An editorial in the Nov. 11, 2010 issue of USA Today drew a sobering metaphor to the number of patients who die on an average day from medical "adverse events." Citing a recent survey from the inspector general of the Department of Health and Human Services, the op/ed piece pondered our fairly blasé reaction to the estimated 180,000 patients who die every year from those "events." That's right: 180,000 deaths per year, 493 deaths per day, 20 deaths an hour. A fatality literally every three minutes. The HHS survey, in perhaps an even more damning estimate, suggests that roughly 80,000 of the deaths are "caused by errors that could be caught and prevented, such as letting infections develop, giving the patient the wrong medication or administering an excess dose of the right drug."
The metaphor employed in the USA Today piece was to jetliner crashes. The article postulated that if a 747 airplane crashed every day, killing all 500 people aboard, "there would be a national uproar over aviation safety and an all-out mobilization to fix the problem." There would simply be no end to the solutions and resolutions proposed on how to fix such a problem.
I'll repeat the same rhetorical question posed by that publication concerning medical errors: Where's the outrage? Put another way, what factors contribute to the absence of outrage? It appears to me that the difference is in the psychology of how people view the issue, the comparisons they can draw and the manner in which they can relate to the question. We can all identify with an airliner crash; it is easy to point to something or someone specific to blame and then launch an investigation into reasons why it happened. In medicine, there is no one identifiable individual, corporation, etc., to target or blame for the 180,000 deaths. Another huge difference is the "my doctor is good" theory; it's those other ones who are causing the "mishaps," - the "bad" doctors, not mine - similar to Congress, where obvious bad apples are somehow re-elected by their local constituents year after year.
But then I started thinking about it from the other direction. What public outcries and news stories are in fact making headlines and creating awareness, fear and manufactured outrage with obviously significantly fewer reported deaths?
The most obvious item that springs to mind is the sensational, albeit incorrect, headline declaring something to this effect: "Chiropractic Manipulation Causes Death or Stroke." Headlines suggesting that "chiropractic kills" or will harm every patient who walks into a chiropractor's office have been utilized in scare campaigns from Connecticut to California in the past several years. Of course, objectively looking at the statistics and latest research makes clear that there is simply no "causal" connection between chiropractic manipulation and stroke. Rather, no more than an association is demonstrated; at the very low level of 1 in 400,000 to 1 in 1 million or even 1 in 5 million manipulations, depending on the study being quoted.
The fact remains that the current available evidence at best supports a chance association between chiropractic manipulation and stroke. Yet the attention from the media and certain other targeted groups such as the Victims of Chiropractic Abuse (VOCA) and Neck 911 continues to be disproportionate to what the statistics support.
Let's move away from health care and look at other examples of disproportionate outrage with fewer fatalities than the medical data demonstrates. Military fatalities come to mind. A quick Google search yields a U.S. military death toll in Iraq from March 2003 through December 2009 of 4,282. That computes to 713 deaths per year or 1.95 deaths per day. Using round numbers, that means almost 250 times more people die every day because of medical errors than in the Iraq war. Yet we are bombarded with "outrage" at the war. What's the difference? What is the underlying basis for this disproportionate chorus of disapproval from various segments of our society?
The underlying issue in response to war deaths gets pretty tangled up. Politics certainly come into play, as we see the death toll elevated by anti-war activists who argue that what they believe to be the unnecessary taking of life is the most powerful case they can make against war. Many of the underlying reasons for this kind of "outrage" are based on ideological grounds rather than the actual number from the "death toll." Yet the fact remains that while even one death is significant, it simply pales in comparison to the numbers relative to medical errors.
What else can we identify and assess in terms of public outrage relative to death toll? How about highway death rates? While the past few years have shown a decline, in 2009 there were 33,808 traffic deaths in this country: 92 deaths per day. Organizations such as "Mothers against Drunk Drivers" (MADD) have become powerful political forces over the years and has spawned, DADD, SADD, and a high awareness of the dangers of driving and drinking. We have dramatically more strict definition and enforcement of drunk driving laws. Highway and vehicle design are all more safety conscious. Seat belt use is now mandatory by law, and just look at the uproar over cell phone use and text messaging while driving.
With all of the information available about medical errors and deaths, we still do not have a nationwide organization such as PADD (People against Doctors and Drugs) or TADD (Truth About Doctor Deaths). We see loud reactions and high demand for action by organizations formed to stop significantly fewer deaths from auto accidents, firearms and military service than for an aircraft-crash-a-day death toll from medical errors, and yet the voices are silent and the outrage still.
Need another example? Let's look at firearms. The Centers for Disease Control and Prevention (CDC) states that firearm deaths from 2000-2007 in the U.S. totalled 240,997; that works out to 34,428 per year or 93 per day. So, the number of deaths by guns - almost exactly the same as that from drunk driving - is a mere 20 percent of those killed by medicine. Yet once again, there is no ad campaign stating: "Guns don't kill people ... Doctors kill people" or "We don't need gun control, we need doctor/hospital control." And yet in some circles, we have virtual hysteria about the supposed dangers of cervical spine manipulation.
The actual body count from any cause often has very little to do with the real disagreements about our choices to allow handguns, go to war, etc. After all, if we truly cherished human life, we would impose 50 mile per hour speed limits on the interstates, manufacture automobiles out of tank armor and ensure strict regulation of firearms. We have culturally decided that saving a few minutes on our way "over the river and through the woods to Grandma's house" is more important than a few lives, as is going there in a sporty-looking, speedy ride that makes us the envy of the neighbors but may not be as safe as it could be.
The "death toll" argument, when utilized in our public discourse, is often simply a red herring, masterfully manufactured, manipulated and marketed to a ravenous public. Perhaps if we didn't play the loss-of-life card so often, we wouldn't be so desensitized to such arguments; perhaps we'd actually pay attention and become outraged when truly warranted. Perhaps then there would be an awareness of the dangers of medicine and a concerted effort made to help minimize the number of deaths attributable to medical errors. After all, we are human and there will always be human error, but there is not enough outrage yet to cause the caregivers to self-police, self-identify and self-assess the failings of a health system out of control.
Chiropractic can learn something from these events; namely that the cultural authority and acceptance of the medical profession enables MDs and hospitals to withstand a death toll from their errors equivalent to a jumbo jet crashing every day. The lesson we can take away is simply this: Until we create a comparable climate of "trust," for lack of a better word, our profession will suffer in every aspect of societal acceptance. Each and every infraction, regardless of how small or seemingly innocuous, will fuel disproportionate outrage against chiropractic and the profession. This underlying cultural bias will continue to be evident in many forms, from denial of chiropractic inclusion in health plans to rejecting chiropractic as a choice of careers. In short, the manner in which our profession is viewed will determine our future.
We must be mindful of the power of predictably irrational thinking and deflect its invidious erosion of our profession by maintaining the highest standards of education, professionalism and ethical behavior. The outrage will come when the population realizes that this information has been available, but suppressed because of economic and competitive forces. Are you prepared to help provide the model for the outrage?
Click here for previous articles by Louis Sportelli, DC.