Guest Host: Derek McGinty

Medical staff at Brook Army Medical Center in San Antonio, Texas, lift a patient from one bed to another after surgery to move him to the recovery room.

Medical staff at Brook Army Medical Center in San Antonio, Texas, lift a patient from one bed to another after surgery to move him to the recovery room.

More than 250,000 Americans a year die from medical errors, including misdiagnoses, communications breakdowns, medication mistakes and botched surgeries. That’s according to a new study by a Johns Hopkins University surgeon and researcher who says that if medical errors were a disease, it would be the third leading cause of death in America. We discuss the scope of the problem and what can be done to improve patient safety.

Guests

  • Dr. Marty Makary professor of surgery, Johns Hopkins University School of Medicine, and professor of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health; author of "Unaccountable"; and co-author of a new study on medical errors
  • Lena Sun health reporter, The Washington Post
  • Bob Anderson chief of the Mortality Statistics Branch with the CDC's National Center for Health Statistics

Transcript

  • 10:20:02

    MR. DEREK MCGINTYWelcome back. You're listening to "The Diane Rehm Show." I'm Derek McGinty sitting in for Diane. We're going to shift gears now away from politics and to a bit of an alarming report just out this week. As you have likely heard over the last few years, we know that medical errors can sometimes make patients in the hospital sicker or even kill them. But now a new study says those tragic outcomes are happening a lot more often than we first thought. It comes our way from researchers at Johns Hopkins, who say medical mistakes should be considered the third leading cause of death in this country, behind the big killers like heart disease and cancer.

  • 10:20:39

    MR. DEREK MCGINTYMore than 250,000 Americans a year die from these medical errors. That would include misdiagnoses, communications breakdowns, medication mistakes and surgeries that are botched up. Joining me now in the studio to talk about the problem and what can be done, Lena Sun, she's with The Washington Post, Bob Anderson of the Centers for Disease Control's Mortality Statistics Branch. And joining us via the telephone from Stamford, Conn., Dr. Marty Makary, a Johns Hopkins surgeon and co-author of a new study on medical errors. I want to thank all three of you for being here.

  • 10:21:14

    DR. MARTY MAKARYGreat to be with you.

  • 10:21:15

    MCGINTYAll right. Very good. I want to also note that we, of course, will be taking your phone calls and questions as we move through the hour. Call us at 800-433-8850. Or drop us an email at drshow@wamu.org. And, of course, there's always Facebook and Twitter. Dr. Makary, first of all, lay out for us what you found in that study.

  • 10:21:36

    MAKARYSure. Well we took the best-available scientific research out there and did an analysis of those studies. And it turns out there's a range of estimates, based on good, solid science, that the number of people who die from medical error in some form ranges from 200,000 to 400,000. And our point estimate brings us at 251,000. Now these are people who are dying from fragmented care, preventable complications, medication errors, diagnostic mistakes, inappropriate treatments. You know, it's not just the technology and sophistication of care that we deliver that makes a difference, it's also the coordination of that care.

  • 10:22:14

    MAKARYAnd if we look at medical errors both at the individual and system level -- and really we're talking about system-level problems here -- it would rank, if it were a disease, as the third leading cause of death in the United States. But it's not ranked in our national health statistics for one simple reason, the tally uses billing codes.

  • 10:22:33

    MCGINTYHmm.

  • 10:22:33

    MAKARYAnd for that reason, this area of patient safety has been vastly underfunded, underappreciated and under-recognized as one of the leading public health endemics in the U.S.

  • 10:22:44

    MCGINTYI wonder, could you control for people who might have died anyway or who were so sick that it didn't matter what the doctors did?

  • 10:22:51

    MAKARYWell, it turns out, if a plane crashes, some folks on there may have died within the coming year anyway and some folks may have had a longer potential loss of life. And when someone dies in the hospital and we fill out a death certificate to document the cause, we are asked to document the underlying cause and the immediate cause. And in neither form field that gets polled by the government for the national statistics can any cause that is a complication of the medical treatment really be considered.

  • 10:23:22

    MCGINTYHmm.

