Doctors may be third leading cause of death in the USA

[Lisa]

Doctors may be third leading cause of death

Doctors Are The Third Leading Cause of Death in the US, Causing 250,000 Deaths Every Year
This week's issue of the Journal of the American Medical Association (JAMA) is the best article I have ever seen written in the published literature documenting the tragedy of the traditional medical paradigm.

This information is a followup of the Institute of Medicine report which hit the papers in December of last year, but the data was hard to reference as it was not in peer-reviewed journal. Now it is published in JAMA which is the most widely circulated medical periodical in the world.

The author is Dr. Barbara Starfield of the Johns Hopkins School of Hygiene and Public Health and she describes how the US health care system may contribute to poor health.

ALL THESE ARE DEATHS PER YEAR:

12,000 — unnecessary surgery 8
7,000 — medication errors in hospitals 9
20,000 — other errors in hospitals 10
80,000 — infections in hospitals 10
106,000 — non-error, negative effects of drugs 2
These total to 250,000 deaths per year from iatrogenic causes!!
What does the word iatrogenic mean? This term is defined as induced in a patient by a physician's activity, manner, or therapy. Used especially of a complication of treatment.

Dr. Starfield offers several warnings in interpreting these numbers:

First, most of the data are derived from studies in hospitalized patients.
Second, these estimates are for deaths only and do not include negative effects that are associated with disability or discomfort.
Third, the estimates of death due to error are lower than those in the IOM report.
If the higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000. In any case, 225,000 deaths per year constitutes the third leading cause of death in the United States, after deaths from heart disease and cancer. Even if these figures are overestimated, there is a wide margin between these numbers of deaths and the next leading cause of death (cerebrovascular disease).

Another analysis (11) concluded that between 4% and 18% of consecutive patients experience negative effects in outpatient settings, with:

116 million extra physician visits
77 million extra prescriptions
17 million emergency department visits
8 million hospitalizations
3 million long-term admissions
199,000 additional deaths
$77 billion in extra costs
The high cost of the health care system is considered to be a deficit, but seems to be tolerated under the assumption that better health results from more expensive care.

However, evidence from a few studies indicates that as many as 20% to 30% of patients receive inappropriate care.

An estimated 44,000 to 98,000 among them die each year as a result of medical errors.2

This might be tolerated if it resulted in better health, but does it? Of 13 countries in a recent comparison,3,4 the United States ranks an average of 12th (second from the bottom) for 16 available health indicators. More specifically, the ranking of the US on several indicators was:

13th (last) for low-birth-weight percentages
13th for neonatal mortality and infant mortality overall 14
11th for postneonatal mortality
13th for years of potential life lost (excluding external causes)
11th for life expectancy at 1 year for females, 12th for males
10th for life expectancy at 15 years for females, 12th for males
10th for life expectancy at 40 years for females, 9th for males
7th for life expectancy at 65 years for females, 7th for males
3rd for life expectancy at 80 years for females, 3rd for males
10th for age-adjusted mortality
The poor performance of the US was recently confirmed by a World Health Organization study, which used different data and ranked the United States as 15th among 25 industrialized countries.

There is a perception that the American public "behaves badly" by smoking, drinking, and perpetrating violence. However the data does not support this assertion.

The proportion of females who smoke ranges from 14% in Japan to 41% in Denmark; in the United States, it is 24% (fifth best). For males, the range s from 26% in Sweden to 61% in Japan; it is 28% in the United States (third best).
The US ranks fifth best for alcoholic beverage consumption.
The US has relatively low consumption of animal fats (fifth lowest in men aged 55-64 years in 20 industrialized countries) and the third lowest mean cholesterol concentrations among men aged 50 to 70 years among 13 industrialized countries.
These estimates of death due to error are lower than those in a recent Institutes of Medicine report, and if the higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000.

Even at the lower estimate of 225,000 deaths per year, this constitutes the third leading cause of death in the US, following heart disease and cancer.

Lack of technology is certainly not a contributing factor to the US's low ranking.

