BMJ  2004;329:58 (3 July), doi:10.1136/bmj.329.7456.58

reviews

Book

Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes

As with so many before them, Wachter and Shojania, practising doctors in the United States, start their book with a prologue outlining their own involvement in patient safety issues. It seems that everyone must undergo a public catharsis before they are able to talk about safety and harm. It was thus, with this formulaic confession, that I was immediately put off this book, assuming that it would not add much to the safety literature. However, as soon as I realised that this book was not for people like me—safety junkies—or even directed at clinicians without a special interest in the field, but for patients, my interest was rekindled.

Rugged Land, $24.95/$C36.95, pp 320 ISBN 1 59071 016 9 www.ruggedland.com Rating:

How would the authors explain this complex field to patients? Rather well in my opinion. Overall they capture the difficult issues involved, including the often conflicting dilemmas facing those working in health care; and the balance between no blame/blame the system, and personal responsibility. But having just described how this book is aimed at patients I would not like to put off others, even those supposedly knowledgeable in the field of patient safety, as the authors put their case authoritatively.

The book takes us straight into an important issue for health care, and indeed for patients—the distorting effects of looking back when there has been harm, known as hindsight bias. It then takes us into the problems this can cause, particularly where solving one safety issue leads to another. In the way in which this was explained, I could see that patients would understand these complicated issues.

Throughout, the book tackles areas where there is ambiguity and conveys the problems that clinicians face every day. I felt as if Wachter and Sojania had done clinicians a favour. I was pleased to see the authors cover the problems—surely more acute in the UK healthcare system—of the divide between hospital and community, outlining, for example, how early discharge has rarely been augmented by better communication and follow up.

If, though, the issues on safety are generally well balanced, there are sometimes problems. For instance, the authors reveal their hospital bias with their support for Hal Luft's research purporting to show that specialist care is better care. The factors around what is "best" are increasingly seen as more complicated than Luft's original research suggests, not least of all because patients themselves have a view on what is good care, and few patients fit into the stereotypical single disease model promulgated in the specialist versus generalist debate. Further, the book is unapologetically US focused (but then the title tells you that). That shouldn't deter non-US readers too much—just make allowances.

The BMJ has outlined the issue of communicating risk, and this book does it elegantly, explaining how risk can be confusing, how irrational perceptions can be, and generally how apparently large differences in outcome affect only a few people (for example, a 50% relative risk change might have a small effect on absolute risk). Unfortunately they fall into the trap of many in health care when later they suggest that different management of a patient with chest pain would have saved her life. If only they had stuck to their aim of not oversimplifying; the truth is that there is a small chance that different management of the patient would have altered the outcome.

Generally each chapter starts with a story, the human dimension of safety. This is effective and certainly catches the reader's attention. But after a while I found myself skipping the stories to get to the underlying issues. The stories began to irritate: they are long, described in too much detail, and—with all their added emotion—begin to read like an episode of ER. One could only wait for the helicopter to slice off an arm.

I wonder who the publishers think will read this book? It is long and, unless the reader has a particular interest in this field, there is a lot to get through. The stories will help some people access it more readily, but for others, like me, they will act as a barrier. However, I would like to think that my patients have read this book so they can better understand the issues facing clinicians.

strategy unit, Department of Health Tim.Wilson{at}doh.gsi.gov.uk

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