  • 10:23:23

    MAKARYSo when -- if you trip over the cord of a ventilator and someone dies because their ventilator is no longer plugged in -- I'm making a theoretical here -- then the patient will die from respiratory failure on the official documentation and national statistics, even though they directly died from a medical mistake. And we need to be honest and open about the problem, document it properly and measure it so that we can allocate the right research priorities as a country to this problem. The list of most common causes of death in the U.S. each year, that list is a big deal.

  • 10:23:56

    MCGINTYAll right.

  • 10:23:57

    MAKARYIt informs all of our public health and research priorities.

  • 10:24:00

    MCGINTYI'm going to turn to Bob Anderson, because he's got some issues. And I can see by the look on your face that you want to talk about them.

  • 10:24:03

    MR. BOB ANDERSONYeah. And I don't want to dispute the numbers. I think, you know, destitute of medical errors is an extremely important issue and it's an important problem and one that needs to be addressed. I do want to take issue with one thing that Dr. Makary said and that is that physicians are asked only to document the immediate and the underlying cause. On the form -- on the death certificate form, the physician is asked to enter the chain of events and that is -- this includes diseases, injuries or complications that led to death and, in addition, any other conditions that may have contributed to the death.

  • 10:24:44

    MR. BOB ANDERSONAnd so what we're trying to get from the physician is a chain events, starting with immediate cause and working back to the underlying cause. And of course we would like them to report any complications or medical errors that may have contributed or may have been part of that chain of events. Dr. Makary's right that we focus on the underlying cause for statistical tabulations typically. That said, we code everything that's reported on the death certificate, all conditions.

  • 10:25:14

    MCGINTYSo you -- are you saying that the numbers we have that have been put forth in this study are wrong? I'm trying to get a sense of what your -- what's your problem with that?

  • 10:25:22

    ANDERSONI'm not saying that at all. My problem is that it seems, from Dr. Makary's statement, that the problem is that the CDC won't let physicians report this information and that we don't code it, when, in fact, if it is reported, we do code it. And...

  • 10:25:44

    MCGINTYSo you're -- are you saying the problem is physicians don't report it correctly?

  • 10:25:48

    ANDERSONThat is the problem. The physicians don't report it on the death certificate. And some may be under the impression that they're not supposed to. My guess is, more likely, they don't really want to.

  • 10:25:58

    MCGINTYLena Dunham.

  • 10:25:59

    MS. LENA SUNWell, I'm thinking that's the larger point here, right? I mean, I think deaths are under -- these kinds of mistakes are under-reported. But it comes from a whole culture where, you know, doctors are not going to be saying, Okay, here. Result of, you know, death was because, you know, somebody make a mistake.

  • 10:26:16

    ANDERSONI left a scalpel inside.

  • 10:26:17

    SUNYeah. And that doesn't even have to be as dramatic as leaving a scalpel. I mean, there's a whole thing of medical errors. You know, doctors in medical school, for years, were not trained to disclose errors. There is a culture and that's changing. But every hospital has a different policy and, you know, doctors are afraid and hospitals are afraid of getting sued. So this whole culture is changing but it's -- there's not a standard way of doing things. For example, last year, Mass General, a very good hospital in Boston, they did a study and they looked at the operating room. And they found that nearly half of all surgeries had some kind of medication error or unintended drug side-effect. Nobody died but there were a lot of mistakes.

  • 10:27:04

    MCGINTYDoes that make you nervous about going to the hospital when you hear there are this many mistakes?

  • 10:27:08

    SUNYes, sir. And I think people -- I think we, as patients, have a role to play here. Because if you ask more questions, don't be afraid to ask the doctor questions if you don't understand something. You know, I think part of this, is this whole culture is changing.

  • 10:27:23

    MCGINTYYou know, but part of the problem here is, I'm in the hospital. I'm in pain. I may be sedated or dealing with some other drug issue. You're asking an awful lot of patients to ask questions and to try to shepherd their own care, when they are at the most vulnerable place in their lives.

  • 10:27:40

    SUNWell, yeah. But maybe you shouldn't, you know, obviously if you're being rushed to the emergency room...

