First Do No Harm

THE OPEN MIND
Host: Richard D. Heffner
Guest: Robert Michels, M.D.
Title: “First Do No Harm”
VTR: 12/14/99

I’m Richard Heffner, your host on The Open Mind. Where our subjects are often quite compelling and of great personal importance to each of and every one of us. None, of course, as much as the fact that between fifty and one hundred thousand patients die in American hospitals each year because of medical errors. More people than dies each year from highway accidents, breast cancer, or AIDS.

This is the statistic confirmed late in 1999 by the Institute of Medicine of the National Academy of Sciences which reported as well that, quote “while errors may be more easily detected in hospital, they afflict every health care setting. Day surgery and out-patient clinics, retail pharmacies, nursing homes, as well as home care. Deaths from medication errors that take place both in and out of hospitals more than 7,000 annually, exceed those from work place injuries”. These rates of medical errors are indeed stunningly high, but many physicians and particularly medical administrators presumably are not totally unfamiliar with them. So why they exist is, of course, then another matter.

And today I want to discuss that matter with my favorite medicine man, the distinguished psychiatrist, Dr. Robert Michels, who practices in New York, was Psychiatrist-in-Chief at New York Hospital, professor and Chairman of the Department of Psychiatry and then Dean at Cornell University’s Medical College. Now Dr. Michels and I have talked many times here on The Open Mind but never about such grim health care statistics. And so my question to him must be, why not? Have they been American medicine’s dirty little secret? Is that a fair question?

MICHELS: Sure, it’s a fair question. I don’t think they’ve been much of a secret. There have been articles published on this over the last decade, studying the frequency and the pattern of serious medical errors, and the morbidity and the mortality that are associated with them. Dick, it would be very easy to stop all medical errors. Just stop all medical care. There are 250 plus million people in the country, they see an average of five or six physician visits a year, plus hospitalizations. So we’re talking about billions of episodes. And the more episodes, the more chance for error. The more complex the treatment, the more complicated intensive care units, or major surgery or dialysis programs or radiation therapy. With many different units that have to interact, the more possibility for error. So, there’s always a trade off. With more complicated treatment and higher error rates, even though the net effect may be saving lives. So you don’t want a zero error rate, because the easiest way to get that is to close down the system and have people die of their diseases without treatment.

HEFFNER: What do you mean by “trade-off”?

MICHELS: I mean that as the health care system gets more complicated, and there are more components involved in each unit of care, that have to be integrated with each other, the more opportunities for error, and there are likely to be some increase in errors. What we want to make sure is that the error rate is the lowest possible rate compatible with superior care, rather than the lowest possible rate.

HEFFNER: Do you think it is now?

MICHELS: No, definitely not.

HEFFNER: Okay. All right because when you said these are figures that have been published before in part, certainly, we the public haven’t been familiar with them.

MICHELS: You probably don’t read the Journal of the American Medical Association.

HEFFNER: Indeed. That’s why I say, “we, the public” …

MICHELS: Right.

HEFFNER: What do you think the reaction of patients is going to be, Bob?

MICHELS: What I hope it is, is to say, “Oh, my god, that’s scary, what can be done to lower the rate? How can we improve the system”. Because I think what they’ll find out and what the medical community is finding out is our traditional attitude toward errors may not be the most effective way of diminishing errors. Blaming someone for doing something wrong feels like an appropriate response to a serious error. But it may not be the best way to reduce the total number of errors. In the current situation, system factors, rather than individual factors are going to be easier to control and influence.

HEFFNER: What do you mean by “system factors”?

MICHELS: Well, let me give a very concrete example. Let’s say that a tired, fatigued doctor makes a mistake and take the wrong ampule and puts it into a syringe and injects it into an intravenous line and the patient dies. That’s a tragedy. That doctor should have checked that ampule more carefully, and we should make sure that he’s had adequate training and adequate motivation to check it very carefully. But no matter how much we focus on that, that kind of error is bound to occur as long as it’s mechanically possible to put that ampule into that syringe. It would be a far better world for all the patients if we changed the way the ampule is constructed so it’s impossible to put that ampule into that syringe rather than blaming the doctor and taking away his license and suing him for malpractice and suspending his career because of the error. In fact, let’s say he does it and then recognizes it in time to stop and no harm comes of it. What we want to do is motivate him very highly to warn us … there’s a system problem here. This ampule is badly designed and I almost made a mistake and somebody else’s is going to make a mistake. And we have to change the system. We need a system that invites advice from the participants on how to improve it. Rather than causes us to seek who to blame when something goes wrong.

