What we fail to talk about when we talk about medical mistakes: time pressure


I find pseudoscience anathema, but that does not mean that I am apologist for contemporary medicine.

I am quite critical of some aspect of medical practice. The subject of medical errors has particular personal resonance for me as my father died at age 60 in the wake of a major medical error that occurred at the hospital where I was on staff and which my professional colleagues tried (stupidly and unsuccessfully) to hide from me.

So when I read papers like the recent BMJ piece Medical error—the third leading cause of death in the US, it makes me angry and frustrated in equal measure that the problem has not gotten any better in the nearly 30 years since my father died.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The relentless emphasis on performance metrics forces doctors and nurses to care for ever more, ever sicker patients in ever less time.[/pullquote]

But I’m also concerned that we are missing something important. When we talk about medical errors we fail to talk about the role of the relentless emphasis on performance metrics that force providers to care for ever more, ever sicker patients in ever less time.

In the last few decades we’re witnessed an extraordinary change in the delivery of medical care. Medicine, typically viewed as a profession guided by elaborate professional ethics, became a business. We let it become a business, indeed we encouraged the change, because we thought it would save money. It’s not clear that much money has been saved, but it’s very clear that the nature of medical care has changed dramatically.

Forty years ago, most people had family doctors that they knew and who knew them and worked directly for them. They were admitted to the hospital early in the course of an illness and stayed until they were nearly fully recovered. Many diseases now successfully treated with elaborate high tech methods couldn’t be treated at all.

Now, in contrast, patients are forced to change physicians frequently as they change jobs or insurance. Doctors work for large corporations who make demands on them that aren’t always in the best interests of patients. There is tremendous emphasis on keeping patients out of hospitals, and when admitted sending them home quicker and sicker. Doctors have no control over the number of patients they are required to care for and may receive bonuses for moving ever more patients through the system ever faster. They waste tremendous amounts of time justifying their medical decisions to functionaries whose only goal is to avoid paying for expensive care.

Nurses are under similar pressure to be more “efficient.” Patient loads have been increased so that a nurse who might have been responsible for 5 patients in various stages of recovery on each shift are now responsible for 6 or more very sick patients, all in need of elaborate monitoring and complicated medical care.

Both doctors and nurses are constantly prodded to care for more patients, and sicker patients, in less time than ever before.

The error that preceded my father’s death was an administrative error. No one told him that a routine pre-op chest X-ray done before minor surgery showed a cancer in his chest since everyone thought someone else had already told him. But there are a limitless array of medical errors, including medication errors, surgical errors, iatrogenic complications and more.

How deadly are they? According to authors Makary and Daniel:

… We calculated a mean rate of death from medical error of 251 454 a year using the studies reported since the 1999 IOM report and extrapolating to the total number of US hospital admissions in 2013. We believe this understates the true incidence of death due to medical error because the studies cited rely on errors extractable in documented health records and include only inpatient deaths. Although the assumptions made in extrapolating study data to the broader US population may limit the accuracy of our figure, the absence of national data highlights the need for systematic measurement of the problem. Comparing our estimate to CDC rankings suggests that medical error is the third most common cause of death in the US. (my emphasis)

This is just an estimate since there is no standard for keeping track of medical errors. Lest you think this is a US problem, the authors point out that both Canada and the UK have a similar problem.

Makary and Daniel offers suggestions for dealing with deadly errors, summarized in the graphic below:


These suggestions include making errors more visible so we can understand the dimensions of the problem, making remedies available and creating a culture of safety by engineering more fail safe measures into the delivery of medical care. We might start by acknowledging that the provision of safe medical care requires TIME.

We have elaborate rules for airline pilots that involve strict limitations on how long they are allowed to work and what they are required to do during that period. What would happen if we insisted that pilots, instead of flying one plane at a time, should be responsible for flying multiple planes at a time AND supervising dozens of others who are also flying planes at the same time? Would we be surprised to find pilots making deadly errors in those condititions?

Yet we have no problem forcing nurses to care for ever greater numbers of ever more seriously ill patients at one time. Should we be surprised that they make errors?

We have no problem increasing “patient panels,” the number of patients a doctor is require to take on, by 10, 20 or 50%, expecting them to be able to provide the same level of care to each patient in a much shorter period of time. Should we be surprised that they make errors?

We have no problem forcing doctors to spend endless hours on phone calls and paper work attempting to get reimbursed for work they have already done, or attempting to get permission for care that they want to deliver. Should we be surprised that they make errors during ever shorter patient appointments?

In forcing doctors and nurses to be more “efficient,” have we made them more prone to errors?

I don’t know the answer to that question; I don’t think anyone knows. It seems to me, though, that if we want to take steps to reduce deadly medical errors, answering that question would be a good place to start.