Doctors Kill

On reflection, I suspect the main thing keeping me from convincing people that the second half of medical spending hurts as often as it helps is a reluctance to believe that "doctors kill."   I should argue more like the October AEI Health Policy Outlook:

Hospital-acquired infections1 (HAIs) are estimated by the World Health Organization (WHO) to kill between 1.5 and 3 million people every year … Even in the United States, nearly 100,000 people die from HAIs every year. Someone who is already sick – that is, a hospital patient – is especially susceptible to new infection, since his immunity is compromised. Whatever bug is going around is likely to flourish. Hospitals can be dangerous places. … A recent study … at fifteen hospitals in Ontario showed that less than one third of doctors and nurses washed their hands between patients as required by good practice …

A recent investigation into how long nosocomial pathogens can survive on dry surfaces [found that] … the most common – Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, E. coli, and tuberculosis lasted for months on surfaces and remained continuous sources of infection if no regular disinfection was performed. The study also flatly contradicts the common belief that HIV can last only a short time outside the body, stating that "blood-borne viruses, such as hepatitis B and HIV, can last over a week on dry surfaces."  …


WHO estimates that at least 16 billion injections are given every year in developing and transitional countries. Less than 5 percent of these are immunizations; over 70 percent are unnecessary or could be given orally. Patients believe injections deliver faster, stronger medicines, and doctors over-prescribe injections to satisfy them. In some cases, nine out of ten patients receive an injection at every visit. … Assessments carried out by WHO in numerous countries have revealed that syringes and needles are often just rinsed in a pot of tepid water between injections. Worldwide, up to 40 percent of injections are given with syringes and needles reused without sterilization. In some countries, this proportion is as high as 70 percent. …

A recent mathematical model suggested that unsafe injections may cause 8-16 million cases of hepatitis B, 2.3-4.5 million cases of hepatitis C, and 80-160,000 cases of HIV annually worldwide … In the past year, a study in Zambia led by the CDC found that medical injections – whether into muscle or veins – "were overwhelmingly correlated with HIV prevalence, exceeding the contribution of sexual behaviours in a multivariable logistic regression." … On demographic, medical, cultural, and sexual behavior … criteria the women were in the low-risk category for HIV… and yet 30.3 percent were found to be HIV positive. … the most significant risk factor to which these women had been exposed was going to a clinic and having an injection. As the authors conclude, "medical injection history made an overwhelming contribution to explaining prevalent HIV infection, even after demographic variables, sexual behaviours, and substance abuse were already parcelled out of . . . the . . . equation." In this study, all risk factors were compared with each other for perhaps the first time, and the results seriously undermine current public health messages on HIV.

A colleague of my wife was a nurse at a local hospital, and was assigned to see if doctors were washing their hands enough.  She identified and reported the worst offender, whose patients were suffering as a result.  That doctor had her fired; he still works there not washing his hands.  Presumably other nurses assigned afterward learned their lesson.  Hat tip to Michael Cannon.

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  • http://www.aleph.se/andart/ Anders Sandberg

    Another major cause of death is medications. There are 180,000 deaths annually from medication errors and adverse reactions. An Australian study found 2.4-3.6 % of hospital admissions to be due to prescription medication events. Of these I would expect medication errors to be of less significance than adverse reactions, which tend to occur because we currently are not very good at tailoring the medication to the patient.

    Phillips D, Christenfeld N, Glynn L. “Increase in US medication-error
    deaths between 1983 and 1993.” Lancet. 1998;351:643-644.

    Barbara Starfield, MD, MPH, Is US Health Really the Best in the World?, JAMA, Volume 284, No. 4, July 26, 2000

    Institute of Medicine (IOM), “To Err Is Human: Building a Safer Health System”, 2000
    http://www.nap.edu/openbook.php?isbn=0309068371

    I guess one could lump the iatrogenic death and injuries into three main categories. One is simply the unavoidable risks: some treatments simply are dangerous, hospital are risky places because there are sick people around. The second one is incompetence: not washing hands, not checking drug dosages carefully, all the things that could have been avoided by paying more attention. People tend to become emotional about this one. The third one is the knowledge category: if people had just known about new research or successful practice, if they had a particular piece of information about the patient, then they would have acted differently.

