Keeping 'em alive

One of the frequent complaints I hear about real medicine is that it is dangerous. Of course, it's true---so is riding in a train, but it sure beats walking. And that's the danger of this particular fallacy---yes, medicine is a sharp tool, but it's also an effective tool, so we must use it properly. And this is where the tools of evidence- and science-based medicine can give us a hand.

The potential harms of modern medicine must be approached carefully. If they are ignored or approached in an ineffective way, we'll miss an opportunity to save lives. This comment is typical of the type of thinking that gets one in trouble:

You asked if so-called traditional Chinese medicine has ever eradicated any diseases. Well, yes. It pretty much eradicated one that is in epidemic numbers in the U.S. and most of the developed world: Iatrogenic disease.

This is wrong is so many ways. The definition of "iatrogenic" is difficult. The traditional definition is "adverse effects of medical treatment or advice," and that's probably the one he's using. One could broaden this to include failure to give proper advice, as inaction by a physician has similar consequences to action, so negligence is also a form of iatrogenesis. The physician has the tools, but doesn't use them, and the patient suffers. But let's examine the original meaning.

The way in which our commenter is wrong is the "false dichotomy". Yes, medical errors would be reduced to zero if we didn't treat people, but the consequences would be rather dramatic. Our goal should not be to abandon modern medicine because it sometimes causes harm. Our goal is to reduce iatrogenic illness in a science-based way.

Strangely enough, this is being done. A recent study in the New England Journal of Medicine (effectively discussed here) described a study in which surgical checklists reduced errors. This study was based on earlier work by Peter Provonost of Johns Hopkins, the subject of a terrific piece in the New Yorker. (Related commentary here.)

The basic idea is this: intravenous catheters in intensive care units (ICUs) often become infected. While they are necessary for the delivery of medications and the monitoring of hemodynamic parameters, infections can be devastating. This study made use of a large number of ICU beds (including 85% of ICU beds in my home state). The project, called "Keystone", asked the ICU staff to do one simple thing (emphasis mine):

The study intervention targeted clinicians' use of five evidence-based procedures recommended by the CDC and identified as having the greatest effect on the rate of catheter-related bloodstream infection and the lowest barriers to implementation.¹ The recommended procedures are hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters.

Strategies to increase the use of these procedures have beendescribed elsewhere.¹⁰ Briefly, clinicians were educated about practices to control infection and harm resulting from catheter-related bloodstream infections, a central-line cart with necessary supplies was created, a checklist was used to ensure adherence to infection-controlpractices, providers were stopped (in nonemergency situations)if these practices were not being followed, the removal of catheterswas discussed at daily rounds, and the teams received feedbackregarding the number and rates of catheter-related bloodstreaminfection at monthly and quarterly meetings, respectively. InApril 2004, a letter and a baseline survey were sent to thechief executive officers (CEOs) of the participating hospitals.The letter outlined the evidence supporting the use of chlorhexidine¹and asked the CEOs to stock chlorhexidine in their hospitalsbefore implementing the study intervention.

A checklist was used. Supplies were provided. Non-emergent procedures were stopped if procedures weren't followed. And a checklist was used.

So what happened?

The baseline rate of catheter-related infections was about 2.7/1000 catheter days. After implementation, the rate was zero.

Yes, zero.

One particular serious iatrogenic illness was effectively eradicated by a simple, easy-to-implement intervention. My earlier commenter was correct; if we stop using modern medicine, we will have no iatrogenic disease. We also will be left with a much sicker populace and a lower age of mortality. It turns out we have a third path---use science-based medicine to solve the problem of iatrogenesis. Not all problems will be solved so well as this one---there will always be some non-zero rate of serious medical complications, but as this study shows, it doesn't always take a whole lot to make a big difference.

References

Peter Pronovost, M.D., Ph.D., Dale Needham, M.D., Ph.D., Sean Berenholtz, M.D., David Sinopoli, M.P.H., M.B.A., Haitao Chu, M.D., Ph.D., Sara Cosgrove, M.D., Bryan Sexton, Ph.D., Robert Hyzy, M.D., Robert Welsh, M.D., Gary Roth, M.D., Joseph Bander, M.D. (2006). An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU New England Journal of Medicine, 355 (26), 2725-2732