Among 29 countries, the United States is second only to Japan in the availability of magnetic resonance imaging units and computed tomography scanners per million population. 17
Japan, however, ranks highest on health, whereas the US ranks among the lowest.
It is possible that the high use of technology in Japan is limited to diagnostic technology not matched by high rates of treatment, whereas in the US, high use of diagnostic technology may be linked to more treatment.
Supporting this possibility are data showing that the number of employees per bed (full-time equivalents) in the United States is highest among the countries ranked, whereas they are very low in Japan, far lower than can be accounted for by the common practice of having family members rather than hospital staff provide the amenities of hospital care.
Journal American Medical Association Vol 284 July 26, 2000

COMMENT: Folks, this is what they call a "Landmark Article". Only several ones like this are published every year.

One of the major reasons it is so huge as that it is published in JAMA which is the largest and one of the most respected medical journals in the entire world. I did find it most curious that the best wire service in the world, Reuter's, did not pick up this article. I have no idea why they let it slip by.

I would encourage you to bookmark this article and review it several times so you can use the statistics to counter the arguments of your friends and relatives who are so enthralled with the traditional medical paradigm. These statistics prove very clearly that the system is just not working. It is broken and is in desperate need of repair.

I was previously fond of saying that drugs are the fourth leading cause of death in this country. However, this article makes it quite clear that the more powerful number is that doctors are the third leading cause of death in this country killing nearly a quarter million people a year. The only more common causes are cancer and heart disease. This statistic is likely to be seriously underestimated as much of the coding only describes the cause of organ failure and does not address iatrogenic causes at all.

Japan seems to have benefited from recognizing that technology is wonderful, but just because you diagnose something with it, one should not be committed to undergoing treatment in the traditional paradigm. Their health statistics reflect this aspect of their philosophy as much of their treatment is not treatment at all, but loving care rendered in the home.

Care, not treatment, is the answer. Drugs, surgery and hospitals are rarely the answer to chronic health problems. Facilitating the God-given healing capacity that all of us have is the key.

Improving the diet, exercise, and lifestyle are basic. Effective interventions for the underlying emotional and spiritual wounding behind most chronic illness are also important clues to maximizing health and reducing disease. <snip references>

[Darth Wong]

Why is anyone surprised by the phenomenon of unnecessary surgery when people can profit from this practice?

Having said that, one should keep in mind that many of these fatalities are people who are so woefully ill that they're about to die anyway, and their death is supposedly hastened by a doctor's imperfect performance.

[Broomstick]

When I go to work this coming week I'll snag our copy JAMA so I can actually read the article myself. Until then, I have a few comments.

This information is a followup of the Institute of Medicine report which hit the papers in December of last year, but the data was hard to reference as it was not in peer-reviewed journal.

Funny - I was able to pull it off the web for free last year... I'll have to go back and see if that was a public publication or something we got through work connections.

12,000 — unnecessary surgery

How is "unnecessary" defined? Cosmetic surgery? Biopsies that later turn out to be negative? Does it include criminal fraud, like the folks in California operating on people for hyperhydrosis who didn't have the condition as part of an elaborate scheme - which is crime, not just bad medicine, and has nothing to do with the safety of the system.

20,000 — other errors in hospitals

What the heck is this? Slips and falls? Scalpels dropped in surgery and nicking blood vessels? Misprogramming of radiotherapy machines leading to burns? Something else? All of the above?

80,000 — infections in hospitals

You will ALWAYS have infections in hospitals. It's a risk of surgery. It's a risk of trauma. The article here seems to imply they're all the doctors' fault. Are they? Or do they lump in people with, say, penetrating injuries from industrial accidents and car wrecks and stupid bicycle stunts?

106,000 — non-error, negative effects of drugs

Those are usually called "side effects" - they're non-error, right? So were these adverse events something foreseeable, or not?

I am really going to have to read what's in the journal.

One of the problems with risk control in medicine is that, unlike engineering or aviation where any death is considered unacceptable and a Sign of Something Wrong, sometimes a doctor can do everything right and the patient still dies. Because, in the end, we all die. So death by itself does not mean something is wrong. Clearly, in many cases questions should be asked and some deaths are preventable, but not all.

What does the word iatrogenic mean? This term is defined as induced in a patient by a physician's activity, manner, or therapy. Used especially of a complication of treatment.