    Category #1 is hard to get rid of, except by reducing overall overtreatment (which is also going to help the other two). #2 is sticky, since much of it is caused more by organisational problems. But since people are emotional about it, it is easier to get support for interventions to reduce this category of causes. There is probably a lot that can be done, but I suspect the costs of doing it can become arbitrarily high. #3 has some components that can be fixed very cheaply and effectively; there was a project a while ago that demonstrated that just by teaching how the most successful hospitals handled various conditions treatment success at other hospitals rose significantly (can’t find the paper for the moment, though). But personalized medicine on the other hand is likely to start out quite expensive and would require expensive changes in how the medical system works.

    Meanwhile the alternative therapy people are gleefully rubbing their hands since they look so good in comparision. After all, they don’t keep *any* statistics of how many they kill.

  • J Thomas

    “I suspect the main thing keeping me from convincing people that the second half of medical spending hurts as often as it helps is a reluctance to believe that “doctors kill.”"

    That may be the main thing that keeps you from convincing people. Once you learn how to convince people, the next step is to convince them that the second half of medical spending hurts patients more than the first half does.

    “I should argue more like the October AEI Health Policy Outlook:”

    Among reasonable people you should avoid admitting you get talking points from AEI. It isn’t that they can’t tell the truth. But at least for me and for many others, when I see that information has passed through AEI I discount it until I have checked that it was independently verified by a credible source.

    “medical injection history made an overwhelming contribution to explaining prevalent HIV infection, even after demographic variables, sexual behaviours, and substance abuse were already parcelled out of . . . the . . . equation.”

    “Even after”? Of *course* it would have an effect after you control for everything else. The important thing is that it’s bigger than some of the other causes that traditionally were thought to be big ones. Maybe that means that the information campaign has been somewhat sucessful and those causes have been reduced. It takes a close look at the study to tell what it actually says, and then it would probably take a longer comment to describe it than is allowed on this blog.

    We shouldn’t try to discuss complicated matters when we’re limited to simple descriptions, unless the simple descriptions include “This is far more complex than I can do justice to in this comment, and my simplifications may be highly misleading”.

  • http://profile.typekey.com/robinhanson/ Robin Hanson

    J, you insinuate that the source I cited isn’t reliable, but can you point to any particular errors?

  • http://billmill.org Bill Mill

    Robin,

    I agree with J that I don’t trust your source, I’ve seen them caught lying too many times. The statistics appear reasonable at first glance, but I maintain, say, 15% doubt instead of 10% because they’re from AEI.

    Anyway, my more important question is: why do 100,000 deaths from HAIs bear any relation to cutting the health budget 50%? Surely that’s a tiny fraction of the number of people hospitalized in a year (maybe the AEI has numbers on that)?

    My girlfriend’s a doctor, so I have no doubt that HAIs exist and kill people. In fact, we both got tested and are suprisingly free of MRSA. I even tend to agree with your hypothesis, though perhaps at 25% instead of 50%, but I don’t see how this statistic helps your case more than marginally.

  • http://homepage.mac.com/redbird/ Gordon Worley

    I’m upset over what happened to your wife’s colleague. It’s infuriating to think of someone losing their job, not only for doing it, but also because it inconvenienced someone who preferred to follow dangerous practices. I certainly hope I never have that man, or one like him, for a doctor.

  • http://profile.typekey.com/bayesian/ Peter McCluskey

    This is not very impressive evidence that doctors in the U.S. kill. What little the AEI report says about U.S. medicine can be rationalized away with the hypothesis that those HAIs are an unavoidable byproduct of practices whose expected value is positive. All you add to the AEI report is an unverifiable anecdote.
    Here’s a somewhat better article on this subject: You Get What You Pay For: Result-Based Compensation for Health Care, published in the Washington and Lee Law Review. See in particular page 9 of the pdf, where demands that anesthesiologists stop killing their patients caused the death rate from anesthesia to drop by over two orders of magnitude without any corresponding advance in medical understanding of anesthesia. There is evidence that most doctors have successfully resisted the kinds of demands that caused anesthesiologists to avoid unneeded deaths, but that evidence isn’t as easy to evaluate as I would like. (The article appears to offer interesting ideas about how to improve medicine, but I haven’t read far enough to evaluate that yet).

