If you spend anytime with the medical industry you soon realize the issue.
I helped launched (the now deadpooled) Theil backed MetaMed a few years -- essentially a private research team for medicine, and what the founders taught me was astounding.
That things like amputating the wrong limbs, doctors not washing their hands and killing you by infection and a horror of other preventable errors are shocking common.
This didn't even take into consideration that things discovered in labs that might cure you take at least 30 years to reach the doctors who might implement them, if they ever do.
The distortion of hubris from doctors, economic incentives and other systemic issues results in a "health care system" that doesn't realily seem to do what it sets out to do -- we spend 10x what some developing countries do per year per person with no better outcomes.
Accute care seems to be reasonably good, fixing a broken arm, etc. (assuming they don't accidentally remove it); but chronic care is often just a pipeline for the recurring revenue model of big pharma (at best).
The examples are never ending but for fun, take a google to discover how many pap smears are performed annually on women who have already had their uterus removed - then consider the cost to insurance and tax payers.
I often think that the medical industry enjoys (or suffers) from some sort of a given god complex. They can do what they want as soon as they reach a certain threshold of saving. Nobody will debate them (most of us don't have the articulate knowledge anyway) and will morally and existentially satisfy from still being alive.
I just went through 4 doctors (gen. and specs.) about deep yet diffuse cardio vascular problems (life altering if not threatening). Their diagnosis was "nothing to see you are depressed". Since my problems started I can't sleep on my right side (causes heart race, pain and suffocation), and have now back pain; in order to sleep without pain I tried on my stomach. This configuration changed something, I felt stings around my heart, and a sudden relaxation, warm blood reaching my fingers and feets (something I didn't feel for a year). Stings moved along, hurting at finger and toe tips. I felt sweetly alive, jumped out of my bed (because now I can). Even cleand my browser tabs. So much for depression.
I tried discussing with doctors calmly. Accepting the data, their knowledge. Yet not backing down if I felt they weren't really solving my problems. But it's impossible. One doctor even dared me to reproduce transient symptoms with an annoyed tone. You start considering being hypercondriac, a crybaby.
Deep down all I want is a way to monitor myself deeply so I can take care of myself but I'm facing this paywall.
I'd do a few things. First, keep a journal for 30 days. pick a few criteria up front, what you eat, physical activity, amount of sleep, and the events you're having seems like a good base.
Second, talk to a psychologist. Follow up that diagnosis. Maybe you are depressed, but maybe the cause of the depression is the pain you're in. Maybe you're not depressed at all. Having that diagnosis will cut off that set of probabilities, and force your doctor to move down the list to less likely possibilities.
Third, maybe get a heart rate monitor, and track that for a few nights. If your heart rate does shoot up to 150 while you're lying down (sometimes) you'd want your doctor to come up with a good explanation for that.
Fourth, perhaps most important, try going to a teaching hospital. It's much much better to have several residents with something to prove thinking real hard about your problem. Get several eyes on your case at the same time.
Think like a scientist. Accept you don't know what's going on, talk with your doctor about what the possibilities are - ask your doctor to assign probabilities to those possibilities. Come up with a plan to work through the list from most likely to least likely. Accept that maybe it is depression, rule that out so you can work further down the list.
Your doctor is just a person, maybe they're having a bad day or a bad year. That's fine, but you still need their expertise to get an answer. Don't contradict, but ask why they think X is most likely, and what's the best way to resolve or rule out X. They may not want to work with you, but you can certainly work with them.
At the end of the day, you want to feel better. I hope you can find someone that'll help solve that problem.
Interesting methodology. Obvious too, but when these kinds of thing happen your mind goes astray and it's hard to keep being organized.
I didn't log anything but I was quite precise and trying to isolate things. Went on a clean diet right away. Tried to find what activity would get me in stable condition, since failing cardio is a vicious circle, I wanted to find a minimum amount of things to keep the machine active without further injury.
Someone suggested your 4th idea. By the time he talked me about it I was a bit lost. I even tried to talk to a hospital cardiologist, the secretary looked at me like I deserved to be in a mental institute.
I tried all I could to ensure discussion, but all the time, they look at me like a poor thing that needs a mood pill, because after all my BP is fine, and I could walk to him so why am I worrying. It's so difficult to find someone that looks at your problems. And to go back to the original topic, medicine is slow to evolve (as expected) and still too invasive. To investigate one told me I'd need a coronarography which is not a trivial exam. There's no in between for them, even though some have access to more recent tools (ultrasonic artery check, instead of echocardiogram, which doesn't take coronaries in account).
ps: at the 4th doctor, I did cave in and accepted anti depressant. It did relaxe muscles for a few days, leading to smoother blood flow. It didn't cure me of my problems, it just made me suffer less for them. The last night event had more impact on my health and mood than 6 months of visits and treatments. Medicine is hard, it's complex, people are human, these guy makes an important and difficult job dealing with pain and problems all day long, I don't deny that. That said, medicine needs to evolve, and I feel they're too satisfied [1] with their result to really reach the best.
[1] surely other factors are responsible for sub par health. Economy, politics, sociology, education... I'm not ignoring this too.
I'm not a doctor, you should follow your doctor's advice. I do have a couple more things to consider.
