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Executive Times |
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2006 Book Reviews |
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The
Medical Malpractice Myth by Tom Baker |
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Rating: |
**** |
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(Highly Recommended) |
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Click on
title or picture to buy from amazon.com |
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Evidence The facts Tom Baker presents in his new
book, The
Medical Malpractice Myth, may lead you to rethink your position on what
needs to be done in this area of healthcare. Along with me, you’ve been led
to believe that a big problem in medicine is the skyrocketing premiums for
medical malpractice insurance, because of huge settlements, often with undeserving
claimants. Baker presents five key points that prove through facts that this
impression is bogus: 1. there is more medical malpractice 2. the real costs are from lives lost
through medical malpractice 3. insurance premiums for medical
malpractice are cyclical and uneven 4. big payments to undeserving claimants
are rare 5. proposed remedies will distract from
the real problem, which is injuries to patients from medical malpractice It’s always enjoyable and worthwhile to
read a book that presents facts that overwhelm rhetorical claims. Here’s an
excerpt, from Chapter 2, pp. 24-31: THE RESEARCH ON THE
MEDICAL MALPRACTICE EPIDEMIC Experts
think that most serious medical mistakes either happen in the hospital or
have consequences that put people in the hospital. For this reason,
researchers who want to learn about medical malpractice usually look in
hospitals. When they do, they use one of two approaches. Either they review a
large number hospital records from many hospitals and count the number of
mistakes. Or they watch doctors and nurses in one hospital, real time. Both
approaches have strengths and weaknesses. The hospital record
approach has two main strengths. Researchers can easily preserve the
anonymity of the hospitals. This makes it easier to get hospitals to
participate. And the researchers can look at records from many hospitals.
This allows them to make a strong claim that the rate of errors they find in
their research is the same as the rate of errors in hospitals generally. The
hospital record approach also has an obvious weakness. Namely, the
researchers look only at the hospital records. Common sense tells us (and the
research we will review confirms) that not all mistakes get noted in the
record. Also, not all mistakes take place in the hospital. The strength of the
hospital observation approach comes from its very nature. Watching doctors
and nurses in the hospital gives researchers a much more complete
understanding of what happens. But we can never be sure how the hospital they
are studying compares to other hospitals. Overcoming that weakness requires
disclosing information about the hospital, making it more likely that we
could figure out which hospital it was. Few hospitals today are willing to
open themselves up to intense public scrutin\,
especially when it is possible that other people could “break the code” and
use that information against the hospital. Over the next few pages
I will review the leading hospital records studies and the leading hospital
observation study. As we will see, all the studies demonstrate that a
surprisingly large amount of medical malpractice takes place in American
hospitals. The
The first important
hospital record study was the mid-1970s The What they found was very
different. They found that doctors
and hospitals injured what must have been to them an almost unbelievably
large number of patients: one out of every twenty patients discharged from
the hospital. Even more striking, one out of every ten of the injured
patients died as a result. This meant that doctors and hospitals injured at
least 140,000 hospital patients in The Thus, the research
clearly contradicted the assumption that injured patients and their lawyers
were exaggerating the malpractice problem. The research also contradicted the
assumption that doctors in Although the California
researchers did not publish any cost calculations, Wharton professor
Patricia Danzon later used their results to show
that there is no way that a broad no-fault system would be less expensive
that the existing tort system. As she demonstrated, only a very small percentage
of injured patients were compensated through medical malpractice
claims—somewhere between one in seventy five and one in a hundred of those
who were injured. This means that at least seventy-five times more patients
would be eligible for no-fault compensation than were then collecting in
tort.8 If even a quarter of the
eligible people actually filed claims, no-fault would be much, much more
expensive than tort, almost no matter how meager the benefits or how much the
cost savings that resulted from eliminating the tort system’s negligence
requirement. So it is easy to see why the sponsors of the Putting all this
together, what can we say? We can say that the The
Harvard Medical Practice Study The next, and most
important, hospital record study was the The Harvard team had the
benefit of both the The Harvard researchers
began by selecting a random sample of 31,000 hospital records from over fifty
hospitals. They reviewed the records in two stages. In the first stage nurses
reviewed all 31,000 records using a detailed screening form. The form
contained a very specific list of conditions that could indicate that the
patient was injured from medical treatment. For example, did the patient
develop an infection shortly after surgery, or was the patient readmitted to
the hospital soon after being sent home? If the record did not contain any of
the evidence that the nurses were looking for, the hospitalization was
classified as not involving a medical management injury and the records for
that hospitalization did not receive any further review. Nearly 8,000 of the 31,000 records—about one in four—contained evidence of a possible
medical injury.9 Each of these 8,000 records advanced to the
second stage of the review process. For the second stage,
the researchers taught doctors how to use hospital records to identify