    Bill, this post doesn’t attempt to say how much medical spending should be cut, it is only intended to undermine the faith in doctors that causes people to assume we shouldn’t think about drastic cuts in spending.

  • http://profile.typekey.com/robinhanson/ Robin Hanson

    Peter, I agree that having harm exist doesn’t show the harm isn’t unavoidable and so on net good. The anesthesiology example is worth remembering.

  • Richard Hollerith

    Thanks for posting this, Robin. The correlation between medical injections and HIV is illuminating.

  • Jor

    A better source of information on errors in hospitals killing patients is the Institute of Medicine’s (part of the N.A.S) report “To Err is Human”. Their estimates put hospital errors I believe around the #10 cause of death in America.

    I’ll also just second or third the point, that this isn’t the type of medical spending that is easiest to cut, because people don’t vacation in hospitals these days.

  • J Thomas

    Robin, I haven’t looked at this particular work yet. My experience following up previous AEI papers has been that I needed to track down each of their references and look at it rather than believe that it says what they said it said. I don’t claim that those guys were liars as opposed to just being very very sloppy. And there could be people at AEI who do good work, I haven’t looked at everything that comes out of there.

    But based on my experience so far, if I meet a guy in a bar who claims he’s an expert in something and he starts telling me about it, I’ll discount his claims more if he says he’s an AEI fellow than if he’s just some random guy in a bar.

    Your anecdote reminds me of a recent controversy that got reported here, where a woman was being considered for tenure based on controversial work about archeology, and one of her vociferous detractors said that she was no more qualified to criticise the people she studied, than a med tech was to criticise a doctor. And here we see that reasoning in action.

    But in all fairness, an MD who never actually touches a patient might not need to wash his hands very often.

  • Jake

    The issue of doctors washing their hands is explored in the book “Better: A Surgeon’s Notes on Performance”

    The main topic of the book is how to measure and improve. The first chapter is all about doctors washing their hands. The rational way in which the subject is approached is very refreshing. First the impact of not washing hands is measured. Then various approaches are tested and measured in the field to see what works. Rinse, repeat. I think the most important part is the emphasis placed on results, attained by properly motivating the doctors. Even the subject of motivation is approached rationally.

  • April

    One of the reasons that there is so much poor quality medical care is because….there is little incentive for medical care organizations to take the difficult steps that are needed to improve quality. Reimbursement by insurers for health care services do not, for example, pay health care organizations higher payments for achieving certain quality standards (or it is very rare). Individuals, when they pay out of pocket, do not pay more for high quality organizations than poor quality. Yet, it is neither cheap nor easy to undertake changes in the way medical care is organized (say, installing sinks in or near every examination room for staff to wash their hands; or installing management information systems and getting everyone, young and old, to actually use them).
    The good news is: in experiments where insurers set quality standards for organizations – and paid for “performance” – the organizations were quite responsive in implementing the process changes that are associated with quality. Here is the reference.
    Casalino L, Gillies RR, Shortell SM, et al. External Incentives, Information Technology, and
    Organized Processes to Improve Health Care Quality for Patients with Chronic Diseases.
    Journal of the American Medical Association. 2003;289(4):434-44

    The most interesting question that comes to my mind when I read this literature is: why aren’t there more efforts to use payment to incentivize quality improvements? Maybe patients(?), employers(?) just don’t care as much about quality of medical care as Robin and the other readers of this blog do? Otherwise, surely they would shift their insurance coverage to an insurer that established a reputation for quality.
    I say this partly with my tongue in my cheek, because the last time I tried to decide which of the THREE insurance packages my employer offers would be the best deal for me, it took my two nights of reading, and assessing, and analyzing and in the end, I honestly had no clue which would be better. And assessing packages is easier than assessing insurers AND packages.

    I admit I am not responding to Robin’s implied goal – which I take to be: finding enough jaw dropping evidence that medical care can be harmful, that we can finally break our society’s addiction to overconsumption of medical care….(the bad half that is). I’ll try to think of some good horror stories….

  • April

    PS: I would second (or third or fourth) my fellow commenters skepticism with information found solely in AEI publications.