That's a pretty broad definition - for instance, puking after cancer chemotherapy is an unpleasent side effect and a complication of treatment, but it's not inherently an indication that anything was done wrong. So it's therapy-induced, but it's not what is usually meant by "iatrogenic". Getting an infection after surgery because the surgeon didn't maintain proper sterile procedures, THAT's iaotrogenic. Getting an infection after being impaled on a fence post - that's probably from dirt introduced into the wound during the accident, which is NOT iatrogenic. Nonetheless, both will manifest post-surgery and be treated in similar, if not identical, manner.

Another analysis (11) concluded that between 4% and 18% of consecutive patients experience negative effects in outpatient settings

Again, how is "negative" defined here?

For example, a lot of "medical imaging" is done outpatient. A lot of it involves the use of "contrast", which is a type of dye that appears on the x-ray or PET scan or MRI or whatever. It is well known among radiological circles that even when the dose is correct a certain percentage of people will have an "adverse reaction" ranging from mild to sudden death. Which is certainly a negative outcome. But that doesn't mean anyone did anything wrong, it's because the universe can be a perverse place sometimes. This is in contrast to, say, someone misplacing a decimal point and pumping a patient with 10 times the therapeutic dose of a drug.

The definition of "negative", therefore, can have quite an impact on the resulting numbers.

However, evidence from a few studies indicates that as many as 20% to 30% of patients receive inappropriate care.

Define "inappropriate" - for example, low-dose asprin therapy is considered a standard item of care and hospitals are rated on how completely they medicate those qualifying. On the other hand, if my husband rolled into the ER with a heart attack you would NOT give him asprin because he is allergic to it. So, by some rating systems, withholding the asprin would be rated as "inappropriate" or "insufficient" care, yet by others it would be entirely appropriate because in his case it is contra-indicated. Which rating system are we using here?

An estimated 44,000 to 98,000 among them die each year as a result of medical errors.

That's a hell of a spread of numbers, isn't it?

These estimates of death due to error are lower than those in a recent Institutes of Medicine report

See above about definitions, etc.

Care, not treatment, is the answer. Drugs, surgery and hospitals are rarely the answer to chronic health problems. Facilitating the God-given healing capacity that all of us have is the key.

Oh, really? So men with enlarged prostates just need more TLC, not drugs and surgery to keep them physically able to piss? People with arthritis should just chuck the painkillers? Asthmatics don't really need those inhalers - they just need hugs!

Yes, the human body has a remarkable capacity to heal. It also can malfunction in maddening ways. I'm not apologizing for the medical system in the US which certainly does have some major flaws, but this is starting to come across as TECHNOLOGY IS TEH EVIL!!!!

Improving the diet, exercise, and lifestyle are basic. Effective interventions for the underlying emotional and spiritual wounding behind most chronic illness are also important clues to maximizing health and reducing disease. <snip references>

So... what is this chick saying? Diabetes is from "emotional and spiritual wounding", not a malfunction of insulin production and use? Schleroderma and lupus aren't the immune system attacking the body, it's a matter of "spiritual wounding" - whatever the fuck that means.

Yes, psychological factors can be important in chronic illness but it's fucking condenscending to say that in "most" cases mind is primary over physical causes.

[Drooling Iguana]

It makes sense. I mean whenever he comes by there's always an alien invasion or Cyberman uprising or whatnot, which always leaves a considerable bodycount behind.

[Darth Servo]

There are other people in hospitals treating patients besides Doctors you know. Nurses and particularly CNAs have their own fair share of incompetance.

[Singular Quartet]

As I recall, around 7,000 people die every year due to Doctor's bad handwriting on prescriptions. And yet Doctors don't want to move to electronic systems, where there are no handwriting problems, and it's possible to look up a patient's medical history in five minutes, rather than five hours. It's not that hospitals don't want them (they save assloads of money in the long run, because they don't have to store paper records), but Doctors refuse to use them.

Servo: Don't forget being overworked. How often do doctors/nurses work 20 hours+? I can barely keep my schoolwork straight after 20 hours.

[Darth Servo]

Servo: Don't forget being overworked. How often do doctors/nurses work 20 hours+? I can barely keep my schoolwork straight after 20 hours.

Yes, it still baffles me that the medical profession continues to require the insanity known as "residency". I actually interviewed for medical school about five years ago and they were so proud of how they had reduced residency requirements to a maximum of 80 hours a week.

