How to stop hospitals from killing us
online.wsj.com
online.wsj.com
There's something seriously wrong with the medical profession if doctors only wash their hands 90% of the time, even if they know they're being watched. The words "reckless disregard for human life" spring to mind. How many deaths from infections per year could be prevented if hospitals just fired any doctors who didn't wash their hands? (Hospitals are a breeding ground for antibiotic-resistant pathogens like MRSA.)
Another interesting article is Atul Gawande's "The Checklist" [1] (later expanded into a book), which describes how the use of simple checklists, similar to those that pilots use, can prevent medical errors like operating on the wrong body part.
[1] http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_...
"The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia."
It's not that they're failing to wash their hands 10% of the time, it's that they're not washing their hands properly 10% of the time. We don't know if the incompleteness is significant or insignificant.
However, I would consider bad hand washing almost as neglegient. It's really not rocket science
Blaming healthcare providers for not washing their hands is like blaming John Q Public for the housing crisis. The reality is much, much more complicated, and solutions to the problem are equally so. Healthcare is an incredibly complicated ecosystem, and even things are simple as hand washing are affected by dozens of factors, many of which are non-obvious at first. Root cause analysis and a judicious application of process change can help greatly, but the reality is that even simple things such as this do not change overnight in healthcare. It's harder than you think.
The bad news is that the majority of CLABSIs happen outside of the ICU where there is no previous data. For these non-ICU settings, the CDC writes, "efforts to improve central line insertion might have limited impact." ("In 2009, an estimated 23,000 CLABSIs occurred among patients in inpatient wards and, in 2008, an estimated 37,000 CLABSIs occurred among patients receiving outpatient hemodialysis.")
Also, CLABSIs account for only a very small percentage of all hospital acquired infections.
Sources: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6008a4.htm/
If I had to nominate three low hanging fruits with respect to medical errors, they would be:
- Hand washing. Colleagues of mine have researched and written extensively about this issue; study after study bears out the numbers people are quoting here. I'll source some references and reply with them.
- Positive patient ID. The high flying stories about operating on the wrong patient, or on the wrong limb are one thing, but much more sinister is the issue of mislabeled blood work, specialist reports that are delayed due to mismatched paperwork, and medication mis-administration (more on this later). The degree to which healthcare professionals operate in an environment of mislabeled, misattributed, and simply missing documentation is astounding.
- Medication Administration. A close colleague of mine has made a career around studying the practice of chemotherapy administration and the reduction of errors therein. The feedback she gets when presenting to practitioners is both very encouraging (they, of course, genuinely want to improve their practice), and also disheartening (very simple changes to process have simply never occurred to many front-line staff. They're consistently amazed that the idea of process improvement is even a thing).
If you've ever been in the unfortunate position of having to see chemo being (properly) administered, you get to see firsthand how rigorous process controls are supposed to work. Every bag that gets hung is triple checked via different calculation paths, every patient's identity is re-confirmed every time (even patients that have been on the ward for months), and every interaction with infusion pumps is double checked by at least two nurses after every action. It's a great thing to witness; it's just sad that it isn't the norm everywhere in healthcare.
Hand washing: I didn't work in this area directly -- many of my colleagues did, however. The principal output of their work was the Human Factors Hand Hygiene Toolkit at http://www.handhygiene.ca/English/Tools/Pages/Human-Factors-...
Positive patient ID: The PPID work that I've been exposed to was targeted at in-hospital evaluations of various vendor systems; I'm not aware of it having been published externally. If you're interested I can follow up with members of the team who worked on this to see if anything public came out of it.
Medication errors: Lots of work here. Presented link-list style: http://www.hubmed.org/display.cgi?uids=20724398 http://www.hubmed.org/display.cgi?uids=22103759 http://www.hubmed.org/display.cgi?uids=20427310 http://www.patientsafetyinstitute.ca/English/research/cpsiRe...
When you don't care about your craft, stuff like this happens.
I was in hospital following an accident last year. When I was discharged from the ICU the following day, the nurse gave me the paperwork for the patient in the next room. I didn't notice, being still rather beaten up by the whole episode - it was my wife who spotted it. For a 12 hour stay I ended up paying over $15,000, and then I hard to fork over an extra $90 to get copies of the medical record. On paper.
