MEDICAL MISTAKES?

Victor Bloom MD

Recently president Clinton has responded to a government 'scientific' statistical report that 40,000 to 100,000 people die every year because of what was classified as medical 'mistakes.' I cannot attest to the accuracy or inaccuracy of this report, one that puts 'medical mistakes' as the 8th cause of death, albeit far behind heart disease, cancer and stroke.

The medical profession is put on notice that these 'excess' deaths can and should be reduced by government surveillance and controls. This new governmental intrusion into the practice of medicine is the most recent in a long process of increasing government bureaucratic controls, which have been of questionable value. Cost cutting through 'managed' (aka 'mangled) was the result of federal economists (aka 'bean-counters' and 'number crunchers') calculating that medical costs were escalating faster than inflation.

And, God forbid, the total expenditures for medical care had grown to 14% of the GDP (Gross Domestic Product). Cost cutting first proceeded from Medicare, and Medicaid followed not far behind. The idea put forth was that doctors were too rich and greedy, and that medical costs had to be controlled. The interpretation which should have been made, but was not made, is that more and more, better and better care had been given to sick Americans. Tiny preemies were kept alive and given a chance to live and grow, and aged people were given options to live, longer and better.

The new technology was very expensive, the CAT and PET scans, ultrasounds, radiation and chemotherapy, more and more delicate and intricate operations. Doctor's personal incomes and charges were not out of line. And yet doctor's procedures were limited by government fiat, as well as their charges.

It is true that a minority of doctors were greedy and fraudulent, but not more than in any field, be it politics, religion, education or finance. I don't think we want Big Government overseeing and regulating every detail of everyday life, to make sure there are no mistakes, and to make sure that medical care is reduced to a lesser figure than 14% of the GDP. I wonder how many Grosse Pointers sense an improvement in their medical care in the last ten years. Medical 'gate-keepers' have come about to approve or disapprove being sent to a specialist. Although private corporate influence has been extensive in reducing healthcare choices, the original impetus was federal.

Let us look at this concept of medical 'mistake'. A mistake is a singular thing--- there either was a mistake, or there was not. Medical care is extremely complex. Every examination and test, every diagnosis and treatment is made within the context of a very complex relationship, the doctor-patient relationship. As more and more potentially dangerous treatments are coming into use, the risk for morbidity or mortality is high, but sometimes the patient wants to take the risk, on the chance that he/she will be cured or ameliorated. When the patient dies, is the government statistician calling it a mistake? The decision to treat or not treat, and which treatment option should be taken, a decision made between doctor and patient, one which may not have been recorded at all, was wrong?

I recently saw a program about the early days of open-heart surgery, way back in the 40's. The American doctor who trained Dr Barnard of South Africa was perfecting his techniques on dogs. He solved the problem of putting the heart at rest and bypassing the heart by connecting the circulatory system of one dog with another's. As time went by he got better and better survival rates, and so he offered to fix the heart of a three year old who was dying because of a large hole in his heart, in the partition between his left and right ventricles. Sadly, the child died, but that was no mistake. The family approved the procedure because the alternative was certain death due to cardiac insufficiency. The doctor's next two cases lived, medical 'miracles.'

Do we want doctors to avoid taking risks with patients on the chance of being blamed for having perpetrated a medical mistake? Do you want your doctor to be too careful to help you? It is well known that the best doctors treat the worst cases and take the biggest risks, but not without informed consent, of course!

A good example of this circumstance is related to me by a brilliant, devoted and creative Emergency Room (ER) physician-specialist. Every time he gets into a helicopter he risks his life for a chance to help someone in a precarious location. He is brought to a mountainous area where a lumberjack cut himself accidentally with an out-of-control chainsaw, severing his femoral artery, the artery supplying his left leg. When the ER doc got to him, the patient was almost dead from exsanguination. He had lost so much blood that he had no blood pressure and soon there would be permanent damage to the brain. The doctor acted fast, applied a tourniquet and two pressure stockings to force the remaining blood from the lower parts of the body to the heart and lungs, providing oxygen and glucose to the brain.

He was worried that he would get sued, because in the process, there was no circulation in the legs, which eventually became gangrenous and required bilateral amputation. He made an informed and experienced decision to sacrifice the man's legs so that he would live. Sure enough, the patient sued. His lawyer might have persuaded him that the doctor made a mistake.

Dr Bloom is Clinical Associate Professor of Psychiatry, Wayne State University. He welcomes comments and questions at vbloom@comcast.net.