"This readily understandable and well-written book should be read by everyone who has a stake in the quality of American medicine—patients, physicians, and policymakers. It presents a comprehensive account of the way the information age is transforming the medical landscape."—C. Everett Koop M.D.
"An exciting and important story."—The New York Times Book Review
"An involving, human narrative explaining how we got to where we are today and what lies ahead."—Philadelphia Inquirer
"Highly readable. It's more than your doctor is likely to tell you."—Boston Globe
"Millenson, an erudite chronicler, has spun a fascinating tale."—Journal of the American Medical Association
"Detailed and thoughtful analysis of key developments in health-care quality.…A 'must read.'"—Annals of Internal Medicine
"A strong, important, highly readable book."—Healthcare Forum Journal
"It will entertain, challenge and strengthen you."—American Journal of Medical Quality
"Fittingly stands beside Paul Starr's Social Transformation of American Medicine and Haynes Johnson and David Broder's The System. If you read only one book this year, read Demanding Medical Excellence. It's that good."—Health Affairs
"Excellent and readable history of efforts to improve the quality of American medicine."—The CQ Researcher
"The most readable, thorough discussion of the quality revolution in the popular press, and it should be required reading for physicians."—David W. Bates and Atul A. Gawande, Annals of Internal Medicine
"An excellent discussion of the impact of technology on health care."—Philip Evans and Thomas S. Wurster, Blown to Bits: How the New Economics of Information Transforms Strategy
"A dynamic and compelling book."—Business Insurance
This interview was published in 1997.
An interview with
Question: You call your book Demanding Medical Excellence. Don't we already have an excellent health-care system?
Michael Millenson: The question is not whether doctors can provide superb medical care. The question is how often they actually do it. People think that if you have the right insurance card, and can get access to a "good" doctor or hospital, then you are getting the best possible care medical science can provide. That's a comforting view, but it just isn't true. As this book demonstrates with both studies and stories of real people, even the best-trained doctors go about their work with an astonishingly shallow base of knowledge concerning the link between what they do and how it affects a patient's health.
Most patients would be very surprised to learn that more than half of all medical treatments, and perhaps as many as 85 percent, have never been validated by clinical trials. Meanwhile, even when there is scientific evidence about what works best, large numbers of doctors don't apply those findings to actual patient care.
Question: Can you give an example?
Millenson: Perhaps the best one is the treatment of heart disease, which is the number one cause of death among both men and women in the United States. One recent study in New Jersey found that just one-fifth of eligible heart attack victims received a class of drugs called beta blockers, even though the drugs have been out on the market for years and they are known to increase a patient's chances of survival by twenty to forty percent.
Another study, by the Medicare program, looked at the treatment of heart attack victims in four states. In this case, 20 percent of patients never received needed "clot buster" therapy that can be critical to survival. Meanwhile, nearly one-third of the U.S. hospitals performing open-heart "bypass" surgery do fewer cases each year than professional societies recommend as minimums for competency. Those enormous percentages of patients getting less than excellent care should be unacceptable. And it's not just in heart disease. One-fifth to one-half of the physicians polled in a random survey failed to make use of clinical advances available to treat conditions like diabetes and asthma.
If a television exposé showed that this kind of failure was happening at a for-profit hospital company or a health maintenance organization or a government agency, there would be an enormous public outcry. Thousands of lives are at stake, but the attention this problem has received is minuscule.
Question: Why is that?
Millenson: In part it's because there's no easy villain to blame. In part, it's because the victims don't know they are victims. We're not talking about obvious malpractice, like chopping off the wrong foot, or a clear access problem, like an HMO member being refused a certain cancer treatment. We're talking about well-intentioned doctors who either aren't able to keep up with the scientific literature or are genuinely unclear about the implications. These are doctors trying to do their best, and, for the most part, unaware of how painfully they are falling short. The seriousness of this problem, however, is an open secret among the profession's leaders. Kenneth Shine president of the Institute of Medicine, put it this way: "If we asked the question of whether physicians have based their practice on scientific principles, it is clear that the profession has been sorely lacking."
I called my book "Demanding Medical Excellence" because I believe nothing will change until the public wakes up to the problem and demands change.
Question: Is there any solution?