  • 10:27:44

    MCGINTYRight.

  • 10:27:45

    SUN...you're not going to, like, give the doctor, you know, go through all the interrogation.

  • 10:27:48

    MCGINTYRight.

  • 10:27:48

    SUNBut if you have elective surgery or just even just going to your regular doctor for a other visit, ask questions.

  • 10:27:55

    MCGINTYDr. Makary, something you said in your report was, I felt, the most disturbing and, that is, airlines, if there is a crash -- and we mentioned airliners -- there's a report that goes out all over the country so that people can try to understand what went wrong and make sure it doesn't happen again. Exactly the opposite happens when medical mistakes are made.

  • 10:28:16

    MAKARYWell, we can learn a lot from medical mistakes. You know, in aviation, there is a culture of learning. And the lessons learned from a crash are received by every pilot in the world. Everyone knows what happened. We don't say, when -- if a plane crashes, the information and the reason is the proprietary ownership of the airline company. We don't say that's corporate proprietary property. No, we say it's part of public safety and everybody should learn. We should do the same with medical mistakes or consequences of poorly coordinated care. Now, on death certificates, when you write down what somebody died from, the CDC will use the ICD billing code system to create the tally of our national health statistics.

  • 10:29:00

    MAKARYSo regardless of what you put in there, it may be tallied, but only national health statistics get reported with a billing code. And there's no billing code for the vast majority of types of errors. People don't just die from billing -- people don't just die from heart disease and bacteria. They die from poorly coordinated care and patient handoffs and medication overdoses.

  • 10:29:20

    MCGINTYSo how would the system have to change to make doctors more willing or able to document these mistakes?

  • 10:29:26

    MAKARYWell, first of all, doctors have to have a safe place to do it. You've got to be able to document what you believe as a doctor is the most accurate, immediate and underlying causes of the death and chain of events, without medical-legal repercussions or will create a malpractice frenzy. The data can be anonymized and sent up for national statistics. We can enjoy the same legal protections we have that make quality improvement data within hospitals non-discoverable. And we've got to have -- we've got to get away from just using the ICD billing code system. People don't just die from billing codes.

  • 10:29:59

    MAKARYAnd in the interim, the CDC could list a special line that says, extrapolating from the nation's best scientific research studies, medical error would fall right here between number two and number three on the list of most common causes of death.

  • 10:30:13

    MCGINTYBob Anderson.

  • 10:30:14

    ANDERSONI think Dr. Makary is right that, you know, there is an issue, whenever you boil things down to a set of ICD codes, you're going to lose information. That is true. That said, I mean, we do have a set of ICD codes for complications of medical and surgical care and these do -- these aren't particularly detailed. But they do include things like adverse effects of drugs and things like medical misadventures and other complications of care. And so we can code these and we do code them. Medical misadventures and complications are reported in about 20,000 deaths annually. Of course, we know, in light of Dr. Makary's research and other research that that's a gross underestimate of the problem.

  • 10:31:09

    ANDERSONThe problem is really in getting physicians to write this information down. And I think…

  • 10:31:16

    MCGINTYIs fear the issue? Is fear of being sued the problem?

  • 10:31:19

    ANDERSONI think so. I mean, that's my sense from talking with physicians and, you know, training them to fill out the death certificate, is they're very concerned about what they write. Because in many states, the death certificate is a public document and what they write is visible to everyone -- anyone who wants to get a copy of it.

  • 10:31:37

    MCGINTYIt seems to me that you have a double issue here. First of all, I would like to know if a doctor made a horrible mistake, because you might need to sue at some point. But on the other side, as you say, you need to be able to deal with the data so you can make improvements. How do you balance that?

  • 10:31:52

    MAKARYData can be anonymized so we can lean lessons and also share it nationally. We've got to know the patterns of medical mistakes, the sub-types. Are we talking about diagnostic errors, communication breakdowns, closed insurance networks and fragmented care that harms patients? If we can anonymized the data and share it nationally, as many state hospital associations are trying to do, we could learn a lot from the problem.

