Medical errors kill more people each year than auto accidents, breast cancer or AIDS. Can automating medicine prevent tragedies like the Andrea Yates case?

Topics: Books,

Andrea Yates was, in the words of a psychiatrist who treated her for one episode of postpartum depression with psychosis, one of the five sickest patients the psychiatrist had ever treated. She neglected to bathe or to drink water, she acted bizarrely and she suffered from severe delusions and hallucinations that experts say made her a clear danger to herself and others. But just days before she drowned her five children in a bathtub, Andrea Yates’ doctor decided to take her off her antipsychotic medications — a mistake, in hindsight, that may have cost her children their lives.

What if we took humans out of the equation? What if a dispassionate computer had been making the decisions about Yates’ care, rather than a human doctor sitting across a desk from her? Would a computer have left her on medication? Would her children still be alive?

Three years ago, the National Institute of Medicine estimated that medical mistakes kill between 44,000 and 98,000 people per year in hospitals. If that’s true, it means medical errors kill more people each year than car accidents, breast cancer or AIDS. Efforts to reduce such errors get only a fraction of the attention — and funding — that goes to AIDS research, but arguably it would be far easier to substantially reduce life-threatening medical errors than it has been to create an AIDS vaccine.

While some researchers have successfully poked some holes in the estimates of the number of patients killed by errors, the real effort should be aimed at ways to change the practice of medicine to make it safer. One doctor declaiming loudly that something should and can be done to reduce errors is Atul Gawande, a surgical resident in Boston, a staff writer for the New Yorker and now the author of a new book, “Complications: A Surgeon’s Notes on an Imperfect Science.”

Gawande is arguably the best nonfiction doctor-writer around; his talents are a source of envy among the rest of us, and this collection showcases his work well. He’s prescient and thoughtful, in awe of the medicine he practices without being an unthinking cheerleader. He is able to enter a story, but never overstates his own role as some doctor-writers are wont to do. The title of Gawande’s book recalls the title of author and scientist Lewis Thomas’ essay collection “The Youngest Science: Notes of a Medicine Watcher.” That’s apt, because Gawande’s work is well on its way to becoming the heir to Thomas’ humble, insightful and brilliantly crafted oeuvre.

Gawande’s greatest contribution, however, is that he has no fear of fighting the myth of the infallibility of doctors. At times, machines can best man. In 1996, attempting to diagnose heart attacks, a Swedish cardiologist read 2,240 electrocardiograms (EKGs) — the squiggly lines that show the electrical rhythms running through the heart. Of 1,120 heart attack readings, the cardiologist picked up 620. A computer, reading the same 2,240 EKGs, found 738. Neither was perfect, but the computer had won. Deep Blue had defeated Gary Kasparov.

Computer-based diagnostic systems have been in existence some 30 years, and more than a decade ago a philosopher suggested that “diagnosis without doctors” would be an improvement over human-based systems. For the most part, however, the medical community has seized on the limitations, not the promise, of such systems. The last major study, in 1994, found that they made correct diagnoses only about half to three-quarters of the time, making them suitable only for teaching medical students how to diagnose hypothetical patients.

It turns out, though, that doctors may have been too quick to reject computerized diagnostics across the board. Hospitals have found that computerized systems are invaluable when used to help make highly specialized decisions such as which antibiotics to use in an intensive care unit and which patients with HIV should be on medicines to prevent deadly pneumonias. Machines are also at least as good as pathologists when it comes to reading Pap smears — and as the Swedish study showed, you may want a computer, not a cardiologist, to check your EKG.

So why not have computers decide which patients — such as Andrea Yates — who suffer from psychotic disorders or depression should be taking medication? If the evidence of her illness was as clear-cut as it seems, wouldn’t a dispassionate computer have left her on medication, instead of bowing to pressure from her or her husband?

Doctors, after all, make mistakes. The central message of Gawande’s book is that despite medicine’s great strides, it’s a fallible and human art often confused with a science. One of the most powerful essays here, “Education of a Knife,” which ran last February in the New Yorker, finds Gawande suspended between the need for doctors-in-training to practice and the needs of patients to have the best healthcare available. It’s an uncomfortable place to be, as Gawande acknowledges.

Gawande tells the story of his own reaction to a cardiology fellow who offered to treat Gawande’s son for a congenital condition that had been stabilized. Gawande turned him down in favor of a senior doctor, even though he knew that the fellow, as a resident, needed the experience. Another doctor, an advocate for asking patients to allow residents to treat them, admitted to Gawande that he and his wife had not allowed residents into their delivery room.

Gawande describes the morbidity and mortality conference, a brutal weekly dissection by his department’s surgeons of the week’s errors. His experiences are similar to those of every medical student, resident and faculty member who has ever sat through an M&M. I remember one irascible senior surgeon from my medical school faculty who used to analyze particularly error-laden cases by asking residents, “So, why didn’t you just take him out back and shoot him?” And when patients do die, doctors analyze their mistakes through autopsies, as Gawande relates in another essay — although they don’t do as many as they should, many experts say.