I'll take socialized medicine any day of the week. the private sector does a terrible job of healthcare.
This. The average hospital patient is the victim of 1 medical error per day, and ~10% of those lead to death or permanent disability. So you could literally go into the hospital being perfectly healthy, and odds are that you'd be dead or disabled in little over a week.
edit: Ignore this, I was mixing two different statistics that, while both accurate, don't seem to be compatible. There is better data below.
edit: It looks like I'm mixing measurements slightly. Basically I did find the source of that stat, it is here:
"There was an average of 178 activities per patient per day and an estimated number of 1.7 errors per patient per day. For the ICU as a whole, a severe or potentially detrimental error occurred on the average twice a day. Physicians and nurses were about equal contributors to the number of errors, although nurses had many more activities per day."
http://www.ncbi.nlm.nih.gov/pubmed/7867355
However, this is from the IOM report:
"Two large studies, one conducted in Colorado and Utah and the other in New York, found that adverse events occurred in 2.9 and 3.7 percent of hospitalizations, respectively. In Colorado and Utah hospitals, 6.6 percent of adverse events led to death, as compared with 13.6 percent in New York hospitals. In both of these studies, over half of these adverse events resulted from medical errors and could have been prevented.
When extrapolated to the over 33.6 million admissions to U.S. hospitals in 1997, the results of the study in Colorado and Utah imply that at least 44,000 Americans die each year as a result of medical errors. The results of the New York Study suggest the number may be as high as 98,000."
Also from the IOM report:
"In a study of 1,047 patients admitted to two intensive care units and one surgical unit at a large teaching hospital, 480 (45.8 percent) were identified as having had an adverse event, where adverse event was defined as “situations in which an inappropriate decision was made when, at the time, an appropriate alternative could have been chosen.” 41 For 185 patients (17.7 percent), the adverse event was serious, producing disability or death. The likelihood of experiencing an adverse event increased about six percent for each day of hospital stay."
Then Leape in his own analysis explains why even the 98,000 figure is probably a fairly large underestimate:
"The [IOM] study’s most serious limitation is probably that it was a retrospective medical record review study. Many important events in patient care are not recorded in the medical record. Some errors are not even known to clinicians caring for the patient. Studies of autopsy, for example, have found potentially fatal misdiagnoses in 20% to 40% of cases. On balance, the reliance on information extracted from medical records most likely led to a substantial underestimate of the prevalence of injury."
"They undoubtedly missed some that did occur because many adverse events and errors are never recorded in the medical record, either because they are concealed or not recognized. Other errors are discovered after the patient is discharged. In fact, in the MPS, an additional 6% of hospital-caused adverse events were discovered after discharge, but were excluded from the analyses because they were an unknown fraction of all such events. Therefore, any record-review study produces at best a 'lower bound.'"
"Second, neither of the large studies examined the extent of injuries that occur outside of the hospital. More than half of surgical procedures (numbering now in the tens of millions) take place outside of a hospital setting, and the adverse event rates for these procedures have not been studied. Even if complication and death rates are much lower than in-hospital care, the absolute numbers must be substantial, as suggested by the recent report of deaths associated with liposuction."
"Third, when prospective detailed studies are performed, error and injury rates are almost invariably much higher than indicated by the large record-review studies. In a large study of patients who died from acute myocardial infarction, pneumonia, or cerebrovascular accident (conditions that account for 36% of all hospital deaths), DuBois and Brook found that 14% to 27% of deaths were preventable. Andrews et al found that 17% of intensive care unit patients had preventable serious or fatal adverse events. The Centers for Disease Control and Prevention estimates that 500,000 surgical-site infections occur each year. One large controlled study found the excess mortality rate of surgical-site infections to be 4.3%, suggesting 20,000 deaths annually from this cause alone. These data are strong evidence that record-review studies seriously underestimate the extent of medical injury."
I look forward to the improvements we can make, including with systematic improvement of things we take for granted (the wonderful Pronovost study). But I feel like it's impossible to have a blogger-style discussion about these kinds of things without everyone being a know-it-all that doesn't actually provide anything in the way of solutions.
The OP problem is so beyond complicated that I'm not even sure how to approach the headline.
