De-bunking The Bad Apple

Patients are sometimes injured during medical care. Outside of healthcare, many ascribe to the “bad apple” theory, which says that bad things happen because of bad people. It then follows that if we punish or get rid of these bad apples, we will get error-free, high quality care. Simple, straightforward, comforting, easy-to-implement, nice sound byte, and complete hogwash!

To show how prevalent the Bad Apple Theory is, look at the Bill #489 passed by the Pennsylvania legislature which punishes providers for bad medical outcomes.

“Bad things” happen in medicine because medical knowledge is in its infancy and only very rarely because of bad apples. In contrast to astronomy, chemistry or physics, medical predictions are statistical probabilities, not individual guarantees. The astronomer can tell you exactly where Mars will be at 3AM on September 24, 2043. Your doctor cannot predict what your personal response will be tomorrow to a drug or an operation today. That is not because she was a bad student or is an impaired physician. No one can give a specific patient a guaranteed medical outcome.

• Which of three available drugs is better and safer?
• How tight should I make the knots during surgery?
• Is that temperature an early sign of infection or nothing to worry about?
• Is it safe to discharge the patient from hospital?

Medicine is much more art than science. The everyday questions above are matters of judgment not proven fact. All decisions made by care providers are judgment calls that must balance risk, benefit and cost. There are no, repeat no absolutely risk-free medical decisions.

The current system expects perfection from providers. That is simply unrealistic. Doctors and nurses are human and therefore imperfect. They make mistakes, few in comparison to the number of decisions they make every minute, but accidents and mistakes happen. Patients suffer.

Punishing providers for being human will not produce error-free medicine. Is the horse that wins the race the one who got beaten the most? Using a big stick on care providers will assure that they make the safest, most risk-free possible choice to achieve short-term positive outcomes. Such choices are often not best for the patient’s long term health.

Without risk there will be no learning. Without learning there will be no improvement. This translates to never getting better care than we get right now. So we will never cure cystic fibrosis or breast cancer.
The answer is not to make providers perfect: that is impossible. Secondly, the present state of medical knowledge is primitive and can guarantee nothing. The answer is to design a system that protects the patient from the facts: providers are human and medicine is in its infancy.

We need a system that protects the patients and encourages learning.
Punishing providers, as the presumed “bad apples,” will achieve neither.

System MD

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30 comments ↓

#1 Universal Health Care Saves Money By… — Medical Malprocess on 10.24.09 at 8:49 pm

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