  • 10:32:16

    MCGINTYBut does anonymizing it mean that patients who may need that data to figure out if something drastically wrong has happened to them, they won't have access to it?

  • 10:32:25

    MAKARYWell, I think we need to go in small steps. I mean, step one is to just recognize that it even is a problem. I mean, right now, many people -- the docs out there with great homegrown ideas on how to make care safer, can't find any grant funding. Because we spend 10-fold more on breast cancer, even though it affects a fifth of the number of people in terms of deaths from medical errors versus breast cancer, because we have not collected any national statistics on the problem of people dying from the care that they receive rather than the disease or injury which brings them to care.

  • 10:33:01

    MCGINTYDr. Marty Makary's on the phone with us from Stamford, Conn. He is at Johns Hopkins. He's co-author of a new study documenting medical errors that are grossly undercounted in this country. Also with us, Bob Anderson, chief of Mortality Statistics with the CDC's National Center for Health Statistics, and Lena Sun is a health reporter for The Washington Post. I'm Derek McGinty and this is "The Diane Rehm Show." We're going to take some phone calls. The number here is 800-433-8850, that's 800-433-8850. And Mike in Gainesville, Fla., you're on the air.

  • 10:33:38

    MIKEGood afternoon. I was an elementary school vice principal, I'm retired now. And when I was taking a student home that had been suspended, she tried to jump out of the car. I caught her wrist. It hurt my back. I was sent for surgery. I got MRSA in the hospital from the emergency room and the back surgery was botched also. It took me four years to get well. I couldn't get any doctors that wanted to treat me because they thought I was going to sue the hospital for negligence. So I was just passed to person to person. I couldn't get my pain under control because the DEA's war on opiates, so you couldn't get -- I couldn't -- and it led me to almost commit suicide. Luckily, now, I've -- pretty much on my own, have gotten well.

  • 10:34:21

    MIKEBut it just shows you how human beings, because of lawsuits, because of all these things and doctors trying to protect themselves, human being can fall through the cracks. And for four years, I was out of work and it just devastated my whole life. And so I think this is a big problem. And I think that, you know, one of the problems is that physicians are just scared, once their error happens, they just kind of want to back away from that patient because they're worried that they could get involved in a lawsuit.

  • 10:34:50

    MCGINTYAll right.

  • 10:34:50

    MIKEAnd in the meantime, people are getting hurt.

  • 10:34:52

    MCGINTYMike, thank you so much for calling. And I'm really sorry to hear about what you went through there. Dr. Makary, you heard what we just heard from Mike. Is what you're talking about, in terms of anonymizing the information, would that help something like this?

  • 10:35:06

    MAKARYIt would certainly allow us, as a country, to establish the priority of looking at not just the sophistication of care, but the coordination of care. Look, health care is messy. I'm a cancer surgeon. I can tell you, health care can be messy. And we're human beings and we always will be. We can't expect us to be perfect but we can try to reduce the frequency of errors and their impact on patients. Doctors are getting crushed right now. They're getting crushed with malpractice, malpractice premiums, fears, overhead, insurance games, regulatory requirements. I mean, they're getting crushed. And right now we need to say, how can we coordinate care better in America, so that people get coordinated care and not fragmented care?

  • 10:35:48

    MCGINTYAll right. Let's go to Maryanne in Brighton, Mich. Maryanne, go ahead.

  • 10:35:52

    MARYANNEYeah. I think it's just the tip of the iceberg because of all the injuries that occur, as the last caller discussed, instead of people who's dying, okay? And I think, to answer the doctor's concern here a little, that we need a technological device with the patient, with their chart. In other words, wherever the patient's body is, that device needs to be there and it needs to be automatically turned on to record auditory and visually all the information of every person that's involved with the patient, even if it's a sweeper in the room.

  • 10:36:29

    MCGINTYAll right.

  • 10:36:30

    MARYANNEBecause a personal experience, I've been through this and with others that have been, plus working in the medical profession.

  • 10:36:37

    MCGINTYMaryanne, thank you. I want to ask you, Bob Anderson, is a technological solution part of the answer here, like as was just described?

