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Medical Error—a Public Health Problem

 

Assessing quality of care can be a complicated and tedious task, the methods for which are reviewed in Avedis Donabedian’s seminal The Quality of Care How Can it be Assessed? In his thorough examination, Donabedian asserts, and I think rightfully so, that the provider is at the center of care. When we zoom in on this center of care, we see the good and bad habits of health care providers which result in unequal outcomes. For years, the extent to which medical error has affected public health has been drastically underestimated. Although Americans have been filing fewer lawsuits in recent years, it seems as though medical malpractice is never more than a stone’s throw away from the doctor-patient interaction.

 

Medical Error in the U.S.

When thinking of the need for malpractice litigation, I, like so many Americans, drastically underestimated the rate of medical error in the U.S. My naivety was justified. In a NPR interview, Martin Makary explains that until recently, rates of medical error and subsequent deaths due to them have been estimated using a 1999 study by the Institute of Medicine. Death certificates list the cause of death that physicians choose to put on them and unsurprisingly, medical error is underreported. Medical error is the third leading cause of death in the United States. While the exact number of deaths due to medical error is hard to measure, Makary’s recent study estimates that it could have been as high as 400,000 in 2013. This should raise some major questions about how medical error is addressed as a matter of public health.

One way of addressing medical error, on the individual level, has been civil litigation. While some would argue that medical malpractice is the cause for so many health care-related issues in the U.S., it accounts for a small amount of annual health care spending. A 2004 Congressional Budget Office report estimated malpractice payouts to account for a mere 2% of health care spending and similar numbers were reported in a 2008 study. This is due, in part, to the fact that a minority of malpractice cases result in payouts. Moreover, a recent study has shown that restricting patients’ ability to sue providers doesn’t decrease the practice of ‘defensive medicine’ which is known to be a bad habit of many providers that drives up the cost of health care. Until systematic review of quality and practice is implemented and the high rate of death due to medical error is recognized as a broader public health issue, malpractice litigation seems to be one of the few ways of compensating those harmed by medical negligence and incompetence.

 

How Doctors Feel about Malpractice

While addressing the quality of health care is complicated and sometimes subjective, medical malpractice is an important process in keeping health care providers responsible for their sometimes life-changing decisions. Just as we investigate airline pilots, in whom we entrust great responsibility, through the National Transport Safety Board, health care providers should also be open to civil litigation. This, of course, has been resisted by the American Medical Association (AMA) in the past as well as at present. Medical malpractice isn’t the only measure of health care quality assurance which health care providers have resisted. Take for example, Atul Gawande’s checklists which he helped pioneer in order to cut down on unnecessary operating room deaths. Despite the checklists’ proven positive impact, many practitioners resisted their implementation because surgeons found them to be bureaucratic.

Insufficient numbers of practicing primary care physicians (PCPs) is a growing concern for public health and health care access in the U.S. and it’s been argued that the rise in medical malpractice insurance premiums have chased doctors out of the field. However, not only is the extent of this phenomenon disputable, but if academic and physician organizations really cared about having more practicing PCPs, maybe they could more seriously reconsider the bottleneck that they’ve imposed on physician residencies since the 1980s which limits the number of PCPs entering the field each year. This measure may be a more effective in increasing accessibility in health care than simply limiting the extent to which doctors can be held financially accountable for their underperformance.

 

Addressing the Broader Public Health Problem

Malpractice compensation is a reactive measure and doesn’t make doctors perform better. The limitations are obvious, as is the need for proactive efforts to improve provider performance and overall public health. What’s needed is a national assessment and improvement in quality of care in order to decrease the number of incidences of medical error. This can be done through publication of performance results, clinical guidelines, and payment system redesign. However, the difficulties of such assessment and improvement are highlighted in Gawande’s The Bell Curve. Outcomes of care often boil down to differences in personality such as aggressiveness and consistency. That being said, while the bell curve of medical results will always remain, openness of information and performance evaluation has helped to illuminate best practices such as in Gawande’s Cystic Fibrosis story. In finding and adopting these hidden yet successful practices, openness of performance information can improve practices across the board.

As organizations such as Don Berwick’s Institute on Healthcare Improvement pop up with the goal of increasing health care quality, the future looks a bit more optimistic. However, a national increase in the quality of care among health care providers is going to require openness to performance data and embarrassment of those who fall in lower percentiles of the performance bell curve. The reluctance of hospitals to give such data has allowed them to go untarnished by the publicity of their performance outcomes. Although the publication of these data is important, we must also avoid creating the unhelpful Death Lists that Gawande discusses in his article.

While malpractice litigation is an important method in addressing specific cases of poor medical care quality, it cannot be used as a way of assessing general health care quality. As Donabedian points out, accurate sampling which represents the population is important and one cannot simply choose to look at cases which ended badly and could have been prevented such as in the cases of medical error. However, malpractice litigation will continue to be a justifiable way of compensating patients who receive subpar treatment until national quality of care is openly and honestly assessed and medical error is more seriously addressed as a public health issue.

 

by Donald Clermont, MPH Candidate ’18

Filed under: Medical Community, Uncategorized

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