I mean this is obviously true for the larger population. Studies show that 90 million Americans can't even understand the directions on their prescriptions. But that recommendation was meant for the HN readers, most of whom can at least read and understand trade books.
"What's the recommendation then? Stay at home the next time something happens to your health?"
No, but I but I think the least you can do is to try to get in and out in a timely manner, rather than dawdling around for an extra day or two.
Also, if you actually learn to manage your health conditions you shouldn't need to be in the ER very often in the first place, unless you break your leg or something and you clearly need to go.
Also, hospitals are starting to be required to report some basic data now so consumers can make more educated decisions about where to go.
And lastly, you can look up the statistics about how good hospitals are at treating different things in general. For example, according to the Commonwealth Fund report from last year ("Why Not The Best?"), hospitals have gotten much better at treating heart attacks in the last five years. Granted, you'd still need to go to the ER if you were having a heart attack anyway, but at least you know now that you have a 96% chance of getting evidence based medicine going in.
"Hospitals aren't great, so therefore they're death camps."
Well I mean it's not like I'm making this up, it's what the IOM and the AMA are saying. As well as the Commonwealth Fund, the NEJM, and basically every other credible source.
Having read How Doctors Think and other similar books, I realize that much of medicine is very difficult, and there are good reasons for why things go wrong sometimes. But at the same time, doctors really shouldn't be cutting off the wrong limbs and giving people the wrong dosages of medicine on a daily basis.
When I was a medical student, I used to ask patients, just prior to discharge, what their hospitalization was for, what their primary diagnosis was, what's the follow-up, etc. I was absolutely disheartened at how few people had any clue whatsoever (though some were due to poor communication on our part). But then again, as a patient it's a ton of work to really be on top of your care. I've tried tagging along with family members who were hospitalized and even I had to press to follow everything.
I've never been hospitalized, so maybe I'm not able to understand the emotional impact of being in those huge, strange buildings on the other side of the white coats (which I refuse to wear anymore for a lot of reasons). I've been on prescription pain pills once, and quit after 2 days because they made me so sleepy; I preferred the pain. So I'm constantly struggled to really get inside the mindset of any patients who don't articulate their thoughts.
Yikes, don't know where I'm going with this. I'd like things to change, but have no idea where to start.
The Truth About Drug Companies by Marcia Angell
Overdosed America by John Abramson
The problems are way too numerous to list, but they're extremely important.
The second thing that needs to change is that we need more data about the state of health care, as well as unbiased research into drugs. The commonwealth fund makes the case that we actually do a decent job of improving at the things we measure, but for the vast majority of the healthcare system we have no idea how safe or effective it is.
The third thing is that medicine needs to actually be regulated like any other industry. Doctors in this country are basically given a free pass for killing people, and that needs to change.
And lastly, as you say, our education system needs to be fixed. It doesn't work to have a society where only 3% of Americans can actually read at the level that college graduates are supposed to be able to read at.
Oh, and all of this needs to be done by the government, or by a combination of government and NGOs. Having private companies do healthcare is a disaster.
In countries where the government runs public health (in which I have worked as a medical aide, have a parent who has been a CEO of a national health organization, and have a sibling in medical practice - so I'm not pulling stuff out of thin air), hospitals typically seek to minimize the number of different doctors and nurses that interact with the patient, so as to minimize confusion, miscommunication, and of course cost. Here the opposite seems to be true, as if every doctor on duty felt obliged to provide (and bill for) their medical opinion. Now, I don't want to make a case on a few anecdotal data points, but my personal observations of my own and family members' treatment experiences over the last 10 years, supplemented with observations from friends who are paramedics, nurses and doctors, are that American healthcare is really wasteful and inefficient.
Go find the nearest veteran and ask them about their experience with government-provided healthcare.
EDIT: I don't mean to say that this is true everywhere, but in the US it definitely seems to be the case.
http://www.biomoda.com/presidents-column/june-presidents-col...
Certainly, the Department of Veterans Affairs itself is poor, and the facilities are dealing with a massive influx of new veterans, but the quality of healthcare in the VHA remains quite good.
By the way, as long as we're all here, this article by a fellow I used to work for is a remarkably insightful view of the problems involved with our current healthcare system:
http://www.theatlantic.com/magazine/archive/2009/09/how-amer...
