On Medical Errors and Mistreatment

For most of his life, my father was at the pinnacle of good health. He loved to travel, golf, and spend time with his family, and he rarely slept more than five hours a night.

But within a few years of retiring from his dental practice, and seemingly out of nowhere, my dad started feeling uncharacteristically tired. A team of skilled physicians diagnosed him with hemolytic anemia, a condition in which healthy red blood cells are destroyed. A surgeon removed my dad’s spleen to reverse the problem and, from a technical perspective, the procedure was a success. But the doctors made one critical mistake—the type of medical error that kills hundreds of thousands of patients every year.

Without a spleen, my father was at risk of developing severe infection from the Pneumococcus bacterium. Every one of his well-trained doctors in New York, where he spent half the year, and in Florida, where he spent the other half, knew he needed the pneumococcal vaccine. But the doctors in Florida thought the ones in New York had administered the vaccination, and the ones in New York assumed his physicians in Florida had done so. In the end, no one had.

If these clinicians had used a comprehensive electronic health record (EHR) or simply communicated more effectively with each other, my father’s premature death might have been prevented.

Nearly two decades ago, the Institute of Medicine (now the National Academy of Medicine) reported that 98,000 people die in hospitals each year because of medical error.(1) New research from Johns Hopkins University concludes that the true mortality statistic from avoidable medical error exceeds 250,000 each year when you include hospital-acquired infections, medication errors, and failures of communication.(2) And this figure does not include omissions in preventive care, failures in cancer screening, avoidable complications in patients with chronic disease, or the multiple lifestyle epidemics that kill hundreds of thousands more a year, such as cigarette smoking, opioid abuse, and obesity.

The Paradox of Patient Care

Our nation ranks dead last in the latest Commonwealth Fund report on healthcare performance.(3) Comparing the 11 wealthiest countries, the United States spends considerably more on its healthcare while consistently placing at or near the bottom of the list in nearly every measure of quality, from life expectancy to childhood mortality.

And yet most patients describe the quality of care they receive as “good” or “excellent,” and believe the United States enjoys the best medical care in the world, even if too expensive.

This is the fundamental paradox of American healthcare. On one hand, patients and doctors marvel at our cutting-edge interventions, pointing to spectacular advances in the treatment of highly complex conditions. On the other hand, hundreds of thousands of Americans die unnecessarily each year from preventable problems.

Contradictions like these are what led me to write Mistreated: Why We Think We’re Getting Good Healthcare—and Why We’re Usually Wrong (PublicAffairs, 2017). In the book, I explain how America’s healthcare system most closely resembles a 19th-century cottage industry, with its fragmented structure, lack of useful modern technology, and piecemeal reimbursement methods—what we call “fee-for-service.”

These are systemic and structural problems, not individual ones. Rarely do problems arise from a lack of physician knowledge or dedication. Most doctors possess the skills and desire to do the right thing for their patients. Unfortunately, the environment of American healthcare makes doing so almost impossible.

One-third of physicians report being depressed. More than 400 commit suicide each year.

Today’s healthcare climate is taking a toll on doctors. One-third of physicians report being depressed. More than 400 commit suicide each year.(4,5) Within the walls of American medicine, the frustrations of doctors and the mistreatment of patients can be traced back to a subconscious process in the human brain that distorts what we see, experience, and do.

Understanding how the context of our healthcare system alters perception and behavior offers insight into the systemic transformation needed to reduce medical errors and increase patient safety.

On Context, Perception, and Behavior

Decades of psychological literature demonstrate the mind-altering effects of the circumstances in which we find ourselves. Think back to Philip G. Zimbardo’s Stanford Prison Experiment, that classic study from the 1970s wherein normal, healthy students were randomly assigned to play the role of wardens and prisoners.

Within 48 hours of the experiment, the jailors perceived their prisoner counterparts as dangerous enough to warrant a series of debasing punishments. The group assigned as prisoners perceived the wardens as sadistic and barricaded their “cells” to prevent further harm. Although the participants “knew” their fellow volunteers were students, the context of this simulated jail caused a shift in their perceptions, leading to behaviors none of them could or would have expected.

Zimbardo’s goal was to make incarceration more humane and rehabilitative. But within six days, and with the safety and psychological well-being of his students compromised, the professor was forced to abandon the experiment.

