Published in the March 2004 issue of Today’s Hospitalist
In the five years since the Institute of Medicine (IOM) grabbed headlines
with its report on medical errors, most physicians have come to admit, if grudgingly, that the health care system they work in is riddled with lapses and blunders.
But what many in medicine still don’t acknowledge, says Robert M. Wachter, MD, a leader of the hospital medicine movement and co-author of a new book on patient safety, is just how daffy cult it is going to be to cure what ails the health care system.
In fact, one of the goals of the book, "Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes," was to reach a physician audience that thinks that fixing the system is as simple as computerizing medical records, working better as a team, and educating and empowering patients. Dr. Wachter co-wrote the book with his hospitalist colleague Kaveh G. Shojania, MD. Both work at the University of California, San Francisco.
As Dr. Wachter told Today’s Hospitalist in an interview just after the book was published in February, many of the proposals to fix the broken U.S. health care system raise distressing issues. "So many of the ‘fixes’ are double-edged swords," he says.
Need for responsibility
To make his point, Dr. Wachter describes a recent experience in which he found himself forced to correct a resident. When the young physician attributed a recent error to problems with "the system," Dr. Wachter gently replied: "No, that was a screw up."
He tells the story to illustrate a simple point: While safety systems need to be made more robust, doctors and nurses must still take responsibility for their decisions and actions. "If we go so far in the systems direction and say that nobody is to blame," Dr. Wachter explains, "we risk forgetting about individual accountability and responsibility."
"I can’t envision a system where there would not be a role for really good doctors and nurses doing the right thing at the right time," Dr. Wachter explains. "There is a reason we spent all those years in medical school."
It’s one reason that he is leery about viewing computerization as a panacea for the U.S. health care system. He worries that physicians who have "smart" computers at hand "will stop thinking."
As an example, he describes how some residents at one hospital no longer bother to calculate correct dosages when ordering drugs through a computerized order entry system. Instead, he explains, "They put in the name of the medicine and then they put in a wacky dose. This forces the computer to suggest two or three possible doses that they can choose from. The problem is that every now and then the computer will not be smart enough to catch their mistake."
The role of patients
Because "Internal Bleeding" is written for both a lay and physician audience, it has been attracting attention from newspapers like the New York Times and talk show hosts like Don Imus. A number of readers and reporters have focused on the theme that patient empowerment is one way to prevent patient harm.
While Dr. Wachter says there’s definitely some truth to that notion, he is quick to add a caveat: "In general, patients are no more able to protect themselves from hospital errors than passengers can protect themselves from harm on commercial airplanes."
He adds that asking patients to shoulder too much responsibility in the bid to prevent errors is a bit of a cop out by health care professionals. "If I’m sick and in the hospital," he asks, "why should I have to worry about my nurse or doctor giving me the wrong medicine? I shouldn’t have to worry about that any more than I have to worry about whether my pilot knows how to use the airplane’s flaps."
If the medical profession is going to rely on patient involvement, he adds, its leaders must first figure out how to better engage patients in decision-making “and also how to understand what patients are really saying when they do express preferences.
Catalyst for change
Dr. Wachter says that he and Dr. Shojania wanted the book to be "a thoughtful reflection of where we stand five years after the IOM report." He says they would like to see "Internal Bleeding" do for health care what Rachel Carson’s "Silent Spring" did for the environmental movement back in the 1960s “serve as a catalyst for change.
In one of their conclusions, they call for a health care system that doesn’t require that its practitioners be perfect. Instead, they say, everyone needs to know that doctors and nurses are fallible. While errors are to be expected, they argue, systems can be designed to ensure that few of them actually harm patients.
"Medicine today is breathtaking in what it can do," Dr. Wachter says, "but as the armamentarium gets more powerful, it actually gets less safe."
"It’s as if we spent the last 30 years building a really souped-up car," the authors write in the book, "but barely a dime or a moment making sure it has bumpers, seat belts, and airbags."
The book goes on to say that while health care needs to avoid "pillorying the doctor or nurse holding the smoking gun," more progress is needed. "In some ways, now that we’ve moved from saying it’s not the fault of individuals because they are human beings to focusing on the system, there’s a little bit of a tendency to say, ‘OK, now we know how to fix this. But it turns out that this is really complicated.’ "
For one, Dr. Wachter continues, the public doesn’t completely accept the argument that systems, not individuals, are to blame for most medical errors. In the short term, the increased attention being paid to unsafe practices in hospitals has attuned patients to the possibility that something may have gone wrong during their treatment. Many patients, he says, continue to believe that someone should be punished and have to pay.
"The attention on patient safety, if anything, has increased public angst about errors," Dr. Wachter explains. "Despite the efforts to end the ‘shame and blame game,’ doctors are more worried about malpractice suits than before."
Doctors as victims
The most vocal critics of the book, Dr. Wachter says, tend to be physicians who argue that the current patient safety movement simply blames doctors for everything wrong with medicine without crediting them for all the good they do.
Dr. Wachter notes that the book’s title addresses this concern. He and Dr. Shojania chose the "internal bleeding" metaphor for a simple reason: "On the outside, medicine looks pretty good, and yet on the inside, there are real problems that are chewing us up."
He adds that doctors are the second victims of this way of practicing medicine. "When an error happens on our watch," he says, "we are shamed by it. We wonder how we could have done that without recognizing that human beings make mistakes."
"The answer is not to admonish hard-working, competent doctors to be more careful or to see them slapped around by a malpractice lawyer," he explains. "We have to look at the system in a different way and make sure that it anticipates that if I do something a thousand times, there is going to be one time that I don’t get it right."
Deborah Gesensway is a freelance writer specializing in health care. She is based in Glenside, Pa.