In Denmark, it Just Works™: I got a health card on my 4th day after being in the country, and it covers everything. No anesthesiologist sending me a surprise $5,000 bill for something that should've been covered; no arguing over preexisting conditions; just professionals actually trying to do their jobs correctly, instead of trying to figure out how to screw me over or pass the buck to someone else.
German hospitals make mistakes too, it's not just in the US.
My premature daughter was born in Berlin and she had club feet (which was already known since you can detect it from the sonogram).
Because our daughter was premature and had to stay in the hospital for 6 weeks, we couldn't go to the professional orthopedic doctor (who has treated hundreds of babies with club feet) since he was off-site. We had to let the on-site orthopedic doctor treat her.
Everyone at the hospital said, "He [the on-site doctor] is great, he has treated club feet before, he knows what he is doing." etc.
So, we let him treat our daughter for 6 weeks while she was the hospital. Every 3 or 4 days she got new casts on her feet.
When our daughter was finally released we took her to the real orthopedic doctor and he took one look at the casts and just laughed. "These casts look like they are from treatments from the 60s, this is not how anyone has treated club feet in decades." He put new casts on her and it was like night and day watching him work- he was a master at putting the casts on compared to the previous doctor.
The good doctor also said he has seen this happen many times before with babies from our hospital. They do the club feet casts wrong all the time and yet nothing ever happens. They don't improve, they don't get trained in how to do it, they don't even get told "DON'T DO IT" when no treatment would have been better than bad treatment. It's infuriating to know that these bad doctors can just keep being bad and no one does anything about it.
Our daughter also had to stay in the hospital for an extra day because they "forgot" to tell us we could take her home.
And these are just the mistakes we know about.
At least the whole experience was 100% free. No copays, no deductibles, nothing. I can't imagine how much all this would cost in the US.
If nobody tells them they might continue to believe it. Likely they have your daughters case chalked up as a success.
"Nothing makes hospitals shape up more quickly than this kind of public reporting. In 1989, the first year that New York's hospitals were required to report heart-surgery death rates, the death rate by hospital ranged from 1% to 18%—a huge gap. Consumers were finally armed with useful data. They could ask: "Why have a coronary artery bypass graft operation at a place where you have a 1-in-6 chance of dying compared with a hospital with a 1-in-100 chance of dying?"
"Instantly, New York heart hospitals with high mortality rates scrambled to improve; death rates declined by 83% in six years. Management at these hospitals finally asked staff what they had to do to make care safer. At some hospitals, the surgeons said they needed anesthesiologists who specialized in heart surgery; at others, nurse practitioners were brought in. At one hospital, the staff reported that a particular surgeon simply wasn't fit to be operating. His mortality rate was so high that it was skewing the hospital's average. Administrators ordered him to stop doing heart surgery. Goodbye, Dr. Hodad."
So we have a known model that improves results. Let the patients who decide which hospitals to visit know beforehand how hospitals compare in getting good results for patients. Give patients power to shop. That provides incentives for hospitals to do better, and nudges hospital managers to do what is necessary to win the trust of informed patients.
This kind of reform would be very good to apply to schools as well. Already, one state in the United States that is conspicuous among all fifty states in educational achievement (the state I live in) allows all residents of the state to enroll in the public schools of ANY school district anywhere in the state. (The school district I live in has inbound open-enrollment students from the geographical territories of forty-one other school districts.) In general, the power to shop is the incentive factor to bolster by government regulation, letting each consumer decide what trade-offs are important. That works considerably better in driving improvement than regulating outcome goals, and better still than regulating inputs into the provision of the important service being regulated.
Often times though, that's not enough as is the case in LA right now where patients are being prevented from using the best doctors:
Two of the most prestigious names in Southern California healthcare — Cedars-Sinai and UCLA — are getting shut out of a major insurance plan for being too expensive.
In a bold cost-cutting move, Anthem Blue Cross has eliminated doctors affiliated with the hospitals from a health plan offered to about 60,000 employees and dependents at the cash-strapped city of Los Angeles.
