Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes
By Robert M. Wachter, MD, and Kaveh G. Shojania, MD New York: Rugged Land
441 pp $24.95

What Your Doctor Can't (Or Won't) Tell You: Doctors, Hospitals, Drugs, and Insurance. What You Need to Know to Take Charge of Your Own Health Care
By Evan S. Levine, MD
G.P. Putnam's Sons
277 pp $24.95

In 1999, the Institute of Medicine (IOM), a well-respected and non-partisan think tank specializing in health care, released a report concluding that as many as 98,000 people die each year from hospital-based errors. In a follow-up study published in July 2006, the IOM reported that the most common medical mistakes were medication errors that were responsible for harming at least 1.5 million people and costing 3.5 billion dollars every year. These alarming statistics were splashed on the front pages of newspapers across the country and catapulted what was once the medical industry's dirty little secret -- the national epidemic of mishaps related to hospital care -- into one of the leading public health issues of the day.

Following these reports, journalists exposed numerous cases in which doctors amputated a healthy body part or operated on the wrong person altogether, hospital personnel injured or killed patients by dispensing either the wrong medication or excessive amounts of the right medication, and patients died while waiting to be transported from one hospital unit to another. Each story seemed to top the last in the degree of ineptitude, carelessness, or plain stupidity it displayed.

Thankfully, two physicians at the University of California at San Francisco Medical Center, Drs. Robert Wachter and Kaveh Shojania, have delivered a compelling and thorough exploration of the issue. While never excusing the truly egregious behavior of some health care professionals, Internal Bleeding skillfully captures the nuances that the headlines invariably miss.

The authors explain in language accessible to the layperson how the majority of medical errors result not from one horrendous act committed by a terrible human being but from a chain of minor slips and glitches that turn what could have been a fixable problem into a potential -- or actual -- catastrophe.

Public outrage in such cases is usually focused on the doctor, nurse, or other professional who commits the final error in the chain. But the authors note that the role played by other factors and players leading up to that moment is all but ignored, leaving the situation ripe for similar problems down the line. And they stress that the best way to reduce or even eliminate the possibility of mishaps is through an approach that focuses on systemic failures rather than one that merely assigns blame and metes out punishment to specific individuals.

"Most errors are made by good but fallible people working in dysfunctional systems, which means that making care safer depends on buttressing the system to prevent or catch the inevitable lapses of mortals," they write. "This logical approach is common in other, high-tech industries, but it has been woefully ignored in medicine. Instead, we have steadfastly clung to the view that an error is a moral failure by an individual, a posture that has left patients feeling angry and ready to blame, and providers feeling guilty and demoralized. Most importantly, it hasn't done a damn thing to make health care safer."

Drs. Wachter and Shojania suggest that medicine's very success has set the stage for serious errors. Complex technology, surgical advances and new medications have given health care professionals an increasing menu of options, opening the door to the possibility of more wrong calls.

Patients are handed off from department to department and from one specialist to another far more than in the past, creating a growing number of opportunities for miscommunication, misreading of charts, and violation of various hospital protocols and guidelines. The authors point out, for example, that in some cases as many as fifty specific steps or actions must occur for a medication prescribed by a doctor to actually reach the patient lying in a hospital bed -- a chain of events that leaves room for many potential errors.

What makes the book such a compelling read is that each point is illustrated with fascinating stories about real-life horror stories, although names and other identifying characteristics have often been changed. And in the authors' analyses of these situations, they point out how the usual emphasis on assigning all the blame to a particular person obscures the deeper and more systemic issues.

Take the high-profile case of a diabetic Florida man, Willie King, whose left leg was amputated instead of his gangrenous right leg. The mistake occurred, explain the authors, after a clerk typed in the wrong information into the surgery department's computer log. An alert floor nurse noticed the mistake and corrected a printout of the surgery schedule with a hand-written note, but no one bothered to change the original computer entry, so subsequent printouts continued to carry the wrong information.

This initial mistake -- serious but potentially correctible -- was compounded by the fact that the hospital's information system had no built-in procedure for automatic or mandatory double-checks. This lack of appropriate safety measures set the stage for the horrible error once everyone was assembled in the emergency room. The doctor who performed the surgery was ultimately disciplined, as he should have been.

"But this was small consolation for Willie King; nor did it do anything to fix the error-prone hospital system that helped put him in his wheelchair," write the authors.

Unlike many books about health care by doctors, Internal Bleeding is extremely well-written, with vivid descriptions that genuinely enliven the text. Here, for example, is what one doctor heard while listening to the breathing of a woman with pneumonia: "Through the stethoscope, each 'deep breath, please' sounded like two strips of Velcro being yanked apart." And the book is not only clear and measured but, in turn, funny, horrifying, ironic, and wise. It also illuminates its points by including many comparisons with other industries, particularly aviation, to show how other complex systems have addressed similar problems.

