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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Iatrogenic benefits and risks
Simplistic risk adjustment in a complex setting
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Richard W. Biek, Madison WI United States Retired Public Health Physician
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See these 3 articles: http://www.health-care-reform.net/causedeath.htm http://www4.dr-rath-foundation.org/features/death_by_medicine.html http://www.garynull.com/Article.aspx?Article=/documents/iatrogenic/deathbymedicine/deathbymedicine1.htm One estimate is that about 5% of us owe our lives to our doctors. That would be about 15 million of us out of 291,500,000. If we assume when our lives were saved by our doctors, we were on average about the same average age of the population (about age 35 years), then on average, we live about 40 years longer than if our lives had not been saved. If we divide 15 million lives saved by 40 years, we get about 360,000 lives saved per year by physicians. But whenever physicians go on strike, within 5 days or so, deaths always drop from 17% to 50%, and stay down till the strike ends, when within 5 days or so, deaths increase from 20% to 100% -- back to where they were before the strike. There have been 2 such strikes in North America: in Saskatchewan and in Los Angeles county, but frequent doctor strikes occur in Israel, where morticians quickly mediate an end to the strike or go out of business. During World War II, virtually all European physicians were drafted, and civilians had almost no medical services, and civilian deaths at all ages from all causes were down about 20% throughout the duration. When the war ended and doctors returned home, European civilian deaths increased 25% -- back to where they were before the war. Our latest mortality rate was 847 deaths per 100,000 in 2002. So for our 291,500,000 population, there would be about 2,470,000 deaths per year. If American physicians were to strike for a whole year, at least 17% (420,000) fewer deaths would occur. If we assume that all 360,000 lives that doctors save per year would be lost during that year-long strike, that means, in a year when there is no such strike, doctors would save about 360,000 lives but cause 420,000 more deaths than lives saved or a total of 780,000 iatrogenic deaths per year. There are a little over 1 billion visits to doctors per year, so the chance of a life being saved is 1 billion divided by 360,000, or about 1 life saved per 2778 visits. While the chance of an iatrogenic death would be 1 billion divided by 780,000, or about 1 death per 1282 visits -- more than twices as many iatrogenic deaths as iatrogenic lives saved. And for every iatrogenic death, there are several nonfatal iatrogenic illnesses, injuries, and disabilities. Why do so many deaths occur within 5 days of a visit to the doctor? In the 1970s, the Benjamin Rose Institute (BRI) in Cleveland conducted an impeccable scientific study to convince the public and elected officials that spending tax funds for medical and social services for the poor would be both humane and economical. BRI compared a demographically identical and unaware control group with their study group. BRI provided health and social services for the study group, sought reimbursement from all possible sources, and as a last resort paid for the care themselves. BRI had funds for an extended study if necessary to obtain incontrovertible evidence. But they were shocked to discover that the study group receiving professionally-recommended health and social services immediately experienced dramatically more illness, disability, and death than the control group. BRI abruptly ended their study, ignored their unpublished findings, continued providing charity health and social services, and now deny that the study was ever started. If we really want to know the outcome of health care, we could easily duplicate that kind of study to find out. It is a simple way to compare care with absence of care outcomes. Also in the 1970s, Harvard correlated each health profession with health status in their communities and found the greater the number in each health profession the worse the health status in the community -- except for nursing. The more nurses the better the health status in the community. If we were to pay nurses what they are worth in terms of outcomes, perhaps they should be paid more than any other health profession. While all other health professions should be fined instead of paid because they are associated with worse health status in their communities. Why do nurses seem to improve health while all the other health professions do the opposite? Perhaps other professions should try to be more like nurses so they can also improve health. Diagnosis and treatment are clearly very beneficial for severe penetrating trauma and newborn distress. When prompt surgical care close to the front lines was available for the first time during the Korean war, combat deaths and disabilities were about 75% less than before. But diagnosis and treatment may not be scientifically (epidemiologically) justified for nonemergency care. Richard W. Biek, MD, MPH, Chief Consultant Biek Public Health Consulting LLC 22 High Point Woods Dr #203, Madison, WI 53719-3287 Home: 608-828-9569, Office: 608-833-0880, Fax: 800-886-4087 Competing interests: None declared |
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David A Katerndahl, Physician University of Texas Health Science Center at San Antonio
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I found this article to be extremely comprehensive in its review of limitations of risk adjustment methods. As the authors point out, this is issue is of particular importance to family physicians. These limitations may explain the failure of RBRVS. In the mental health arena, we have long recognized the inadequacy of DSM diagnosis to reflect what is seen in primary care. Such inadequacies extend to assessment of risk as well. The ultimate problem with current risk adjustment methods is their failure to reflect the complexity of primary care. However, now that we have recognized the limitations of current systems, how do we deal with them? Competing interests: None declared |
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