Barbara Starfield's commentary

[Paul C. Anagnostopoulos]

Many of you have probably seen the following paper by Barbara Starfield, published in JAMA:

http://www.som.tulane.edu/departments/fammed/t3/ushealth.pdf

In this paper she takes the US health industry to task. In particular, she uses some statistics to reach the conclusion that iatrogenic deaths are the third leading cause of death in the US. This figure is being touted by the alt-med community as proof of the horrors of alopathic medicine.

She reaches that conclusion by lumping together deaths from unnecessary surgery, medication errors in hospitals, other errors in hospitals, nonsocomial infections in hospitals, and nonerror adverse effects of medication. It seems to me that this is like lumping together deaths from automobiles, planes, trains, buses, boats, and horseback riding and then moaning about the death rate from transportation.

I'm not suggesting that her commentary is totally pointless. She makes some interesting observations about our quality of health care and how that relates to our health care system, our income inequality, and other factors.

Thoughts?

~~ Paul

 

[Goshawk]

Just that her logic seems unassailable--"automobiles, planes, trains, buses, boats, and horseback riding" are indeed all "transportation", and deaths from "unnecessary surgery, medication errors in hospitals, other errors in hospitals, nonsocomial infections in hospitals, and nonerror adverse effects of medication" are indeed "deaths that take place in a hospital other than dying of what you came in with".

The problem is that both statements are generalizations, and you can't prove things with generalizations.

 

[pupdog]

How did the researcher count the death of someone in an ambulance crash on the way to the hospital?
Most of the iatrogenic death factors appear to be caused by errors in procedure, not by theory or accepted methods; steps are being taken to reduce these (such as typing and barcoding medication instructions to avoid problems caused by illegible handwriting). The rate of Hospital infections can be reduced, although this likely is a tougher problem. The numbers of iatrogenic deaths is cause for concern, but certainly needs to be considered with respect to the numbers of nonfatal treatments.

 

[Paul C. Anagnostopoulos]

Discussing absolute numbers is definitely misleading. Also note that we aren't given the same iatrogenic death statistics for other countries.

The two biggies are infection and drug reactions. The first one seems like it ought to be easy to fix. If all those other countries have lower percentages of deaths from infection, then find out what brand of disinfectant they use and switch to it. Sounds facetious, but you know what I mean.

Nonerror drug reactions is tougher. If the other countries have lower percentages, why?

~~ Paul

 

[Soapy Sam]

Goshawk said "The problem is that both statements are generalizations, and you can't prove things with generalizations"

Well, that's a bit of a general statement in itself. Presumably you can prove a general point. Which sounds like what she was making- namely that the medical industry kills a lot of people, which is indisputably true. It also keeps a lot alive and improves the life of others. Noone said it was infallible. You pay your cash and take your chance.

I don't think anyone would argue with that level of generality. The question of interest is how can it be improved?

And regarding the comments of the alt med community- until they can produce their own statistics , to a similar level of accuracy, they should watch what they say. If homoeopathy really is as powerful as they claim, then it will kill people when used wrongly. Conversely, medecine with no side effects is unlikely to have any effect at all. Possibly the only actually people saved by alt med are those who might have perished of iatrogenic disease in a mainstream hospital, but got better anyway while waiting for the Reikiman to do something.

 

[Paul C. Anagnostopoulos]

I agree, Sam, that the question is: How can medicine be improved? However, the paper mixes two issues. First, it suggests that possible reasons for the supposedly better health care in other countries are things like more equal income levels and the nature of the health care system. Then is cites the scare statistics about iatrogenic deaths in the US, without doing the same for other countries. Are our death percentages significantly higher than those in other countries? The paper certainly implies so.

~~ Paul

 

[Soapy Sam]

Don't have the stats, Paul. There has been much comment here of late about secondary infections (especially MRSA) in state hospitals. The emerging conclusion seems to be that since the advent of antibiotics, our hygiene standards have become lax; new hospital designs aim to cope with this by getting away from large wards and creating isolation zones, similar to (though less stringent than) bio-research labs.
Doctors who wash their hands would get my vote.
Cleaning in the NHS is mostly done by low paid workers, often first generation immigrants. They may lack the training, the time and the money to keep the places sterile. Ironically, the safest place in many NHS hospitals may be the toilets, which are generally cleaned frequently and with bleach.
The use of immunosuppressive drugs has been implicated in secondary infections as well. It looks like we need to get back to old time standards of cleanliness.

I once asked my GP what "iatrogenic" meant. He didn't know. This is interesting. The med community likes to bury its failures quietly. I suspect in our system, many people die while awaiting treatment (especially surgery) because of limited staffing and budgets in hospitals. They would not appear in statistics as medical-related deaths.

Of course we also had Dr, Harold Shipman, who may have killed over 200 of his patients on purpose. (He recently hanged himself in prison). He alone may have squewed our statistics pretty heavily.

My own (distant) take on medecine in the 'States is that people were more med-aware than is good for them. I recall being surprised by a TV ad (I think for Tylenol), with the line "Which is your brand of painkiller? My what?!! . In the last decade though, we have gone the same way.

Seems to me that if you take more drugs and spend more time in surgery, you will have a higher related death rate. (How many people die on the operating table in Ethiopia? What percent of operations is that?)

Obesity is the biggie. What percentage of deaths are related to overeating and our attempts to correct for it- by drugs, surgery and diet? We need to take personal responsibility for our health , rather than turn it over to experts, so far as possible. (Walk to the gym?)I know every time I go near a doctor I emerge feeling sicker than when I went in.

 

[pgwenthold]

Well, that's a bit of a general statement in itself. Presumably you can prove a general point. Which sounds like what she was making- namely that the medical industry kills a lot of people, which is indisputably true. It also keeps a lot alive and improves the life of others. Noone said it was infallible.

More to the point, how many of those people who died from surgery errors would have died without any modern medical treatment at all?

Would she count those people who died from a botched appendectomy?

Sure, procedures can be improved and a better job can be done to prevent mistakes. However, what the anti-medical establishment folks are doing is throwing the baby out with the bathwater. There is a tradeoff involved. Would those people be better off with something different (e.g. homeopathy)? Or is it just an issue of doing "traditional medicine" (for lack of a better word) better?