The Norm Chronicles (36 page)

THE DOCTOR–PHILOSOPHER
Raymond Tallis says he is privileged beyond the dreams of his ancestors, thanks to modern medicine. That’s a bold but fair claim, and Tallis is a superb advocate for the benefits of healthcare.
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Medical drama goes even further. Doctors in fiction are saviours. Sick people are pulled through by techno-miracles or genius. If patients die, the failure is heroic or inevitable. On the whole, our fictional doctors don’t kill us slicing out the wrong bits.

Although when a real doctor ordered that an epilepsy drug – phenytoin – be given to Bailey Ratcliffe, a six-year-old boy with a bad fit who seemed unresponsive to other drugs, she got the dose wrong by a factor of about 6. He died. ‘I’m sorry,’ she said at the inquest in December 2012, ‘I made a mistake.’

Doctors do. For all medicine’s heroics, and for all the genuine, extraordinary good that it does, white-coat confidence like Kieran’s has not always been as well earned as doctors like to believe, or like their patients to think. So here’s a question: does popular fiction about life and death risks in medical drama reflect the data? Or by taking on a life and conventions of its own, does it distort popular and professional belief about the dangers?

Kieran is a calculated insult to medicine, partly – wickedly – just
to see how it sounds, a parody of the medical hero who kills people by accident and incompetence. It’s not the way the story is normally told. We’re not suggesting Kieran is the norm, but should the medical story be told that way more often?

Medicine today is coming round to a wider acceptance of error and uncertainty, more willing to acknowledge risks from mistakes and ignorance about what really makes us better, or not. As a result, it is making more of the progress Raymond Tallis describes. But it can still be guilty of what the
British Medical Journal
once satirised as seven alternatives to evidence-based medicine, among them: ‘eminence-based medicine’, where the more senior the colleague, the less need for anything so crude as evidence that the treatment works; ‘vehemence-based medicine’, or the substitution of volume for evidence; and ‘eloquence-based medicine’, for which ‘the year-round suntan, carnation in the button hole, silk tie, Armani suit, and tongue should all be equally smooth’.
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The growing popularity of statistical hard graft to find out who makes most mistakes, or if people really get better, or worse, because of how we treat them, and how much better, is surprisingly recent. The
Journal of the American Medical Association
announced the arrival of ‘Evidence-Based Medicine – A New Approach to Teaching the Practice of Medicine’ that ‘de-emphasizes intuition [and], unsystematic clinical experience’ only in 1992.
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One critic still maintains that
most
published research findings are false,
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because studies get it wrong and yet the ones that seem most exciting tend to be those that are published. All of which hardly puts your mind at ease if you’re about to go under the knife.

Some medical dramas have picked up this humility. One in particular – the American comedy
Scrubs
, which follows a group of all too imperfect new doctors
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– was inspired in part by a compelling account of medical error by a surgeon, Atul Gawande, in his book
Complications.
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Gawande is fascinated by fallibility. His books burst with medical mistakes, and he readily admits his own, including bodging the insertion of a central line into the main blood vessel to a patient’s heart. In
Gawande’s version of the medical narrative, cock-ups, large or small, are routine, even necessary to medical training.

‘The stakes are high, the liberties taken tremendous’, he writes. ‘What you find when you get in close, however – close enough to see the furrowed brows, the doubts and missteps, the failures as well as the successes – is how messy, uncertain, and also surprising medicine turns out to be.’

He describes it as an imperfect science, ‘an enterprise of constantly changing knowledge, uncertain information, fallible individuals and at the same time lives on the line’.

But is that the public perception? Or is our mental model dominated by simple stories and ideas of treatment and cure? If the latter, we might underestimate the risks. Hence our story. We wanted to play with the tradition by giving the hero feet of clay, a sack of moral failings and a huge error of judgement.

So, having felt Kieran’s disgrace, do you feel any different about medical risks? Probably not. His is just one story. And to be credible stories need – as lawyers say in cases of defamation – a substratum of provable fact. That is, they also need evidence, or at least belief about what the facts and data really say.

As ever, then, some facts and data.

Surgery is simple. A human body is soft, so it takes only a sharp knife to slice out giblets and a saw to hack bits off. The complication is how to stop the patient dying from blood loss, agony, infection etc. Given what we now know about these hazards, it’s hard to read about surgery in the past without flinching: at the crudity of the tools, the lack of hygiene and anaesthetic, and, not least, the insane ambition.

Take trepanation, in which part of the skull is removed to reveal the brain, once widely practised either as relief for headache or following injury. The head was particularly prone to damage from slings and clubs and other primitive weapons. The aim of trepanation was to relieve what felt like extreme pressure, release blood and ‘evil air’, and leave the brain nicely aerated.
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Excavations reveal that in Neolithic times as many as one skull in every three has holes drilled or scraped out. The even more remarkable finding is that the original owners of many of these skulls – between
50 and 90 per cent, according to some sources – survived. We know this because the edge of the hole has healed. The procedure was popular in Europe as a treatment for epilepsy and mental illness up to the 18th century, and afterwards for head injury. Cornish miners in the 19th century apparently insisted on having their skulls bored as a precautionary measure after even minor head injuries.

But it was when hospitals took over that holes in the head became especially dangerous. The problem – as with maternal mortality in
Chapter 11
– was hygiene, with the infection risk inside a hospital so high that doctors managed to take a mad idea and make it worse. The mortality rate shot up to about 90 per cent. Once again, professionals and institutions were bigger killers even than the procedure itself, taking out perhaps an extra 80 per cent of their patients. Which is why the high numbers of survivors found in 19th century excavations seemed so unbelievable. How could ancient Peruvian natives carry out this operation successfully? Like giving birth in the 19th century, it was far safer to have a hole drilled in your head at home.