So what do they propose to fix what's broken? Not surprisingly, they suggest broad-based solutions, such as computerized physician order entry systems that reduce errors related to patient identification and medication; increased federal funding for research in patient safety; better systems for reporting and collecting data on medical errors; and the hiring of patient safety administrators with real authority to implement procedures with multiple back-up systems.

Perhaps most controversially, they propose an overhaul of a medical malpractice system in which rates are rising so much that some doctors are leaving the profession altogether. The best solution, they say, would be to create a system of no-fault insurance that would compensate people for medical mistakes but limit the large, attention-getting awards and assignment of liability to the most egregious cases of malpractice.

Some might interpret their call for no-fault insurance as a self-serving ploy. But they make an exceptionally strong case for some sort of reform that should persuade everyone except trial lawyers. The authors convincingly argue that the current system works against the best interests of the majority of patients, despite the huge awards awarded to a few, because lawyers take on only those cases that they believe will allow them to earn substantial monetary victories.

They stress that the system penalizes doctors who agree to take on particularly risky cases and punishes others who must make snap decisions with incomplete information --decisions that seemed right based on the available data but still led to tragic results. Moreover, the malpractice system, they write, has made health care professionals increasingly fearful about discussing complicated cases and decisions with both colleagues and patients themselves.

"Tort law is adversarial by nature, while a culture of safety is collaborative," they write. "In a safety-conscious culture, doctors and nurses willingly report their mistakes as opportunities to make themselves and the system better. An overly litigious environment devalues this learning and turns earnest caregivers striving for improvement into sitting ducks."

If the health care industry is portrayed as deeply troubled but peopled by courageous and embattled professionals in Internal Bleeding, Dr. Evan Levine presents a starkly different view in What Your Doctor Can't (Or Won't) Tell You. Levine, a cardiologist in New York and an assistant clinical professor of medicine at Albert Einstein College of Medicine in New York, offers a scathing indictment of the entire medical field.

Levine's primary goal, he writes, is to help patients obtain the best health care possible, starting with suggestions for how to select a doctor.

"Over and over again," he writes, "I see the same tacit assumption made by patients of both sexes, of all ages, of all levels of education, and from all walks of life, namely that every individual with a physician's shingle hanging out in front of his or her office is equally talented, insightful and trustworthy. Do you make the same assumption about lawyers? Or accountants? Even your electrician?"

Levine makes some important and salient points. He advises people to learn everything they can about the physicians they sign up with, to fire doctors with messy offices and a discourteous staff, to choose to be treated at university hospitals rather than local community facilities whenever possible, and to always seek out second or even third opinions. He warns patients not to participate in clinical trials unless it's a last resort and to leave doctors engaged in any one of a number of practices that he deems shady, such as selling nutritional supplements; prescribing medications because of some connection to a pharmaceutical company rather than the drug's lower cost or increased efficacy; referring them to specialists with whom they have financial relationships rather than those who would provide the highest quality of care, and so on.

Obviously, much of this advice makes common sense. And Levine is particularly good on the ways in which the pharmaceutical industry has co-opted many doctors into becoming, essentially, a key element of their marketing machinery. This is, indeed, a scary development, and one that needs as much public attention as possible.

But unlike Internal Bleeding, this book comes saddled with some serious problems. The first is one of tone, which shouldn't necessarily detract from a book's message. In this case, however, it does. Levine comes across as self-righteous and arrogant, a moral crusader who smacks down everyone who does not live up to his own impeccable standards.

Although many of the practices he cites are indeed questionable, he divides his world into the sort of good-and-evil dichotomy that is heard most often these days in the over-heated rhetoric of politicians in Washington, DC.

This approach leads him to engage in precisely the kind of finger-pointing that the authors of Internal Bleeding manage to avoid in their efforts to look at systemic issues. Dr. Levine includes a lot of juicy anecdotes, but they generally appear to have a villain -- usually a doctor--who is guilty of every sin this side of murder. All the bad guys are motivated by -- what else? -- money. The good guys -- most often Levine himself -- place principle above everything else.

It would be nice if life were so uncomplicated. But this perspective is such an oversimplification of difficult realities that it becomes hard to accept Levine's arguments without factoring in the effect his self-regard might have on them. That's unfortunate. He does have many serious and thought-provoking points to make, but his attitude serves to undermine rather than reinforce them.

In a way, Levine’s final paragraph clearly displays both aspects of his book: his desire to impart practical advice and his extremely irritating hubris.

"I've tried to give you the inside story, to tell you about the sick condition of the medical profession as truthfully as I can, but most important, to give you tools to help you get the best possible medical care," he writes. "For those who will condemn this book, most likely the duplicitous types I have written about, I can only say that I understand your position. Perhaps this will be the beginning of the end of the greatest rip-off ever imposed on the American consumer."

-- David Tuller reports regularly on health for The New York Times. A former staff writer for the San Francisco Chronicle, he has written for the Washington Post and Salon.com and is the author of Cracks in the Iron Closet: Travels in Gay and Lesbian Russia (Faber &Faber 1996).

First published June 22, 2004
Last updated February 26, 2008
Copyright © 2004 Consumer Health Interactive