Customer Reviews: Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes
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VINE VOICEon April 28, 2004
I strongly suspect that the publishers insisted on the title of this book over the objections of the authors, because (as another reviewer has noted) the title is clearly sensationalistic and very much out of line with the even-handed and level-headed treatment of the rest of the book. Indeed, the title is perhaps the ONLY thing I would criticize about this otherwise excellent and gripping description of the underlying causes of medical mistakes and what can be done about them.
I cannot praise the quality of the writing enough. The authors accomplish just the right blend of fascinating case studies and theoretical analysis. They make their basic point (that any system run by humans is fallible and medical mistakes are inevitable) very effectively in the beginning pages of the book by describing two case studies where mistakes were made...with the punch line being that the mistakes were committed by the authors themselves. Beginning the book this way was in part so effective because it gets across the message that the vast majority of mistakes that are made are not the result of negligent, careless, or malicious physicians; rather, they are the inevitable consequence of a system that struggles to cope with the complexity of the ever-changing demands of a never-ending stream of patients.
The second most admirable feature of this book, in my opinion, is that it does not merely criticize but also offers suggestions for improving the delivery of medical services to eliminate errors, from such simple steps as physicians "signing their sites" (to prevent, say, amputation of the wrong limb) to computerizing medication orders (to prevent errors due to physicans' notoriously poor handwriting) to more systemic changes in malpractice law. I thought the authors' suggestions on this latter topic to be highly intriguing and novel. The idea of adopting a modified no-fault system for compensating patients injured by medical errors is, in my mind, a terrific idea, and I would love to see the authors' recommendations in this regard enter the national debate on malpractice litigation reform.
Perhaps the only part of the book I found even slightly disappointing was the authors' reluctance to deal more bluntly with the problem of incompetent or alcoholic/drug dependent doctors. The authors acknowledge that these "bad apples" exist, but they do little beyond saying that hospitals and physicians tend to cover up for the incompetents in their ranks. My mother-in-law died from botched surgery; after she died, the hospital risk manager told us to our faces that this particular surgeon had had "other surgeries that did not turn out as he had planned." I think if I had read this book before my mother-in-law died, I would have been more proactive in pressing our complaints about this surgeon, who--a scary thought--is still operating on people but probably should not be.
But these kinds of physicians are in the minority, and the contribution this book makes is to describe the much more common ways in which patients end up being hurt by medical care designed to help them.
I read a lot of nonfiction, and this book is one of the rare examples of nonfiction that can keep you glued to your chair and turning the pages eagerly. I think it ranks right up there with Jon Krakauer's "Into thin air" and Richard Preston's "The hot zone" in terms of readability and interest value. Yet it also probably outranks those and other books in terms of potential social value. It could well be one of the few books with potential to inform and enable real changes in social policy that has been published lately.
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on February 20, 2004
I highly recommend this book!
I first saw Dr. Wachter on IMUS. The interview was terrific. Not only was the subject matter interesting, the doctor spoke in a language anyone could understand, and he was funny to boot. He made a great analogy about calling his favorite Chinese take-out restaurant to place an order. Before they hung up, they repeated the order back to him (like the world would end if he got the wrong kind of soup), but nurses and pharmacists have not been trained to do the same when a prescription is phoned in. The just say thanks to the doctor and hang up.
Well, I immediately bought the book and could not put it down. So many of these types of books speak to other medical personnel, this one is for everyone. I have recommended it to my book club (15 suburban Moms) and the discussions have been quite interesting. We all have our own stories to share about the medical process. Who doesn't have a story about a doctors appointment with an ailing parent or a 2:00am emergency room visit with their toddler? I now feel better equipped to deal with these situations.
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on February 9, 2004
Nearly every disease or medical condition has a group that works to bring attention to the importance of spending time and money to understand and control it. A key activity for these groups is to bring the disease to the attention of the public in an effort to influence the flow of money and talent to their cause. Some diseases affect such a small number of people that it is impossible to reach a critical mass of affected or interested people to be able to influence politics or market forces. Others may affect a large number of people, but fail to receive the support of the public and those that fund research. In the 1980s AIDS was in this latter category until the a critical mass of activists took up the cause and moved it high on the list of diseases receiving support from federal sources, private industry (pharmaceutical companies), and the public at large.
