Half full. Half empty.

At a recent presentation, a respected doctor expressed some frustration with the criticism that is sometimes directed towards the medical profession. He pointed out that the medical community has actually done a very good job taking care of serious illnesses in the population. He noted that this is because doctors really devote their lives to improving patient outcomes.

To support this point, he presented the chart above from the AHRQ Center for Delivery, Organizations and Markets (full study here) that demonstrates improvement in hospital risk-adjusted mortality for important diagnoses and procedures. Whether you have a heart attack or pneumonia, or whether you have an aneurysm repair or a hip replacement, your chance of dying in a hospital has gone down over the years. (I know this data ends in 2004, but I would be confident that the trends have held.)

I hope you, like I, am impressed with these numbers. They are a story worth telling and retelling.

But there is another story that has to be retold, too. It remains a bit of a paradox for me, one I discuss in my speeches. The paradox is how this group of extremely able and well intentioned clinicians, while accomplishing these great things, also constitute an important public health hazard, in terms of the number of people who are killed or otherwise harmed while in hospitals.

The famous Institute of Medicine Report, To Err is Human, was published in 2000. It documented, in a way that many people find uncomfortable, the number of unnecessary deaths that occur in hospitals. We now understand that much of this harm is caused by the systems of care, by how work is organized in hospitals, by excessive levels of variation, or, to put it another way, by insufficient levels of standardization based on process improvement principles. I summarized Brent James on this point in a post below:

We continue to rely on the "craft of medicine", in which each physician practices as an independent expert -- in the face of huge clinical uncertainty (lack of clinical knowledge; rapidly increasing amount of medical knowledge; continued reliance on subjective judgment; and limitations of the expert mind when making complex decisions.)

And, as noted below, we also often do not draw on our greatest resource, patients, in the design of care delivery. And finally, many hospitals and doctors are held back by a fear or reluctance to publish clinical outcomes in real time so that organizations can hold themselves accountable.

Is the glass half full, or half empty? As in such cases, probably both. Let's give tremendous credit to the medical profession for what it has accomplished. But let's hope that members of the profession also take to heart the fact that the job of reducing harm is not nearly done.