Please show me ONE patient who wants to be treated by a physician who hasn't slept in two days. The reason for keeping it? The older doctors had to endure it so the new ones should too in a colossal appeal to tradition. Never mind that its practically begging for accidents to happen.

[Darth Wong]

Case in point: a while ago my son was suffering from a rash that wouldn't go away. So the doctor prescribed a medication for it. We went to the pharmacist and the guy immediately said "Holy ... he prescribe this for a child?" He then proceeded to point out that the manufacturer warned against ever using it for children because it could cause permanent damage. This doctor was simply incompetent. But because no real harm was done, there's no case for a lawsuit.

Not to mention the fact that contrary to popular belief, a surprising number of people don't actually sue even when the doctor is completely at fault and there is actionable harm. When I was at the Shouldice clinic there was an American patient who was getting hernia surgery because the doctors had accidentally sliced his muscle tissue apart while removing his gallbladder. Totally their mistake, but he shrugged and said "People make mistakes" and said he had no intention of suing them.

[General Brock]

Kind of makes you wonder, are these evenly distributed errors, or are there individual doctors or even hospitals contributing more than others to the stats.

Perhaps the regulatory system needs an overhaul, like they have done in Britain.

A conclusion Dame Janet Smith who chaired the Shipman inquiry, "accused the GMC regulatory body in her 2004 report of being more interested in looking after doctors than protecting patients". This a common enough "layman" suspicion of professional self-regulation given formal recognition. I have to wonder how many walking wounded are brushed off, if fatalities are poorly handled.

"The proposals include:

* Senior doctors such as GPs and consultants are to face five-yearly MOT-style checks, known as revalidation.

* Medics who fail the tests will have to undergo retraining and supervision and may even be struck off the medical register.

* The GMC is to lose its power to adjudicate on fitness-to-practice cases, which will be considered by an independent body.

* Such cases will also be judged on a civil standard of proof - on the balance of probability - albeit with a sliding scale depending on the seriousness of the allegations. At present, they are based on the criminal standard - beyond all reasonable doubt.

* The GMC will be left to concentrate on investigating complaints against doctors - but will not be responsible for deciding on sanctions.

* However, the GMC will be allowed to keep control of undergraduate education - despite Chief Medical Officer Sir Liam Donaldson calling last year for it to lose that responsibility.

* All regulators will be expected to move towards at least a 50:50 split between lay and professional members. ... [The General Medical Council is set to lose its power to adjudicate on fitness-to-practise cases. The GMC will also have to change its membership to 50% doctors, 50% lay people in a move away from the much criticised profession-led regime.]

* NHS trusts will have to appoint a "medical examiner" to sign off all death certificates filed by doctors. At the moment, this only happens routinely for cremations."

The U.S. Britain have different health care systems, but a perceived failure of traditional professional oversight may be shared in common. The professional review system seems to be based on trust, fair benefit of doubt, and personal integrity among professionals, and ill-prepared to deal with savvy cheats determined to deliberately beat it.

At the same time, qualifying 'laymen' on these panels raises some questions; what happens if a large number have links to the drug lobby, or in a U.S. version, the drug and HMO lobby.

Situations like this could presage 'reforms' that actually make the situation worse - crony capitalism given a back door under the guise of patient safety, yet further undermining professional oversight with its non-medical agendas while retaining distance from genuine public oversight.

[Broomstick]

Case in point: a while ago my son was suffering from a rash that wouldn't go away. So the doctor prescribed a medication for it. We went to the pharmacist and the guy immediately said "Holy ... he prescribe this for a child?" He then proceeded to point out that the manufacturer warned against ever using it for children because it could cause permanent damage. This doctor was simply incompetent. But because no real harm was done, there's no case for a lawsuit.

Right - pharmacists, nurses, and others are supposed to be a double-check on this sort of thing. My father, who was a pharmacist before he retired, caught a LOT of errors. Also did a lot of double-checking when he couldn't read bad hand-writing. That's an illustration of where the system caught an error before it became a real problem. It's just as important to have a mechanism to catch and correct errors before they hurt someone as it is put in place systems that make it harder for errors to occur - because mistakes will be made

[PainRack]

As I recall, around 7,000 people die every year due to Doctor's bad handwriting on prescriptions. And yet Doctors don't want to move to electronic systems, where there are no handwriting problems, and it's possible to look up a patient's medical history in five minutes, rather than five hours. It's not that hospitals don't want them (they save assloads of money in the long run, because they don't have to store paper records), but Doctors refuse to use them.