  • 10:36:43

    ANDERSONWell, I mean, that's a good question. I don't really know the answer to that. I don't know how that would, you know, factor into privacy concerns and such.

  • 10:36:54

    MCGINTYDr. Makary, you have a thought?

  • 10:36:57

    MAKARYWell, there's a lot we can do to record what we do. We've even asked ourselves, since most of the procedures in medicine are video based, can we save those videos. I, as a surgeon, wouldn't mind watching what the video of the previous operation was of the last surgeon who was in there. So we could do a lot to use video and technology for quality improvement and external peer review, to get away from the internal peer review that's polluted with politics and competition.

  • 10:37:23

    MCGINTYAll right. I'm Derek McGinty sitting in for Diane Rehm. And you're listening to "The Diane Rehm Show." We'll be back with your calls and questions in a minute.

  • 10:40:02

    MCGINTYWelcome back to "The Diane Rehm Show." I'm Derek McGinty in for Diane as we continue our conversation about medical errors that may hurt you or kill you and the fact that, apparently, they've been grossly underestimated over the last several years. The author of the study in question, Dr. Marty Makary, a surgical director of the Johns Hopkins Multidisciplinary Pancreas Clinic. He's also a professor of surgery at Hopkins and is co-author of the study. Bob Anderson is chief of the Mortality Statistics Branch with the CDC's National Center for Health Statistics. And Lena Sun, health reporter for The Washington Post.

  • 10:40:36

    MCGINTYWe are taking your phone calls as well, 800-433-8850. And, Lena, let me ask you, we've been hearing about medical mistakes for years now and the toll they take. I thought things had gotten better, that there had been improvements made.

  • 10:40:51

    SUNThere have been improvements made. A lot of hospitals and a lot of doctors have put in place programs where they talk to patients more. In some places, hospitals have this thing where they do like a root-cause analysis, where they take a particular mistake and they try to learn from it and they have a monthly meeting. And it's, of course, only internal to the hospital. But in some places, they've begun to bring in patients, so that they can get the patient's perspective and get the understanding of the family.

  • 10:41:22

    MCGINTYHmm.

  • 10:41:22

    SUNWe've been talking a lot about medical errors. But I would point out to you that, last fall, the Institute of Medicine came out with a report that said that diagnostic errors -- when you get a wrong diagnosis -- is a much bigger deal. In fact, they estimate that most Americans will get a wrong or late diagnosis at least once in their lives.

  • 10:41:44

    MCGINTYWow.

  • 10:41:44

    SUNAnd that these kinds of errors could affect at least 12 million adults each year. So, you know, getting the wrong diagnosis can set you down the path for a -- you know, that's a much broader thing than, you know, the surgeon left a sponge in your, you know, gut.

  • 10:42:01

    MCGINTYYeah. This sounds like it's in that human error category again, though. And I wonder how you fix that? Dr. Makary, any thoughts?

  • 10:42:10

    MAKARYWell, in medical school, we're taught when to operate but not necessarily when not to operate. And this issue of appropriateness is sort of the great frontier in medical education. It's the one piece that gets lost in the reflex that we generate coming out of medical school, where the only way you can memorize all this information is to pair everything -- the diagnosis, treatment, diagnosis, treatment. And then it comes out, it's no wonder that we're pulling back the recommendations to start treating high cholesterol and high blood pressure after age 80 an to pull back some of the screening recommendations and aspirin and PSA testing.

  • 10:42:50

    MAKARYAnd we're realizing that this reflex misses on the individualization and the sense of appropriate care, what's appropriate to people. And that's what we need to focus on as a health-care system. And that's what we're seeing with this empowered generation that's saying, hey, I've got a high insurance deductible. I really want to know what my treatment alternatives are.

  • 10:43:09

    MCGINTYHmm.

  • 10:43:10

    MAKARYAnd the patients that we see getting the best care are the ones that are well-read, bringing a loved one in with them and asking about the alternatives.

  • 10:43:17

    MCGINTYWhat's your sense of how much, though, hospitals have changed in the last few years. Now I noticed a few years ago, when you walk in a hospital, you see these hand sanitizer things all over the place, trying to deal with the issue of infections. But it sounds to me like this goes way beyond that.