Recent brain-scanning studies support what psychological experiments of the past have determined: in circumstances that elicit fear or offer major reward, our minds undergo a shift that causes us to see the world around us in ways that contradict objective reality.

This neurobiological process offers a lens through which to view the failings of the American healthcare system. How doctors think and act has as much to do with the context in which they find themselves as it does their personal morals, ethics, or desire to do the right thing.

Dozens of research studies have observed physician behaviors in the typical hospital, finding that more than 30% of the time doctors fail to wash their hands when going from one patient’s room to the next. This can lead to the spread of Clostridium difficile, a bacterium estimated to infect 400,000 people each year and cause 14,000 U.S. deaths annually.(6) To prevent this behavior, every physician takes mandatory classes on infection control and the vital role that handwashing plays. There isn’t a doctor in the country who would fail a test on the devastating consequences of C. diff. transmission or the importance of hand hygiene. And of course, no physician wants to harm a patient. And yet it happens. Brain science tells us why.

While running late for the office, or wanting to see a new consult, doctors feel rushed, triggering the fear centers of the brain and altering perception. In this context, they see themselves as incapable of carrying the bacterium. The conclusion is neither conscious nor logical, but what people know and what they perceive differs in the face of fear and reward. This same kind of perceptional shift—the kind that leads to potentially harmful choices—happens to doctors across the nation.

The Four Pillars of Transformation

Learning from researchers such as Zimbardo, who have the power to affect human perception in negative and destructive ways, I believe we can modify the structure, financing, and technology of medical practice in a positive way, to achieve better outcomes for patients.

As I detail in Mistreated, the transformation of American healthcare into a more ideal system will depend on four pillars of change:

• Healthcare will have to be integrated, both horizontally within specialties and vertically across primary, specialty, and diagnostic care.

• It will have to be prepaid, moving away from pay-for-volume toward paying for value and superior outcomes.

• It must be technologically supported, with comprehensive EHR systems, patient access to medical information, and the ability to obtain care using mobile and video technologies.

• Finally, healthcare will have to be physician led, which will require greater leadership training and development.

Of course, such changes will not be easy to accomplish. But the best integrated health systems have already instituted them, and their quality scores lead the nation, resulting in significantly lower patient mortality rates for heart disease, cancer, and sepsis within these care settings.

What Hospital Administrators Can Do

Hospital leaders need to understand the power of perception and, based on this, change the way they educate physicians.

Across this country, administrators and regulators have put in place online modules designed to improve patient safety and infection control. The problem, as we have seen, is that these courses do little to modify behavior. Instead, leaders need to understand the power of emotion, and replace these intellectual solutions with the real-life stories of patients.

Most physicians care deeply about the lives they touch. As the hand-washing anecdote reveals, however, the doctor’s lack of time leads to a subconscious shift in perception, thereby increasing the risk of medical error. Lecture physicians on the dangers of hospital-acquired infections, and little will change. Bring in the family of a patient who died from such an infection and the doctors will lean forward in their chairs.

Facilitating the successful implementation of the four pillars of transformation begins with understanding this neurobiological process. For example, knowing doctors are pressed for time, administrators should seek ways to make the EHR easier for clinicians to use. Knowing doctors will perceive prevention as more important in the context of prepayment, hospital leaders can move their institutions and the hospital-based clinicians away from a pay-for-volume reimbursement model to one such as capitation, which rewards value. Recognizing that physicians who are integrated into a single medical group see the other doctors as teammates, not competitors, administrators may wish to promote a more collaborative approach and help create accountable care organizations.

What Individuals in Healthcare Can Do

Understanding how our minds work can be useful at the individual level as well. For physicians looking to curb medical error, this means stopping to ask whether their decisions and actions are, in fact, scientifically based or merely a reflection of the reward and fear centers of their brain.

Following Patient Safety Protocols

How we practice medicine should be based on published data, yet doctors tend to value intuition over science. We believe that if the last patient did not become infected when we failed to wash our hands, that the next patient also will be fine. Even when evidence from peer-reviewed medical journals and hospital data reports indicate the need to change our practices, we resist. As a result, we skip steps, whether during the “time-out” in the operating room or in obtaining the blood lactate for a patient who does not look overly sick but could have sepsis.

