Now what kind of an attitude is that, 'these things happen?' They only happen because this whole country is just full of people who, when these things happen, they just say 'these things happen,' and that's why they happen! We gotta have control of what happens to us.
A world expert in linguistics, a former Associate Provost of MIT, an engaged and curious world traveller, an accomplished musician, Samuel Jay Keyser is no ordinary man. But in the blink of instant, he suffered a medical catastrophe and became Everyman in the American health care system. His story is one of extraordinary performance by EMTs, doctors, nurses, and physical therapists, allowing him to overcome a high likelihood of lifetime paralysis. His story, though, also reflects the disjointedness of the healthcare system, the occasional insensitivity and ineptitude of those in it, and the potential for harm while under the treatment of otherwise highly trained medical professionals. Finally, his story is one of inequity, the random process by which some Americans receive the best of care at virtually no cost to themselves, while others are deprived of life-giving technologies and therapies for financial reasons.
In the 1963 comedy film, It’s a Mad, Mad, Mad, Mad World, Milton Berle reports of an awful automobile accident to his wife, Dorothy Provine, and his mother-in-law, Ethel Merman (Mrs. Marcus). “It’s a terrible thing,” he notes, “but these things happen.” Mrs. Marcus responds with the quote above.
So it is with the U.S. healthcare system. While we must acknowledge the great work that is done by many within this system, we must also face the fact that bad things continue to happen because clinicians, administrators, and policy-makers engaged in the sector often respond to its inadequacies by saying, “These things happen.”
Professor Keyser’s distress with the inequities of the system mirror the concerns of many expert observers. For example, equity is one of the “Aims for Improvement” in the Institute of Medicine’s 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century. The report describes the divide between what would be included in good health care and the health care that many people receive. William C. Richardson, PhD, chair of the committee that produced the report offers this summary: “It’s not an overstatement to say that the health care delivery system doesn’t consistently provide high-quality care. Or said another way, many people simply do not benefit from what medicine has to offer.” Ability to pay or (more precisely) having someone else cover one’s costs of diagnosis and treatment is highly variable among the US population. One’s financial standing in this system can literally be a matter of life and death.
The problem of inequity is not limited to the US. Even in countries with national health delivery systems, those with means get to bypass the public system. Whether United Kingdom investment bankers in the City who are provided with supplementary private health insurance and access to private hospitals; or Mideast royalty, whose government’s pay for travel to Europe for treatment; or wealthy Israelis and South Africans who pay private doctors for expedited and customized care; there is always a path for those better off to avoid the congestion, waiting, and other untoward aspects of the public system.
But as Professor Keyser reminds us, inequity is the hallmark of the US system. Accidents of service in the military allow access to the extensive resources of the Veteran’s Administration system. The expertise garnered by the VA in treatment of traumatic brain and spinal cord injuries from the battlefield is offered to a few lucky eligible civilians who, like Keyser, find themselves suddenly on their back. Meanwhile, others find that their length of stay in Medicare-approved rehabilitation centers is limited by Congressional statute; or they find themselves evicted if they are not making sufficient progress in their rehabilitation. Other unsuspecting civilians whose care is covered by private insurance can find large unexpected charges from out-of-network doctors working in in-network hospitals. Many moderate and lower income people chose to purchase high-deductible health insurance plans to obtain smaller monthly premiums. There is documentation that people who do this then avoid taking their children in for necessary pediatric care so they won’t have to pay large out-of-pocket expenses.
Another subtle message from Keyser’s experience is the degree of harm that occurs to patients, even in the finest of institutions. He experienced a major surgical site infection, catheter-associated urinary tract infections, C. difficile, thrush, malnourishment, MRSA infections, and life-threatening bodily harm from malfunctioning equipment. It cannot be our place here to assert which of these events were preventable. After all, Keyser’s was an extreme and complex case, and some harm can surely occur in such circumstances. But the level of preventable harm generally in the health care system is truly epidemic in nature. Indeed, as Dr. Brent James of Intermountain Health notes, going to the hospital is one of the highest ranked public health hazards in America. While some institutions have focused on the systemic origins of such harm, those hospitals remain islands of excellence in a sea of mediocrity. Clinicians, administrators, and even the government judge improvement in this arena against substandard benchmarks. Again, “these things happen” is more often the watchword than should be the case.
Finally, Professor Keyser’s story is a clarion call for greater understanding by health care professionals of the cognitive errors that can occur during treatment. Key among these is “diagnostic anchoring,” the tendency for a doctor to make a quick judgment about the condition of and prognosis for a patient. Such anchoring is often accompanied by “confirmation bias,” our unfortunate ability to pay attention to observations and test results that support our prior diagnosis while ignoring such data that is contradictory. The health care profession fails greatly in training doctors to recognize and beware of such cognitive errors. The profession likewise is remiss in not training teams of doctors in “crew resource management.” Developed by the military for cockpit settings, CRM consists of series of techniques that meld the need for a hierarchical form of team organization with specific procedures for subordinate members of the team to inform the pilot (or surgeon) that he or she is about to make a life-threatening mistake. CRM has been extended with great result in several clinical settings around the world, but its application remains few and far between in US hospitals and rehabilitation settings.
In short, a major agenda awaits the US health care system. That change will only result from committed leadership at all levels. Perhaps this book will offer a bit of momentum along that path.
I cannot end this foreword without a tribute to Samuel Jay Keyser and his wife Nancy Kelly, whose story should be an encouragement to many. Their honesty in allowing us to observe the heart-breaking up’s and down’s of a couple’s handling of traumatic injury and recovery is a gift to all of us. The glory of Keyser’s trombone rings in my ears, and the picture of this loving couple is an indelible memory!