In 2003, the British philosopher – Onora O’Neill – gave a series of lectures on the philosophy of trust – A question of trust. I am currently reading these lectures in book form – but all the lectures are available on the website.
She has many interesting thoughts on the importance of trust. What happens we lose trust in institutions or professions?
She argues the trust in the professions is decreasing (here she includes the police, teachers and physicians). She does point out that this trust decrease does not seem to have had a practical impact on our desire to use those professionals when necessary.
In her 3rd lecture, she makes this point –
The new accountability is widely experienced not just as changing but I think as distorting the proper aims of professional practice and indeed as damaging professional pride and integrity. Much professional practice used to centre on interaction with those whom professionals serve: patients and pupils, students and families in need. Now there is less time to do this because everyone has to record the details of what they do and compile the evidence to protect themselves against the possibility not only of plausible, but of far-fetched complaints.
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In theory again the new culture of accountability and audit makes professionals and institutions more accountable for good performance. This is manifest in the rhetoric of improvement and rising standards, of efficiency gains and best practice, of respect for patients and pupils and employees. But beneath this admirable rhetoric the real focus is on performance indicators chosen for ease of measurement and control rather than because they measure accurately what the quality of performance is.
The now famous IOM report on medical errors – To Err is Human had as a goal to improve medical care. The authors, honorable though they are, contributed to decreasing trust in our medical institutions. Many have debated the validity of this report, but few would debate the negative impact this report has on perceptions.
In reflection , I wonder what motivated the IOM panel. Why did they release the report in such a dramatic fashion? I assume they would argue that they wanted to “shake up” the institutions. But have they done more good or more harm.
We all strive to improve medical care. We want to do the best for our patients. I personally believe that this report caused more harm than good.
Even if the report is 100% accurate (and many critics suggest hyperbole reigns in their estimates), the authors did not consider all the potential impacts of such a report. Or perhaps they did and did not care about the negative impacts.
{ 11 comments… read them below or add one }
I am continually amused at the fundamental cause of the massive overstatement of iatrogenic deaths in the IOM report. They reviewd deaths and then looked at any medical error in the hospitalization leading up to the death, no matter how insignificant, and then counted that death as “caused” by the error. How amazingly egotistical to think that what we do matters that much! Skipping a dose of antibiotics is as bad an error as giving a lethal potassium bolus? Please. The hubris is unbelievable. Hell, most of what I do in the ICU hasn’t been proven (by randomized, double blinded studies) to matter AT ALL. Believing that you can determine a patients fate if only you do the unproven interventions EXACTLY “right” is faith-based medicine at it’s most pathetic.
As a concrete example of the fallacy I give to you a case in point: 73 year old lady admitted with fall down a flight of steps, massive intracranial bleed, essentially 100% fatal but the family wants to “give her a chance.” We keep her alive on the ventilator for a week or so and she gets pneumonia (essentially routine in long-term vent patients). I prescribe Unasyn and instead she gets Zosyn (an antibiotic that covers all the same bacteria plus some others). The mistake is id’d after the first dose. She gets put back on Unasyn and gets over her pneumonia. A week later the family accepts that she is never going to wake up and withdraws support (the ventilator) and she dies. This gets counted as a “medical error related death” in the IOM report.
The 100,000 number was hyperbole designed to make a name for the authors, pure and simple.
Excellent example.
Lay people don’t realize the complexity of care nowadays, and the often unrealistic expectations of family.
how can u trust…?
- when ur treated like a puppet
(compare ur last restaurant experience with trip to high-priest doc)
- when that bowl of jello will end up costing $75.67
(1000% markup is not a business model its robbery, see Costco 15% markup on all generics including drugs)
- when credentialing is not open
(cartel-style artificial scarcity)
- when wait times r sooo Soviet bread-line
(thats the cartel again)
- when informatics and microfluidics are emerging
(diy health…. dont be fooled into thinking any biology major doc has intuition about what a false positive vs true negative really means- when surveyed most think chances of having a disease is just the accuracy of the lab test itself- so go engineered patient/consumer empowerment)
-when McClinics and overseas health are emerging
(now i just want an insurance package targeted at a market segment, say small business, that will tie it all together with low deductibles… there are a few offerings in Europe- i’m sure underwriters will pick up the risk state-side soon enough)
-when “save the children” really means collect the rent
-when u dream of the day that docs are treated no different than detectives, engineers, teachers… ie the rest of society that works hard, responds to market forces, contributes to meeting of minds, and takes on risk/innovate if they desire greater rewards.
chow
Most laypersons aren’t even aware of reports like the IOM. I wasn’t, and I pay attention to this stuff. Many of us have lost faith in doctors after direct experiences. I know I did. My long story as briefly as I can put it: Two heart attacks misdiagnosed as panic, three more correctly diagnosed, all brought on by medication reaction–I have variant angina/cardiac spasm, no blockages, and react badly to beta blockers–a cardiac arrest when I was taken out of CICU too early, and no one responded to THREE calls for help before I finally died and had to be revived. And this was a good hospital. And I’m a nice patient, even. I’m not really all that difficult a gal; I’ve even been known to make doctors laugh.
