financial resources to get better medical care elsewhere. This is indeed ironic, since the stated purposed of the ACA was to provide excellent healthcare to everyone. We now have a stark two-tiered system, in which everyone – rich and poor – is likely to get mediocre or even bad care in community ERs and hospitals, while only the wealthy can afford world-class care at academic medical centers.