medical management injuries and how to evaluate whether the injuries resulted
from substandard care. Two doctors reviewed each record using a special form
prepared to guide the review. The doctors worked independently, so that no
one doctor’s conclusions affected any other doctor’s conclusions. This is
one of the hallmarks of good research. Each doctor first
confirmed that the nurse who had reviewed the hospital record had accurately
identified one of the conditions indicating a possible medical injury. If
not, the research team classified the record as a “no injury” case, and set
the record aside. If the nurse had correctly interpreted the record, the
doctor gave the hospitalization an “adverse event” score from one to six
indicating the strength of the evidence of a medical management injury.10 If that adverse-event
score was two or higher, the doctor filled out a section of the review form
titled “Is there evidence for negligence?” The first step in the negligence
section asked the doctor to answer “yes” or “no” to the following question:
“Was this adverse event possibly due to a reasonably avoidable error, or
carelessness by either an individual or medical care system, or both?” If the
doctor answered “no,” the review was over, and the team classified the
hospitalization as a “no negligence” case. Importantly, if either doctor
answered “no,” the research team classified the injury as nonnegligent. If the answer to the
first negligence question was “yes,” the doctor answered questions about the
circumstances. The questions ended by asking the doctor to reconsider whether
the injury was possibly due to negligence.” If the doctor changed his or her
mind, the review was over, and the team classified the hospitalization as a
no-negligence case. Otherwise the doctor gave the hospitalization a
negligence score from one to six indicating the strength of the evidence for
negligence (like that for medical management injuries). A score of six meant
“virtually certain.” A score of one meant “little or no evidence.” A supervisor took the
two doctors’ forms, checked to be sure that they had looked at the same
records, and then calculated the averages of their confidence scores. The
supervisor classified the hospitalization as an injury case only if the
average of the doctors’ confidence scores on that point was more than 3.5.
Similarly, the supervisor classified the injury as negligent only if the
average of the reviewers’ confidence scores on that point was more than 3.5.
The practical effect of this 3.5 cutoff is that either doctor could veto the
decision of the other. If one doctor classified the case as a no-injury case,
that was it. And if one doctor said that the injury did not result from negligence, that also was it. This was a very
conservative approach to identifying negligent medical management injuries,
an approach that would be trusted by doctors. Doctors designed and
supervised the study Doctors trained the nurses who carried out the
first-stage review. Doctors conducted the second-stage review And the review
process had a variety of safeguards against a mistaken conclusion that there
was a medical management injury or negligence (and essentially no safeguards
against a mistaken conclusion that there was not negligence).12 This
means that we can be reasonably confident that there is even more medical malpractice than the Harvard team reported. It is important to be
clear that I am not criticizing the Harvard team. They knew that their
results would be scrutinized and that organized medicine stood ready to
attack even the slightest weakness in their data or analysis suggesting that
they were exaggerating the extent of medical malpractice. Given that
political reality, it was perfectly reasonable to design the study to
withstand the anticipated attack. After all, even their very conservative
estimates showed that medical malpractice was a much bigger problem than
almost anyone had thought. The results were
essentially the same as the earlier This means that there
were at least 27,000 injuries from medical malpractice in hospitals in By comparison, there
were only about 3,800 claims filed in The
During the 1990s two significant research projects found even higher rates of
medical management injuries than either the Harvard or the In light of these other
studies, the Harvard team decided to conduct a second study to check their
earlier results. In order to avoid the objection that their results were
unique to As before, the team
obtained a sample of records from almost every hospital in the region. They
put the records through a two-stage review similar to the one in The The slight differences
between the results of the two Harvard studies make sense in light of the
changes they made in the hospital record review process. The new
Utah/Colorado review process did an even better job of eliminating false
positives, so it makes sense that they found a lower rate of injuries. But the
Utah/Colorado review process also did a better job of reducing the chance
that negligence would be overlooked, so it makes sense that they found that
more of the injuries resulted from negligence. All in all, the differences in
the Details aside, both
studies showed that there is much more medical malpractice than most people
think. Imagine if a new drug made one out of a hundred people sick. How long
would it last on drugstore shelves? Or if one out of a hundred planes or
buses crashed? Or if one out a hundred lawn mowers sent people to the
emergency room? Yet the Harvard studies represent the low end of estimates.
Other well—regarded studies suggest that there is even more—a lot
more—malpractice. In most fields, there’s an intense
focus on preventing errors. In medicine, Baker contends that many mistakes
are buried, and lessons are not necessarily learned. “The real medical malpractice
problem is medical malpractice. It is not pretty to say, but doctors and
nurses make preventable mistakes
that kill more people in the Steve Hopkins,
January 25, 2006 |
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The recommendation rating for
this book appeared in the February 2006
issue of Executive Times URL for this review: http://www.hopkinsandcompany.com/Books/The
Medical Malpractice Myth.htm For Reprint Permission,
Contact: Hopkins & Company, LLC • E-mail: books@hopkinsandcompany.com |
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