Perhaps I had too much faith to begin with. Had I been more questioning I might not have taken the drug that began the whole mess, given for borderline hypertension; I didn’t really think it necessary, as I was undergoing severe stress at the time and figured it would resolve once things had calmed down. But I trusted my doctor. I don’t blame him for not knowing I’d have the reaction–there was no way to know. But I did quickly lose trust in his practice as they dismissed my chest pain as panic, and then in the cardiology team as with the best of intentions they bungled my case time and again.
To this day no one will tell me what happened to me. I’ve had to dig it up with my own research. No one on my medical team believed what I found out about beta blockers and my situation until the week of unstable angina that ended with my cardiac arrest. Now they believe me. It’s amazing how dying focuses one’s medical team.
I sympathize with doctors under siege by malpractice cases and reports like the one you describe. My uncle is a doctor who was unfairly sued.
But.
As long as the medical profession insists on putting itself above the rest of society, above question and reproach, it only encourages a high level of faith that can only be disappointed in the end.
Um, Lynn your entire reply obviates your final paragraph. How can we “put ourselves above question and reproach” when you are clearly questioning and reproachful, when the entire blog entry was about a report which actively exposes the profession (I believe unfairly) to calumny? I’m sorry you had a lousy experience. But you should realize that none of what happened to you would have been classified as an “error” as per the IOM report in my understanding of their methodology. Errors in diagnosis are difficult to determine and classify. So your post essentially reiterated the point that the IOM report sucks.
A problem with the IOM estimate of the number of medical errors is that it is based on a model. The debate about the validity of the number could be lessened by directly counting the medical error rate.
Take wrong site surgery as one medical error and try to find its error rate. Not easy. There is an article which has this error rate and is quite interesting – Kwaan MR, Studdert DM, Zinner MJ, Gawande AA Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006;141:353-7; discussion 357-8. This is the same Gawande who writes for The New Yorker.
> the real focus is on performance
> indicators chosen for ease of
> measurement and control rather
> than because they measure accurately
> what the quality of performance is.
This happens at first in every profession — we do at first what’s cheap and easy regardless of whether its particularly useful. I have long experience in computer programming — one of the first performance (productivity) metrics for programmers was “source lines of code per hour”. The metric does not take into account the difficulty of the problem at hand. In medical terms, the SLOC metric isn’t acuity-adjusted.
What bad metrics do is motivate improved metrics. Quality metrics will also help to figure out what we mean by “quality”. Personally I think we’re misusing the term “quality”. Pirsig was right about quality — to attempt to define it is to destroy it. We need other language.
> the number of medical errors is [...]
> based on a model
Right. Models are not evidence. Notwithstanding, we’re going to spend trillions to stop man-made (or is that model-made?) global warming. Nary a peep is heard from so-called scientists because it would stop the gravy-train they’re all jumping on. Sound at all familiar?
I do not mean to argue that we should not monitor process compliance or that we shouldn’t try to link process variation to outcome variation. We should expect compliance. But it is also true that non-compliance observed along with a poor outcome does not imply causality.
t
Lynn S may have never heard of the IOM report, but anyone who watches Oprah Winfrey listened to her stating that medical errors killed as many Americans as a jumbo jet crashing once a week for a year. Cultural icons like Oprah are never asked for their sources or evidence backing up their assertions. Undoing the damage will take….what?
Undoing the damage is impossible. “A lie can travel ’round the world before the truth can get its boots on.”
Once the media repeats something enough perception becomes reality. I just like whining about it though.
Regarding Oprah…
It’s just math. 98,000 deaths per year (the IOM number) = 1,885 deaths per week, which would be more than 1 jumbo jet per week.
Recommended:
Trust in a Medical Setting. Hauppauge, NY: Novinka Books, Nova Science Publishers, 2006.
Experience dealing with a host of difficult to impossible situations may help others in their encounters with these difficult and distrusting patients. These individuals may make up a small per cent of patients and family members, probably less than 2 per cent, but take up 90 per cent of energy in coping with day-to-day conflicts that arise from their behavior. Difficulties managing distrustful patients and family members must be dealt with on the spot, and they don’t go away.
Examples come from office experiences or wards, including situations that keep doctors and nurses and therapists awake at night, aggravate waking hours and poison leisure, that is, empirical, based upon experience and observation alone without science or theory. To survive an outrageous patient or relative requires resourcefulness, patience and imagination. Street wisdom learned the hard way is what I present, and without a guide or mentor to soften the bewilderment and sense of failure and frustration that accompanies these individuals. We seldom talk about these difficult, distrustful and sometimes threatening individuals amongst ourselves; rather we suffer and endure them silently, by ourselves. The problem is timeless as recorded in the world’s literature.
Out of the wreckage of human behavior comes valued experience leading to maneuvers and tactics of survival that are appropriate to almost all aspects and settings of human interaction including day-to-day medical care.
Links:
http://www.novapublishers.com
richardsmithmd.com