  • http://profile.typekey.com/robinhanson/ Robin Hanson

    April, Bill, and J, are there any other think tanks you find have similarly unreliable reports?

  • Constant

    Unless I have missed something, so far no one has provided any actual examples of AEI misinformation. Meanwhile, some of the responses have suggested animosity toward AEI that seems to go beyond rational suspicion. I also notice that AEI tends to be pro-market, and as a general phenomenon, anything pro-market tends to attract mud.

  • http://billmill.org Bill Mill

    Robin,

    I would say that the Gartner Group is a thinktank (maybe? I’m not sure exactly what they are) that is much less reliable than even the AEI. I can’t think of any others that deal with economic issues that I don’t trust.

    I think what really sullied there name for me is the Laffer Curve they drew in the Wall Street Journal; I seem to remember other instances of bad numbers from them, but I can’t specifically recall them, so my bias may be unfair.

  • http://billmill.org Bill Mill

    Also, @constant: I consider myself generally a libertarian; although certainly not a Libertarian. I highly doubt that their free-market bias is what’s affecting me.

  • http://billmill.org Bill Mill

    oh my gosh… “their” not “there”, I hate that error.

  • Constant

    Bill – the Laffer curve that you link to is not bad (false) numbers. It is bad curve fitting. It really is not the same thing. There’s a big difference between (say) a scientist with out-there ideas which have scant empirical support, and a scientist who falsifies his data.

    Presumably you know that there isn’t just one way to fit a curve to the data. Curve fitting 101. There’s more than one curve. You need to add constraints, and those constraints are going to derive from your theory. So those constraints are going to import something of your theory. Also, the data as shown does – barely, weakly – support the idea that there’s a downward slope on the right. You can see it in the dots, from Norway to the US. That might be just an accident. But it might not. I don’t know. Do you know absolutely for sure?

    On the matter of your bias, it doesn’t have to be your bias. It might be somebody else’s bias, somebody who has influenced you.

  • http://billmill.org Bill Mill

    > the Laffer curve that you link to is not bad (false) numbers

    Of course that is correct.

    That their name is tied to an example of extremely poor math and economics may not be their fault at all; the WSJ could have been solely responsible for (what I consider to be) a ludicrous curve fit.

    However, If my experience with the AEI consists entirely of 1 terribly misleading graph, which they may or may not be responsible for, isn’t it fair for me to jack up my doubt percentage a bit? As I said before, I only guess that I’m going from 10% to 15% because of the source.

  • Constant

    I thought that Megan Mcardle’s recent comment on the Laffer curve was apropos.

    The Laffer Curve and the supply siders pushing it seem to be the teacher’s unions of the right.

    (That’s not meant as a compliment.)

  • http://www.aleph.se/andart/ Anders Sandberg

    The AEI issue is interesting, and might merit its own dedicated thread. We quite often evaluate the reliability information almost solely based on the originating organisation – and this organisation/reliability information is likely often picked up from others rather than arrived at by experience or deliberate evaluation. I remember a friend who almost hyperventilated when I mentioned dealing with a certain centre-right Swedish think tank. He had never read anything from them, but “knew” from his social democrat context that everything they did was biased and bad.

    When is this approach a bias and when is it just a prior? It seems to be very vulnerable to several bias-promoting processes like stereotyping, groupthink, outgroup bias, halo effects and availability biases. If group X has opinion Y, then adherents of opinion Z have an incentive to argue against everything related to X, and to promote this even when Z and Y are not the direct subject of discussion.

  • http://www.stafforini.com Pablo Stafforini

    I’m inclined to think that any agent who holds views on a wide range of topics is likely to be biased if those views can be reliably predicted by the agent’s position on the left-right continuum, since there is no good reason to expect anything more than a weak correlation between the truth of a view on some random topic and the political horientation of those who subscribe to it. This applies to individual and institutional agents alike, and may explain why many of us are sceptical about the AEI.

    Like Anders, I also find this issue interesting, and second his suggestion to start a dedicated thread.

  • http://www.stafforini.com Pablo Stafforini

    “horientation”? now that’s a weird typo.

  • anonymous

    Doctor’s often make serious mistakes that maim or kill people. I personally had a routine surgery when I was a teenager and now have a serious chronic illness that resulted from the doctor removing too much tissue.

