America has a love affair with blame. When tragedy hits, do we ask what we can do to help, what we may have done to add to the problem, or other such pedestrian nonsense. Heavens no, we want to know who screwed up and we want them to pay. Who let this happen, we ask. Journalists make it their only question. Headlines wring out for weeks. Politicians will find someone to throw under the bus. People will go into defensive mode. If we run out of proper candidates, we then pile it on God. Hand wringing is everywhere, but actually identifying and solving a problem, now that is rare.
This is not a new problem. It is evident in our invasion of Iraq, any time a plane crashes, in the current housing lending crisis, 9/11 terrorist attacks, or pretty much any tragedy to have ever befallen us. Blame feels good. Blame is sometimes even justified. It gives us a direction and outlet for anger that bad things happen, even to us. But it has a darker side. Blame causes us to cover our mistakes. It causes some to beat themselves into depression. It causes us to move away from self examination or less comfortable truths. It slows acceptance of things we may not be able to change. It lets anger fester until it twists and distorts us. It breeds cynicism and distrust.
This is extremely clear in the way the legal system works in medicine. The objective is to identify fault, and make them pay, including punitive damages for good measure. The more fear that can be induced in a jury, the harsher the verdict. It feels good, after all, to help victims by lashing out at those who inflicted the mistake. My question is, does this really help them? Does it really help us? I know what you’re thinking. As a doctor, I readily admit this argument may be self serving. I only ask, Doctors being human, what does fear of patient reprisals cause people to do when a mistake is made? What does this fear do to the doctor-patient relationship in general? What does it do to the way we practice medicine? In the end, is it worth it?
The goals of medical malpractice are twofold-
1) Reimburse those who experience medical injury
2) Inhibit medical errors.
It fails both spectacularly. It turns out only 1 in 8 patients who experience avoidable medical injury sue and of those only 7% win anything. Why is this? Because it has to be proven someones fault. Sweden has a system of no fault insurance that removes this obstacle and leads to many, many more people receiving compensation.
As for mistakes, In the year 2000, The Institute of Medicine put out a landmark report on the commonality of Medical errors which caused quite a commotion. Among their alarming conclusions-
- Between 44,000-98,000 Americans die from medical errors annually (Institute of Medicine, 2000; Thomas et al., 2000; Thomas et al., 1999)
- Medication-related errors for hospitalized patients cost roughly $2 billion annually (Institute of Medicine, 2000; Bates et al., 1997)
- The lag between the discovery of more effective forms of treatment and their incorporation into routine patient care averages 17 years (Balas, 2001; Institute of Medicine, 2003b)
- 18,000 Americans die each year from heart attacks because they did not receive preventive medications, although they were eligible for them (Chassin, 1997; Institute of Medicine, 2003a)
- Medical errors kill more people per year than breast cancer, AIDS, or motor vehicle accidents (Institute of Medicine, 2000; Centers for Disease Control and Prevention; National Center for Health Statistics: Preliminary Data for 1998, 1999)
- More than 50% of patients with diabetes, hypertension, tobacco addiction, hyperlipidemia, congestive heart failure, asthma, depression and chronic atrial fibrillation are currently managed inadequately (Institute of Medicine, 2003c; Clark et al., 2000; Joint National Committee on Prevention, 1997; Legorreta et al., 2000; McBride et al., 1998; Ni et al., 1998; Perez-Stable and Fuentes-Afflick, 1998; Samsa et al., 2000; Young et al., 2001)
Lest you should write off medicine entirely and stay home I should also note that they found-
41 million uninsured Americans exhibit consistently worse clinical outcomes than the insured, and are at increased risk for dying prematurely (Institute of Medicine, 2002; Institute of Medicine, 2003a)
It is now eight years later, and I honestly don’t think a presidential task force on the problem and a whole lot of policy wonking has really changed anything. The solution we naturally look to, blaming, does not get problems out into the open. It does not figure out whythe mistake was made, just who is thought to have made it. If the real problem is a loss of manpower, a problematic policy, poor communication, or some other nick in the system, it is never changed. It is never asked what can be done in the future to keep other people from making the same mistakes. It may surprise you to learn that in VA hospitals, simply implementing a system where barcodes were scanned to assure the right medicine was given, decreased medication errors by 86%. And they say the government can’t do anything right.
Truly fixing problems requires avoiding blame. It requires learning to accept that systems and people are not perfect, a sense of realism. At the same time it requires being able not to lash out at the system, people, or the problem. It requires forgiveness. This in turn enables us to change the root cause of the problem, in essence repentance. Isn’t it funny how when we model our approach to imperfection after the Savior’s, that only then do we start to see real progress.
After all, “to Err is human, to forgive divine.”