The government wants you to be terrified of emergency medicine

This would not be the first time a federal agency cobbled together a scare for public consumption and media hype to improve its public position, would it?

Dr. Matt Bivens, an emergency physician in Massachusetts, wrote an excellent article, "AHRQ Errors Report was 'Outright Unconscionable,'" in Emergency Medicine News, on the 744-page report by the U.S. Agency for Healthcare Research and Quality (AHRQ) on patient safety in the E.D.  Dr. Bivens addressed the deceptive and mendacious methodologies that were designed to create extravagant headlines about the patient safety risks of emergency care.  The subtitle of the Bivens article study points to the basic lie: "Study called a highly misleading, deeply flawed analysis based on three small studies."  That criticism deserves our attention. 

Patient safety studies by government agencies and officialdom in general have always been plagued by  methodology problems, all the way back to original 1978 study by Don Harper Mills for the California Med Association, intended to evaluate feasibility of no-fault malpractice insurance.  Here's the problem: patient safety bureaucrats are motivated to exaggerate the risks to the public so they can ride the wave as saviors and rescuers.  That's what public officials enjoy a lot: a role as a savior bureaucrat, scholar, and conscientious public official.

Dr. Bivens artfully begins his critique by setting up the deceivers based on the headlines they sought and got:

Emergency physicians are literally killing people!

"As many as 250,000 people die every year because they are misdiagnosed in the emergency room, with doctors failing to identify serious medical conditions like stroke, sepsis and pneumonia," reported The New York Times.

It's a bloodbath in there, chimed in CNN, warning that the ED gets it significantly wrong for every 18th patient. As a result, the news channel continued, a staggering 2.6 million people suffer a preventable harm every year.

Then Dr. Bivens recites the source research for the accusations and exposes the sins of methodology they commit to create their scare:

The review was commissioned by the Agency for Healthcare Research and Quality, which describes itself as the lead federal agency charged with improving the safety and quality of health care for all Americans. Unfortunately, it's a deeply flawed analysis.

CNN reported that the authors "reviewed nearly 300 studies" from the past 20 years. But the fine print — or at least the second bullet point in the abstract! — specifies that "overall error and harm rates are derived from three smaller studies conducted outside the United States (in Canada, Spain, and Switzerland, with combined n=1,758. [Author note — n is the total number of cases studied.]

That's right. The claim that we are killing a patient every other day with misdiagnoses is based on three small studies from other countries.

Two of those studies were used to calculate the error rates. Each involved a single hospital, one in Spain, the other in Switzerland. Neither country at that time had emergency medicine residency-trained physicians. [Author — in the U.S., that's a three-year training program in emergency medicine.]

Dr. Bivens, who obviously knows his statistics and medical research fundamentals, then eviscerates the AHRQ study for basic problems like these:

  • The Spanish studied 72-hour bounce-backs in an E.D. in the Canary Islands staffed by untrained emergency physicians 19 years ago.  Such a study cannot be used to project error rates for an American hospital Emergency Department.
  • "The Swiss study looked at 755 consecutive admitted patients and found the discharge diagnosis 'differed substantially' from the admittance diagnosis in 12.3 percent of cases."  The telling point is that the one predictor of diagnostic discrepancy was the stated uncertainty about the diagnosis by the admitting emergency physician.  That's not negligence; that's uncertainty, which can be cleared up by admission and testing.  Not a measure or emergency physician incompetence.
  • "The Swiss study combines this 12.3 percent diagnostic discrepancy in Switzerland with the Canary Islands 4.1 percent misdiagnosis rate, and calculates that U.S. emergency physicians make a misdiagnosis 5.7 percent of the time."
  • The 250,000 U.S. deaths loudly pronounced by the study and the media "were extrapolated from the third study — 503 high-acuity emergency patients in two Canadian emergency departments."  Guess what: one patient died from a dissection of the aorta — a ruptured main artery.  "One missed aortic dissection divided by 503 high-acuity patients equals 0.199 percent. When that is multiplied by 130 million undifferentiated (high- and low-acuity) U.S. emergency department visits, the result is 'more than 250,000' misdiagnosis deaths."  There you go: the lying researchers play the big numbers from small numbers game by projection.
  • "It's pretty incredible to say that U.S. emergency physicians kill a quarter of a million people every year based on one death in Ottawa in 2004."  That's why even our politically correct medical associations were up in arms at the government high-handedness.  "'Highly misleading,' fumed our professional societies, 'if not outright unconscionable.'"

Here's is my contribution.  The AHRQ report and the attitude of government apparatchiks is the problem.  They targeted the physicians as incompetent, as all the patient safety studies do, because bureaucrats have physicians as enemies — they need to get control of them.  The best way to do that is prove they are incompetent.  The AHRQ has been around a long time and has changed names over 30 years, and their game is always to pronounce something like that "ED diagnostic errors were mostly cognitive errors linked to the process of bedside diagnosis," as the AHRQ report claims.  Then they claim they have the proof because of malpractice claims filed.  Physicians win most malpractice lawsuits because it is not so easy to establish negligence in the real world as it is on the desktop in D.C.  No matter; the apparatchiks continued in their report: "Most often these were attributed to inadequate knowledge, skills, or reasoning."

I have said, long before Dr. Bivens was in kindergarten, that patient safety researchers have always chosen methods that amplify the scare data to get headlines, and also to promote their role of policy and regulatory wonks that will save the populace from incompetent physicians and nurses and pave the way for bureaucrat-controlled health care.

My criticisms are piled on this excellent essay by Dr. Bivens.  I have criticized the patient safety research over four decades.

Patient safety in America: comparison and analysis of national and Texas patient safety research:

Unreliable Research on Error-Related Hospital Deaths in America

Unreliable Research on Error-Related Hospital Deaths in America

Gerard J. Gianoli, M.D. John Dale Dunn, M.D., J.D

Many emergency medicine medical organizations have objected to this effort by the AHRQ to denigrate and vilify emergency care providers, to  knife them in the back with a ridiculously biased and inadequate study, and then publicize it for their own selfish bureaucratic purposes. 

Dr. Bivens did a fine job of exposing their perfidy. 

John Dale Dunn is a retired emergency physician and inactive attorney in Brownwood, Texas.

Image via Max Pixel.

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