Monday 16 May 2016


Q. What do you call the chap who graduates bottom of the class in Med School?
A. Doctor.
This old joke is clever but not so funny. Especially if you reflect on a new report in the BMJ which suggests that medical error is the third highest cause of death in the US. I mentioned this at the end of a trilogy of pieces on compassionate usemedical hubris.and medical certainty. Here's a summary of the findings and suggestions for change. Mederror, at an extrapolated count of 250,000 US cases/year is a long way behind heart disease [615,000] and cancer [590,000] but a long way ahead of respiratory issues, accidents and strokes. Should we not be glad that Alzheimer's also features high on the list?: it means that your father has survived the other killers into old age.  As always, there is interesting commentary on Metafilter, from people are the coal-face or in the firing line and so have something relevant to say. Such as:

1) Of course Med-error is a large killer because US society (neither the doctors, nor the patients, nor the insurers) can stop itself picking at scabs. Insurers are paying for everything and passing on the costs to the insured whose tab is picked up by employers because individuals can't even afford the insurance let alone the real cost of medicine, let alone the cost of medical treatment. Every change from 'normal' has an intervention and the medical profession believes it can cure everything at least some of the time.  If every sniffle, every rash, every pain and every lump is swung at by one or many medical practitioners then some mistakes will be made.  Even if the proportion is small beacuse the doctoring is excellent, the volume will make error a large player in the statistics.

2) Let's look at the BMJ study critically, instead of accepting the credulous take on it by journalists who would like to make A Story of it. To one commenter it looks like the study is statistically flawed and therefore redundant.  If the statistical methodology is crap we can, along with Trisha Greenhalgh, move on to other matters without getting our knickers in a twist.  Without sound methods and sound statistics there is really nothing to see here.

3) In one study, a survey of 184 US hospitals found 38,000 definite and 3,300 possible errors but only 1,233 =3% of these had an adverse effect on patients. That shows that you can vary the dose or give the wrong drug and still not cause damage 97% of the time.  If getting it wrong has so little effect, is the corollary true - that the right dose and drug does pretty much nothing for you 97% of the time?  Is a large chunk of the medical bill only doing good for MegaPharm's shareholders?  We know that 50% of HepCV patients don't respond to the standard interferon-alpha treatment but they all get given it.

4) For safety's sake! can we turn [junior] doctors out of the emergency room after they completed an eight hour shift?  Let them get a couple of beers, a meal and a good night's sleep and come back 16 hours later refreshed. Sleep deprivation makes you angry, careless and make mistakes.  You wouldn't or shouldn't drive a car if you haven't slept for 24 hours, so don't think that you can make difficult decisions or carry out delicate procedures while dopey. Of course, if there's a train crash, everyone will work crazy hours until the emergency is cleared.  But routine 24 or 48 hour shifts speaks culpable bad management.

counter 4) The argument is made that doctors are made by experience and experience is delivered by hours at the coal-face. You can't clock up your 10,000 hours if you have to knock off and go home after every 8.  Having long shifts in emergency rooms means that you have to take responsibility for long-term care - you can't hand the patient over to the next guy with the insouciant thought that she was alive when I left.  On 36 hours shifts, when things take a turn for the worse, you know exactly what you did earlier - you don't have to scrabble through the notes left by the last doctor which may be unclear or incomplete.  At least electronic notes means you don't have to read their handwriting!

5) In a litigious society like the US or Ireland, it is financial damaging to admit error, so nothing is learned from mistakes because they didn't happen. I particularly like the phrase"even discounting defensive sophistry on the hospital's part" when the system closed ranks to prevent a family finding out what went wrong. That is a continuing theme in a recent series of medical misadventure cases in Ireland that involved children. No amount of compensation can bring the child back to the bosom of its loving family - but a full and frank investigation might prevent the loss of another child from the same cause. That's what the parents want: a memorial.

6) An interesting critique of EHR electronic hospital records, which are designed to make the doctor's job easier and make sure s/he doesn't forget some vital test.  It's a mighty checklist, which my surgical pal Mac fingered as being all glossy optics which can cover bad practice,  But most EHRs are just a tsunami of information pulled in from the path.lab., the patient's general practitioner, the CAT scan facility, and the pharmacy.  These things are designed by designers not doctors so you get possible contra-indications listed alphabetically (why?) rather than by severity. Another beef is that the software allows the harrassed and time-short doctor to import yesterday's report for today's, rather than having to write out the same-old-same-old again.  Doctor's get into the habit of doing this without editting the import - so that the patient is much improved much improved much improved for days on end but never gets actually better.  The EHR, is deconstructed / exposd: not as a mechanism to promote efficiency but as a means to record everything . . . so that it can be billed.

Don't worry! It may not happen; probably won't happen to you because you're younger than me. Most of those 250,000 medical errors happen to old folks whose time would have come soon anyway. As I suggest in 1) above almost all your lifetime experience with medicine occurs in the last three months of your life.

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