Updating the Classics: Urgent Business Then and Now
From its early days in the 1980s and 90s, the patient safety movement has been blessed with high quality, accessible writing. Many of the early contributors—Michael Millenson, Bob Wachter, Atul Gawande, to name only a few—continue to contribute and update their research and reflections. Millenson and Wachter have recently commented on their earlier works and reflected on what if any progress they have seen over the years.
These recent updates are important in their own right and serve as a welcome nudge to return to the original publications, which remain relevant, sobering reminders that problems identified years ago remain unsolved. There’s been progress, but in many cases progress amounts to enhanced understanding of underlying complexities and appreciation for the patience and perseverance that long-range, cultural change requires.
Bob Wachter offered the final keynote at the 6th annual conference on Diagnostic Error in Medicine (DEM), held in September at Northwestern University’s Feinberg School of Medicine in Chicago. Wachter had also been the keynote speaker at the first DEM, in 2008. At DEM 2013, Wachter explored where diagnostic errors stand in the patient safety field now compared to DEM 2008, finding that diagnostic error still flies under the radar even of the patient safety movement, in large part because it’s a complex problem that lacks clear definition and solutions:
If you were to read the literature, you’d believe that healthcare-associated infections, particularly CLABSI, are the most important patient safety problems facing the U.S., which is not true. But CLABSI is a problem that has relatively clear definitions, relatively easy measurement techniques, and a pre-existing workforce in the form of infection prevention professionals and some solutions that are of demonstrated worth. That’s what gets you attention, all those criteria.…Diagnostic error is still not able to meet many of those criteria.
After performing a fast-paced review of the patient safety movement since 2000, Wachter described the current landscape, finding much progress in the past 13 years as well as persistent, unsolved problems. In a recent blog post, he recaps his recommendations for the future, especially the potential for professional organizations such as the American Board of Internal Medicine (which Wachter served as chair in 2012) to advance improvement on diagnostic error through ongoing education and certification of physicians. His presence and participation throughout the DEM conference—unusual for a lead keynote speaker—seemed to signal his commitment to helping solve the problem, which was noted with appreciation by the conference organizers.
Also in recent weeks, Michael Millenson revisited themes he explored in his book, Demanding Medical Excellence, more than two years before the Institute of Medicine (IOM) published To Err Is Human. In a Health Affairs article and an accompanying blog post, Millenson acknowledges some progress has been made since 1997, especially in the areas of health information technology (IT) and public access to information, and continues to push for more. Other topics Millenson explored first in 1997—medical error, evidence-based medicine, population health, organization of care, and patient empowerment—still pose disruptive challenges to current medical practice. Public discourse, media scrutiny, and political action continue to turn up the heat on the need for change in healthcare.
With their recent reflections, Wachter and Millenson offer important, nuanced answers to those who continue to ask the patient safety community, “Are we there yet?” “Are we better off now than we were when To Err Is Human was published?” More than “yes and no,” the answer is that progress must be measured across multiple dimensions of safety and quality, as Millenson does by acknowledging advancement in health IT, for example (even if that has come through bribery), but in medical error, not so much. Sometimes the only progress we make is to better understand the problem, which may feel as if we’ve only set ourselves farther back. By many measures, patient safety is greatly improved—CLABSI rates, medication errors, for example—but if we’ve been blind to the most common error of all—diagnostic error—can we say that we’ve made progress? Bringing diagnostic error to the table represents improvement, but is discouraging nonetheless. In his recent blog post, Wachter reflected,
Here’s how I ended my 2010 Health Affairs article:
As one vivid example of how far we need to go, a hospital today could meet the standards of a high-quality organization and be rewarded through public reporting and pay-for-performance initiatives for giving all of its patients diagnosed with heart failure, pneumonia, and heart attack the correct, evidence-based, and prompt care – even if every one of the diagnoses was wrong.
Sadly, this statement remains true today.
Wachter is not pessimistic overall and continues to advance quality and safety improvement through his many activities. For other sources of hope, be sure to read the comments on Wachter’s blog post and visit the website for the newly formed Society to Improve Diagnostic Medicine (co-sponsor with AHRQ of the DEM conference), where discussion and study continue.
At the end of his recent Health Affairs article, Millenson quotes the until-very-recently director of AHRQ, Carolyn Clancy, as saying that she feels “simultaneously exhilarated and depressed” as she looks back at the earlier state of healthcare and forward to the work that remains to be done. Turning his own attention fore and aft, Millenson finds reason for optimism:
At this time when entrenched medical myths are finally being undermined and new traditions established, the hopeful conclusion of Demanding Medical Excellence is even more relevant: “The destruction of the old ways of medical practice may be an unavoidable source of anxiety, but it should not be a source of despair. Patients and caregivers alike should celebrate better days ahead. Destruction often precedes renewal, and it is in that renewal that the future of American medicine lies.”