What Do the Five Stages of Death and Dying Have to Do With Medical Error? – Part 3

Anger:

Despite my attempts to dismiss the IOM report, the media continued to give it considerable press. Unlike many media events related to medicine, this one did not go away after the initial fanfare. It was repeated multiple times and increasingly the number of deaths was linked to images that the public could easily understand. Comparisons of the how many jumbo jets would need to crash per week to equal 98,000 people were graphic representation of the problem. My cousin sent me an email that was undoubtedly meant to be funny, but it indicated that physicians were more lethal to the public than handguns. There came a point at which I was no longer in denial, I was just angry. I thought of the years of study and the sacrifices that I, and many of my colleagues had made to become physicians. Now, despite the time and the efforts we were being cast as error prone people who were not able to correct or own problems. Furthermore, it remained inconceivable that as a group physicians could or would remain ignorant of such appalling circumstances. Since I did not believe that the majority of physicians were involved in a system wide conspiracy, the ongoing assault on the integrity and the ability of physicians and health systems was infuriating.

However, despite denial and anger, the drum beat around medical errors continued to build.  To begin with, the IOM report itself simply summarizes what was already a large body of research and evidence that medical errors were a widespread problem. This report received significant attention, but it was neither the beginning nor the end of what has become an avalanche of research further defining shortfalls within the medical system. A recent article found that Americans receive medical care indicated by current research only 55 percent of the time [McGlynn EA, Asch SM, Adams J, et al.: The Quality of Health Care Delivered in the United States. N Eng J Med 2003; 348:2635-45]. Estimates exist that as many as 80,000 Americans perish each year because they do not receive appropriate, well proven, care for common conditions such as diabetes and hypertension [National Committee for Quality Assurance, State of Health Care Quality 2004 (Washington, D.C.: NCQA, Sept 2004]. While these reports focus on under-use of medical care, over-use is also a problem leading to complications and increased cost [Bernstein, S.J., E.A. McGlynn, A.L. Siu, et al., “The Appropriateness of Hysterectomy. A Comparison of Care in Seven Health Plans. Health Maintenance Organization Quality of Care Consortium,” Journal of the American Medical Association 269(18):2398-402, May 12, 1993]. 

Along with these and many other reports that cast doubt on the quality of health care provided, evidence also exists which documents the enormous variation in the way health care is delivered. Researchers at Dartmouth University have been documenting large geographic variations in the use of health care resources by equivalent populations for almost three decades [Ref}. Variability in the resources used for specific diseases may be appropriate if more resources could be linked to improved outcomes, but this is not the case. In fact, in many cases increased resource utilization can be linked to poorer outcomes [Ref]. An analysis by the Hospital Quality Alliance (HQA) has found that the quality of hospital care varies across conditions within individual hospitals as well as by geographic region [Jha AK, Li Z, Orav EJ, et al.: Care in U.S. Hospitals – The Hospital Quality Alliance Program. N Eng J Med 2005; 353:265-74].

The evidence for poor quality as well as highly variable practice in the delivery of medical care is already substantial and it continues to grow. The articles discussed above hardly scratch the surface and under this weight of evidence neither denial nor anger is acceptable any longer.  

Table 1: Kubler-Ross’ five stages of dying

In her 1969 book, On Death and Dying [On Death & Dying, (Simon & Schuster/Touchstone), 1969] Swiss-born psychiatrist Elizabeth Kubler-Ross outlined the five stages of grief of someone who is dying: 
• Denial and isolation: “This is not happening to me.” 
• Anger: “How dare God do this to me.”
• Bargaining: “Just let me live to see my son graduate.”
• Depression: “I can’t bear to face going through this, putting my family through this.”
• Acceptance: “I’m ready, I don’t want to struggle anymore.”

References:

1. Institute of Medicine, To Err is Human: Building A Safer Health System (Washington, D.C.: National Academies Press, 1999
2. McGlynn EA, Asch SM, Adams J, et al.: The Quality of Health Care Delivered in the United States. N Eng J Med 2003; 348:2635-45
3. National Committee for Quality Assurance, State of Health Care Quality 2004 (Washington, D.C.: NCQA, Sept 2004
4. Bernstein, S.J., E.A. McGlynn, A.L. Siu, et al., “The Appropriateness of Hysterectomy. A Comparison of Care in Seven Health Plans. Health Maintenance Organization Quality of Care Consortium,” Journal of the American Medical Association 269(18):2398-402, May 12, 1993
5. Wennberg JE, Cooper MM, eds., The Quality of Medical Care in the United States: A Report on the Medicare Program, The Dartmouth Atlas of Health Care 1999 (Chicago: American Health Association Press, 1999)
6. Fisher ES, et al.: Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors. Health service Research 2000; 34:1351-1362
7. Jha AK, Li Z, Orav EJ, et al.: Care in U.S. Hospitals – The Hospital Quality Alliance Program. N Eng J Med 2005; 353:265-74