Health Wonk Review, a compendium of some of the best health care blog posts of the past two weeks, is up at the ever-informative Health Affairs blog. Be sure to check it out.

This post was written by Maggie Mahar and Niko Karvounis

In 1986, Nancy Reagan made it clear that there is “no moral middle ground” when it comes to drug use. You either don’t take drugs—which means you are a “good” person—or you do take drugs, which means you are a “bad” person.”

The Reagan-era outlook on drug addiction has dominated our political culture for nearly three decades, though not without sharp criticism.  In March, for instance, the writers of "The Wire," the critically-acclaimed HBO series that brought the Realpolitik of Baltimore’s war on drugs to the small screen, made it clear what they thought of the Reagan approach: “what once began, perhaps, as a battle against dangerous substances, long ago transformed itself into a venal war on our underclass. Since declaring war on drugs nearly 40 years ago, we’ve been demonizing our most desperate citizens, isolating and incarcerating them and otherwise denying them a role in the American collective. All to no purpose. The prison population doubles and doubles again; the drugs remain.”

They’re right; we are not winning the war on drugs. But the question remains: what should we do now? Those who view illicit drug use as willful behavior believe that we have no choice but to jail those who choose to continue committing crimes. Others who argue that drug addiction is a disease that weakens the addict’s ability to choose argue that rather than stigmatizing the addict and punishing him, we must find new ways to “treat” the patient.

One could argue about who is right. But rather than engaging in yet another political argument about personal responsibility vs. society’s responsibility to help its poorest citizens, it might be helpful to take a look at what medical science has been learning about drug addiction over the past few decades.

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Sometimes physicians are overly confident; sometimes they narrow their hypothesis too early in the diagnostic process. Sometimes they rely too heavily on advanced diagnostic tests and accept the results too quickly. As I explained in part one of this post, these are some of the reasons why physicians misdiagnose their patients up to 15 percent of the time. Of all medical errors, misdiagnosis is the one that we talk about least—in part, because we don’t know what to do about it, in part because most doctors have no way of knowing how many diagnostic errors they make.

“Complacency” (i.e. the attitude that “nobody’s perfect”) also is a factor, reports Drs. Eta S. Berner and Mark L. Graber in the May issue of the American Journal of Medicine. “Complacency reflects tolerance for errors, and the belief that errors are inevitable,” they write, “combined with little understanding of how commonplace diagnostic errors are. Frequently, the complacent physician may think that the problem exists, but not in his own practice…”

Autopsies

It is crucial to recognize that physicians are not simply deceiving
themselves: in our fragmented health care system many honestly don’t
know when they have mis-diagnosed a patient. No one tells
them—including the patient.

Sometimes a patient who isn’t getting better simply leaves the
doctor and finds someone else. His original doctor may well assume that
he was finally cured. Or the patient may be discharged from the
hospital, relapse three months later, and go to a different ER where he
discovers that his symptoms have returned because he was, in fact,
misdiagnosed. The doctors who cared for him at the first hospital have
no way of knowing; they think they cured him. In other cases, the
patient gets better despite the wrong diagnosis. (It is surprising how
often bodies heal themselves.) Meanwhile, both doctor and patient
assume that the diagnosis was right and that the treatment “worked.”

In still other cases, the patient dies, and because everyone assumes
that the diagnosis was correct, it is listed as the “cause of
death”—when in fact, another condition killed the patient.

When giving talks to groups of physicians on diagnostic errors, Graber says that he frequently “asks whether they have made a diagnostic error in the past year. Typically, only 1% admit to having made such a mistake.”

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Lately, I’ve been thinking about the difference between stories and stats- those hard and fast numbers that give us “objective” information about everything from  the body politic to the human body.

Social scientists like data, perhaps because it makes social science seem more “scientific.”  They like to square things off and measure them. They like to count:  How many? How much? What do the polls say?  Percentages are impressive.

Try to tell a story, and a purist will remind you that “the plural of data is not anecdote.”

But what some social scientists—and some physicians—forget is that statistics measure only what can be counted. Many of the things that are most important, in medicine as in life, are immeasurable.   Stories are valuable because they can capture some of the messiness of reality, including the ambiguities and contradictions that make both human experience and the human mind/body just beyond comprehension. (Since we have only the mind with which understand the mind, ultimately investigation must end in a stand-off.)

I began thinking about the difference between stories and statistics this week end, while reading Dr. Chris Johnson’s blog. A pediatrician and former head of pediatric critical care at the Mayo Clinic, Johnson confides that he sees medicine as “complicated mish-mash of science, near-science, intuition, guesswork, and blind luck.”

And that, he explains, is why he has been thinking about “the enduring power of the anecdote in how we humans understand things. . .

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In the past I’ve spoken highly of VistA, the Veteran’s Administration computerized health records system—and with good reason. VistA has a lot going for it. In 2006, it won an “Innovations in American Government Award” from Harvard. Studies show that use of VistA has improved VA productivity by 6 percent a year since national implementation was achieved in 1999. In a time of sky rocketing health care costs, VA care has become 32 percent less expensive than it was in 1996 in part thanks to VistA. The computerized system also has helped the VA reach an amazing prescription accuracy rate of over 99.997 percent. And last—but certainly not least—VistA is a flexible program that allows for much independent tinkering in the name of improvement, both by techies outside of the VA and those within the administration.