Dispassionate analysis of errors, in which blame is not assigned and the analysis is carried out by an outside agency, is key to turning the lessons of M&M’s and autopsies into better medical practice, Gawande writes. Just as the Federal Aviation Administration has used these principles to improve airline safety, the American Society of Anesthesiologists has been at the forefront of preventing medical errors. Other groups are coming on board the effort, although the prevailing culture of medicine — God complexes are not uncommon — has slowed progress.

There are any number of little things that could be done to dramatically improve patient safety. Making sure all doctors entered prescriptions into computers would allow a double check, preventing two similarly sounding medicines from being confused and stopping ubiquitous doctors’ bad handwriting from leading to incorrect prescriptions.

Still, even Gawande has some reservations about the wholesale mechanization of medicine. “Western medicine is dominated by a single imperative — the quest for machinelike perfection in the delivery of care,” Gawande writes in an essay in which he visits Shouldice Hospital, a “hernia factory” outside of Toronto. At Shouldice, named for a pioneering hernia surgeon, doctors do nothing but perform hernia repairs, all identical according to a standard protocol. But the experience left Gawande cold.

“Maybe machines can decide,” he writes, “but we still need doctors to heal.”

He’s right, because healing takes more than diagnosis and treatment. Andrea Yates and her husband Rusty, however, were hardly ideal patients. Dr. Park Dietz, a psychiatrist who testified for the prosecution in the Yates case, told the court that the couple had repeatedly ignored medical advice in the past. When doctors had told her to stay on her medications, avoid future pregnancies and undergo shock therapy, she refused. Patients with the disorders suffered by Andrea Yates are often in denial of their illnesses and are understandably loath to take medications that can have serious side effects. They often complain of feeling sluggish, both physically and mentally. In Yates’ case, she and her husband may have feared endangering future pregnancies.

A computer might have continued Yates’ prescription, but it could not have convinced her to actually take her medications. To do that, we need doctors, perhaps with a little help from machines. If anything, leaving certain analyses and decisions to computers could help doctors work on their bedside manners, which many patients say have declined as a result of managed care.

Featured Slide Shows

  • Share on Twitter
  • Share on Facebook
  • 1 of 11
  • Close
  • Fullscreen
  • Thumbnails

    Ten spectacular graphic novels from 2014

    Beautiful Darkness by Fabien Vehlmann & Kerascoët
    Kerascoët's lovely, delicate pen-and-watercolor art -- all intricate botanicals, big eyes and flowing hair -- gives this fairy story a deceptively pretty finish. You find out quickly, however, that these are the heartless and heedless fairies of folk legend, not the sentimental sprites beloved by the Victorians and Disney fans. A host of tiny hominid creatures must learn to survive in the forest after fleeing their former home -- a little girl who lies dead in the woods. The main character, Aurora, tries to organize the group into a community, but most of her cohort is too capricious, lazy and selfish to participate for long. There's no real moral to this story, which is refreshing in itself, beyond the perpetual lessons that life is hard and you have to be careful whom you trust. Never has ugly truth been given a prettier face.

    Ten spectacular graphic novels from 2014

    Climate Changed: A Personal Journey Through the Science by Philippe Squarzoni
    Squarzoni is a French cartoonist who makes nonfiction graphic novels about contemporary issues and politics. While finishing up a book about France under Jacques Chirac, he realized that when it came to environmental policy, he didn't know what he was talking about. "Climate Changed" is the result of his efforts to understand what has been happening to the planet, a striking combination of memoir and data that ruminates on a notoriously elusive, difficult and even imponderable subject. Panels of talking heads dispensing information (or Squarzoni discussing the issues with his partner) are juxtaposed with detailed and meticulous yet lyrical scenes from the author's childhood, the countryside where he takes a holiday and a visit to New York. He uses his own unreachable past as a way to grasp the imminent transformation of the Earth. The result is both enlightening and unexpectedly moving.

    Ten spectacular graphic novels from 2014

    Here by Richard McGuire
    A six-page version of this innovative work by a regular contributor to the New Yorker first appeared in RAW magazine 25 years ago. Each two-page spread depicts a single place, sometimes occupied by a corner of a room, over the course of 4 billion years. The oldest image is a blur of pink and purple gases; others depict hazmat-suited explorers from 300 years in the future. Inset images show the changing decor and inhabitants of the house throughout its existence: family photos, quarrels, kids in Halloween costumes, a woman reading a book, a cat walking across the floor. The cumulative effect is serene and ravishing, an intimation of the immensity of time and the wonder embodied in the humblest things.

    Ten spectacular graphic novels from 2014

    Kill My Mother by Jules Feiffer
    The legendary Pulitzer Prize-winning cartoonist delivers his debut graphic novel at 85, a deliriously over-the-top blend of classic movie noir and melodrama that roams from chiaroscuro Bay City to Hollywood to a USO gig in the Pacific theater of World War II. There's a burnt-out drunk of a private eye, but the story is soon commandeered by a multigenerational collection of ferocious women, including a mysterious chanteuse who never speaks, a radio comedy writer who makes a childhood friend the butt of a hit series and a ruthless dame intent on making her whiny coward of a husband into a star. There are disguises, musical numbers and plenty of gunfights, but the drawing is the main attraction. Nobody convey's bodies in motion more thrillingly than Feiffer, whether they're dancing, running or duking it out. The kid has promise.

