US Healthcare: Is It a House of Cards?

A recent publication in the British Medical Journal reports that medical errors are the third leading cause of hospital mortality in the US. Impossible? As a physician who has practiced critical care in a large university hospital for 16 years I can answer this question- not only is this possible, but, in reality, the vast majority of errors of omission and commission don’t result in significant harm or are too subtle to be captured by a study. My guess is that if one performed a confidential survey of increasingly enlightened "consumers" of US healthcare, the results of the report would be widely accepted. Though the study design and third party “coverage” of its results were widely condemned by many physicians, these reactions are either uniformed at best or conscious attempts to mask the ugly reality. Though not a classic example of evidence-based medicine, the message it sends is quite clear: widespread, systematic changes are needed to rehabilitate the previous first-rate reputation of the US medical establishment.

Sicker, more complicated patients are increasingly occupying hospital beds; to a large extent, inpatient medicine is evolving into "critical care". Has our system of medical education, healthcare delivery, and the goals of our health care and hospital "leaders" changed to meet this challenge? The short answer is NO! In truth, despite strong selection pressures, the evolution of US healthcare delivery continues to diverge from a system that is concordant with demands. The historical foundations of our system- consummate teachers imparting wisdom to eager, elite students producing world class dedicated physicians practicing in an environment where the primacy of the doctor-patient relationship was unquestioned- is "history". The base has eroded; are we just building on a "house of cards"?

I strongly believe that the ideal care of an individual patient, especially one that is critically ill, is in large part dependent on meticulous, hands-on, flexible and thoughtful care. Despite tremendous advances in medical technology and the colossal growth of Information Technology allowing the new generation of health care providers immediate access to oodles of valuable information/data, these same providers, on average, are ill equipped to manage our current cohort of hospitalized patients.

The forces that have contributed to this unfortunate situation are innumerable and pervasive. From changes in medical school curricula, to work hour restrictions and lack of care continuity, to the acceptance, or even encouragement, of the middling medical practitioner- the system is rapidly devolving!

The system may fall apart at the bedside but it the same “system” that is responsible for shaping our medical school curricula, the doctors they produce and the hospitals where they practice. On paper, recent applicants to medical school, residency and fellowships are intelligent, well rounded and accomplished. Despite this, I have found that the art of relevant history taking and a directed, skilled physical exam as well as the thoughtful, individualized assessment of a patient's problems has nearly vanished! Repeated analysis of the original hypotheses generated on a patient’s presentation as the course evolves and new data is available- much of which is done by talking to and "laying hands" on the patient - seems far less common as the years pass.

Regulations, checklists, huddles (all potentially beneficial) arise to provide some framework to a chaotic system. Combined with the rigidity and time "suck" of ensuring the accuracy and completeness of a redundant EMR and house staff work hour mandates, far less time is spent with the patient. The relative disappearance of the physician at the patient’s bedside is quite evident to patients and families, contributes significantly to their dissatisfaction, and, in my opinion, is a prime cause of medical errors.

I understand the picture I paint is not pretty. I am not happy with the current state of US medicine. I am not nihilistic either. I think we have taken our eyes off the ball. I remain hopeful that reemphasis on the doctor-patient relationship as a core objective will lead to a productive, vicious cycle, restoring the respect and autonomy of the physician and bringing “the best and the brightest” back to medicine. With appreciation and time, new physicians will be energized, rededicating themselves to study of the ”basics”, learning to combine the “ancient” wisdom with the remarkable advances of today. In this model, caregivers will spend more time at with the patient and medical errors will decrease. Quality will improve, care will be more efficient and satisfaction of the patient and the doctor will skyrocket.