Macrocosm: Medical Error, A Skeleton in America's Closet
FG Trade
The U.S. healthcare system isn't broken. It was built this way.
The relationship between patient and healthcare worker is a very unique one. There aren’t many people we’d let cut us open, stab us with needles, or give us drugs. We trust that they have our best interest at heart. That they would never do anything to intentionally hurt us. So, when they violate that trust, even if unintentionally, we take it personally.
For far too long the US healthcare system has been plagued with issues at both the systemic and personal care levels. Now, the consequences of these troubles are finally beginning to rear their ugly heads.
A 2016 study conducted by researchers from the Johns Hopkins School of Medicine revealed that nearly 251,000 deaths annually result from medical error making it the third leading cause of death in the United States.
The study, led by Dr. Martin Makary, examined death rate data over an eight-year period and discovered that on average, about 9.5% of annual deaths stemmed from medical error. In a stark and concerning contrast, the CDC credits unintentional injuries as the third most common death with 169,936 per year.
There is a reasonable explanation for this discrepancy. To generate its list, the CDC relies on death certificates which assign an International Classification of Disease (ICD) code for each mortality. The ICD code does not take into consideration human and system factors, thus medical error deaths are not accounted for. Unintentionally, this classification method has concealed an astronomical healthcare system breakdown.
Most people would readily assume that medical error occurs strictly as a consequence of inept healthcare works. How could they not, when we often watch TV and film doctors take oaths where they promise to ‘first, do no harm’. Medical error is generally defined as a preventable outcome of care that may or may not has caused harm to the patient.
This can include errors of execution, errors in planning, and deviations from the process of care. It is important to understand that medical error can transpire at both the individual and systemic levels because when it comes to the deaths that occur as a result, Makary insists, “it’s the system more than the individuals that is to blame”.
“The US Healthcare System is Broken”
For years this phrase has been echoed throughout America. The US spends more on healthcare than any other developed nation, but still has the lowest life expectancy, highest chronic disease burden, the largest number of hospitalizations from preventable causes, and the highest rate of avoidable deaths. This fact is so alarming it reads like it was ripped straight out of the Onion. We can all plainly see that there is a problem, but the source of the issue isn’t so clear.
Patients typically see more than one doctor, usually their primary care physician and other specialists. Naturally, these clinicians must share medical information and have an open dialog.
However, this rarely happens. A Commonwealth Fund study found that among 11 high-income countries, the US has the highest rate of poor primary care coordination. In the US, poor coordination was independent of outside factors (e.g. insurance status, household income, and gender) making it a systemic issue. This is troubling as poor care coordination leads to higher hospitalization rates and more emergency visits.
Despite having government healthcare programs such as Medicare and Medicaid, in 2018 27.5 million Americans did not have health insurance. Healthcare safety nets are providers who deliver medical care to our vulnerable populations. These institutions receive partial funding through disproportionate-share hospital (DSH) payments made by state Medicaid programs.
The payments are meant to offset uncompensated care costs which in 2018 alone totaled $41.3 billion. In reality, DSH payments only cover 51% of this amount. If hospitals can’t find a way to fund the remaining 49%, they are required to take on debt. Years of doing this can result in bankruptcy or even shut down. To make matters worse, in 2017 Congress passed the Tax Cuts and Jobs Act (TCJA) which eliminated the Affordable Care Act (ACA) mandate requiring Americans to have health insurance.
The Congressional Budget Office says that this could lead to an addition of 13 million uninsured Americans by 2027. ACA insurance expansions were to be offset with reductions in DSH allotments by a total of $44 billion by 2025. These cuts are still set to take place even though the TCJA has effectively reversed insurance expansions. This will no doubt increase the number of underfunded and indebted hospitals exponentially.
The US health insurance system is like a very complicated puzzle no one can seem to solve. Which doctor, hospital, lab, or pharmacy can I visit? Are there cheaper alternatives? How much will my co-pay be?
These are just a few of the many questions Americans find themselves regularly asking. With hundreds of insurance companies on the market each offering multiple different health plans, things can get very confusing.
A PolicyGenius survey found that fewer than a third of people have proficient health literacy and 27.2% have avoided seeking medical treatment due to uncertainty over their healthcare coverage. Poor health literacy leads to increased healthcare costs (e.g. as patients use services outside their network) and postponing treatment can increase the risk of hospitalization and mortality.
