In the last week there have been two articles written addressing medical errors. In the Wall Street Journal, surgeon Dr Marty Makary discusses the alarming costs of medical errors and offers suggestions to improve the system. In medicine, particularly during the training years of residency and fellowship, young doctors are not given the opportunity or security to report shortcomings of their superiors. As discussed in the article, all of us have a memory of a particular surgeon or clinician who was not very proficient at his or her specialty but was allowed to continue practice due to perceived national or international academic prestige or reputation. (not to mention the dollars brought in to the University via grant funding, etc). Dr Makary offers up solutions that he believes will decrease error rates including: publishing hospital scorecards online, installing cameras for peer review, open notes and eliminating the culture of “gagging”.
As part of national training requirements, all teaching hospitals are required to have a regularly scheduled Morbidity and Mortality (M & M) conference for housestaff. These meetings typically consist of a case presentation by a trainee where the outcome of the hospitalization was suboptimal and the deficiencies in care are debated and discussed. The focus of the best conferences is always placed on the central question of “what could we have done differently to change the outcome?” Unfortunately, these conferences (although required attendance by the housestaff is standard) are not well attended by faculty. Much can be gained from actively discussing cases and learning from the experience of others. In practice, there are standardized peer review processes that are in place in hospitals today. These are very different from the M and M conferences from training. I have served on QI (or quality improvement) committees at numerous hospitals over the years. These committees are made up of very diverse specialists and primary care doctors. Unfortunately most of these committees stop short of dealing with real physician deficiencies. Often, letters are issued and cases are discussed with little or no penalty or constructive criticism provided. Most often, the QI committee responds to complaints about promptness and appropriateness of emergency on-call care–particularly after hours. Only once in my tenure on these committees has true competency and clinical skill been addressed. Many of the cases are brought to the committees attention by competing groups and the motivation for the reports can be called into question. Much of what these committees do is done so that the hospital can remain accredited and remain in compliance with government regulations.
In reality, physicians need to work together to improve care and reduce errors. Government regulation as suggested by the Obama administration’s creation of an error-reporting system for consumers and reported on in an article in the New York Times is NOT the answer. Many consumers may interpret poor outcomes as errors in care when in fact no error occurred. Many times, disease may “defeat” even the most skilled physicians. A national “reporting system” as described in the Times, may ultimately lead to increased liability concerns for both hospital systems and physicians alike. Certainly, lapses in care and medical errors must be tracked and addressed in order to save lives, health care dollars and improve overall quality. However, the practice of medicine is an honorable profession with a long tradition of excellence in the US. Most physicians see the practice of medicine as a privilege. As such, we must all take responsibility to maintain high quality care throughout our profession. Thorough, unbiased evaluations of care need to be undertaken in both teaching and non-teaching hospitals if we are to impact medical error rates and reduce healthcare costs. Dr Makary has several important suggestions–we must continue to hold medical professionals to high standards of care. Transparency of care and physician decision making is a must. Video critiques can serve as a great learning tool. As we did in the M &M conferences in residency, we must continue to discuss cases formally with colleagues and both give and receive feedback and constructive criticism. All physicians, no matter how well funded or respected, must be held accountable for the care that they provide. By working together as a team, we can all reduce errors and improve care. Ultimately, both patients and doctors will benefit.