A Broken Medical System
The scene is played out tens of thousands of times each year in American hospitals. A patient lies helpless in an intensive care unit, heavily sedated, and often intubated and restrained so he cannot speak. He is isolated from family members. Meanwhile, his loved ones sit waiting, hoping against hope that technology can give him another shot at life, as sincere critical-care specialists offer shreds of hope and describe flashes of improvement, only to eventually admit defeat.
In August 2012, in Fairfield, Ohio, this scene happened to someone who was no ordinary citizen. Lying in the intensive care unit, clinging to life, was the first man to set foot on the moon, Neil Armstrong. He was a person of faith and a vigorous eighty-two-year-old. A few days earlier, he had walked into his family doctor’s office with some mod- erate heart symptoms. He ended up in the local hospital, where he was advised to undergo coronary bypass surgery. He signed the papers, the surgery was performed, and then a cascade of postoperative procedures and complications left him nonviable even before he went off to the ICU for more than a week. An appalling story, you say, but what does it have to do with the overall care system in this country? To lower his operative risk, perhaps Armstrong should have gone right down the road to Cleveland Clinic, the world pioneer in heart bypass surgery, instead of letting his local hospital talk him into having the procedure done in his hometown?
No, his tragedy was not selecting the wrong hospital to have the surgery performed—it was agreeing to have the surgery performed at all. He made the assumption, based on unsubstantiated advice, that bypass surgery was indicated for his condition and that arduous coro- nary artery bypass grafting (CABG), would likely extend his life more than conservative treatment. That’s a dubious and unwise assumption. That’s what we mean by overtreatment! Would Cleveland Clinic also have recommended CABG for Armstrong? We’ll never know. We do know that this American hero didn’t get the medical wisdom he needed.
David S. Jones of Harvard University points out in his book Broken Hearts: The Tangled History of Cardiac Care that even though CABG rates in the United States are five to six times higher than in Ontario, Canada, the two have completely comparable heart disease survival rates. Armstrong, who never had a heart attack, made the mistake of assuming that the $75,000 procedure he was being offered was his very best option for an extended life.
Because of his fame, world hero status, and the loyalty of his two sons, Neil Armstrong’s family got a $6 million payment from the hospital, in return for no admission of fault and a confidentiality agreement. But that small comfort did not remove his family from the ranks of tens of thousands of other families who made a series of fateful medical decisions—decisions that seemed wise at the time, but ultimately ended with premature death or death under agonizing circumstances.
A recent New York Times article about the Armstrong family’s tragedy treats Armstrong’s death as an unfortunate but somewhat anomalous event, perhaps rising to the level of substandard care. But cases like his are not rare anomalies. Armstrong’s fate and other celebrity cases that make it to the popular press—like comedienne Joan Rivers’s throat endoscopy that went very wrong and caused her death, Andy Warhol’s gallbladder removal that turned tragic through a horrifying mistake in post-op care in 1987, and comedian Dana Carvey’s cardiac bypass in 1998, in which the wrong artery was bypassed, show us that anyone can be a victim. They are symbols of a pervasive problem that has overtaken American medicine. In the context of huge growth in complicated procedures and increased use of multiple interacting drugs, medical mistakes have become the third leading cause of death in the United States.
That startling assertion has moved past marginalized circles and into the mainstream literature of medicine. And it means that you and I need to shift our approach to medical care or risk being part of this national tragedy. It has become a life-or-death matter for us.
In 2000, an organization called Institute of Medicine (IOM) released a study of patient harm called “To Err Is Human: Building a Safer Health System.” It posited up to 98,000 preventable deaths per year in hospitals. The report created a few press ripples and then faded away. The breakthrough into mainstream medical reporting has come through the impassioned efforts of Dr. Martin Makary of Johns Hopkins University School of Medicine. His study was published in one of the “big five” medical journals, the British Medical Journal, in May of 2016. It estimated that annually more than 250,000 hospital deaths in the US alone are caused by medical errors, far ahead of car crashes and every other cause of death except heart disease and cancer. It wasn’t easy for Dr. Makary to assemble statistics for this landmark conclusion when the previous information had been mostly anecdotal. And here’s why.
The Johns Hopkins team explains that the Centers for Disease Control and Prevention’s (CDC) way of collecting national health statistics fails to classify medical errors separately on death certificates. The researchers at Johns Hopkins are advocating for updated criteria in true cause of death on death certificates. “Incidence rates for deaths directly attributable to medical care gone awry haven’t been recognized in any standardized method for collecting national statistics,” writes Makary. He goes on to explain that the international classifications adopted in 1949 did not include any recognition for iatrogenic (physician-caused) disease because it was not recognized as a problem at the time. According to the CDC in 2013, more than 611,000 people died of heart disease, 584,000 died of cancer, and 149,000 died of chronic respiratory disease—the top three causes of death.
But this newly calculated figure for medical errors in hospitals alone would move this cause of death to number three according to Makary— behind heart disease and cancer, but ahead of respiratory disease. The rank of a cause of death as reported by the CDC is the basis for funding priorities. Since medical mistakes don’t appear on the list, it is under- standable that very few resources have been allocated to solving them.
