Beyond To Err Is Human

James Pate, 2007

In 1998 the Institute of Medicine initiated the Quality Health Care in America project with the following goals: synthesize health care quality of care literature, increase public awareness of medical error, create policy framework that provides positive incentives to improve quality and accountability, and identify factors that encourage continual improvement of quality of care. To Err Is Human[i] is the result of that effort.

According to the book, there are two ways to err: you can fail in the execution of a good plan or you can also follow a faulty plan. When it comes to medical error either can be devastating. Recently a VA patient in California had the wrong testicle removed.[ii] Much more sobering however is the finding that an estimated 44,000 people die in the US each year due to medical error. Malpractice claims and insurance premiums demonstrate that it is easy to point fingers, to single out individuals and to punish them severely when such errors do occur - a jury recently awarded $7.2 million to a woman in a medical-malpractice case over the death of her mother.[iii] But the fear of such repercussion has not been sufficient to sufficient to significantly change outcomes. Why? Hindsight bias oversimplifies problems and ignores contributing factors. In essence they've been "swatting mosquitoes" instead of "draining the swamp." Occasionally physicians do deserve the brunt of the blame. But far more often it is the accumulation of latent errors and "normalization of deviance" in a complex system of health care delivery that creates a swamp where mosquitoes thrive.

I believe that there is yet another inherent error in out medical system responsible for substandard patient care. Inadequate policies and guidelines contribute to the murky swamp in which doctors make life changing decisions. We are not always certain of our legal responsibility to act or the legal ramifications of an action we are contemplating. And there are many other areas outside of legality such as medical ethics and professionalism that contribute to uncertainty. End-of-life care, abortion, and homosexuality are not merely contentious social issues; they also represent classes of individuals who often receive inadequate care due to poor governing policies. Only a systemic approach on a national scale will result in significant and necessary change in policy and practice.

Katrina

On August 29, 2005 Hurricane Katrina hit New Orleans and surrounding areas. Around 2000 people died making it one of the worst national disasters. Many doctors, nurses, and others stayed behind to help anyway they could. In most cases their aid was highly appreciated, but in at least one case it wasn't. The medical community and many others were indeed shocked when Louisiana Attorney General Charles Foti charged Dr Anna Pou and two nurses with second-degree murder for alleged administration of morphine overdose to four patients at Memorial Medical Center.[iv] I remember attending an Emergency Department ethics discussion on this topic and listening to various opinions regarding the situation. Did they commit murder? Was it euthanasia? Physician assisted suicide? Malpractice? Or were they merely making their dying patients "comfortable?" I was surprised to find out that many patients are made "comfortable" when the end is near and nothing else can be done. Whether this is considered standard practice or not and what the legal implications are I am still unsure. While there may be legal precedence for physician immunity in this regard, the fact that an attorney general charged a physician with murder insinuates tat the common practice may in fact still be legally murky. Without clear guidelines and standardized policies error and legal accountability are unavoidable.

Abortion

During one of my classes a faculty member shared that at age 19 she felt she had only two options: either get an abortion or commit suicide. Fortunately she was able to find and had access to an abortion provider so that she did not have to consider the latter option. Yet such information and accessibility is not always available even among physicians at Oregon Health & Science University (OHSU).

"Not only will he not perform an abortion, he won't refer a patient to another physician who will. For [Dr Bill] Toffler, a devote Catholic, the practice guidelines dictated by his own moral code trump the practice guidelines of his profession. 'I will go to jail before I will do that,' Toffler said. 'I will not aid and abet knowingly someone who wants to do something outside my practice boundaries.' But Toffler, also a professor at the OHSU School of Medicine, does not practice in a vacuum. His patients also have rights. And sometimes, rights come in conflict."[v]

Dr Toffler made the statement in 2006 to the Portland Tribune. He is clearly in violation of OHSU policy yet has faced no sanction. This issue is larger than Dr Toffler and OHSU however because he is not alone in his refusal to refer patients for abortion. Asserting religious beliefs such physicians extend the provision of conscientious objection beyond its limits, place their morality and rights above those of their patients, and become barriers to their care. Physicians have a moral responsibility to put patients' needs before their own and withholding medically important information from their patients is, in my opinion, malpractice. Such discussion deserves more attention than local committee meetings regarding conscientious objector policies. Physicians should be required to provide standardized care to their patients in accordance with national standards and refer them on to other practitioners when the care warranted or requested is beyond the scope of their practice. In no circumstance should they be allowed to become barriers to patient care.

Homosexuality

The medical community has a poor record in advancing the health of the lesbian, gay, bisexual, and transgender (LGBT) community. In fact, its involvement has often been detrimental. It wasn't until 1973 that the American Psychological Association (APA) finally removed homosexuality from its Diagnostic and Statistical Manual of Psychiatric Disorders. Prior to this time behavioral therapists commonly "treated" homosexuals with electric shocks, noxious chemicals, and other forms of adverse conditioning in vain attempts to reprogram them. Today all major medical professional groups have made statements in support of a homosexual identity. Additionally, the APA has stated:

"The nation’s leading professional medical, health, and mental health organizations do not support efforts to change young people’s sexual orientation through therapy and have raised serious concerns about the potential harm from such efforts."[vi]