First, contact a psychologist, like talk therapy. They'll be able to back up or reject a depression diagnosis. Sure, it's possible it's all imaginary, but stuff like imaginary pain usually happens with amputees. Something happening that's a big deal. They'll also be able to provide some support in dealing with this whole mess. It's nice to have someone say, yah, you're not crazy, you're in a crazy situation and that would frustrate anyone.
Second, lots of anti-depressants have to build up to work. it takes weeks for them to have any sort of effect, and you should taper off of them. Read the details about how the one they gave you is supposed to work. It's not really surprising you felt better for a couple of days, you felt like you were making progress. Perhaps you were a little willing to overlook things that would worry you.
Maybe go back to doctor four after talking to a head shrinker. A therapist can help you express what you need from doctor 4. "I feel like i'm following your advice, but my other doctor and i think my depression (if you're even depressed, which seems like it hasn't been nailed down yet!) comes from the feeling that i'm not being taken seriously and current treatment doesn't seem to work very well." I'm trying X but X doesn't seem to be a complete solution, what else can we do?
In any case, things suck for you right now. You are not powerless, and i'm sure you'll find a way to make things better. You're on a tough road right now, i'm sure you have friends and family that care about you, and will support you through this struggle. If nothing else, there's a random internet stranger that is rooting for you.
Don't give up! I was told the same thing you are depressed. Doc even wanted to push meds on me. Took months of seeing specialists but ended up getting a real diagnosis which required a major surgery. Now I'm finally better but you have to work within the system which means finding a good doctor.
Sleeping on your stomach often helps problems with sleep apnea, which is often something that isn't something patients know they have.
If you stop breathing in your sleep, it can make your body enter a "flight or fight" state that makes your heart race and adrenaline rush through your system. It also decreases o2 saturation and the poor sleep quality negatively impacts daytime mood and concentration.
Consider getting a sleep study, at least to rule that out as the root cause
It's worth noting that many developed world's medical systems have a problem with the acute-chronic gap. Remember that pretty much all systems grew out of acute care - as a result, nearly all of them are quite good at it. But one of the problems with increasingly good acute care, as well as general increase in public health is the rise of chronic care issues.
The sheer inefficiency and ineffectiveness of America's chronic care is not alone. Here in Canada, it's pretty clear that our system strains when put up against chronic care.
There's certainly a lot to fix, but as you've pointed out, doctors are a huge component in the current system that has the change. This points to the fact that somehow we need to engage and get buy in from them.
One of the things that I'm always wary about when reports like this come out is that while they present a wonderful opening into engaging with current stakeholders, it's also very easy to put current stakeholders on the defensive, and have them quickly adopt a us-vs-them mentality, something that certainly is not conducive to change.
> There were 15.892m total hospital admissions in 2014/15, 31 per cent more than a decade earlier (12.102m).
(Not all of those will be surgeries)
and:
> In 2015, across Hospital and Community Healthcare Services (HCHS) and GP practices, the NHS employed 149,808 doctors, 314,966 qualified nursing staff and health visitors (HCHS), 25,418 midwives, 23,066 GP practice nurses, 146,792 qualified scientific, therapeutic and technical staff, 18,862 qualified ambulance staff and 30,952 managers.
tl;dr - The US has similar "sentinel events" that are decided upon by a not for profit Joint Commission organization that accredits health facilities across the US. Failure to "respond" to a sentinel event and make meaningful attempts to prevent future occurrences can jeopardize a hospital's accreditation. Hospitals voluntarily report "most" sentinel events to the Joint Commission so their data is explicitly not usable for frequency/trending over time.
To add additional info on the subject, the US employs a similar concept (and name) to "sentinel events." Relevant to surgery, this includes:
"Invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure"
"Unintended retention of a foreign object in a patient after an invasive procedure, including surgery"
More broadly, sentinel events are generally defined as:
"a patient safety event...[that] results in any of the following:
Death
Permanent harm
Severe temporary harm" (1)
Outside of surgery, there are around a dozen additional, specific events that are always deemed to be "sentinel events." This includes forms of assault, abduction, unauthorized departure (i.e. the medical team has not yet discharged the patient) leading to patient death/harm, and specific, highly avoidable outcomes due to standardized procedures such as blood transfusions, too much bilirubin in newborns, and prolonged radiation. (1)
These sentinel events policies are guided by the Joint Commission in the US, a not for profit organization that guides many patient safety initiatives and accredits health facilities in the US. At least for hospitals, site visits are unannounced around every 3 years. (2) Failure to gain/maintain accreditation, among many outcomes, threatens a hospital's ability to participate in Medicare/Medicaid as the Centers for Medicare & Medicaid Services (CMS) considers the Joint Commission a national accrediting organization. (3) Revenues from Medicare + Medicaid are generally essential for the solvency of a high majority of hospitals in the US - in 2013, the national average was ~58% of hospital revenues (4).
Hospitals are "strongly encouraged" to report sentinel events to the Joint Commission but it remains voluntarily. Thus, the Joint Commission's data is available but explicitly not "an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time" (5)
However, hospitals are "required" to respond to a sentinel event through a comprehensive analysis and planning to prevent future occurrences. If the Joint Commission becomes aware of an event during a site review or other means that was not addressed in compliance with the lengthy review policy required, then the facility will risk its accreditation status. (1)
(Post often references "hospitals" but applies to many health facility types.)
> "health care system" that doesn't readily seem to do what it sets out to do -- we spend 10x what some developing countries do per year per person with no better outcomes.