  • 10:43:32

    MAKARYYeah. You know, what matters to a patient is a doctor's judgment and skill and whether or not they're getting the appropriate care. What matters with health policy and publicly reported metrics tend to be the things that are not as central. There's things that are just easy to measure, like bloodstream infection rates, or patient satisfaction scores. Those are important, but let's not fool ourselves, those are just things that are easy to measure. It may not represent comprehensive quality. And as metrics mature, we are slowly getting to the point of getting doctor-endorsed metrics that are fair that we can put out there at a hospital level.

  • 10:44:12

    MCGINTYLena, now you report that it actually may get worse before it gets better because our systems are becoming more and more complicated and therefore more and more prone to errors.

  • 10:44:22

    SUNWell, I think -- I'm just talking about the diagnostics.

  • 10:44:24

    MCGINTYOkay.

  • 10:44:24

    SUNRight? So people are -- most doctors will tell you that, in America, that lot more complex conditions. People are older, they're sicker, they have lots more chronic diseases. And so that, it's often not just one specialist that you're seeing, you're seeing multiple specialists. And if that communication is not handled well, like, if your kidney specialist doesn't tell your primary care doctor what's going on, you might not get the right diagnosis. And if you, you know, that set's you down the path to -- opens up a door to lots of other things, right? If you're told that you have X when you really have Y. And then the doctor doesn't -- that information doesn't go in your file.

  • 10:45:05

    MCGINTYBob, what is the -- well, let me rephrase that. How significant a problem are we dealing with in terms of misdiagnoses here?

  • 10:45:12

    ANDERSONWell, it's really hard to say. I mean, there's the -- from the standpoint of mortality statistics, of course, diagnostic errors is a big issue as well. Because, you know, you want an accurate cause of death. And if the decedent wasn't diagnosed correctly, then we may never know. I mean, the problem is, is that diagnosis is part art, part science. And we don't really have a true gold standard to compare against when we're looking at mortality statistics.

  • 10:45:45

    MCGINTYAll right. Let's go back to our phones here. Leslie, in Biloxi, Miss., you're on the air.

  • 10:45:50

    LESLIEHi. I was calling -- I just wanted to make the point that when a patient has a mistake, it's not the same as what you were saying earlier with the airlines, and that everyone can learn when, you know, a mistake is made on model planes, whatever it is, that everyone who flies in that can learn from that mistake. Patient care is so individualized, you know, even amongst the same disease process or the same surgery, everything has to be individualized to that patient. You can't learn the same thing from a mistake on patient X and apply it to patient Y. It's just not the same. And so I think that's part of why this is so hard to study.

  • 10:46:31

    LESLIEAnd even if, you know, using ICD codes to look at it and study it is terrible, you know, then there's not necessarily a much better way at this point. And so that's part of the difficulty. So, thank you.

  • 10:46:46

    MCGINTYAll right, Leslie. Great point. And, Bob Anderson, that, to me, goes back to your original point of a couple minutes ago about this being more art than science in some ways.

  • 10:46:56

    ANDERSONYeah. I mean, I'm not a physician and so I can't, you know, comment on the issue of individualized care. But, you know, we do have records for each individual in a mortality file. And their pathway, even for the same underlying cause, the pathway that we see leading to underlying cause is often different.

  • 10:47:18

    MCGINTYDr. Makary, what about that point, that each patient is so individual?

  • 10:47:20

    MAKARYWell, I couldn't -- I couldn't agree more. And Bob is right, medicine is an art form and you can't regulate it and you can't protocolize it. We've got to individualize care for individual patients. But, you know, Derek, the underlying problem in health care is variation around the way we should do things. It accounts for medical inflation. It accounts for this vast problem of medical errors being the third leading cause of death in the United States. It's variation in the way care is delivered.

  • 10:47:50

    MAKARYNow, you know, simulation exists for doctors just like it does for airline pilots. We have simulation centers. But it's highly variable how they're used.

  • 10:47:58

    MCGINTYGive me an example of what you mean by variation.