The city opted for Anthem's plan because it will save $7.6 million in annual premiums next year by excluding physicians from the two institutions known for tending to the Southland's rich and famous. About 2,200 city workers and family members are expected to lose access to their doctors under the plan.
This dramatic step shows that even some of the most-respected names in medicine can't get by on reputation alone at a time when the U.S. is grappling with a $2.6-trillion healthcare bill annually. Major hospitals and medical groups face growing pressure to justify their charges. And employers increasingly are willing to risk the ire of workers by cutting popular providers to clamp down on costs.
- http://www.latimes.com/business/la-fi-hospital-costs-2012092...
lets say you have a complicated problem which only has a 25% success rate. but due to these statistical models, nobody will do the procedure for you, since it will skew their results. what do you do?
Since doctors tend, as I understand it, to state the expected success rate to patients before surgery - this could be used as a factor in the reporting.
A more confident surgeon might be willing to quote a higher success rate, which would attract more patients (or patients willing to pay more) but would be more punishing were he shown to be incorrect.
Obviously this is very vague, and whilst I work with statistics I don't deal in medicine. But the difference between a surgeon/hospitals success rate and the expected success rate seems like a good measure of competence?
I have a medical condition that took over two years to officially diagnose. During one of my hospital stays toward the beginning of that ordeal, a doctor had decided that my issue required major surgery involving the removal of an organ. Less than one day before the scheduled surgery, the doctor decided to do "one more test" for an easily treatable condition. As it turned out, he had misread a previous doctor's note suggesting a possible diagnosis, as a dismissal of the diagnosis.
I'll never know whether the confusion was due to poor handwriting or poor attention to detail, but I feel lucky that the error was caught in time. I met multiple people during my numerous, lengthy visits whom I suspect were not as lucky.
This is wrong, it's at least the third leading cause of death. And realistically if you don't smoke and you exercise once in a while, medical 'oopsy daisies' are probably your #1 risk of death:
C.f. The IOM's report To Err is Human: http://wps.pearsoneducation.nl/wps/media/objects/13902/14236...
And then also read Lucian Leape's commentary in JAMA on why it is probably a huge underestimate: http://jama.jamanetwork.com/article.aspx?articleid=192842
(Leape is one of the authors of the original IOM report, and the report cites a lot of his own research, including his study estimating that only 5% of medical errors are ever discovered.)
C.f. also Barbara Starfield's estimate in JAMA: http://jama.jamanetwork.com/article.aspx?articleid=192908#RE...
Realistically, all of these estimates are at the low end. In fact most of them only count deaths in hospitals (and severely undercount them), when at least half of all medical errors are thought to happen at local doctors offices, plastic surgery clinics, nursing homes, etc.
C.f. also the CDC figures for Hospital Acquired Infections, which IIRC the IOM report doesn't count as being medical errors:
http://www.cdc.gov/HAI/pdfs/hai/infections_deaths.pdf
My personal rule of thumb is to avoid taking any drugs or getting any non-trivial medical procedure unless I've read at least three books about it. The problem is that all the papers published in medical journals are basically complete bullshit (except the occasional well-done NIH ones), which means if you want real information about a given drug then the only way to get it is to subpoena the FDA, or read a book written by someone who has.
The way drug approval works is that you need 2 tests demonstrating that the drug is better than a placebo, but you're allowed infinite tries to get there. So often a drug will be better than a placebo in only 2 out of 10 trials, but it will still get approved and only those two trials will get published in medical journals. And then those journal articles will have very little in common with the actual data from the FDA trials because the pharma companies completely spin it, which is why the vast majority of the most popularly prescribed drugs are not only no more effective than placebos, but in fact significantly worse when you look at the total quality/length of life.
There have been significant improvements here motivated by e.g. battlefield medicine, and great results out of academic or humanitarian labs, but much of our current work is stuck in a loop between patents and the FDA approval process. Good intentions aside, the system acts to motivate certain patterns of action in order to stay profitable and continue growing year-to-year which aren't optimal for our long-range interests.
How one would go about motivating such a grand project - I have no idea. Perhaps it's a matter of continuing to make such small improvements as we can until the system is primed for one giant leap. The road of progress was never a well-paved or straight one except in hindsight.