Servo: Don't forget being overworked. How often do doctors/nurses work 20 hours+? I can barely keep my schoolwork straight after 20 hours.

ahhh..... 7300 odd deaths due to prescription errors is not equals to bad handwriting alone. It can be a person misreading the order or a mislabelling of the patient meds.

To be honest, I don't understand the residency system either. I mean, are doctors really that overworked or healthcare so expensive they can't afford more doctors on the roster?

[Colonel Olrik]

To be honest, I don't understand the residency system either. I mean, are doctors really that overworked or healthcare so expensive they can't afford more doctors on the roster?

It's the same thing in Germany. My girlfriend works from 7.30 to whenever, and whenever is more often 23.00 than 20.00. Now, she and all her colleagues have to be there at 7.30, because at 8 there's the daily, interdisciplinary meeting where all the patients are discussed and their status updated. And before leaving the hospital she has to make sure that everything is in order since if something goes wrong with one of her patients it's always her responsability. Nurses in Germany earn little less money than Doctors and work easily half the time. And of course, she often works Saturdays and Sundays, but that part of the job cannot be avoided.

They are overworked here and the government doesn't care, because they have a source of cheap labour that is forced to do this. That is, until they finally give up on this being a doctor thing and go to the private industry. oops!

[Broomstick]

I really wanted to read the JAMA article and comment on it, but I can't find it! Does anyone know which specific issue of JAMA this is in? Because I looked through everything we have from May and can't find it, so this may be older news than it may appear to be.

[M]

I really wanted to read the JAMA article and comment on it, but I can't find it! Does anyone know which specific issue of JAMA this is in? Because I looked through everything we have from May and can't find it, so this may be older news than it may appear to be.

Journal American Medical Association Vol 284 July 26, 2000

You can find the full article here if you have access to JAMA archives. The article itself doesn't define "unnecessary surgeries" and the like, but the referenced articles apparently do; at least as far as I could see at a quick glance.

How is "unnecessary" defined? Cosmetic surgery? Biopsies that later turn out to be negative? Does it include criminal fraud, like the folks in California operating on people for hyperhydrosis who didn't have the condition as part of an elaborate scheme - which is crime, not just bad medicine, and has nothing to do with the safety of the system.

Leape's article from 1992 (which Starfield cites) is a bit vague, but as I understand him "unnecessary surgery" is surgery that is either ineffective to archive the desired result, or no more effective than a less risky alternative.

By that token, I guess lacking better alternatives biopsies would be considered necessary because they are effective in determining whether the patient requires certain treatments.

Cosmetic surgeries could be considered necessary if they are competently executed, and criminal fraud would be clearly unnecessary. However, I don't think Leape ever thought of such cases in the first place, and even if he did, the 12,000 (actually 11,900 in Leape's article) number is a little suspect, considering it is cited from an extrapolation made in 1976 with Zeus knows what definitions and assumptions.

Methinks Dr. Starfield's numbers can't be taken all that seriously.

So... what is this chick saying? Diabetes is from "emotional and spiritual wounding", not a malfunction of insulin production and use?

The "spiritual wounding" interpretation comes from the Chattanooga Health article, not Dr. Starfield.

[Darth Wong]

I seem to recall some articles about hysterectomies and how many of them were unnecessary, but I would have to dig around to find them.

[Broomstick]

Actually, hysterectomies are a good illustration of how "necessary surgery" is a moving target. There are uterine disorders that can be managed without surgery, but that isn't necessarially the best way to manage the situation. And this is a case there lifestyle and the individual really do count.