HEFFNER: Bob, let’s take the example, you offer … do you mean … I’m sure you mean that that has happened … it’s happened many times.

MICHELS: Of course, it’s happened.

HEFFNER: Do you mean that Dr. X has not, in all likelihood confronted whatever there is of a system and said, “we must design capsules … or we must design receptacles so that this cannot happen.”

MICHELS: Certainly some doctors have done that. But there’s no systematic encouragement or requirement that every doctor does that. There’s no reward for doing it. And in fact there’s often even a reward for not doing it. Because our current “blame system”, the tort system of malpractice law makes it dangerous to say, “I almost made a mistake” or “I did something wrong, but caught myself just in time”. So we’ve developed a system in which people who make mistakes that don’t lead to dire consequences are somewhat rewarded for keeping them quiet. Rather than for helping us use them to improve the whole system.

HEFFNER: Well, you were the Dean at Cornell Medical School. Were you able to, were there areas where you could have changed part of the system and did you?

MICHELS: Well, one important area was to make sure that the medical students and the residents, the recent medical students were familiar with this literature and knew about the problem and had dialogues about it and discussed it. That we, in effect, saw part of the profession of medicine as not only being involved with treating individuals, but in changing the health care system so that it’s more reliable and more consistent in the treatment it provides all individuals. In effect, it’s sort of a professional ethical theme that whatever any member of my profession does, I’m responsible for if I’ve ever had an opportunity to in any way modify or influence his behavior. So that attitude and that knowledge base is an important part of contemporary medical education. The second question, and the more immediate one is what do we do about the actual practices in the current health care system. The medical schools only medical practice is largely out-patient. Most of the changes that have been, have been made in more intensive, more complex in-patient medicine. One of the pioneering disciplines in switching over to this new style has been anesthesiology. And it’s no surprise, anesthesiology is a highly technological specialty. It deals with very important interventions which have the capacity to do great harm. As well as to do great good. And an error can be lethal. And the anesthesiologists have pioneered in developing a system where errors are opportunities for system improvement rather than occasions for blame. I think we slow and early in moving the rest of the system in that direction. But I think we’re beginning.

HEFFNER: What enabled the anesthesiologists to do this? What in their culture, if I may call it that enabled them to take those steps?

MICHELS: I’m not sure I’m a historical expert on that. But I think several things at least contribute to it. One is that they tend to work in systems. You don’t see a single anesthesiologist alone in private practice …

HEFFNER: MmmHmm.

MICHELS: … you see them working in settings where there are groups watching each other and where there are a lot of records kept about what they do. And where one of them changing the system can rapidly share the change with all the others in the group with him, and therefore improve all of their practice. I think a second thing they do is work in sort of public structures, and I mean public in the sense that they’re looking over each others’ shoulders, surgeons are looking over their shoulders, nurses are involved. And they’re working in a transparent arena, rather than as many physicians who have direct patient contact do, in a closed room with no one but the patient. So there are many opportunities because of that. But I think we also have to say they were courageous and bold in leading the fray because of some leaders who took the initiative.

HEFFNER: The Hippocratic Oath, I know of “do no harm”. Is there anything in it that would correspond to what you are talking about now?

MICHELS: Well, again, I think that “do no harm” has to be put in context. Because the easiest way to “do no harm” …

HEFFNER: Is not to do anything [laughter].

MICHELS: … is to do nothing. And that would be really harmful. I think that the modern notion is that do something that on balance is more likely to lead to good than to harm. And that may mean doing a lot of harm in order to do even more good.

HEFFNER: But you know, Bob, that notion runs so much against our culture, runs so much against our culture of blame, as you suggest. Runs so much against the adversarial system. I wonder how you could even anticipate the possibility of making that bold change.

MICHELS: Well, I think that’s been a major barrier to the change. For example, the malpractice system makes it highly unlikely that individuals will come forward and say, “I made a mistake and others might learn from it”, because by doing that they put themselves at great risk. I think the only thing that will change the system, is education of the public as well as the profession about what the potential value of that change will be. Of how many lives we lose by not changing it, and how many we might save by changing it. One of the common examples that used is as a sort of analogy is airline pilots and the way they function. If airline pilots functioned the way that medicine functioned we’d have a lot more airline accidents. You never hear of an airline pilot being sued for malpractice because he made an error. What happens is every time he comes close to even almost making an error, he fills out a report and people study what happened and try to figure out how they can change the system so other pilots won’t have the chance to make that kind of error. We need that psychology, that has to change the way physicians think about their work. And importantly the way the public thinks about their doctors, and that’s a long, slow process.