In the last few years it has become it has become clear that medical errors can be thought of as an epidemic (though not a new one) needing the same kind of support that led to significant improvements in the transmission and treatment of AIDS 15 years ago. There have been a number of reports about the problem in the medical and lay press, but it remains a disease that doesn't yet have many energetic and vocal activists. Internal Bleeding may change that.
Wachter and Shojania have written an entertaining and easy to read overview of the problem, including the work done by a handful of very talented researchers to understand the root causes and potential solutions. It is full of anecdotes of medical mistakes with a more thoughtful analysis of them than what one can learn from the newspaper or nightly news. The book is likely to engage the public more than previous academic reports and TV news segments. It may move medical mistakes and healthcare quality overall, up on the list of our nation's priorities more successfully than other efforts to date.
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on January 21, 2004
A fearless and eye-opening look at the terrible mistakes that occur in medical settings. Not just a collection of horrific anecdotes (though there are PLENTY of those.) There are REAL solutions set forth here and I hope someone is paying attention. To their credit, the authors reveal what lay people have never before been privy to--some of which falls into the "Yikes! Maybe ignorance really IS bliss" category, but makes for engrossing reading.
I could not put it down until the last page. This should be required reading for policymakers and potential patients alike.
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on February 23, 2004
This extremely informative book provides unjaundiced insights into the way errors occur, describes the hierarchy and complexities of medical training, helps to demystify the culture of medicine, and enlightens readers about the organization of hospitals and delivery of medical care in a dramatic and engrossing manner. The authors have a mission, but choose to teach, rather than to proseletyze. There are helpful suggestions for patients, as well as sophisticated and thoughtful analysis for medical professionals.
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on February 7, 2004
More than just dramatic tales of all the things that can go wrong in medicine, an unblinking, and really quite gutsy, insider's look at what American healthcare has become. The book grabbed me right from the first page, and it remained compelling, easy to read, and remarkably insightful till the very end. Not only will it make me a better consumer of medical care (I'll know what questions to ask and what to watch out for), but I have gained a measure of sympathy for my friends who are doctors and nurses. We really have to tackle this problem in a whole new way. I hope this book is the starting point for doing just that. Bravo!
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on March 11, 2004
I'm a nurse administrator and educator at the medical center that is home to the authors of this book. I would make this required reading for any of my students, since they will be working in similar systems and can greatly benefit from the wisdom offered by Drs. Wachter and Shojania. I would also make this required reading for patients, families, and friends (and have already given many copies to my own friends and family!), since they are in the best position to be thoughtful about their own care and they way in which they proceed through any of the healthcare systems. If both providers and patients are informed and engaged in communication, the outcomes will surely be more positive.
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on February 5, 2004
My wife is a physician and has explained bits and pieces of this field of medical error and patient safety to me, so I decided to pick up the book. Also, as a teacher, I'm always on the look out for potentially interesting books to recommend to motivated students.
I'm not sure what personal animus "Typical Wachter" guy has with one of the authors, but I found the book anything but typical.
Despite the sensationalistic title, I found the writing to be a nice balance between drama thoughtful explication of the underlying issues. One of the reviewers on the cover jacket described it as ER meets Fast Food Nation, and I think that actually captures the book surprisingly well. Last year I read FFN, and, though I admired the writer immensely for his accomplishment and found the material quite interesting, I have to admit I faded towards the last third. Not so with this book. Many of the chapters are quite self-contained (the way a New Yorker, Harpers, or Atlantic article might be), but I still found myself going from one chapter to the next without losing any steam..
My wife's reading it now, too, and she has also been impressed with the degree to which the material is likely to be interesting to medical audiences (she already plans on recommending it to a few of her colleagues) as well as the general public.
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"Internal Bleeding" is a good primer on medical culture. The authors focus on the issues related to medical errors. The book is largely well written, but occasionally the authors resort to hyperbole to make points; terms like "crisis" and "epidemic" are occasionally warranted, but their overuse tends to occlude important nuances within the issues discussed.

