Intended for healthcare professionals

Analysis

Medical error—the third leading cause of death in the US

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2139 (Published 03 May 2016) Cite this as: BMJ 2016;353:i2139

The medical bubble and the opportunity to harm

I thank the authors for having enlightened and allowed to debate an aspect of modern health system which remains largely misundesrstood and still denied by many doctors, as it has been evidenced in some responses, and ignored by patients.
However, the discussion here was held mostly about the technical side of the problem, resulting in counts ranging roughly from 170 000 to 251 000 deaths caused by medical errors in hospitals in the United States defined by the authors as people dying” from the care they receive rather than from the disease or injury that brings them to care”.
As US healthcare system is a model for the world, a model intended to extend and be imitated by emerging countries this would legitimate, in my opinion, a less technical and more global approach to the problem of medical harms elicited by this model.
At the turn of the twentieth century, leading causes of death in the United States like in european countries were infectious diseases. At this time people died mostly from pneumonia, tuberculosis and diarrhea and life expectancy at birth was about 50 years just like it is still now in poorest countries [1] [2]. During the twentieth century there was the so called epidemiologic transition in developed countries and degenerative non communicable diseases have replaced communicable diseases as the leading causes of deaths [3]. The same phenomenon is seen in non developed and emerging countries and It appears as the natural consequence of progress and improvement in quality of life standards [3].
Historically, medicine deals with disease and doctors are committed to cure diseases, essentially with invasive procedures. In medical schools, students are trained to be highly confident in the power of medicine and are taught that there is a precise and effective procedure for every disease that has to be implemented. They are prepared to be heroes and to save lives. As heroes they are armed with potent weapons that is medical devices and sophisticated drugs and the more the weapons a doctor can use are numerous and powerful, the more he uses them the more it gives him prestige and money. Just like heroes doctor’s creed is action and abstention and caution are not part of the vocabulary they are taught. For all the duration of their studies, medical students are trained in a way that will give them a highly distorted vision of the benefit risks balance of medical procedures and of the part played by medicine in improving public health.
But diseases responsible for most morbidity and mortality in developed countries have profoundly changed in nature. As it si for degenerative diseases, when acute or chronic symptoms appear the disease has already been evolving for years or decades and when the hero comes in, the die is cast and the end of the play is close.
It is now widely admitted that degenerative diseases are caused and that their evolution is accelerated by our environment and our lifestyles.
Nowadays, per capita mean refined sugar consumption is ten times higher that it used to be two centuries ago [4], we spend many more hours a day sitting than our parents and many much more that our grandparents [5], air pollution in urban areas has a major impact in morbidity and mortality due to COPD [6] and this has been known for long…
Physicians don’t feel very concerned about these facts as there are not within the reach of traditional therapeutic medicine but are more a matter of public policies, personal behavior and choices and cultural habits . As the epidemiology changed, instead of changing their approach to medicine, they have tried to do the same that they were used to do with symptomatic diseases with degenerative diseases. So they have started screening for them to find these diseases earlier and cure them with the usual invasive methods. During the eighties and nineties there has been, in developed countries, a myriad of mass screening programs concerning prostate cancer, breast cancer, thyroid cancer, colon cancer… Most of these programs require highly technical devices and highly invasive procedures, are used in persons that have no complaints and have been demonstrated to have bad benefit risk balance because of overdiagnosis and adverse effects of the procedures used [7].
Mathematically, when you use widely invasive procedures and you target millions of healthy non complaining people you sharply increase the opportunity to harm and so to impair public health.
Moreover, more interventionist and tehcnophiles trends in medicine lead to the extensive use of invasive , costly but also rewarding procedures and drugs with marginal benefits and involve the abandonment of common diseases and of those who are more in need of medical care. This has been theorized by Julian Tudor Hart in the early 70 and is called “the inverse care law”[8]. In the modern medical perspective every healthy patient is “un malade qui s’ignore” but really ill patients don’t deserve appropriate care.
So, modern medicine can harm by doing too much on one side and too little on the other that is by misdirecting medical care.
Naturally medical harms are not only about medical errors and medical care misdirection. They are also about adverse effects of drugs and procedures, useless polymedication and drugs interaction and malevolent behavior of pharmaceutical companies , as well as the culpable negligence of patients groups, politicians and medical associations funded by these companies as it was highlighted once again in the opioïd crisis affair [9] [10].
So we don’t just need some technical adjustments to end with medical wanderings and with medical harms. We need a revolution. And firstly, medical students should be taught to have a much more humble and skeptical attitude towards medicine, and a more balanced approach of the benefit risk issue.

[1] http://jama.jamanetwork.com/article.aspx?articleid=768249
[2] http://apps.who.int/gho/data/node.main.688?lang=en
[3] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690264/
[4] http://ajcn.nutrition.org/content/81/2/341.full
[5] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2996155/
[6] https://www.researchgate.net/profile/Joel_Schwartz2/publication/12689466...
[7] https://www.thyroidcancercanada.org/userfiles/files/Welch_Overdiagnosis%...
[8] http://www.sciencedirect.com/science/article/pii/S014067367192410X
[9] http://emupdates.com/wp-content/uploads/2015/06/Strayer-Opioid-Misuse-SM...
[10] http://www.bostonglobe.com/opinion/2016/07/01/senate-should-release-opio...

Competing interests: No competing interests

28 August 2016
Claudina A MICHAL-TEITELBAUM
Primary preventive care, MD
Lyon