HEFFNER: Any indication that that’s happening aside from the report which recommends that panels be set up.

MICHELS: I think the report, the public coverage that it received, are themselves indications that it’s happening. I think the collection and reporting of data within the professional literature about various medical procedures and the variations in them from community to community are a step toward that happening. We now get data regularly from many hospitals in the community about their differential rates of morbidity or mortality for performing one or another procedure. Those are opportunities to find out what are the best practice patterns, what are the ones that aren’t working well. It’s often very hard to tell in a single institution how well or how poorly you’re doing until you get the data from ten similar institutions that can look most focused on the outliers who are doing particularly well or particularly poorly and see if there’s something to learn from them. We have the information systems that are available to give us that kind data now that we didn’t have a decade ago.

HEFFNER: Still, I wonder where is the responsibility. I don’t mean in terms of the use of the word “blame” or “responsibility” that way. Where is the opportunity because this corresponds more, I think, to what you had suggested. Where is the opportunity in the medical system for the … for doctors to be that wise and to make use of whatever modern computer techniques, or whatever, will enable them to do.

MICHELS: Dick, this is part of a sea change in the entire world of health care. If you go back a few decades ago, the modal event in the world of health care was someone felt sick, they went to see their personal doctor, they had a visit with them, he examined them, he might have done a test, might have run it in his own office, wrote a prescription for them, they left and no one ever collected any information about that event. No one ever assessed whether it could have been done better or it might have been done poorly. And that was the end of the story. Today we’re in a health care system where most patients who see doctors have some other organization that employs the doctor or pays their insurance or supervises the hospital in which the event occurred, or collects data from the lab that did the test. Some other organization that’s looking at this as one unit in the health care system. And collecting information that can be used to analyze the system as a whole. And find out what units are outliers and can be studied. So that every episode of care has to been seen not only as a therapeutic attempt, but also as a unit of data that will be fed back to improve the entire health care system. And the same way that every airplane flight is not only a way to get from St. Louis to New York, but it’s also a way to study what happened on that flight so that all future flights will be safer. Our airlines are immensely safer than they were only a few decades ago. Our health care system is just entering the era in which medical care is part of a system rather than a series of unique, unconnected events.

HEFFNER: Of course, you know as well as I do, or you know much better than I do that the complaints one hears from individual physicians range around and about and concerning just exactly that which has happened thus far. They are in a system, not the system that you’re describing, but they feel themselves … so many of my doctor friends have said “No, I don’t want my children to go into my profession, there’s not enough autonomy any longer”. Aren’t you talking about something that will even further … you don’t want it to … but will even further limit the autonomy of the practitioner?

MICHELS: I consider myself one of those physician friends and you’ve heard those kinds of complaints from me …

HEFFNER: Yes.

MICHELS: … and in this room, I think. Certainly that’s true. The transition from this cottage industry of solo practitioners to large organized systems of care has had many negatives. We’ve heard about those, the public is angry about them, we’ve had legislation suggested to help limit them and regulate them or correct them. But there are some advantages to a large, organized system. One of the greatest reasons for doing it … one of greatest advantages is the opportunities it offers to use that information in order to improve the quality of care. I think there are many problems in reducing the autonomy of physicians. But it would be really tragic if we suffered from the problems and didn’t benefit from some of the potentials. There are immense potentials for good it in. Unfortunately the curve shift motivated more by cost control than by improved quality of care has given us the problems front end and the benefits are trailing behind. But this is a very important benefit that can only be accomplished by dealing with system wide attitudes toward health care. And it’s important we begin to benefit from it.
HEFFNER: Do you think this points toward … or I was going to say a single payer system. What I really meant was a unitary system. You seem to be asking that from everywhere information flows into a central point so it can be made use of. Not just approval of procedures to save dollars. Do you think this points toward a centralization of medicine that has been so long in the coming.

MICHELS: I think it points toward using the information about our health care system in sufficiently large assemblages so that we can get useful results from it. Because of modern statistical methods and the huge ends involved in this we don’t need information about every event, we just need information about a significant sample of events that we can make inferences from. So I have no doubt that we could get immense value in this area if there were six competing systems across the nation and each of them tried to develop improvement in their processes because of this. Furthermore, it doesn’t mean that we have to have a single provider system, as long as we have an integrated data system that can collect and use the information. It would be heaven as far as I’m concerned to preserve the appropriate professional autonomy of the individual practitioner with the patient while using the information from that event to improve all other individual practitioners practices.