  • 10:48:01

    MAKARYWell, for example, there's a technology that will bar-code sponges so they can be perfectly counted so they're not left behind in surgery. But yet it's variable whether or not a hospital has -- uses this technology. There's tremendous variation in the way surgery versus medical treatments are recommended for the same presentation, whether or not a prostate cancer gets treated with radiation, surgery, chemo or observation, whether or not somebody gets 10 diagnostic tests or two diagnostic tests. These are things where there are best practices and we can standardize care better, at least to eliminate the outlier patterns that are dangerous to patients.

  • 10:48:41

    MCGINTYRick in Scott City, Mo., your question.

  • 10:48:45

    RICKYes. I have a comment. As a health special, I'm -- I've worked over 30 years. And it's very difficult for people that are not physicians, working in a profession, to either report or notify someone if they see a physician acting in a manner that might cause problems or whatever, because of the fear of reprisal and possibly even legal issues as far as being sued for slander or libel or whatever. And I believe Johns Hopkins is kind of at the forefront of making that a little bit more easily done, without those issues.

  • 10:49:25

    MCGINTYWell, we've got Dr. Makary right here to address that. He works at Johns Hopkins. Doctor?

  • 10:49:31

    MAKARYWell, we have a tremendous research effort in the area of patient safety. And, in fact, the ideas of surgery checklists originated at our hospital. But the issue is that when -- every time we go to make the case for more research funding in this area, we're told by the NCI, this is out of our scope. We're told by the National Cancer -- the National Institutes of Health, this is out of our scope. We need to invest in this stuff. And, you know, there's a huge problem out there that's affecting people every day. And the question is, do we want to create an open and honest conversation about the problem. We've got to create the culture within medicine to be open and honest about the problem of medical care gone wrong.

  • 10:50:12

    MAKARYAnd that's what I tried to do in the book, "Unaccountable." I try to be very honest with the first-hand experiences of places where I felt like I did something I shouldn't have done, or the system failed, or a safety net could have prevented a problem.

  • 10:50:25

    MCGINTYBut what I think Rick is also talking about is an arrogance on the part of physicians or some surgeons that maybe if someone's assisting them and sees a mistake, they feel afraid to speak up. I mean, can you address that at all?

  • 10:50:37

    MAKARYWell, what makes a great doctor is oftentimes not their fund of knowledge or their technical excellence -- that's important, but it's their humility. It's their ability to tap a senior partner for their clinical wisdom or expertise. It's their ability to work as a team. It's their ability to communicate effectively. It's not just the technical skills that make you a great doctor, it's the non-technical skills, the behavioral and communication and team-based skills to deliver great care. And the coordination of care gone wrong is the third leading cause of death in the United States. It's another way of saying that medical error is a problem.

  • 10:51:14

    MCGINTYLet's take another phone call. Carl, from Indianapolis, you're on the air.

  • 10:51:18

    CARLYeah. I'm a health-care worker and I work in surgery in long cases that last five to six hours. In that room, there's always six people. There might be upwards to 10 people, due to lunches, breaks. And I just don't think you can correct human error. And if we think of all the other professions around the world and, you know, people make mistakes. And I mean -- and it's just -- it's part of the process. And you -- we have tons of fail-safes. We do many, many counts. And still problems happen just because people are human. And to -- I feel like there's kind of a vilification of the health care system. It's pretty good. And people, you know, as hard as we try, people come in and they have bad days and they're stressed. And...

  • 10:52:10

    MCGINTYYou know, I feel you on everything you're saying there. But when mistakes -- they're the third leading cause of death, I'm hoping that we can do just a little better than that. Lena Dunham.

  • 10:52:20

    SUNWell, I mean, I think that health care is the only place where you go where oftentimes the patient is not heard. And if you go and talk to any patients, you will -- they will tell you that, if somebody had just listened to them or told them why something is taking too long or have that -- feel like they've been heard, it would make a big difference. And I think when Dr. Makary was talking before about what makes a great doctor, being humility and learning from others, I think part of that also means listening to the patient. And, you know, in the United States, there's one hospital system that has decided that, if you don't feel like you've gotten a good care experience, they're going to give you a refund.