Granted that anecdote != date, it can illustrate a real life dilemna. There was a case some years ago of a woman who suffered from severe fibroids. In her case, there was no only pain but bleeding - not only during her normal menstrual period (although even that wasn't entirely "normal" in her case" but also during the rest of the month, off and on, unpredictably, to greater or lesser degree. As she aged, the condition worsened. After a particularly bad episode where the bleeding resulted in anemia requiring a blood transfusion she went to her doctor and asked for a hysterectomy because she didn't want another blood transfusion, regarding them as far too dangerous. The doctor reassured her that really wasn't necessary, this could be medically managed and anyhow, blood transfusions were quite safe these days. Problem was, the woman in question was a diplomat who spent half her time stationed in South Africa where blood transfusions really were much higher risk than in the US, not to mention the problems involved in managing a condition through prescription drugs while traveling extensively between two continents. The woman got her hysterectomy, and in her case that was the correct decision. On the other hand, a young woman for whom having children of her own is extremely important might choose a different course, even if the chances of conceiving in such a case might be small, because to her that is the most imporant thing.

There is a broad gray area between "clearly necessary" and "clearly unnecessary" in regards to hysterectomies. Some women prefer an intricate program of medications to surgery. Some would prefer surgery to lots of pills. Whether or not a woman has children, or intends to have children, is also important. Some invasive "procedures" carry similar risks to surgery. I've known far too many women who suffered years with pain and medication side effects before having a hysterectomy - only to wish they'd done it much sooner. And I've known women rushed to surgery with no discussion or opportunity to consider alternatives.

It's not that different from the discussion about cesearian sections - how many IS too many? Some of the procedures mentioned above for uterine problems that spare a woman a hysterectomy and allow women to carry children who otherwise could not also mandate cesearians because of scar tissue left behind in the uterine muscle. It's a cesearian that wouldn't have occured 50 years ago because the woman would have had a hysterectomy, and wouldn't have occured 100 years ago because her medical condition could have left her unable to conceive and carry a child to term.

Cesearians used to be much rarer because they are major surgery and major surgery used to be much more dangerous. Now, the risks of major surgery may be less to mother and/or child than, say, breech birth. Just because many children have survived breech birth undamaged doesn't mean others weren't damaged or dead as an end result. For a breech birth, a C-section may be MUCH safer for the child, with only slightly greater risk to the woman - and most women are willing to assume some risk to protect their children from harm. In the long term, when considering all costs, the burdens of C-sections for breech births may be less than the burdens of vaginal birth for breech deliveries.

And THAT is why there is often such discrepancy between numbers when folks discuss hysterectomies and C-sections -- because often you're dealing with statistical risk AND personal choices. Yes, it's complicated. Medicine can be extrememly complicated. I could probably name a dozen different surgeries or procedures where the definition of "necessary" is fluid and shifting

[Setesh]

Honestly the system is more than a little fucked up. An ER Doctor works the most hours sometimes not leaving the hospital for days, sleeping in the breakroom or empty beds when he can catch a break. Yet they are some of the lowest paid doctors.

Conversely the so called 'specialists' work maybe 16-20 hours a week. Some of them don't have set schedules at all just are 'on call' to come in when needed then they go right back to the golf course. And they are the highest paid people there.

Add it the residents, who are there in theory to gain experience before graduation, who are virtually unpaid labor and seem to have forgotten what sleep is. Funny thing is if you actually asked a doctor what he remembers from his residency he'll probably only remember the really bizarre stuff. Part of the point of sleeping is to fix information into long term memory.

It makes sense. I mean whenever he comes by there's always an alien invasion or Cyberman uprising or whatnot, which always leaves a considerable bodycount behind.

Just for that watch this!

[Broomstick]

Honestly the system is more than a little fucked up. An ER Doctor works the most hours sometimes not leaving the hospital for days, sleeping in the breakroom or empty beds when he can catch a break. Yet they are some of the lowest paid doctors.

Conversely the so called 'specialists' work maybe 16-20 hours a week. Some of them don't have set schedules at all just are 'on call' to come in when needed then they go right back to the golf course. And they are the highest paid people there.

And other specialists might perform operations that last 12-16 (or even more) hours, or work in an area with a very high mortality rate... It's a little simplistic to say specialists are rolling in dough from part-time work and all the ER docs are working slave wages for days on end.

Yes, the compensation rates are skewed in many areas.

What pisses me off the most are the residents's schedules - too often they are exploited and their insane hours are regarded as a right of passage of some sort - which is fucked up. It might have been tolerable in an earlier era but now, with intesive technology, large caseloads of patients so sick that in that previous time they probably wouldn't have lived to get to the hospital.... it's stupid and reckless.