I think that small teams and open sharing of knowledge are both key ingredients. The amount of resources currently in play in medicine is staggering, but social systems tend to lose efficiency very quickly as they scale. Perhaps startup culture will be a key piece in making this happen, but the timescales involved in speculative medical research tend to be beyond the scope of the typical VC-backed endeavor.
How about a "space race" to destroy destructive nonsense like homeopathy, anti-vaccine idiocy, reiki, and all of the other non-scientific crap people try to use instead of real medicine.
Getting rid of quackademic medicine would be a good first step.
http://en.wikipedia.org/wiki/Quackademic_medicine
http://www.sciencebasedmedicine.org/index.php/quackademic-me...
Stricter rules about null hypothesis testing would be a start, but the bigger problem is one of education. We're still plagued by government that gives the nod to creationism and horrifically distorted sex ed in public schools.
I'd like to say we've become empirical enough about what practices we place belief in that we could just treat all cases of quackery as malicious fraud - but the very prevalence of such issues tends to support the opposite conclusion.
And homeopathy, which even James Randi admits was more effective than western medicine in the 1800s. (In the video that was submitted to HN recently.)
I hope you realize how worthless this statement is in a discussion of modern medicine.
Also, it's incredibly racist to call 'medicine that works' 'Western medicine'. Do you also call 'math that works' 'Western mathematics'?
I assure you that's not how I'm using the phrase.
Except it is. Medicine can be practiced by anyone who knows how, not just people with the right-colored skin.
In Hahneman's time, medicine was actively harmful and virtually never actively helpful. The risk benefit analysis would not come out in favor of getting treatment.
In contrast, homeopathy does nothing. It's placebo. And giving placebo, it turns out, is safer than actively sticking dirty instruments into your patient's bloodstream and giving them bacteremia.
In that context, the statement makes sense, but is still obviously tongue in cheek. Homeopathy never worked, but medicine at the time actively harmed.
Well, yes and no. It is a placebo, but the research seems to show that placebos do significantly more than nothing, at least for some diseases (pain, depression, etc.).
The comment I was replying to was asking for examples of where things that were once believed to be quackery were later vindicated. At the time homeopathy was believed to be quackery. In fact the reason the AMA was launched was to combat homeopathy because it was cutting into their profits; one of their first acts was to launch a 'propaganda department' to scare people off of homeopathy. (Essentially the AMA was founded to kill people. They knew they were less effective than homeopathy at the time and they knew they were killing people, but they just didn't care because they wanted the money.)
The point is though that at the time homeopathy was actually significantly better than western medicine. Now if the definition of something not being quackery is if it's the best treatment available to us at the time, then homeopathy couldn't have been quackery by definition, since it was in fact the most scientifically advanced (or however you'd phrase it) form of medicine available at the time.
It still is believed to be quackery, because it still is quackery.
> In fact the reason the AMA was launched was to combat homeopathy because it was cutting into their profits; one of their first acts was to launch a 'propaganda department' to scare people off of homeopathy. (Essentially the AMA was founded to kill people. They knew they were less effective than homeopathy at the time and they knew they were killing people, but they just didn't care because they wanted the money.)
This sounds like conspiracist nonsense. Do you have a single cite for any of it?
Read the book Homeopathy: The Academic Years. Even the AMA admits that this is true, and they give the book a very favorable review on their website. (And also the AMA talks about their propaganda department on their own timeline of their history.)
I do not believe that to be the common definition of quackery.
>then homeopathy couldn't have been quackery by definition, since it was in fact the most scientifically advanced (or however you'd phrase it) form of medicine available at the time.
Again, this is misleading. Homeopathy was and still is completely scientifically bogus. It was never and is not now advanced. It is misleading to say that a field that unintentionally had no effect was scientifically advanced. It's simply the (undisputed) truth that their outcomes were better because of their lack of real intervention, not because of any scientific merit whatsoever.
You can call it whatever you want, but the fact remains that if homeopathy was quackery then western medicine was the whole duck.
Also, it's not really fair to say that homeopathy was better merely by accident or that it wasn't scientific, since they're the ones who pioneered evidence based medicine. It might have been completely wrong, but it was scientific. They at least tested their ideas empirically unlike western medicine at the time, which by any reasonable definition must make it more scientifically advanced than the alternative.
