Customer Reviews

Demanding Medical Excellence: Doctors and Accountability in the Information Age

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The National Academy Institute of Medicine reports in their new book "To Err is Human":

"Two large studies, one conducted in Colorado and Utah and the other in New York, found that adverse events occurred in 2.9 and 3.7 percent of hospitalizations, respectively. In Colorado and Utah hospitals, 8.8 percent of adverse events led to death, as compared with 13.6 percent in New York hospitals. In both of these studies, over half of these adverse events resulted from medical errors and could have been prevented. When extrapolated to the over 33.6 million admissions to U.S. hospitals in 1997, the results of the study in Colorado and Utah imply that at least 44,000 Americans die each year as a result of medical errors. The results of the New York Study suggest the number may be as high as 98,000. Even when using the lower estimate, deaths due to medical errors exceed the number attributable to the 8th leading cause of death. More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516)."

These are only confirmed and documented hospital deaths induced by error (wrong medication, wrong operation, failure to deal with documented symptomology, etc.) For example, Millenson points out one study that showed in a single hospital there were 51000 errors in a year and only 36 reported. There are at least 180,000 deaths and over a million injuries caused by medical error every year in the U.S. Many professionals (including the reviewer who was funded by NIH for eight years to do risk analysis in healthcare) believe that these numbers are severely undereported and that medical error is the third leading cause of death after heart disease and cancer.

This book is the best available overview on the topic. If you value your life you will read it. The patient must take responsibility for monitoring treatment. If the patient is unable, family or friends must closely monitor it. Every time I give a talk on this subject someone in the audience has a personal horror story to share. Last month it was the son of the Chair of a conference I was attending whose child had a brain tumor and was in surgery the week before my talk. After surgery, the nurse was about to overdose the kid on morphine. A family member had been sleeping with the child in the hospital and logging every medication in a notebook. When they showed the log to the nurse and prevented her from administering the drug, she was shocked.

These stories are not isolated events. If airlines were like hospitals, every time 200 people disembarked from a flight, 7 passengers would be injured or dead.

The most tragic part of this story is that if healthcare institutions where automated like most industries, over 50% of these errors would disappear the first day they turned on the computers.

Experts estimate that over one hundred thousand patients die each year as a result of medical malpractice. Why does this continue to happen in a country as sophisticated as ours, and what can we do to stop it? In "Demanding Medical Excellence", Michael Millenson, a three-time Pulitzer Prize nominee and former reporter for the Chicago Tribune, believes that he has found a few solutions to this overwhelming problem. "The keys to medical excellence," Millenson writes, "are information and accountability."

Millenson, who was thrust into the middle of this country's health care crisis, while researching patient's horror stories, examines our health care system from every angle. He believes that the breakdown in this country's health care system can be traced to two things - the sudden plethora of medical information and technology, and the failure of the health care system to distill this knowledge to its physicians in a way that is understandable and useable. In other words, the knowledge may be there, but is it really helping American patients get well and stay healthy? From his research, the answer is no.

In his book, Millenson makes a strong case for making our health care system as quality-minded as other previously antiquated industries. He tests his theories by examining health care systems that have redesigned themselves into well-oiled machines that would make Deming proud. For example, Salt Lake City's LDS Hospital. LDS has designed a technologically-advanced computer system, that gives physicians the data they need to treat a patient right at the bedside, enhancing the physician's knowledge, with data culled from the treatment of thousands of patients with the same illness. The results were startling, in some cases, improving patient care and mortality by forty or fifty percent.

Although many HMOs are trying to reinvent themselves, Millenson doubts that managed care or nominal exercises in quality assurance, will be the answer to our health care problems. He believes that by harnessing technology, the health care industry can give physicians the knowledge they need, to treat patients with the best result in mind. Millenson is quick to add that, after knowledge, comes physician accountability. In the end, it is only by holding physicians and hospitals accountable for their treatment decisions, that the patient will ultimately win.

"Demanding Medical Excellence" is a thoughtful, well-researched, credible illumination of both the stumbling blocks to providing efficient, quality health care and the opportunities afforded by new information technologies. I am an experienced health care professional and am very involved in efforts to influence health policy and health services delivery. "Demanding Medical Excellence" added depth to my understanding of the issues of accountability in medicine and information as a currency of power. I highly recommend this book to anyone interested in understanding the facts and implications of current efforts to change the way health care is delivered. It is engaging, informed and important.

A fairly thought provoking book, but does leave a little to be desired. Millenson uses individual cases to thoughtfully express the challenges of healthcare which makes for fairly interesting reading. His biases are fairly open with a range of emotion from enthusiasm to anger of the complexities of healthcare. This is not your cup of tea if you're averse to journalistic hyperbole.

While technologic successes have left many in the public optimistic about medical care in the U.S. and serious public health lapses would make one conclude otherwise, healthcare has evolved into a combination of a success and mess. Unfortunately there are few easy answers.

One caveat: there are some errors in this book: On page 90 he notes, "In 1897, the Austrian physician Ignaz Semmelweis realized..." and on page 156 he states, "...postoperative damage to the kidneys, a condition widely known as massive hepatic necrosis."

I'm no genius, but Semmelweis of handwashing fame made his case 50 years earlier. Also, hepatic necrosis would be the liver, not the kidneys. Fortunately, Millenson is only a reporter and not a doctor who he repeatedly lambastes. At least no was injured by his errors. Makes you wonder if there aren't many other mistakes, though.

There are two things that jump out at me about this book. Firstly that if you are a physician you would probably benefit from the ideas and historical narration in the book. Secondly it is obvious right from page one that the author has only an outsiders view of the medical world and does not fully comprehend the complexities and intricacies of practicing medicine. This leads to a bias against physicians. Overall though I must admit this is an excellent primer to understanding evolution of current medical systems and I have beneffited much in the reading of this book.

Millensen provides an insightful and historical view of the evolution of managed care (or managed competition). However, as a professional who can uniquely view the medical arena from both sides, he misses the point...managed care is here because educated baby boom generation demand more autonomy in their medical decision making, all the while supporting their medical and non-medical peers who have found profit in the system too hard to resist...we want it all.

This is a tremendously readable study of a very dry subject. While meticulously documented, Millenson's style is so entertaining that this book makes for good vacation reading for anyone involved in the health care industry. I am one one of those company benefit managers described at the start of Chapter 10, caught between employees unhappy with managed care rules and a management intent on holding the line on costs. This book gives me hope. With time and the right incentives, managed care can be the framework in which quality management in health care becomes visible to consumers. Congress and the medical profession ought to focus on making it happen.

Well written survey of how the practice of medicine is just like other professions--it's difficult to propogate best practices, human beings tend to do the same things over and over without understanding whethe they are effective, and health care providers are complex systems. Uses anecdotes, statistics, successes and failures to illustrate how far we've come and how far we've yet to go to provide state of the art medical care in the US.

This important book is not perfect, and it drags towards the middle. Nonetheless, it demands our attention. Health care is beginning to wake up to these issues thanks to works such as this. This book should be a must read for health care professionals. It is extremely well researched and quite enlightening. I highly recommend it to all.

The mistakes mentioned by a reviewer below concerning hand-washing and hepatic necrosis were either not present or corrected before the printing of my copy of the book.