It's a for-profit healthcare system. It does exactly what it sets out to do. Spending 10x more without having to deliver better outcomes is a success. If it could get 20x more cost for half as good outcomes that would be even more of a success.
Healthcare can never really be a consumer market without an acceptable, nearly-free-at-point-of-use baseline alternative or very heavy government intervention in its operation.
(The NHS is arguably at the other end of the scale, since it manages demand with triage and queuing. If your condition is merely uncomfortable and not life-threatening you'll have a long wait. It is, however, very cheap.)
Healthcare could easily get costs controlled precisely by being a consumer market. If we wrote the checks for our health care ourselves, and if there weren't laws against publishing prices for procedures, and insurance companies could operate in all states, then there would be tremendous lowering of costs in a very short time.
Pro tip: if you're going to have surgery, especially to have part of your body removed, use an indelible marker to write clearly on the operating site as well as the opposite side. Something like "remove this kidney" and "do NOT remove this kidney".
These kinds of metrics are almost not interpretable, for two main reasons :
(1) as logicallee has mentioned, we're getting better at treating patients and preventing death due to disease. The better we get, the more different treatments patients get, the higher is the risk of a medical error happening.
(2) it is very difficult to know exactly what proportion of "medical errors" are preventable. For instance, the seemingly "simple" case of healthcare-associated infection is far from simple, and except for a few cases (infection associated with elective surgery, and so on), there are NO known intervention to reduce risk further. I will give you an example: a patient needs a central catheter in order to survive. If we don't put it in, and he dies, he'll be classified as a "death due to primary disease X". If we do put a central line, and he acquires an infection (and a certain baseline rate of infection IS inevitable, because the catheter is indwelling and gets colonized by the patient's own flora), and dies 2 months later due to sepsis, it will be codified as "medical error". Adverse drug reactions are also codified as medical errors, even if the drug was administered in a life-or-death situation, when even the patient's ID was not known, even less his full list of medications (and thus, the error could not be prevented in any way). I could go on and on.
That being said, I also see stupid preventable errors like quietly giving the drugs to the wrong patient going unreported. Hospital stay is certainly dangerous.
Actually research shows that many central line catheter infections are preventable. The AHRQ and CDC have published best practices and checklists, yet many hospitals still don't adhere to those.
> many central line catheter infections are preventable
Again, of course some of them are preventable, and nobody's saying its OK to install central lines without putting gloves on, and so on. However, there is a baseline rate of infection which is not preventable, and will continue to happen. Check the Figures S1 and S3 in this recent study : http://www.nejm.org/doi/suppl/10.1056/NEJMoa1500964/suppl_fi...
> many hospitals still don't adhere to those.
What is the source ? As far as I'm aware, around ~ 90% facilities do have checklists -- I do not follow this literature closely, though.
Not accepting any failure as 'unpreventable' has long term benefits. Medical errors need not be any specific persons fault, the root cause may be poor understating of what's going on.
EX: It's generally accepted that people get sick going to the doctors office and being around sick people. Reducing this by installing UV lights is viable even if such illnesses where not any specific persons fault.
Of course, but those kind of reports do not make the difference between at least theoretically preventable events and those are related either to basic physiology or to dying people for whom the choice is between dying a little bit faster due to their disease, or lingering as long as they can, and dying due to a "medical error" all while taking 50 different medications concurrently.
I am especially irked by the constant airplane analogies. Healthcare is not comparable to an assembly line nor modern aviation. The checklists/verifications/pathways only work when you take pretty healthy people and you submit them to a standardized, elective, safe procedure. In those cases, errors are obvious, and the efficacy of any quality improvement method is easy to assess.
Unfortunately, in most cases, healthcare works like a completely chaotic, black box kind of system, in which the output can hardly be predicted with any kind of certainty. It is easy to get excited by "quality initiatives" which may improve the one tiny and unimportant outcome that we measure, all while not realizing the severe side effects it causes on other outcomes.
These studies do not prove that medical errors _caused_ these deaths. It proves that people who died had some sort of medical error in the weeks leading up to their death.
As it turns out, people who are going to die soon get a fair number of medical 'interventions', which means there are many opportunities for errors to occur. This inflates the error rate for these patients. But if we're talking about patients who are going to die very shortly anyway, did a nurse accidentally giving them a double dose of their evening antacid really hasten their death? Probably not...
This is not to say that there aren't preventable deaths due to medical errors. There absolutely are. But studies like this seriously inflate the numbers...
Isn't this simply because the US tries to run everything as a company or takes economics and legal above everything else? You can't do anything unless you make a profit or are completely legally covered (or can completely sue something/something out of existence). It's that the US runs on, and as soon as you get near something that doesn't work that way (i.e. infrastructure - a road needs to be good, it doesn't need to be cheap or legally covered) or that can't work that way (humans and health don't bend to the rules of law or economics) you're going to have a really bad time.
This. Recent exposure to the US healthcare/medical system has horrified me. The fact that it's majority for-profit enterprises and isn't equal-access leads me to conclude the US shouldn't be able to call itself a developed nation.
From the article:
He said that in the aviation community every pilot in the world learns from investigations and that the results are disseminated widely.
“When a plane crashes, we don’t say this is confidential proprietary information the airline company owns. We consider this part of public safety. Hospitals should be held to the same standards,” Makary said.
