National reporting isn’t the answer to reduce medical errors

Two articles recently addressed medical errors.

In the Wall Street Journal, surgeon Dr. Marty Makary discusses the alarming costs of medical errors and offers suggestions to improve the system. In medicine, particularly during the training years of residency and fellowship, young doctors are not given the opportunity or security to report shortcomings of their superiors.

As discussed in the article, all of us have a memory of a particular surgeon or clinician who was not very proficient at his or her specialty but was allowed to continue practice due to perceived national or international academic prestige or reputation. Dr. Makary offers up solutions that he believes will decrease error rates including: publishing hospital scorecards online, installing cameras for peer review, open notes and eliminating the culture of “gagging.”

As part of national training requirements, all teaching hospitals are required to have a regularly scheduled morbidity and mortality (M and M) conference for housestaff. These meetings typically consist of a case presentation by a trainee where the outcome of the hospitalization was sub-optimal and the deficiencies in care are debated and discussed. The focus of the best conferences is always placed on the central question of “what could we have done differently to change the outcome?”

Unfortunately, these conferences (although required attendance by the housestaff is standard) are not well attended by faculty. Much can be gained from actively discussing cases and learning from the experience of others. In practice, there are standardized peer review processes that are in place in hospitals today. These are very different from the M and M conferences from training. I have served on QI (or quality improvement) committees at numerous hospitals over the years. These committees are made up of very diverse specialists and primary care doctors. Unfortunately most of these committees stop short of dealing with real physician deficiencies.

Often, letters are issued and cases are discussed with little or no penalty or constructive criticism provided. Most often, the QI committee responds to complaints about promptness and appropriateness of emergency on-call care–particularly after hours. Only once in my tenure on these committees has true competency and clinical skill been addressed. Many of the cases are brought to the committees attention by competing groups and the motivation for the reports can be called into question. Much of what these committees do is done so that the hospital can remain accredited and remain in compliance with government regulations.

In reality, physicians need to work together to improve care and reduce errors. Government regulation as suggested by the Obama administration’s creation of an error-reporting system for consumers and reported on in an article in the New York Times is not the answer. Many consumers may interpret poor outcomes as errors in care when in fact no error occurred. Many times, disease may “defeat” even the most skilled physicians. A national “reporting system” as described in the Times, may ultimately lead to increased liability concerns for both hospital systems and physicians alike. Certainly, lapses in care and medical errors must be tracked and addressed in order to save lives, health care dollars and improve overall quality. However, the practice of medicine is an honorable profession with a long tradition of excellence in the US.

Most physicians see the practice of medicine as a privilege. As such, we must all take responsibility to maintain high quality care throughout our profession. Thorough, unbiased evaluations of care need to be undertaken in both teaching and non-teaching hospitals if we are to impact medical error rates and reduce healthcare costs. Dr. Makary has several important suggestions — we must continue to hold medical professionals to high standards of care. Transparency of care and physician decision making is a must. Video critiques can serve as a great learning tool.

As we did in the M and M conferences in residency, we must continue to discuss cases formally with colleagues and both give and receive feedback and constructive criticism. All physicians, no matter how well funded or respected, must be held accountable for the care that they provide. By working together as a team, we can all reduce errors and improve care.

Ultimately, both patients and doctors will benefit.

Kevin R. Campbell is a cardiac electrophysiologist who blogs at his self-titled site, Dr. Kevin R. Campbell, MD.

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  • karen3

    I so wish that I could post attachments. First, Kevin it is so insulting to waive off the seriousness of patient harm by the swish of “but it’s a misunderstanding.” Many respected entities, using physician reviewers, have found an epidemic of preventable medical harm. To minimize that harm by saying that patients are misunderstanding poor outcomes as errors. There is no misunderstanding. Medical error is the third leading cause of death in this country. If I were a doctor I would be ashamed of my profession.

    Clearly, status quo solutions such as QI and M&M do not work. There was an M&M on why my mother was left without treatment for 31 hours for a spinal cord injury. The hospitalist who chose to treat her, over the phone, for constipation instead, clearly should have been fired. But he continued, and then oversaw a massive overdose of steroids for my mom. When one of the doctors and I confronted him about his incompetence, he thought it was hilarious. A wonder, funny joke. After we fired him, Dr. Death showed up again, this time presiding over discharging her with lung cancer, without note to anyone. Hospital administration viewed that as the most expedient solution when we demanded a new doctor (again) M&M’s don;t work.

    As to the supposed “honor” of the medical profession, I give you this. My mom was starved (no advanced directive, no documented terminal illness) for over a week on the orders of an attending. That means NO NUTRITION in case you think I am “misunderstanding” the situation. The hospital’s records are clear as can be that Mom received no TPN, feeding tube, no food by mouth, nothing. The cardiologist who oversaw my mom having a heart attack due to hypokalemia apparently chose to do nothing about the lack of nutrition, but instead saw the dollar signs of a procedure opportunity. The residents and nurses who documented her starvation on literally an hourly basis had no conscience. The pulmonary attendings from the same practice as the doc who ordered the starvation had no conscience. And my dad was pilloried by the hospital staff for firing Dr. Starvation when he came back after the end of the week, demanding dad to agree to unnecessary procedures or he would have mom sent to hospice to die. Sick bastard needs to be in jail.

    And you think risk of medical liability is something that is a negative???? Cry me a river. The only thing a decent percentage of your profession cares about is money. That is the motivator and that is the only way you will reach someone like Dr. Starvation or Dr. Death. Oh, and Dr. Cancer, who documented that mom had lung cancer and decided not to tell us. She transferred to another state. Her new employer apparently had no concern that she was on her fourth attending job in three years, in three different states. I bet when they get hit with a malpractice case for the next patient she kills, they wish that there had been a registry that was honest.

    The medical profession has utterly failed in policing itself. Incompetent doctors and incompetent. Patients deserve to be safe. They deserve that the physicians who treat them are competent.

    Finally, whatever “honor” there is in the medical profession, it most certainly does not extend to hospitals, which are big business and most often about profit. We spoke with the head of the hospital where mom was, stating that her care had been so poor as to constitute criminal neglect — stage IV pressure ulcer, horrific bruising, starvation, neglect of multiple medical conditions, medication overdoses, and eventually an unexplained black eye while in the sole care of a hospital sitter. His response was that mom was getting “great care.” Seriously, with hospital administration like that how can you expect that anything would work right? An M&M ain’t gonna fix that. Without a doubt, hospital personnel know that their institution is a failure. M&Ms are confidential. Patients should have warning about facilities like this — it is not right to hide that information from the public under the guise of peer review. Would you think it right to deal with a company that is producing poisoned food to be dealt with in a “peer review” process, because farmers are “honorable.” Or would you support an FDA recall?

    Instead of slamming Dr. Makary’s solutions and downplaying the seriousness of the problem, you should be applauding his efforts to speak the truth, and to advocate for real solutions.

  • Robert Luedecke

    Medical errors are at epidemic proportions in the US. It takes more than just critiques of colleagues and “trying harder.” Thousands of people die each year in the US because of preventable errors. We are all human and imperfect. The story which best helped me understand is to look at nuclear power plants. If the error rate there is .0001%, it sounds great unless a nuclear explosion happens with each very infrequent error. Their error rate is the lowest because they have systems in place to double check and prevent catastrophes, not just because they have very careful people working there. Those who have done great work on this are Dr. Atul Gawande and the American Society of Anesthesiologists. We very much need their approach of designing safer systems.

  • buzzkillersmith

    Medical errors, oh such terrible things. And yet life expectancy continues to increase….