    I live in pain every day because of it. All the while all the doctor’s that diagnosed me did not find the problem. I ended up finding the issue on my own on the web. I then went and confirmed the diagnoses with two separate physicians. All that being said, a doctor gave me a chronic illness during a surgery and it cannot be cured.

    While I do believe doctor’s try their best to help patients they are often not aware of the damage they are doing. Some doctor’s are out to make a buck and will recommend surgery for the slightest of reasons. For example a region in the Midwest had 10 times more heart bypass operation that in any other county in the U.S. There didn’t seem to be any reason for it except that this county’s doctor’s got huge bonus’s for doing this type of surgery.

    I guess that if you feel healthy and your doctor recommends surgery. Make sure you research it yourself to make sure it is necessary. Sadly even some doctor’s will make a buck at the cost of a person’s health or life.

  • anonymous

    Doctor’s often make serious mistakes that maim or kill people. I personally had a routine surgery when I was a teenager and now have a serious chronic illness that resulted from the doctor removing too much tissue.

    I live in pain every day because of it. All the while all the doctor’s that diagnosed me did not find the problem. I ended up finding the issue on my own on the web. I then went and confirmed the diagnoses with two separate physicians. All that being said, a doctor gave me a chronic illness during a surgery and it cannot be cured.

    While I do believe doctor’s try their best to help patients they are often not aware of the damage they are doing. Some doctor’s are out to make a buck and will recommend surgery for the slightest of reasons. For example a region in the Midwest had 10 times more heart bypass operation that in any other county in the U.S. There didn’t seem to be any reason for it except that this county’s doctor’s got huge bonus’s for doing this type of surgery.

    I guess that if you feel healthy and your doctor recommends surgery. Make sure you research it yourself to make sure it is necessary. Sadly even some doctor’s will make a buck at the cost of a person’s health or life.

  • retired urologist

    Being a newcomer to the blog (and a doctor): believe me, I apologize to all of you for my pointless life. If only I had known, I should have been a tenured university professor. In addition to my intended purpose of improvement of my understanding of quantum mechanics, of efforts to bring about the Singularity, and of human cognition processes, I have read some of the archives on medicine; hence this late thread entry. I didn’t see any of the participants on this thread state that he/she was in a full-time, at-risk occupation for subsistence wages; medical practice is a job, for which the workers wish to receive as much remuneration as is legally and ethically possible. It is definitely true that some get much better results than others, while still receiving similar income; yet none is “tenured”, with a guaranteed income regardless of production. While I realize that much more is spent on health care than on education, I had a thought when I read Dr. Hanson’s comment in the thread that he teaches medical economics to his students semester after semester, and they never seem to learn what he is teaching. Then, it occurred that, by definition, all the doctors mentioned are products of the university educational system. Perhaps the Rand and other studies did not go far enough to find the root cause of the ineffectiveness of our health-care delivery personnel, even to the point of killing their own patients. Surely if they had understood economics better, they would realize that there are extreme diminishing-return issues when one kills his own customers. I say this somewhat (but not completely) tongue-in-cheek; perhaps every profession is fortunate to make a difference only once in a while, and then when examined economically, it is discovered that that one impact experience cost society beaucoups dollars. It’s going to get worse: see this.

  • http://vesnavuynovich.blogpot.com Vesna

    I just found your blog, and this post, through Seth Roberts blog here: http://www.blog.sethroberts.net/2008/09/13/the-case-of-the-missing-evidence/

    There’s some discussion in the comments as to the reliability of the fired-nurse story. Could you please shed some light on that — whether you actually ever met and talked to the fired nurse, how strong her evidence was that she was fired for the reason in the story, etc.? Did your wife actually know her, or know someone who knows her (who might turn out to be someone who knows someone who knows someone), that sort of thing? Thanks!

  • http://hanson.gmu.edu Robin Hanson

    Vensa, the nurse was a close co-worker of my wife, who I’ve met.

    • http://morningtableaux.blogspot.com Benquo

      of my wife, who I’ve met

      One would hope so.

  • frelkins

    “if doctors were washing their hands enough”

    I wonder how many doctors if any are participating in UN Hand Washing Day today.

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