Seems like this number would be higher if they also included HAI's (healthcare associated infections, about 75K additional deaths): https://www.cdc.gov/hai/surveillance/
The WHO suggests by reducing HAI, the EU could reduce deaths by about 95K/year vs. US's 75K (actually normalizing by population makes the US's number look really bad..assuming stats apply to entire EU's pop of 508-ish million and the US's ~308 million).
I can't find in the cited study (original article) if they included hospital acquired infections like the WHO does. If they didn't then we've a lot of work to do. Likely will never be an issue though, unless we treat the med profession like any other professional service provider with the power of life and death. We need to open the books on investigations, share data publicly, and likely provide more oversight. Also...seems like a wonderful area where big data and ML could contribute to meaningful improvements...
1. Is there a metric similar to deaths per passenger mile in automobiles? That is, is it possible that more people go and stay at the hospital, more new kinds of diseases (which were considered incurable previously) are now being treated, even if people know it is some what futile? How much of the jump would it explain? How about the increase in the population itself?
2. From the word "now", we could infer a couple of things. It is possible that medical error itself has risen drastically (or not, depending on whether we have a good answer for 1), or just that treatment for whatever used to be number 3 previously - respiratory disease - has improved in recent times? It is entirely possible that medical error could climb further up and top this chart and still allow the possibility that medical care is actually improving.
3. From the article:
---------
Although all providers extol patient safety and highlight the various safety committees and protocols they have in place, few provide the public with specifics on actual cases of harm due to mistakes. Moreover, the Centers for Disease Control and Prevention doesn’t require reporting of errors in the data it collects about deaths through billing codes, making it hard to see what’s going on at the national level.
"The CDC should update its vital statistics reporting requirements so that physicians must report whether there was any error that led to a preventable death, Makary said.
“We all know how common it is,” he said. “We also know how infrequently it’s openly discussed.”
---------
There was a similar discussion a while back, about the topic of the coding of the cause of disease not being consistent and that it could be misreported. Before that situation is improved, shouldn't we be considering these kinds of articles from a more skeptical viewpoint?
I suspect this statistic is inflated by "failed to extend this person's life by another three weeks" type errors. A genuine medical error is one which creates a problem completely unrelated to the treatment or original health issue.
I wouldn't be surprised at all. Far more than most people realize, a lot of medicine today is focused on keeping people who likely have no hope of recovery alive for just another week.
Thank you. I find it bizarre that these days articles include text such as "Their analysis, published in the BMJ on Tuesday" without providing a link, even though the article is sadly paywalled.
I know that each of these deaths is a tragedy, but if we turn back the clock to an era of polio, TB, cholera and malnutrition it is amazing to find doctors preventable mistakes in the top three.
Yes it needs fixing, but it also needs a quiet fist pump in the same way more people die from obesity related diseases than starve to death.
It's the very definition of a first world problem.
Their analysis, published in the BMJ on Tuesday, shows that “medical errors” in hospitals and other health-care facilities are incredibly common and may now be the third-leading cause of death in the United States — claiming 251,000 lives every year, more than respiratory disease, accidents, stroke and Alzheimer’s.
Title of article omits the "may". I hope someone is able to review their report and data.
Just an anecdote but on a subreddit I sometimes browse there's two MDs who boast of sleeping only 3 hours per day.
And then on the financial incentives side of things, at this point practice insurance might be so robust that it might not be so risky any more to end up committing a medical error while working those extra 3 to 4 hours per day might mean you're making enough money to retire in your early 40s.
> working those extra 3 to 4 hours per day might mean you're making enough money to retire in your early 40s.
The only way you could retire in your 40s as a doctor these days is if you were already independently wealthy before becoming a doctor.
If you go into medical school today, you're looking at finishing off your student loan payments in your 40s (depending of course on which school you go to, where you do your residency, whether you do a fellowship, and what specialty you choose).
The pre-tax, pre-insurance, pre-expenses, gross pay looks high on paper, but the lifetime ROI on going into medicine is nowhere near as good as what you describe, no matter how many hours you work.
That is a gross generalization. It is true in the US if you are a primary care physician or one of the lower-paid/lifestyle specialists. It is far from true if your are a higher-paid specialist or sub-specialist.
Also consider that unlike tech, where you get paid more for working in higher-cost-of-living cities -- in medicine you get paid more for working in lower-cost-of-living cities.
Also note that unlike tech, the peaks and valleys are much less pronounced.
> Also note that unlike tech, the peaks and valleys are much less pronounced.
The point is that, unlike tech, you have to take on massive amounts of debt before you can even begin to work[0]. And even after that, there's a really high latency before you're earning enough to make more than the minimum payments. Six-figure debt compounded over a decade or more really adds up.
> That is a gross generalization. It is true in the US if you are a primary care physician or one of the lower-paid/lifestyle specialists. It is far from true if your are a higher-paid specialist or sub-specialist.
It's actually more true if you're a specialist or subspecialist. People who don't practice medicine tend to overestimate what specialists get paid, and to underestimate what PCPs get paid. It also doesn't help that, in the last ten years, the relative reimbursement rates have changed dramatically, and to top it all off, private practices have been rapidly going the way of the dodo - so it's understandable that the public perception would be out-of-date.
Overall, reimbursement rates for specialists have been slashed far faster than they have for primary care (with some specialties hit harder than others). Combine that with the fact that they have to spend even more time in training (during which time their debt compounds
> Also note that unlike tech, the peaks and valleys are much less pronounced.