Millenson: The airlines don't depend on each individual pilot's unaided skill to fly a complex jetliner; they give that pilot checklists and automated systems to help him make the best possible decisions. In the same way, doctors need help to become more consistent in their practice. And, once again, most patients aren't even aware of how bad the problem of medical practice variation is.
Here's one vivid example: There's been a great deal of attention paid to the fact that some health plans try to send women home from the hospital within 24 hours after receiving a mastectomy for breast cancer. But a report from Dartmouth Medical School, released a few months before the "drive-through mastectomy" controversy, showed something just as shocking. There was nearly a 35-fold variation in different cities and towns across the United States in the rate of mastectomies versus breast-conserving surgery given elderly women. The only difference was where the woman lived.
Now, which is more disturbing: a woman's being given only a 24-hour hospital stay after a mastectomy or her unnecessarily losing that breast to surgery in the first place based on where she lives? That is the type of question we're going to have to ask if we want a medical system that's truly accountable to patient needs.
Question: Is anyone successfully dealing with this problem?
Millenson: When doctors talk about trying to infuse more science into everyday practice, the term they use is "evidence-based medicine." I give the example of a major teaching hospital in Los Angeles that performs surgery on children with a heart defect called tetralogy of Fallot. After the operation, the children received a painful therapy that involved trying to get them to cough up mucus from the lungs to prevent a possible infection. But when the hospital launched an evidence-based medicine program, the medical staff was shocked to discover a study showing this procedure actually increased the chances of infection. The staff found that many standard practices in other areas also were based not on the literature, as they had always assumed, but on "expert" opinion that may or may not have been correct.
What's equally interesting is the financial impact. The hospital developed practice guidelines for treating tetralogy of Fallot. These weren't rigid rules, but advice about "best practices." After the rules were implemented, the hospital was able to cut the cost of care by 20 to 30 percent even while the outcome of care stayed the same or improved.
Question: Is that kind of result unusual?
Millenson: No. Just like American industry found that better quality also means lower costs, American medicine is learning the same lesson. I spent a great deal of time at the Mayo Clinic, and I relate in the book how Mayo is making a major effort to adapt the principles of continuous quality improvement, or "CQI," to clinical care. Mayo believes that accountability will reward those who practice the best medicine.
Question: Is "Information Age" medicine, then, good news for patients?
Millenson: Yes. An information revolution is transforming the everyday practice of medicine. By tracking what treatments works best, we are beginning to get answers to some extraordinary questions: what are the chances that someone with clinical symptoms similar to mine will live or die from this surgery? What are the chances that I will regain normal functioning? These are the kinds of patient-centered questions that doctors have always given rough guesses about; now, we're starting to gather hard data.
The Information Age is also empowering patients. As patients start to get the kind of information about the outcomes of care that was once reserved for doctors, we will begin to become partners with our doctors. The good news is that patients who have a real say in their treatment actually have better outcomes in a whole host of diseases.
Question: Is managed care a threat to this consistent excellence you talk about?
Millenson: It can be if it becomes just a cover for managed cost. But managed care can also become an invaluable tool for holding the health-care system accountable for results. There's no way any company can oversee all the doctors and hospitals its employees use. However, a company can set performance standards for a health plan and demand that it hold doctors and hospitals accountable for those standards. A number of leading employers are starting to demanding quality "report cards" from health plans and are sharing the results with their employees. That's exciting news.
Question: Are you an optimist?
Millenson: Writing this book was at times very depressing. I uncovered how decades of research on preventing medical errors has largely been ignored. Similarly, it became clear that the profession has had to be pushed into quality measurement of everyday care. Still, I ended the book looking forward to a much better medical future for both patients and those who provide care. I believe that most doctors and hospitals will eventually embrace accountability from the same motivation cited by Dr. Robert Waller, the chairman of the Mayo Clinic. "The goal is the best care possible for every patient every day," Waller says. And he adds: "Our patients deserve nothing less." I couldn't agree more.
Copyright notice: ©1997 by Michael L. Millenson. All rights reserved. This text appears on the University of Chicago Press website by permission of the author. This text may be used and shared in accordance with the fair-use provisions of U.S. copyright law, and it may be archived and redistributed in electronic form, provided that this entire notice, including copyright information, is carried and provided that the University of Chicago Press is notified and no fee is charged for access. Archiving, redistribution, or republication of this text on other terms, in any medium, requires the consent of the author.