Counting the blessings of American medicine

WE keep reading the same old statistics about the poor quality of health care in the United States as a justification for how it needs to be fundamentally changed. We hear that the U.S. ranks 37th in infant mortality, has lower life expectancy than that of many developed countries in the Western world, and that there are 90,000 deaths per year because of medical errors — all despite higher costs per capita. These notions have been cited so frequently that they seem to gain traction simply from their repetition.

Of course, once quoted, scant attention is paid to any analysis of their validity. Several reasons should make us pause before accepting such numbers. Different reported outcomes might have to do with different methods for gathering results from country to country. Filling out a death certificate or coding a medical outcome, usually the basis for our "vital statistics," is surprisingly inexact. In addition, we assume that patients are alike around the world, but it is clear this is not the case and skews the data. (Certainly there are genetic differences at the very least).

Often, health care is not the primary cause of the outcome: poverty, nutrition, alcohol and drug use come to mind, problems that are societal in nature and that vary from culture to culture. And since we respect patient autonomy, if someone does not make the effort to sign up for health-care benefits, or take the time to come in for prenatal care, or have the willingness to follow simple advice, should their outcomes be charged to medicine's account? Mark Twain admonished us to beware of "lies, damn lies, and statistics."

How robust is medicine in the United States? One historical root traces back to a caring physician driving a horse-drawn carriage to the bedside of a sick patient in the middle of the night, for little recompense and at a time when little could be offered beyond holding a hand. That compassion is still alive today.

We followed pioneers like Abraham Flexner in making medical education rigorous and based on an exacting science. William Stewart Halsted's legacy has given us gifted and creative surgeons, while the disciples of Sir William Osler have illuminated the paths of critical thinking. And when science isn't enough, we can fall back on the quiet words of poet William Carlos Williams, M.D.

Our students are the product of intense competition, providing promise for future generations. Outstanding medical centers have arisen in most major cities in the country, attracting talent from around the world, places where knowledge about both arcane and common ailments grows through fundamental inquisitiveness, limited only by intellectual capability and hard work.

Our national conferences routinely attract thousands who seek to validate their ideas on the most competitive stage. The best journals, the most publications, and the most scientific accolades are garnered by physicians working in this country.

We have deciphered the genome and developed dialysis, bone-marrow transplantation and catheter-based cardiac interventions. Our population can get advanced imaging studies or virtually any laboratory test performed promptly and reliably. A simple call to 911 provides instant access to a remarkable countrywide system of emergency care. We have many reasons to be proud, and I am disappointed in my colleagues who are too modest to defend vociferously what is good in our system.

The 2002 Institute of Medicine report (which actually estimated not 90,000, but between 44,000 and 98,000 deaths per year attributable to medical error) is old hat. We have long since internalized its message and taken it to the floors of hospitals to improve care at the bedside. We work hard to surpass standards and reach error rates below 1 in 100,000.

Our medicine is not static. But amid all the turbulence, let us pause and give thanks for the bedrock of American medicine that is the envy of all the world.