    Ten spectacular graphic novels from 2014

    The Motherless Oven by Rob Davis
    This is a weird one, but in the nervy surreal way that word-playful novels like "A Clockwork Orange" or "Ulysses" are weird. The main character, a teenage schoolboy named Scarper Lee, lives in a world where it rains knives and people make their own parents, contraptions that can be anything from a tiny figurine stashable in a pocket to biomorphic boiler-like entities that seem to have escaped from Dr. Seuss' nightmares. Their homes are crammed with gadgets they call gods and instead of TV they watch a hulu-hoop-size wheel of repeating images that changes with the day of the week. They also know their own "death day," and Scarper's is coming up fast. Maybe that's why he runs off with the new girl at school, a real troublemaker, and the obscurely dysfunctional Castro, whose mother is a cageful of talking parakeets. A solid towline of teenage angst holds this manically inventive vision together, and proves that some graphic novels can rival the text-only kind at their own game.

    Ten spectacular graphic novels from 2014

    NOBROW 9: It's Oh So Quiet
    For each issue, the anthology magazine put out by this adventurous U.K.-based publisher of independent graphic design, illustration and comics gives 45 artists a four-color palette and a theme. In the ninth issue, the theme is silence, and the results are magnificent and full of surprises. The comics, each told in images only, range from atmospheric to trippy to jokey to melancholy to epic to creepy. But the two-page illustrations are even more powerful, even if it's not always easy to see how they pertain to the overall concept of silence. Well, except perhaps for the fact that so many of them left me utterly dumbstruck with visual delight.

    Ten spectacular graphic novels from 2014

    Over Easy by Mimi Pond
    When Pond was a broke art student in the 1970s, she took a job at a neighborhood breakfast spot in Oakland, a place with good food, splendid coffee and an endlessly entertaining crew of short-order cooks, waitresses, dishwashers and regular customers. This graphic memoir, influenced by the work of Pond's friend, Alison Bechdel, captures the funky ethos of the time, when hippies, punks and disco aficionados mingled in a Bay Area at the height of its eccentricity. The staff of the Imperial Cafe were forever swapping wisecracks and hopping in and out of each other's beds, which makes them more or less like every restaurant team in history. There's an intoxicating esprit de corps to a well-run everyday joint like the Imperial Cafe, and never has the delight in being part of it been more winningly portrayed.

    Ten spectacular graphic novels from 2014

    The Shadow Hero by Gene Luen Yang and Sonny Liew
    You don't have to be a superhero fan to be utterly charmed by Yang and Liew's revival of a little-known character created in the 1940s by the cartoonist Chu Hing. This version of the Green Turtle, however, is rich in characterization, comedy and luscious period detail from the Chinatown of "San Incendio" (a ringer for San Francisco). Hank, son of a mild-mannered grocer, would like to follow in his father's footsteps, but his restless mother (the book's best character and drawn with masterful nuance by Liew) has other ideas after her thrilling encounter with a superhero. Yang's story effortlessly folds pathos into humor without stooping to either slapstick or cheap "darkness." This is that rare tribute that far surpasses the thing it celebrates.

    Ten spectacular graphic novels from 2014

    Shoplifter by Michael Cho
    Corinna Park, former English major, works, unhappily, in a Toronto advertising agency. When the dissatisfaction of the past five years begins to oppress her, she lets off steam by pilfering magazines from a local convenience store. Cho's moody character study is as much about city life as it is about Corinna. He depicts her falling asleep in front of the TV in her condo, brooding on the subway, roaming the crowded streets after a budding romance goes awry. Like a great short story, this is a simple tale of a young woman figuring out how to get her life back, but if feels as if it contains so much of contemporary existence -- its comforts, its loneliness, its self-deceptions -- suspended in wintery amber.

    Ten spectacular graphic novels from 2014

    Through the Woods by Emily Carroll
    This collection of archetypal horror, fairy and ghost stories, all about young girls, comes lushly decked in Carroll's inky black, snowy white and blood-scarlet art. A young bride hears her predecessor's bones singing from under the floorboards, two friends make the mistake of pretending to summon the spirits of the dead, a family of orphaned siblings disappears one by one into the winter nights. Carroll's color-saturated images can be jagged, ornate and gruesome, but she also knows how to chill with absence, shadows and a single staring eye. Literary readers who cherish the work of Kelly Link or the late Angela Carter's collection, "The Bloody Chamber," will adore the violent beauty on these pages.

  • Recent Slide Shows



Comment Preview

Your name will appear as username ( settings | log out )

You may use these HTML tags and attributes: <a href=""> <b> <em> <strong> <i> <blockquote>