Quite the opposite - tech salaries are relatively flat and stable compared to most other industries, and we get to take home pretty much 100% of our salary, less taxes. Yes, the industry as a whole has booms and busts, but so does literally every private industry. In medicine, unlike tech, even if you're salaried, you're oftentimes paying for a large chunk of your business expenses out of your "salary". This is one of the reasons why looking at listings of what doctors make is incredibly misleading. The insurance rates vary dramatically between fields of medicine (and practice locations), as does the necessary equipment and mandatory continuing medical education expenses (again, even salaried doctors will oftentimes have to cover these out-of-pocket).
In tech, we don't have to worry about any of that. We have it pretty easy.
> in medicine you get paid more for working in lower-cost-of-living cities.
This used to be the case. It still is, for some fields like emergency medicine. It's a lot less the case in other fields, partly because of the consolidation of practice groups and the downward pressure on reimbursement rates across the board.
[0] Unless, as I said in my previous comment, you're independently wealthy beforehand, in which case this whole discussion of early retirement is moot.
With respect - you are comparing apples vs oranges. You are comparing independent/priv-practice doctors vs salaried technologists. If you had an independent contractor technologist, they also have to eat all the overhead (Liability insurance, E&O insurance, benefits, office, supplies.) Similarly, if you have a doctor working at the hospital, just like a salaried technologist they don't have to pay the overhead.
To be fair, doctors' overhead is higher for certain practices, but remember that facility fees can be billed back to the insurance or directly to the patient and even sent for collection. Those are extra fees on top of the doctor's pay -- essentially a form of rent forwarded to the patient for the doctor's facility costs.
Finally, we're not comparing tech salaries to other industries, we're comparing them to doctors. I've rarely seen doctors face a 2001 market crash or 2008 market crash and mass unemployment or had their entire training wiped out when JE22 went south. Tech is very volatile. Also consider that doctors generally make more as they age, whereas technologists often face increasing age discrimination. Yes, MLK in LA and St Vincent's in NYC did shut down, but have you ever seen the equivalent of a Lucent or Lehman or IBM or Intel in medicine? Rare...
You are right that I don't practice medicine, but I work 75hrs a week in hospitals since my startup sells to hospitals. I've seen the relative function and dysfunction of both American and single-payer overseas systems. And BTW, i pay gigantic liability insurance bills for my diagnostic technology product , and it effectively comes out of my salary.
I do think doctors have a hard and stressful job but they are mostly well compensated. A while back I was wondering who were owning the most expensive homes in our city. Turned out 7 out of 10 were doctors and the others made money being a CEO/executive of a tech company. I was expecting more technology/engineering people given that is is in the middle of the bay area.
It is usually not because of doctor-shortages that doctors work long shifts -- it is because hand-offs create errors themselves. Think of it as a game of telephone. 8 hour shifts means 3 hand-offs. 12 hour shifts mean 2 hand-offs. One is 50% greater risk of mis-communication as the patient shifts from one doctor's shift to the other.
During training, the long hours serve a double-purpose -- compressing more years of training into fewer. If residencies were 1.5x longer, more doctors would choose not to be doctors. Residents working 80 hours vs 40 helps compress the training time and let doctors get on with their lives and careers faster. Unlike in tech, medical residents get paid little for their training period. Shifting 3-6yr residencies into 6-12 year residencies would make residencies viable only for already-wealthy individuals who can withstand 4yrs undergrad + 4yrs med school + 6-12 yrs of low salaries in a captive residency.
(btw, w/r/t/ shortages, it is probably due to the doctors themselves -- specialty boards such as the Board of Radiology essentially throttle the number of available training positions (residencies) per year creating artificial scarcity and keeping up their own pay.)
> It is usually not because of doctor-shortages that doctors work long shifts -- it is because hand-offs create errors themselves. Think of it as a game of telephone. 8 hour shifts means 3 hand-offs. 12 hour shifts mean 2 hand-offs. One is 50% greater risk of mis-communication as the patient shifts from one doctor's shift to the other.
So long shifts are due to errors ? I hardly see the logic in that... We work long shift because we are expected to work long shift, because nothing is done to prevent medical exhaustion, and because there is a strange societal archetype of the never-sleeping doctor that goes against any recent (or old) research on learning, stress management and work performance (among other).
> During training, the long hours serve a double-purpose -- compressing more years of training into fewer.
That is also incorrect. In every country except maybe Switzerland, residency programs last 3-5 years, whatever the number of hours worked per week, and medical errors are not the first, the second nor the 3rd cause of death in those countries... Cortisol is a brain cell killer, stress reduces our ability to learn and adapt, sleep deprivation reduces both encoding and storage of long term memory, and most research on attention shows that you cannot work more than 5 full hours per day with a NORMAL lifestyle and sleep cycle.
BTW 80 hours is on small weeks in surgery, at least it was for me.
> If residencies were 1.5x longer, more doctors would choose not to be doctors.
I believe this also to be incorrect, there is no shortage of applicant to medical schools. Actually it would be a problem to finance residency programs..
> So long shifts are due to errors ? I hardly see the logic in that...
There is no logic in that, i'm not sure why you asserted that. I noted that long shifts reduce handoff errors.