Nevertheless medically licensed "reparative therapists" like Benjamin Kaufman, MD (Clinical Professor of Psychiatry, UC Davis) continue to practice on misinformed, psychologically-tormented individuals. The National Association for Research & Therapy of Homosexuality (NARTH) states: "We believe that clients have the right to claim a gay identity, or to diminish their homosexuality and to develop their heterosexual potential... We call on our fellow mental-health association to stop falsely claiming to have 'scientific knowledge' that settles the issue of homosexuality."[vii] The damage they inflict on confused patients and their families continues to this day. In 2005 a 16-year-old named "Zach" from Bartlett, Tennessee made international news when he blogged that his parents "tell me that there is something psychologically wrong with me..." and forced him to attend an "ex-gay Love in Action" camp to cure him of his homosexuality.[viii]

In 2004 the Michigan House of Representatives introduced the Conscientious Objector Policy Act designed to give doctors the right to deny medical services to LGBT individuals based on "moral" beliefs.[ix] The legislation did not pass but the ramifications would have been great if it had. Without national policies to stipulate physicians' responsibility to treat all people equally, certainly some physicians would have taken advantage of the law and LGBT patients would have suffered.

According to CytoJournal, "anal and cervical lesions share many histological and pathological characteristics including the implication of human papilloma virus."[x] The Journal of Infectious Diseases reports that "concurrent HIV infection has increased the incidence of anal SCC in HIV-positive men who have sex with men (MSM) to almost 9 times the rate of cervical cancer in women and to ~37 times that of HIV-negative MSM."[xi] In spite of these dire findings, in 1999 JAMA reported that although "the screening of HIV-positive MSM with anal Pap smears once per year provided an incremental cost-effectiveness ratio... similar to that for other widely accepted screening procedures... several policy barriers exist."[xii] And even though MSM could clearly benefit from the HPV vaccine, Gardasil, in the prevention of anal carcinoma, the FDA only approved it for use in females 9-26 years of age.[xiii] No mention was made of its potential benefit in the MSM population for the prevention of anal carcinoma. In November of 2006 I was fortunate to attend the Oregon chapter meeting of the American College of Physicians in Eugene. When the topic of Gardasil was discussed I asked all in attendance why the vaccine was not being marketed for MSM as well. My question was politely brushed off with a comment to the effect that physicians could use it for that purpose if they saw fit. Perhaps the real reason goes all the way up to Ian Frazer, the Australian scientist who designed the vaccine. Regarding gay men's demand for the vaccine in London he commented, "It's their money and their choice, but the reality is that adult males who have sex with other males, and who have been in anything other than a monogamous relationship, are very unlikely to benefit."[xiv] Just as Ronald Reagan refused to acknowledge the AIDS epidemic until the larger population was also at risk, so continues the marginalization of LGBT citizens in targeted health care policy. Apparently it's a waste of time and money to save the lives of sexually active gay men.

Recommendations

From these examples it is clear that there is discrepancy in how various doctors practice medicine and how policy is made and sustained. The issues of end-of-life care, abortion, and homosexuality are only a few of the areas where physicians will have differing opinions and different practices. While no physician should be forced to practice contrary to his/her conscientious or religious beliefs, clearly patients have rights as well that need to be respected. The unequal relationship between provider and patient allows for abuse of power. When wills and rights are opposed, the physician has the upper hand. Steps must be taken to protect patient rights and to ensure that they have access to the care that they need.

In recommendation 5.1 of To Err Is Human, the IOM states that a nationwide mandatory reporting system should be established, set into motion by congress, and run by government. It is certainly sad that we as doctors would need lawyers, politicians, and external bureaucracy to create and manage such a system. If anything else needed to be said about the failure of decentralized health care delivery this is it. It is time that we organize ourselves centrally as a profession with oversight committees and adopt nationwide policies to ensure an ever improving standardized care for our patients.

While I can understand how our fragmented medical community came to be, I cannot understand why we continue to allow it to remain so disorganized. It is my opinion that the decentralization of our profession is a major contributor to medical error. Standardization would vastly improve patient care and reduce physician legal vulnerability.

Recommendation 1: A national accreditation board must be formed to insure standardized policy and practice. State accreditation boards could be modified to enlarge the scope of their oversight. Representatives from each board could meet regularly to discuss and cement policies and physician expectations on a national scale.

Recommendation 2: Standards of care for each medical concern must be clearly defined in writing by this committee. They should evaluate and summarize recommendations made by other medical organizations to create cohesive unified guidelines. Areas without standardization should be identified and listed.

Recommendation 3: Ethical dilemmas should be evaluated by a subcommittee of this board both proactively and retroactively. Guidelines and protocol should be established and disseminated to state accreditation boards and all physicians.

Recommendation 4: Physicians acting within nationally established medical guidelines should not be held individually accountable in a court of law.

Recommendation 5: Medical ethics should be incorporated into MD licensure examinations.

Recommendation 6: MD licenses should have to be renewed every 10 years with satisfactory examination.

Recommendation 7: Physicians who violate established guidelines should be reprimanded. Serious and/or repeat offenders should have their medical licenses revoked.

Conclusions

Medicine is as much an art as a science. Given scientific uncertainty and human shortcomings, medical error is inevitable. However, much of the error plaguing our profession is in fact unnecessary and preventable. It is my opinion that a major contributor to this error is the lack of national standardization and clarity with regard to physician expectations. The only way to significantly reduce the number of medical errors is through orderly systemic change. We can either wait around for politicians to create more non-medical supervision or we can organize and begin to supervise ourselves. I honestly think it is in our patients' best interest and our own as well that we standardize our practice. The best way to do this is through the development of a national organization with the power to define the standard of care.

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