  • 10:53:11

    MCGINTYI'm Derek McGinty and you're listening to "The Diane Rehm Show." I want to just remind everybody that we're taking your phone calls at 800-433-8850. That was Lena Sun. She's health reporter at The Washington Post. We're also sitting with Bob Anderson, chief of Mortality Statistics at the CDC's National Center for Health Statistics. And Dr. Marty Makary is on the phone with us. He is the author -- or co-author of the new study describing medical errors as the third leading cause of death in this country. Let's go to Elizabeth in Tampa, Fla. You're on the air, Elizabeth.

  • 10:53:41

    ELIZABETHThank you so much for taking my call. I would like to just briefly offer a different perspective. I am a retired registered nurse and I am also a cancer survivor that nearly died, not from the cancer but from an infection that followed through the surgery. Number one, I think it's a systemic problem. I was a nurse when the day you gave the patient a bath, the nurse would be able to tell whether there was something wrong with the skin or a bedsore. Now the nurses are pill pushers and the care to the patients are in the hands of maybe lesser qualified people that do not know what they're looking for. And they throw a washcloth up and then say, save yourself.

  • 10:54:19

    ELIZABETHNow, if six weeks post-op, when I had my breast cancer surgery and reconstruction, I told everyone at this system I had soreness in my chest, I had a fever, I did not feel well. And I told triage nurse, after triage nurse, after triage nurse, and I was septic by the time I got there. And they found that, lo and behold, in the operating room, they had never given me antibiotics once they placed the prosthetics in. And this was in, might I tell you, the largest in the country, Cleveland Clinic Medical Care. So when I was nearly dead in ICU from sepsis, I had a unique perspective.

  • 10:55:01

    ELIZABETHBut when your doctor says to you -- I asked him, who had their hands in my chest during the operation? And the physician says, I'm sorry, this conversation is over, and I am a vocal patient, there is a bigger systemic problem going on in this country.

  • 10:55:16

    MCGINTYWow. All right. Elizabeth, thank you for sharing that with us. Who wants to take that on? Dr. Makary?

  • 10:55:22

    MAKARYYou know, there's a lot of strong emotions when it comes to the treatment of people at a vulnerable time. And I just want to point out that the problems are ubiquitous. It's inherent to a complex and sometimes messy, sometimes highly fragmented medical system. We don't want to blame individuals. We want to look at the system. We attract good people into medicine. The sort of kid that says they want to be a nurse or a doctor, they're good. They've got a sense of calling and mission to help people. We attract good people, even at the level of hospital leadership. But sometimes, working in a messy system is complex. The old figure of 100,000 deaths a year from medical mistake, from 1999, a report citing a 1984 and 1992 prior study, needs to be updated.

  • 10:56:13

    MAKARYAnd that's essentially what we did in our study, is simply update the figures to say, this is a major national endemic.

  • 10:56:21

    MCGINTYSixty seconds left in the show. Lena Sun, any sense of how much more can be done to fix this problem?

  • 10:56:29

    SUNTons. Tons can be done, right? But as you -- as I think we've heard on this show, the problem is that they're -- it's up to the individual hospitals, up to the individual doctors. And I think Dr. Makary makes a really good point, you know, if there was more research and more studies, then it might point the way to say, okay, it looks like the problem is in these three fields, or in this part of the country, or in hospitals that are, you know, this size, or those that are taking these -- care of these kinds of patients. And then you can take those metrics and say, okay, you know, here's what the numbers show. Put in place programs to do better.

  • 10:57:11

    MCGINTYLena Sun, she's health reporter for The Washington Post. Also with us, Bob Anderson, chief of the Mortality Statistics Branch with CDC's National Center for Health Statistics. And Dr. Marty Makary was on the phone with us from Connecticut. He's in surgery at Johns Hopkins Medical Center, also co-author of the new study on medical errors. We hope you found it interesting. And we'll hope we can do something about that. By the way, I'm Derek McGinty. This is "The Diane Rehm Show."

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