I was particularly interested in the analogies the authors made to the aerospace field, and found the cultural comparisons insightful. The discussion of the space shuttle accidents (pp. 49-51) are a proper indictment of NASA management, and makes the argument that in medicine and aerospace as well, taking routinely good outcomes as positive reinforcement of perceived infallibility is asking for disaster. ("NASA had forgotten how to be afraid.") On pp. 88-89 the authors discuss the differences between "slips" and "mistakes" and include a valuable commentary on trapping errors, much like the latest iteration of aviation training attempts to trap errors with "Threat and Error Management".

The authors provide excellent commentary on the makings of master diagnosticians, hypothesis testing, and the applicability of Bayes' theorem to medical reasoning on pp. 110-112 and p.117. This section provides an excellent view into the minds of doctors as they make challenging evaluations in complex cases: although not specifically stated at this point, similar thought processes are used in other highly skilled, tightly-coupled professions, such as aviation. The authors also explain why overreliance on automation and underreliance on physician wisdom is certain to result in bad medicine, despite the utility of computer systems in medicine. ("Any doctor who could be replaced by a computer should be.")

The authors return to their aviation subtext on p.147 in their discussion of pilot selection versus medical school selection; the conclusion reached is that the real-world evaluations given to pilot candidates would be a much better template for medical school applicants than what is currently used. On pp.156-157 the authors discuss doctors as being psychological perfectionists, and provide examples from other professions which tend to validate their hypothesis. The crux of the discussion is the intolerance for mistakes within the profession and within the psyche of individual surgeons, a trait common to pilots. Furthering the discussion of error-intolerance is a discussion (p. 176; p. 366) of one of the most common types of errors in both aviation and medicine: communications and the handoff error, a theme that is common throughout the remainder of the book. The authors make clear that while pilots are lauded for soliciting input from others (it wasn't always so), surgeons are known for being exceedingly inflexible (p. 191; p.222) to the detriment of the patient. When coupled with communication issues and power-distance problems, inflexibility is not a desirable trait in a surgeon. On pp. 222-224 there is an informative discussion of the roles of communications in both medical and aviation errors, concluding with a recounting of the worst aviation accident in history at Tenerife, which was caused largely by communication problems.

All of chapter 20 is laudable as it really distills the culture of safety concept down to the essentials. Notably, pp. 348-349 discusses the potential usefulness of Failure Mode and Effects Analysis, a longstanding aviation tool, in medicine, while p. 351 serves to recap the aviation safety from a historical vantage point.

Finally, the authors detail one of the most potentially beneficial changes that could be made in American healthcare (pp. 342-343) where they discuss the advantages of a no fault system of compensation for victims of bad healthcare.

This book is really a study of safety systems in a hospital environment, with relevant discussions of other germane industries (especially aviation) throughout. It is not a dry, academic tome; it is quite accessible to anyone who is interested in healthcare in the US. I recommend the book for safety professionals in any field, to physicians and medical professionals, and to anyone else with an interest in curbing errors in medicine. No book is perfect, but "Internal Bleeding" does cover the most salient points in the dialogue that is taking place (or should be taking place) in hospitals across the country.
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on September 7, 2015
This is an interesting depiction of the problem of medical errors and the reporting of and dealing with them in America. It's sometimes hard to get through because it's frankly a rather depressing and sometimes terrifying picture, but it does give us a good blueprint for how to participate in our own medical care and be proactive as patients. I recommend it for anyone to learn about how our medical system deals with errors and how to hopefully avoid being a victim of them.
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