Consider two scenarios: Scenario 1: 8 hour shifts:
Doctor 1 hands off to Doctor 2 at end of 8 hrs
Doctor 2 hands off to Doctor 3 at end of 16 hrs
Doctor 3 hands off to Doctor 4 (or perhaps 1) at end of 24hrs
Each handoff is a game of telephone. In theory it should not be, but in reality it is. Details are missed, directions mangled, and risk accrued. Just like a technical design document going from a product manager to the development lead to the developer...things go wrong in the process.
Just like with tech teams where each added person creates overhead and waste from communications overhead and mis-aligned understanding of requirements, hospitals face the same issue. Unlike technology, you dont just push a fix and rebuild -- an error such as forgetting to record a symptom on the binder/EMR could mean mis-diagnosis or death. Shifting to 12-hours shifts means just two handoffs instead of three. You dont eliminate errors, but you reduce them. In some sense, it may be better to have 4 days of 12-hour shifts than 5 days of 8 hour shifts.
Of course, this is just one aspect of medical errors. There are others which may be brought on by increased shift lengths. We'd need to look at the total sum.
Regarding your other point:
> In every country except maybe Switzerland, residency programs last 3-5 years, whatever the number of hours worked per week,
That makes no sense. If that were the case, residents would choose to work an hour a week and easily graduate in 3-5 years. But that would make for a poor doctor, as they need a certain # hours of training.
> There is no logic in that, i'm not sure why you asserted that. I noted that long shifts reduce handoff errors.
Consider two scenarios: Scenario 1: 8 hour shifts: Doctor 1 hands off to Doctor 2 at end of 8 hrs Doctor 2 hands off to Doctor 3 at end of 16 hrs Doctor 3 hands off to Doctor 4 (or perhaps 1) at end of 24hrs
Each handoff is a game of telephone.
This is not how this works. You either have acute patients who would indeed need handoffs between day and night teams, and you have programmed patients who usually do not need any handoff. Acute patients are usually managed by very specialized teams both in terms of managing physicians, nurses, and usually residents are not alone at night. Those patients are also indirectly managed by other specialists, wether it be the surgical teams, or the imagery team on call. They are also hooked to at least an EKG machines, and depending on the condition will have more invasive surveillance system (arterial catether, articial life support, dialysis etc...). Those patients might die from a medical error, but actually the handoff are not the problem, those are repeated, digitalized, supported and surveillance is maximal. Errors are due to the team's reactivity and knowledge in front of the severity and extremely fast time course of their condition. That is the deciding factor, of course if the doctors are exhausted, they forget things, they miss the jugular vein, they take more time cauterizing the bleed, or closing the wound, they are afraid to wake up their senior because they know he has not slept since yesterday.
On the other hand you have chronic patients, who are under light surveillance by the nurses at night, who sometime call the doctor on call who knows absolutly nothing of the patient, and is sometime not even of the speciality. If things get rough, the patient becomes "acute" and is managed by the acute team. At night for those patients, handoffs WOULD have been nice, be they were none, not because the residents did not do their 12-15 hour day but because those patients are not supposed to have handoffs to the night team, and because no doctors are paid to stay at night in all chronic services.
> Regarding your other point: > In every country except maybe Switzerland, residency programs last 3-5 years, whatever the number of hours worked per week,
That makes no sense. If that were the case, residents would choose to work an hour a week and easily graduate in 3-5 years. But that would make for a poor doctor, as they need a certain # hours of training.
So they do finish in 3-5 years, and make for as good doctors as US doctors, although they work more reasonable hours which is around 60 hours a week. Although I believe that is still too much to insure quality of care.
You're correct that handoffs are a common point-of-failure, and also that residency programs are already near the tipping point of financial non-viability for the non-wealthy.
However, to your last point:
> (btw, w/r/t/ shortages, it is probably due to the doctors themselves -- specialty boards such as the Board of Radiology essentially throttle the number of available training positions (residencies) per year creating artificial scarcity and keeping up their own pay.)
The actual bottleneck on residency positions is not artificially imposed by any external group - the bottleneck is the funding for residency positions themselves. Residency programs run at a loss, which is why Medicare has had to step in to fund GME. There are a very small number of non-Medicare funded residency slots, but they're also funded through external means.
5 years ago my uncle was hospitalized with a knot in the gastrointestinal tract which usually gets treated within days. He never left the hospital and died 3 weeks later after every single organ in his body started failing post-treatment. The man has always been healthy and never had any serious illnesses. His daughter witnessed (and on a few occasions so did i) plain stupidity and negligence of the medical staff who insisted to take him off life-support after putting him on it. We eventually ended up moving him to another hospital where he showed signs of improvement but eventually died when his kidney and then lungs gave out. She and her mother are convinced that he died because of numerous medical errors. I watched him suffer for 3 weeks and have since developed a phobia of hospitals. I basically lose my shit over any hospital visits these days.
There's an old joke inside hospitals. Hospitals are where people go to die. Unfortunately, it's not a joke. Hospitals are the definition of asymmetric information warfare. You know nothing and they think they know everything. Absolutely have someone on your side who knows what's what. Family/friend who is a doctor, nurse, PA, NP, etc. Hospitals are so wedged that some actually have "patient advocates" who work there and whos sole job is to be that advocate for the patient and patients family.
I am sorry to hear about your uncle and your feeling that the medical system failed him.
In my experience a small bowel obstruction is not such a benign condition as you might think, it is a mortal condition if left untreated and has mortality rate between 10 and 25% if surgery is needed.