Despite having clear names and categories for most diseases, treatments are rarely as straightforward. Physicians will usually adopt different approaches to treatment based on the biases they’ve acquired through their own personal beliefs, life experiences, and training.
As diversity becomes a priority in American Culture, why shouldn’t we encourage variations in practice style? In 2018 researchers from the Mayo Clinic conducted a survey in order to grasp clinicians' beliefs on unwarranted practice variation. They found that of the 250 participants, most agreed that practice variation should be reduced.
If the offenders themselves are saying that there is a problem, then it may well be worth examining. This becomes a more pressing issue when considering that unwarranted practice variations can lead to underuse of effective treatment, medical opinion dominating patient preferences, and increased healthcare costs.
Twisting the Facts?
Having shed a bright light on the deep cracks in the US healthcare system, Makary’s discovery has garnered tons of praise. However, not everyone has been a huge fan of his work. In a recent article, doctors Benjamin Mazer and Chadi Nabhan assert that Makary’s findings are unwarranted and only work to encourage distrust in the healthcare system.
They argue that the data Makary utilized was inaccurately combined, overly exaggerated, and was not meant to be generalized to the entire population. Some researchers have calculated figures as high as 440,000 meaning Makary’s estimate is relatively conservative. Even if there is some truth to these criticisms, recent events have inadvertently confirmed Makary’s suspicions.
In Light of the COVID-19 Pandemic
Although it makes up only 4% of the global population, the US has suffered about one-quarter of all COVID-19 deaths (130,000 and counting). As a result of the outbreak and the US’s disastrous medical response, we are all seeing the consequences of an inadequate healthcare system firsthand.
Since the very beginning, this pandemic has been highlighted by shortages in supplies from personal protective equipment (PPE) to ventilators and testing kits. Increased demand, misuse, panic buying, and hoarding have caused the price of PPE to skyrocket.
As a result, healthcare workers are being forced to reuse equipment. This not only puts their lives at risk but could potentially accelerate the spread of the virus. A recent study has shown that the SARS-CoV-2 virus, which causes COVID-19, can remain viable on some surfaces such as plastics and stainless steel for up to seven days.
For years, experts have warned that the US is not prepared for a respiratory virus pandemic. However, with all of this foresight, how could we get things so wrong?
On an episode of the Netflix series Patriot Act with Hasan Minhaj, Minhaj explains why America is experiencing shortages in medical supplies. The US has spent decades streamlining its supply chains. Once the pandemic hit, these supply chains started to deteriorate leaving life-saving supply chains vulnerable. Although the US is supposed to have a reserve of supplies for a situation like this, we used up most it during the H1N1 pandemic and never replenished it.
Now that we need these supplies, we cannot acquire them because most of our PPE is manufactured in China. Healthcare workers have had to rely on donations from different sources, but even this has presented issues.
On the Fresh Air radio show, Danielle Ofri a professor at the New York University School of Medicine and author of the book When We Do Harm: A Doctor Confronts Medical Error, spoke of her experience working on the frontlines of the Covid-19 fight. She states that over the course of the past few months, “there were issues in care that really weren't related to specific misjudgments but just the fact that the system was overwhelmed”.
The U.S. has been experiencing a physician drought since before the pandemic began and the sudden influx of patients has only exacerbated the situation. Physicians are now working outside of their specialties, many have come out of retirement, and some medical students were graduated early. Now we have orthodontists and psychiatrists treating patients for a respiratory illness.
This is in addition to physicians with little experience and those who have not practiced in years. To make matters worse, all of these individuals are working longer hours in a high-stress environment. Naturally, this seems like a recipe for disaster.
So, What Now?
All of the facts highlighted here paint a bleak picture. We have unwittingly created a system in which medical errors are overlooked. The CDC’s annual list of leading causes of death informs prevailing research, meaning items on the list get more funding and dictate public health priority. Because medical error does not appear on the list, it has received limited attention.
We cannot begin to seal any of the cracks in the healthcare system until we establish a method to classify medical error-related deaths. Doing so is now more vital than ever because as we’ve seen with the COVID-19 pandemic, we are unnecessarily putting peoples’ lives at risk.
For a very long time, the healthcare system has been screaming for help. The real question now is: when are we going to start listening?