One would expect that a doctor working in a facility with a higher hospital-acquired infection rate would want to learn from and emulate hospitals with much lower infection rates. But that is not what usually happens in the context of fear and reward. Instead, people are likely to question, rather than learn from, the data. And because physicians rely so heavily on their own judgment and skill, the pace of improvement in our nation’s overall health remains slow. Accordingly, The Institute of Medicine estimates that it takes 17 years for a major clinical advance to become standard practice.(7)

Understanding Our Brains When We Feel Overwhelmed

Time is a precious asset, as valuable as money. When we lack the time necessary to complete tasks, we experience anxiety. This fear distorts what we see and how we behave, independent of conscious thought.

Consequently, we might omit the required steps when inserting a central-line catheter or fail to follow the protocols designed to reduce hospital-acquired pneumonia. We deride checklists as “cookbook medicine” and refuse to recognize the superior outcomes of those who follow them. Once we become aware of this subconscious phenomenon, we are more likely to slow down and adhere to these life-saving techniques.

Getting Out of the Specialty Mentality

The lack of a comprehensive medical record prevents specialists from focusing on prevention. Its absence, likewise, makes physicians who care for hospitalized patients less likely to know what care their colleagues are providing or what medications they are ordering for patients. As a result, patients suffer unnecessarily from preventable diseases, complications of chronic illnesses, and even lethal drug interactions.

On morning rounds, we focus on the specific organ system in which we are trained and do not take the time to ensure the patient’s care is coordinated.

The Real But Painful Solutions

Our nation’s hospital system is broken. It was designed back when transportation was slower and in-patient costs much lower. As a result, we have too many hospitals that lack the patient volumes necessary to maximize physician expertise and generate the quality outcomes patients deserve.

In Silicon Valley, for example, there are 10 heart surgery programs, three of which perform fewer than 300 cases a year. If we combined these three lower-volume facilities, as nearly every other sector in the American economy would, the improvement would be undeniable. Surgeons would gain valuable experience, nurses would bolster their expertise, and operating costs would plummet. Best of all, patient health would improve.

High-volume hospitals around the world have demonstrated what is possible. They are the subject of numerous case studies. And yet half of the orthopedic surgeons doing total joint replacements and half of the OB/GYN surgeons doing hysterectomies do not perform enough of their respective procedures to enable them to achieve the best outcomes.

Putting the Pieces Together

Hundreds of thousands of people die prematurely every year from medical errors, failures in prevention, and avoidable complications of chronic disease. Meanwhile, the feeling of fulfillment, once intrinsic to the medical profession, is crumbling.

It doesn’t have to be this way. We need to change the context of American healthcare in order to change the perceptions and behaviors of its workforce. Mistreated was written with the hope that once we understand what is possible, all of us—doctors and patients—will want it and then demand it.

Changing the structure, reimbursement and technology of the healthcare delivery system will be painful for institutions, individuals and communities. But it will be worth it.

In the future, we will need more primary care physicians, and fewer hospitals and fewer specialists. We will need the manufacturers of EHR systems to open their application programming interfaces to third-party developers who can connect the disparate systems. And we will need physicians to use comprehensive EHRs, scientifically based algorithms, and proven protocols to avoid medical error, maximize prevention and reduce the complications from chronic disease.

The “knowing–doing” gap is our biggest challenge today. By changing the context of healthcare, we can close that gap and elevate the quality of American healthcare. And when we do, hundreds of thousands of lives will be saved, and my father’s death will have served a purpose.

References

1. Kohn LT, Corrigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, Institute of Medicine; 1999.

2. Makary M, Michael D. Medical error: the third leading cause of death in the US. BMJ. 2016;353:i2139.

3. Schneider E, Sarnak D, Squires D, et al. Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care. The Commonwealth Fund. 2017:5.

4. Mata D, Ramos M, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. JAMA. 2015;314:2373–2383.

5. Center C, Davis M, Detre T, et al Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003;289:3161–3166.

6. Lessa F, Mu Y, Bamberg W, et al. Burden of Clostridium difficile infection in the United States. New Engl J Med. 2015; 372:825-834.

7. Balas E, Boren S. Managing clinical knowledge for health care improvement. Yearbook of Medical Informatics. 2000:65–70.