For example if the cause was an entanglement, it could lead to occlusion of the bowel's nourishing arteries and cause irreversible necrosis. In those cases a septic surgery is necessary, the dead tissue is cut out below and above the lesion and the bowel has to be sowed back together. Sometimes the tissue seems ok but is in fact weakened, and rupture in the days following surgery. Sometimes it has already ruptured or cannot be sowed back immediately... It is in my opinion a very serious condition.
Doctors are pre-disposed to do something rather than nothing, and doing something is more dangerous than doing nothing in the vast majority of medical cases. This is especially true when "doing something" has unknown or unbounded side effects and the original ailment is something that the body will take care of by itself in short order.
Every prescription you take for a minor inconvenience is a tiny chance that you're taking the next recalled drug for something that does long-term damage that wasn't found in short-term medical trials, or the chance that your pharmacist makes an error in filling the prescription.
Going to the doctor or taking a medication, even if the _chance_ of risk is low, has a downside that is a lot worse than the upside, except in cases that are life-threatening or have potential long-term health downsides.
So next time you're thinking of taking something to fix your acid-reflux, maybe try listening to your body and changing your diet, instead of risking that the drug you take to mask the symptoms is the next Nexium.
Everything has risks. Maybe you change your diet and end up doing an unfamiliar food preparation and you screw it up and end up with a case of salmonella or e. coli. Or you do your usual thing and it happens anyway.
It's inane to suggest anything labeled "medication" should only be taken in life-threatening circumstances. Everything you ingest is going to have an impact on your body - some good, some bad, many both. Medications have a particularly strong impact, but are also highly controlled. You can judge the probability of various outcomes very well, which makes it a lot easier to come to a clear conclusion about using them or not.
And I'm going to assume you didn't intend to say that merely going to the doctor should be avoided except in life-threatening circumstances.
Of course everything has risks, but I'm just advocating not taking risks with extreme downside when the positive upside is small. Eating is necessary for life, but taking a pill to reduce the risk of acid-reflux symptoms is not.
> _Medications have a particularly strong impact, but are also highly controlled. You can judge the probability of various outcomes very well, which makes it a lot easier to come to a clear conclusion about using them or not._
This is the main point where we disagree. You say medications are controlled, but I see alarming numbers of recalls of drugs [1]. Controlled studies only show a small part of the picture of the long-term impact of a particular drugs' use.
> And I'm going to assume you didn't intend to say that merely going to the doctor should be avoided except in life-threatening circumstances.
All I'm saying is that going to the doctor has risks that need to be considered. And when a doctor recommends some treatment, ask what he would do if he was in your situation, or what recommendation she would give to her brother.
It's not just a question about the magnitude of the possible upside or downside though, it's also about how likely they are to occur. If you offer me the opportunity to almost certainly make every day slightly better with the risk of killing me at a rate of once in the current age of the universe I'm going to take it. It's a tiny upside with a massive downside, but it would be irrational not to take it given the chances involved.
Medications absolutely are controlled. That doesn't mean they don't have issues, but are you willing to suggest medications are less controlled than food? I don't need to hope I've washed my medications well enough, nor do I need to ensure I've heated them to at least a certain temperature for a length of time, nor do I need to worry about cross contamination or any such thing. This isn't to say medications are without risk, but compared to produce, meat, or eggs I have a much better idea about what exactly is entering my body when I consume it.
>All I'm saying is that going to the doctor has risks that need to be considered.
I doubt that very much. Are the risks significantly greater than the risk you likely took getting to the doctor in the first place? I'd be shocked.
If all causes of death were medically preventable (which would be awesome), by definition preventable medical errors would cause 100% of deaths. (Since they could have prevented it and assuming it's an error not to.)
It's simple logic. In other words, the better the standard of medical care, and the better the state of medical science, the higher this number will be, right up to 100% if medical science has an answer to everything. It will never be 100% of zero, as obviously in practice not everything will be done perfextly - but medical error is the delta between theoretical standard of care and actual outcome. The better the theoretical standard, the more deaths must be deemed errors.
It can still be far better than if that were not the standard.
Just looking at the cause of death percentages misses the point. Imagine your dream scenario has been achieved and all deaths are caused by errors. 2 hospitals that treat the same number of patients (with similar complexity across the patient populations) are performing similarly on the death metric, 100% of deaths are caused by errors. Never mind that Hospital B kills 100 times as many people.
Putting it another way, without some information about what good performance is, you'd better not make any conclusions about whether this is a good thing or not.
For those interested in this topic I strongly recommend reading the Institute of Medicine report "To Err Is Human" linked in the article.
https://www.nap.edu/catalog/9728/to-err-is-human-building-a-...
It set the foundation upon which a lot of this later research is based.
Nobody has comment on the ridiculous amount of hours doctors have to work on emergency rooms.
7 hours with 3 hours of sleep between going to class and being into the ER again. This is actually illegal but every student I talk to is afraid of complaining and risk their careers.
My foster son died in 90's after taking a powerful steroid where the dosage was multiplied by 10 by a transcription error. I never found out if the doctor or pharmacist was the one responsible.
Hm. Article strongly states we need to measure this invisible killer. Also ranks this (unmeasured) risk high on a chart by number of deaths per annum. Seems like guessing to me?
I'm thinking 'medical error' is a catchall for some constellation of events, and only shows up high on the chart because its an aggregate of several causes. Once its measured and dissected, it will turn into 12 low-frequency entries and disappear from the conversation.