I don't think the literature is nearly as scientific as you seem to think it is, nor do I credit Hahnemann with the shift to empiricism in medicine, which came later.
Again, just saying that medicine was harmful and that Hahnemann was observant does not make homeopathy of the time scientific.
Well I should admit that I'm not an expert on this, but if you read the JAMA book review of the book I mentioned above:
"By taking the homeopathy of that period seriously himself, Haller is able to remind readers that 19th-century homeopaths pioneered systematic drug-testing research, challenged the dangerously depleting procedures of mainstream physicians at that time, established rigorous professional standards, and valued advanced education at least as highly as their mainstream counterparts did. It was not without reason that homeopaths considered the bases of their approach to medical problems to be more logical and more promising than the inherited tradition of the ancients, upon which mainstream physicians still based their practices."
You have to remember also that 'scientific' is a relative term. Placebo controlled trials weren't invented until the 50s. And doing properly controlled placebo trials (with active placebos) is very rare even today.
Homeopathy of the 1860s and 1870s might not seem at all scientific by today's standards, but that doesn't mean it wasn't a significant advance in science at the time. (And by the way this was well after Hahnemann, who did most of his work on homeopathy in the 1810s and was already long dead by this time.)
Early medicine was in a large portion, quackery. Some of it was actively harmful. Something that has no effect whatsoever will be more effective than something that harms and doesn't cure.
There are enough cognitive biases I can't support this conclusion. Confirmation bias alone accounts for a lot of this crap, I'm sure.
Fundamentally, though, there's a big difference between crap we know doesn't and can't work, like homeopathy, and therapies that are in the pipeline and might be accepted or rejected on their merits.
Homeopathy has had its turn and it failed. That goes for everything else I called quackery. Don't confuse that with something we haven't tried yet.
Anti-vax nuts wouldn't be the public health threat that they are if there were two of them in a pool of hundreds of millions. The segment acting on these beliefs is manifestly large enough to enable outbreaks of diseases we otherwise could suppress almost totally.
Placebo effects have been proven in many cases extremely strong and a main obstacle for the pharmaceutic industry to prove the statistical significance of their products. And as long as people get better, even if it is just by the believe in the effect, it is in my view a legitimate approach.
So fraud isn't really fraud if people are going to get better anyway?
It doesn't matter. Science doesn't work by popular acclaim.
But the commercialization process sure sucks. Testing and verifying a drug is expensive, long and complex. But there seem to be some work going to improve that:
1. The FDA is becoming a bit more friendly[1]. 2. There are some new innovations in how to run clinical trials. One example is [2].They claim they might bring drugs 1-3 years faster to market. 3. Organs on a chip are starting to become available and this might be more accurate than the mouse models used today.
Since some of the new innovations in clinical trials do use web/mobile technology, i wonder what role startups can take in this area.
[1]http://www.xconomy.com/national/2012/09/10/the-fda-turns-fri... [2]http://disruptiveinnovationsinclinicaltrials.blogspot.co.il/...
(Edit: oh, this was already discussed: http://news.ycombinator.com/item?id=4560263)
This is incorrect. All clinical studies must be registered before they are started, precisely so that negative results are reported.
Also, the last time I heard phase IV trials didn't need to be registered at all, except for when they were required as a condition of approval.
Seriously asking.
And for some weird reason this feels like wikileaks for drugs...
Absolutely, but you would need to pay their costs, which could be several thousand dollars per drug and several million dollars overall. At some level though you probably would need to go to court to win. And even if you were successful, no one would believe you anyway. Books like Goldacre's or reports like this are published all the time, well-researched and true, but they're no match for the billions of propaganda dollars spent by the medical industry and big pharma each year, and the complete ownership of the media, congress, medical education, hospitals, and the FDA.
http://www.thedailybeast.com/newsweek/2010/01/28/the-depress...
I imagine that registered studies that are completed are published if they have positive results, or negative results that contradict other well-known positive results. There's no reason not to publish if you get a good or interesting result. But publication can take years, so I don't think it's particularly unusual to see a completed study without a corresponding publication.
But again, the specific cases you linked predate the current registration and reporting requirements.
1) Research is carried out by academics with no ties to phamaceutical companies. 2) The negative results make a competitors drug look even worse.