Given all these pluses, you’d think that the government would be happily throwing its weight behind VistA and ensuring that the system is firmly institutionalized for the long-term. But in fact, just the opposite is happening. VistA is under attack; and it’s the federal government that’s leading the assault.

According to Dana Blankenhorn, a writer at ZDNet (a much-trafficked techie website),  VistA is dying “of starvation and neglect.” It’s demise comes in part from an unlikely source: the Department of Defense (DoD). In 2005, the DoD introduced it’s own computerized health records system, called AHLTA. The system was developed by Integic, a private firm that was acquired by defense giant Northrop Grumman a mere nine months before AHLTA’s formal roll-out.

So why would the DoD contract out the development of a health records system instead of co-opting VistA, which can be reworked for different contexts? It’s not because of it’s too difficult, that’s for sure. Blankenhorn quotes Phillip Longman, a senior fellow at the New America Foundation and an outspoken champion of the VA  noting that the government “could wire Walter Reed or Bethesda (the two biggest military hospitals) for VistA in an afternoon. Technically there’s no big problem….”

Yet still, the DoD created an entirely new system—one which has only limited interoperability with VistA. Longman, the author of The Best Care Anywhere: Why VA Health Care is Better Than Yours, explains just how bad things are: “I just gave 11 [speeches] to front line VA employees in the last few weeks, and I heard over and over again their frustration over not being able to get to the people at the [DoD] making the hand-offs [of patients between departments]. Not only can’t the computers talk to each other, they can’t get the Army doctor in Germany on the phone to answer a simple question.”

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This post was written by Maggie Mahar and Niko Karvounis

Despite all of the talk about medical errors and patient safety, almost no one likes to talk about diagnostic errors. Yet doctors misdiagnose patients more often than we would like to think. Sometimes they diagnose patients with illnesses they don’t have. Other times, the true condition is missed.  All in all, diagnostic errors account for 17 percent of adverse events in hospitals according to the “Harvard Medical Practice Study,” a landmark study that looks at medical errors.

Traditionally, these errors have not received much attention from researchers or the public.  This is understandable. Thinking about missed diagnosis and wrong diagnosis makes everyone—patients as well as doctors—queasy. Especially because there is no obvious solution.  But this past weekend the American Medical Informatics Association (AMIA) made a brave effort to spotlight the problem, holding its first-ever “Diagnostic Error in Medicine” conference. 

Hats off to Bob Wachter, Associate Chairman of the Department of Medicine at the University of California, San Francisco, and the keynote speaker at the conference. On Monday, Wachter shared some thoughts on diagnostic errors through his blog, “Wachter’s World.”

Wachter begins by pointing out that a misdiagnosis lacks the concentrated shock value that is needed to grab the public imagination. Diagnostic mistakes “often have complex causal pathways, take time to play out, and may not kill for hours [i.e., if a doctor misses myocardial infarction in a patient], days (missed meningitis) or even years (missed cancers).” In short, to understand diagnostic errors you need to pay attention for a longer period of time—not something that’s easy to do in today’s sound-bite driven culture.

Diagnostic errors just aren’t media friendly. When someone is prescribed the wrong medication and they die, the sequence of events is usually rapid enough that the story can be told soon after the tragedy occurs. But the consequences of a mistaken diagnosis are too diffuse to make a nice, punchy story. As Wachter puts it: “They don’t pack the same visceral wallop as wrong-site surgery.”

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“False Hopes, Unwarranted Fears: The Trouble with Medical News Stories.” If you find the headline alarming, you should read the editorial, published just last week in PLoS Medicine. There, the journal’s editors summarize  what the Health News Review has discovered over the past two years while evaluating medical stories about new products and procedures throughout the mainstream media.

“It’s not a pretty picture,” says Gary Schwitzer, the University of Minnesota School of Journalism professor who publishes the online project.

In a video linked to the Health News Review website,  Schwitzer points out that “about 65% of the time” major news organization are not telling viewers and readers how “big the potential harms” of new treatments are–or “how small the potential benefits.”

Meanwhile, about three-quarters of the stories about a new product or procedure fail to talk about how much the idea costs.  “At a time when the U.S. is spending 16 percent of GDP on healthcare, I find this unfathomable,” says Schwitzer. “No one is asking: ‘How are we going to pay for it?’; ‘Who will have access to these things’?; ‘Who’s to say that we even need some of these things?  This is what we need to discuss.”

Ultimately, “these stories are painting a ‘kid in the candy-store’ picture of US health care,” Schwitzer charges, “whereby everything is made to look terrific, risk-free, and without a price tag. Nothing could be further from the truth.”

Health News Review is supported by a grant from the nonprofit Foundation for Informed Decision Making, which was founded in 1989 by Dr. Jack Wennberg and colleagues. Its mission is to assure “that people understand their choices and have the information they need to make sound decisions affecting their health and wellbeing.”

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How often have I said: “There is no Consumer Reports guide to healthcare—and with good reason”? Often I add that “rating refrigerators is a lot easier than measuring the quality of care provided by a hospital or doctor.”

Guess what?

Consumer Reports has just launched a new online “compare your hospital” tool  (Thanks to Gary Schwitzer, who reported this on Schwitzer Health News Blog over the week-end.)

And where did Consumer Reports get their information?  They’ve taken it from the Dartmouth research on treatment, overtreatment and outcomes that I cite so frequently.

I have always liked Consumer Reports–ever since I was a young bride buying my first air-conditioner. It didn’t let me down then, and, I’m glad to say, it hasn’t let me down now.

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