After Makary’s work brought medical errors into the mainstream, CNBC reporter Ray Sipherd did a commendable follow-up in February of 2018 pointing out that appeals to the CDC to change the way it collects data from death certificates have not been answered. To the date of this writing, no changes have been made.
The CNBC report also points out that the 250,000 deaths include only hospital-related deaths, so it substantially underestimated the issue by any measure, perhaps by an order of magnitude. This had already been recognized by the Journal of Patient Safety. In 2013, the Journal put the inpatient and outpatient total of preventable deaths in the US at more than 400,000 per year.
In 2013, the Journal put the inpatient and outpatient total of preventable deaths in the US at more than 400,000 per year.
And then medical columnist Dr. Gary Kohls points out that even these numbers do not take into account the 50,000 opioid overdose deaths annually, many of which were prescribed by health care providers.
Nor do the numbers account for the thousands of suicides associated with psychiatric drugs, the thousands of heart attacks from NSAIDs, or the thousands of premature deaths from chemotherapy, which are currently included in the cancer death category. Says Dr. Kohls, “One also wonders that if accurate figures were available, combining inpatient and outpatient iatrogenic deaths together (a rational approach) it would cause heart and cancer deaths to drop to number 2 and number 3.”
Joe and Teresa Graedon, bestselling authors of The People’s Pharmacy, came up with the highest annual iatrogenic death total of all, an astounding 788,558—all footnoted with full citations in their newest book. That number, if believable, would catapult medical mistakes and unnecessary deaths to first place, ahead of heart disease in the US. That number would not make the medical establishment happy, but it would indicate the profession’s need to get a handle on this problem.
Not only do many of us die early, but many of us “die badly.” Dr. Ira Byock, director of a Robert Wood Johnson program on end-of-life care, also leads a team that treats and counsels patients with advanced illnesses. He says modern medicine has become so good at keeping the terminally ill alive at tremendous expense by treating the complications of underlying disease that the inevitable process of dying has become much harder and is often prolonged unnecessarily.
An overwhelming number of people—93% in one study—say they want to die at home surrounded by people they love. Only 25% get to do that. Seventy-five percent of Americans die in a hospital. An astounding 18 to 20% die in an ICU, isolated from everyone they know. And this was before the coronavirus pandemic and the national rush to create thousands of ICU beds and manufacture hundreds of thousands of excess ventilators.
“Families cannot imagine there could be anything worse than their loved one dying. But in fact, there are things much worse. Most generally, it’s having someone you love, die badly,” Byock says.
All of this has taken a toll on the position of the US in terms of world health indicators, based on longevity. Of course, America is a much larger and more diverse society than some countries it is compared to. But of thirteen countries in a recent comparison, the US ranks twelfth for sixteen available health indicators, including longevity. In another study, the US ranks fifteenth amongst twenty-five industrialized coun- tries on some of the same health indicators.
This is often explained away by saying that the American public engages in bad behaviors: smoking, drinking, drug use, poor eating habits, and perpetrating violence. That’s clearly always been a factor in America. But those issues turn out to be a stable factor, not an increasing one. Another factor often cited in American health concerns is income inequality and limited access to health care. That is an alarming social injustice that must be corrected on a high-priority basis. But access to health care among the poor has actually improved marginally over recent years, studies say. For instance, in 2010, 37 million people were uninsured in America; by 2018 that number had shrunk to 23 million. Increasingly, it is recognized that neither of these causes is the driver in declining longevity. David Goldhill states, “Increasingly, researchers are being driven to the recognition of the harmful effects of health care interventions and the likely possibility that they account for a substantial proportion of the excess deaths in the US compared with other comparably industrialized nations.”
All these excess and premature deaths show up in individual disease categories because they don’t have their own category, making data collection on this topic difficult but not impossible. The data is hiding in plain sight. But you have to know where to look.
For most leading causes of death, mortality rates are higher in the US than in comparable countries. That includes infant mortality and maternal mortality. And then, to add insult to injury, other wealthy countries spend about half as much per person on health care as the US spends.
In the faced of all these disturbing facts, the purpose of this website is to prevent heartache and regret and to allow wise and discerning people to live lives uninterrupted by the third leading cause of death in the US, iatrogenic disease. We leave the reformation of the runaway American medical system to others. Our goal is simpler: to protect the lives of those who want to pursue medical wisdom.
The Facts
Robert Pearl, MD, Why We Think We’re Getting Good Healthcare and Why We’re Usually Wrong
Philadelphia: Perseus Books, 2017
Dr. Pearl’s book is the most recent of the potential blockbusters that have somehow failed to start a reformation movement even though they have the potential to do so. Dr. Pearl is a caring reconstructive surgeon who was CEO of Kaiser Permanente Medical Group, one of the nation’s largest health care providers. He is on the faculty at both Stanford Medical School and Stanford Business School. He went through the untimely death of his father, which occasioned the book. Dr. Pearl’s book has been endorsed by bestselling physician- author Atul Gawande. The facts in the book and the credentials of the author have all the makings of a reformation movement. The lack of popular press attention and the peer silence demonstrate just how entrenched this problem is.