Medical error is actually underestimated. You get preventable deaths that are attributed to "complications of an underlying cause".. You might consider MRSA infections as a preventable medical error but frequently sepsis is not listed as a cause of death.
Among other things I have worked as a researcher, a Psychiatrist, a Neurosurgeon, and a web developper. Reading comments about how much distrust there is in doctors saddens me. Medical errors are killing people but it has to be put in perspective to the reality of modern medicine in hospitals. Usually medical errors kill patients that are the most vulnerable, who need several invasive acts, strong and potentially harmful treatments, who need to stay in bed, in the hospital, for days or even months. The first comment by ada1981 talks about how acute medicine seems to be doing ok, that is not because acute doctors are good, and chronic doctor are asshole sold to big pharma. It is because longer stay in the hospital means a more severe condition, and an incremental risk of yes, preventable errors. Actually, this feeling of mistrust is one of the main reason I stopped practicing, the other reason was that I was frustrated by the way doctors have to practice medicine and is of course related to this issue. The way we practice medicine has not changed for years, although medical knowledge increase exponentially and doubles every two years. This immobility is mainly due to three things: the highly hierarchical and rigid structure of the medical field that resist adaptability and innovation, economic constraints imposed by big pharma and insurances who basically decide of how medicine is practiced in the whole world, as well as misguided political/societal views as to what should be a doctor of the 21st century, what tools should he use and how should he study.
In the article, the author - who by the way seems pretty biased and judging from previous work to hold a profound grudge against physicians, is comparing doctors to pilots, and medical errors to crashes. And besides the simple demagogic argument of doctors are dumb and proud and pilot are better formed and humble, the reality is that pilot are using machines worth millions that are able to diagnose, fix, and steer themselves. They are three in the cockpit, and communicate with flight controllers for the most critical parts of the flight. They have real time weather prediction and course change. Their tools are evolving in time, does she even know that modern airplanes produce more than a terabyte of data on every flight ? This data is used to make airplane safer every year, update software, hardware, security...
Practice of medicine has to change yes, and article pointing at medical errors will help change minds and practices in the coming years. Technology will play a big role in it.
But the author, and some people commenting here should remember that pilots are not battling death. People who die in hospitals from medical errors are usually the one who are suffering from chronic and hard to treat diseases. You all want to live forever, blaming doctors of the sad reality that most of you will die from a chronic disease.
Instead of drawing a dark portrait of physicians who for the most part work selflessly to make a positive change in the world, you should ask yourself: why is there medical errors, what can they do better ? What could they do in this context ? Go to school 18 years instead of 12? Work 120 hours instead of 90 ?
The solution is a deep change of how medicine is practiced, a revolution driven by technology (IOT, big data, AI) and the open science movement. But you have to realize that this revolution was not possible before maybe 4-5 years ago. Now it is, and soon it will change.
Is there a strong correlation in any field between remuneration and quality of service? And even if there is, is there also evidence that changing the remuneration will have a proportional effect on the quality? Where in the s-curve/sigmoid/logistic function are we?
It seems plausible to me that simply increasing the supply of doctors and implementing air transport style safety systems would be much more beneficial than anything else we could do.
Unions for upper-middle-class professions aren't demonized as much as unions for those with less influence, so they get to control access to their profession.
I think has not improved service any is also at least overly simplified. There's all sorts of treatments available now that were unheard of 10 years ago, never mind further into the past than that.
This. In Australia, half of the doctors do a 6 year undergraduate degree in medicine straight out of highschool while half do it as a 4 year postgraduate degree. Those that do the postgraduate degree don't need a PhD level GPA (they just need to do well in a test). Residency is not some sort of hazing ritual.
Everyone is much happier, and it fixes the supply vs demand problem.
Indeed, one of the things that needs to be kept topmost in mind when reading statistics like this is that people are going to die of something, and as we reduce or all but eliminate other causes, something or things are going to shift to being the new "top causes".
ADDED: and because nowadays, no later than the end of WWII, the former somethings have be forestalled by medical interventions, as those increase, the number "killed" by the simple fact that healthcare workers are fallible humans is going to rise.
My father survived the immediate post-WWII period when he got a nasty bacterial pneumonia I think it was because civilians were then able to get the earliest form(s) of penicillin. Thanks to that medical intervention, which could have killed him (I've read that penicillin would never get approved by the FDA today because of its allergy potential), and others, now he'll die of Alzheimer's in his mid-'80s or his '90s, if nothing else gets him first.
I helped launched (the now deadpooled) Theil backed MetaMed a few years -- essentially a private research team for medicine, and what the founders taught me was astounding.
That things like amputating the wrong limbs, doctors not washing their hands and killing you by infection and a horror of other preventable errors are shocking common.
This didn't even take into consideration that things discovered in labs that might cure you take at least 30 years to reach the doctors who might implement them, if they ever do.
The distortion of hubris from doctors, economic incentives and other systemic issues results in a "health care system" that doesn't realily seem to do what it sets out to do -- we spend 10x what some developing countries do per year per person with no better outcomes.
Accute care seems to be reasonably good, fixing a broken arm, etc. (assuming they don't accidentally remove it); but chronic care is often just a pipeline for the recurring revenue model of big pharma (at best).
The examples are never ending but for fun, take a google to discover how many pap smears are performed annually on women who have already had their uterus removed - then consider the cost to insurance and tax payers.