If neither of these things are true, then negative results just sit in a file-drawer somewhere. Compulsory registration (clinicaltrials.gov) will help with this for new medicines, but this will take years before we have any decent information
https://indicators.ic.nhs.uk/webview/
The spreadsheet:
http://indicators.ic.nhs.uk/download/SHMI/July_2012/Data/SHM...
Sadly, you can pretty much guess the results. Poorer areas = higher death rates.
It will be very interesting to see if developing countries manage to leapfrog our current system and establish a medical industry that is less dependent on people.
Note 1: My comments here relate to the German health system, with which I am most familiar with, but I assume that other systems work similar, if not less efficiently.
In my opinion, there are many other problems in the broad field of medicine, but the following two points could be resolved with the support of IT, so I will confine my remarks to those.
1. Plausibility checks
Virtually no plausibility checks will be carried out in todays hospitals. Often conflicting drugs are prescribed, which produce uncomfortable side effects. One should start to make all medications and treatment measures subject to automatic (computer based) plausibility checks. This would also lead to a cognitive relief of the clinical staff.
2. Statistical evaluations (data mining)
The lack of inadequate statistical analysis is another concern. Germany has begun to build a national cancer database only this year. One can only imagine what valuable information is hidden in those statistics and have been missed up to this day. Imagine an international database in which all patients who are admitted as an emergency to the hospital are captured statistically. This data could be stored completely anonymous. The only thing of importance would be the provision of relevant laboratory values and the patient's symptoms described in the context of the (verified) final diagnosis. Such a system could support the finding of completely new knowledge (data mining) and support the doctor in finding the right diagnosis.
And of course the hospitals need strong incentives to implement these measures. Which is why I support the author's call for absolute transparency.
The common sense suggestions in this article are a good step towards improving things by increasing transparency and accountability via documentation but may not address the root problems.
Hospitals and doctors alike have to change to make things better -- more advanced technology, different business models, etc -- but throwing them away entirely is just downright silly.
I'm not suggesting this happen by tommorrow, just that it is technically possible with the enough investment.
I'm just suggesting that when it comes to medical matters innovation is happening at a snails pace.
The aerospace industry manages to lose almost no lives, while the medical industry loses people left and right. There's something deeply wrong there.
Recently, Vinod Khosla suggested 80 percent of doctors are superfluous and medicine still operates in a voodoo magic kind of way for the most part.
So here is the easy problem: using information technology to help doctors deliver high quality healthcare.
Here is the hard problem: replacing the entire health system with technofantasy buzzword medicine.
If no one can solve the easy problem, why should we listen to anyone who thinks they can solve the hard problem? That's the voodoo magic.
If you want to get rid of 80% of doctors, then you would need to think of how to replace the role of the doctor in the following situations, which crop up every day in the hospital:
Making the decision to stop chemotherapy balancing the risks and benefits in a patient with advanced cancer that has failed multiple lines of treatment.
Managing a patient with borderline personality disorder who tried to hang herself early that day and needs to be observed medically who is demanding at all costs to walk outside and smoke.
Managing a patient with chronic severe abdominal pain of unknown aetiology, that has had all the tests known to man, multiple surgeries etc with no result.
Managing a patient with severe emphysema who passes out at home from breathing failure, comes to ED, gets resuscitated, then rips off the mask and drives home on her scooter. Repeat this 150 times a year.
A woman has advanced cancer. She is dying, no treatment will benefit her. The family decides to keep her comfortable. Her last son finally comes back from overseas and starts demanding that everything be done to save her.
So this is the thing... Doctors do lots of things, they do tests, they think, they prescribe drugs, they do surgery etc etc... all of those can be replaced by other specialised practitioners and probably robots one day. But what they actually, really do, most of the time, is take responsibility for a patient, in the face of often great uncertainty and very imperfect science.
And about the role of doctors: Pilots do also have huge responsibility. Part of them being responsible is being able to defer themselves to checklists, to algorithms and to machines when needed, which is practically always in their profession.
Doctors resist that need. They resist checklists. They resist expert systems. They resist evidence based medicine(why else is evidence based medicine so slow ?).
How would healthcare looks if our the people who treated us stopped resisting to those factors?