Other than having your head excavated with a sharp stone, the only pain relief available for so-called primitives was intoxication. Alcohol, cannabis and opium were the basic anaesthetics until Humphry Davy personally experimented with nitrous oxide, or laughing gas. In 1800 he had the foresight to write: ‘As nitrous oxide in its extensive operation appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place.’ Naturally, nobody in medicine took any notice for 50 years, while laughing gas and ether were used as party tricks. ‘Ether frolics’ were hugely popular in the US. At last it dawned on some medical students that the frolickers appeared not to care about injury. Could this be put to practical use, they wondered.

The first public anaesthetic using ether was delivered by William Morton on 16 October 1846 at the Massachusetts General Hospital. The idea soon spread, especially after Queen Victoria grasped at chloroform for the birth of Prince Leopold in 1853, although chloroform later lost favour owing to sudden deaths from heart arrhythmias, now known as ‘sudden sniffer’s death’ among teenage solvent abusers.

To be numbed and put to sleep for an operation is now routine – the World Health Organisation reports that each year there are 230 million major surgical procedures under anaesthesia – with rates strongly dependent on healthcare spending.
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Anaesthetics are fairly safe now – the UK Royal College of Anaesthetists says that there are life-threatening allergic reactions in less than 1 in 10,000 people, and that most recover.
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But not all. Around 1 in 100,000 general anaesthetics still leads to the death of the patient. That’s a risk of 10 MicroMorts, equivalent to around 70 miles on a motor bike, or around that of a parachute jump. Around half of that risk, 5 MicroMorts, arises from errors made in administering the anaesthetic, which is nice to know. Risks for day-cases are lower, and higher if you are older or it’s an emergency operation.

Anaesthetists are fond of saying that the risk is less than that from driving to the surgery, which is only generally true if you come a long way on a motor bike or are a spectacularly reckless driver. If the rates claimed in the UK applied to all the 230 million operations reported by the WHO each year, this would mean 2,300 deaths by anaesthesia – almost certainly a big underestimate.

And hospitals can hurt you in other ways than through surgery, whether it’s getting an infection or slipping on a pool of something unpleasant. We can work out roughly the overall risks of a fatal accident during a visit to hospital by taking the 135,000 people who occupy a hospital bed each day in England and noting that, although inevitably some of these die of their illness, not all these deaths are unavoidable. In the year up to June 2009, 3,735 deaths due to lapses in safety were reported to the National Patient Safety Agency, and the true number is suspected to be substantially higher. This is about 10 a day, which means an average risk of around 1 in 14,000, assuming few of these avoidable deaths happen to outpatients. So staying in hospital for a day and a night exposes people, on average, to at least 75 MicroMorts of avoidable death – about the same as giving birth, or a motor-bike trip from London to Edinburgh.

So Kieran’s complications story conveys a truth about hospitals: they remain dangerous to our health even while helping it beyond the dreams of our ancestors.

Risk in medicine is unavoidable. But the scope for error adds to it, as does plain bad luck. So it is no surprise that the risk of an operation varies between hospitals and surgeons. The concept of measuring their performance began with Florence Nightingale: after tackling the squalor of military hospitals in the Crimea, she was keen to do the same in England. Obsessed with statistics and a passionate admirer of Quetelet, she viewed the patterns in the data as an indication of God’s work. To study them was a spiritual endeavour.

She proposed the collection of ‘uniform hospital statistics’ to ‘enable us to ascertain the relative mortality of different hospitals’.
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But she was aware that hospitals were adept at fiddling the figures by dumping hopeless cases onto someone else: ‘We have known incurable cases discharged from one hospital, to which the deaths ought to have been accounted, and received into another hospital, to die there in a day or two after admission, thereby lowering the mortality rate of the first at the expense of the second.’ Nowadays we call this practice ‘gaming’. The Victorians could be ruthless in concealing poor performance, just as some hospitals are now, as various scandals suggest, and her grand plan fizzled out.

Forty years after Florence Nightingale, the Boston surgeon Ernest Codman took a different approach to checking the quality of care. Rather than publishing overall statistics, his ‘End Results Idea’ required hospitals to complete a small card for each patient that explained publicly and in detail whether the treatment was successful and if errors were made. He began this himself from 1900, and even opened his own private hospital in 1911. He claimed that his ideas ‘will not be eccentric a few years hence’
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and, unlike Nightingale, he courted controversy, causing uproar at a public meeting by unveiling a huge cartoon satirising the Boston medical establishment for carrying out expensive and unproven procedures and so grabbing the ‘golden eggs’ laid by an ostrich representing a gullible public. His scheme, unsurprisingly, did not catch on. He was sacked from Harvard, and his hospital closed in 1918.

There have been modern attempts to emulate Nightingale and Codman, notably for heart surgery, but the quality of the data about hospital performance is probably still not as good as the public thinks it is. Let’s take a closer look at one of the exceptions, where the data are not
bad, and with a little nosing around we can begin to discover the limits of what we can know about medical risk. This is the coronary artery bypass graft, known as a CABG (pronounced like the green vegetable). CABGs are intended to relieve angina by improving the blood flow to the heart with a piece of artery or vein taken from elsewhere in the body. This type of operation started in the 1960s, and mortality in the US was down to 3.9 per cent in 1990 and to 3.0 per cent in 1999.
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The UK now reports a ‘98.4 per cent survival rate’, based on 21,248 operations in 2008.
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Note the different framing of the information in the US compared with the UK. In the US, people die from surgery, while in the UK they do not survive. This change of framing is a neat device that tends to make performance look better and obscure differences: the difference between two hospitals with 98 and 96 per cent survival, as we would describe them in the UK, looks negligible, while the same comparison expressed as it would be in the US, as 2 per cent versus 4 per cent mortality looks like double the trouble.