HEFFNER: Nirvana.

MICHELS: Nirvana.

HEFFNER: Do you think it will happen that way?

MICHELS: Not soon. I think we have to have a system that rewards it happening that way.

HEFFNER: What do you mean?

MICHELS: I mean that right now the providers of care aren’t themselves viewing their problem as how to create a long term increase in the overall quality of the health care system. That’s not the way a for-profit makes more money. So we clearly need a public role in requiring this kind of attitude in the industry. Similar to the attitudes we have in aviation, for example, or in the construction of automobiles, or in other similar industries where in order to improve the benefit of safety for all, we have to have a government regulation that imposes certain data collection and certain standards on each of the components of the system.

HEFFNER: Isn’t it likely given the very nature of medicine as contrasted with the nature of producing widgets or cars or shoes or whatever, that the controls are going to be much greater. Must be.

MICHELS: Well, you would think so, but in fact in some areas they’re much less right now. So, for example we have very, very tight controls on the manufacture of drugs. But we have almost no government control on the surgical procedures. The tradition of the autonomy of the profession is so great that it really hasn’t moved that way except where there are commercial industries such as pharmaceutical firms involved. I think we need to move toward a view in which the importance of regulation and collecting data doesn’t have to do with the commercial profitability of that component of the system, but with the public health significance of collecting and using the data for the good of the general public.

HEFFNER: Well you’ve described this as, in a sense a cultural problem as far as physicians are concerned. What will change this?

MICHELS: Well, one thing that will change it is medical education. Now this is a task for our medical schools to change the attitudes and interests and knowledge base of practicing physicians. There was a recent survey of the attitudes of academic physicians … Deans and Chairman of departments of medicine and surgery and pediatrics and professors in our medical schools … and their attitudes towards managed care. They largely dislike managed care. They think it’s interfered with their autonomy. They think it’s lowered the morale of the academic facilities, they think it’s deprived the medical schools of resources they need to do their job. But they like this aspect of managed care. They like the fact that managed care and the related movements in health care have moved toward more reliable information systems that can be used to improve the way in which all physicians practice. That’s something I think that we’re moving toward and I think the medical schools will play a leading step in changing the culture of the medical students and future physicians above it.

HEFFNER: But now you’re talking about more than information. You’re talking about action just as you said … building …making it impossible physically for the wrong medicine to go into a syringe … where, where is that going to take place?

MICHELS: Well …

HEFFNER: How is that going to take place?

MICHELS: I think once we can describe things like that, if … we’re in a competitive world of people who build syringes and build ampules and if one company knows how to build an ampule and a syringe where you can’t make an error and another one doesn’t know how to do that. I know who’s going to win in the market race. In the same way we’re going to have monitoring machines that don’t just collect data, but ring the bell appropriately when the data means somebody has to do something right away. Or we have computer assisted prescribing systems in our hospitals now, instead of writing a prescription on a pad of paper, you enter orders in a computer. If a doctor orders a drug which is incompatible with another drug the patient is now taking, instead of accepting the order and delivering the drug, the system says, “hold off, this is incompatible, do you really want to do it? If you really think you want to do it, explain why and press the button. We’ll review it and let you know whether you have to talk to someone.

HEFFNER: You know we have a minute left, or something like that and I’ve wanted to ask you about that story … recent story in The New York Times, the front page story about doctors developing devices in which they have an interest and then trying to sell them. And I wonder how that would impact upon your hopes in this area.

MICHELS: I would hope that there would be immense profit in improving the quality of care in our health care system and somebody would be very, very rich because they’ve saved lots of lives. I guest I come from an old fashioned culture in which I think that person shouldn’t be a practicing physician and that the doctors should modestly stick to trying to use those systems rather than making money from them in order to maintain his or her credibility as a care taker.

HEFFNER: Will that old-fashioned idea prevail?

MICHELS: Not in the short run.

HEFFNER: That’s your favorite expression now … “not in the short run” … you want to be an optimist.

MICHELS: I want to be an optimist. I think that in time the arcane special knowledge of the physician won’t be necessary to make money in helping people’s health and therefore they’ll step back to their more traditional role of taking care of the sick.

HEFFNER: Dr. Robert Michels that you so much for joining me again on The Open Mind. It’s always a pleasure to have you here.

MICHELS: Thank you.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. If you would like a transcript of today’s program, please send four dollars in check or money order to: The Open Mind, P. O. Box 7977, F.D.R. Station, New York, New York 10150

Meanwhile, as an old friend used to say, “Good night and good luck”.

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.