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A Defense of Military Medicine

By In Blog, Military Medicine On July 28, 2014


 

The Hippocratic Oath

The Hippocratic Oath

“…and I will do no harm or injustice to them.”                                                       ~ Hippocrates (460-370 b.c.)

An article from the New York Times titled In Military Care, a Pattern of Errors but Not Scrutiny was published on 23 June 2014. This exposé directed strong criticism against the quality of military healthcare.  Given the timing of this piece of investigative journalism,  it is easy to suspect the authors of an attempt to profit from the recent buzz over the Veterans Affairs (VA) scandal.  Although, the article did explicitly differentiate between healthcare provided to Active Duty (and Reservists and National Guard) military personnel from the VA system (medical care to separated or retired veterans), this point can be subtle and confusing to the public.

Times reporters, Sharon LaFraniere and Andrew W. Lehren, describe a substandard healthcare system that is crippled by a poor safety record and high rates of preventable mistakes.  Between the FOIA-derived reports  and professionally-generated graphs, tragic anecdotes are intertwined which provoke strong negative emotional responses against a large, faceless military-governed healthcare system.  The reader is left angry and depressed at the medical care forced upon our Armed Forces.

But is military healthcare really as bad as these two journalists suggest?

A critical analysis of the claims made by the article is one way to determine the accuracy of the article’s arguments.  Pointing out strengths, weaknesses or bias in reporting is another approach.  Before tackling these questions, however, it may assist the interested reader to first identify the specific quality metrics that any healthcare system should be measured.  The NYT article focuses almost exclusively on patient safety, which although one of the most important aspects with which a healthcare system should be judged, should not be the only criterion.  Before discussing other aspects of healthcare quality, it may be valuable to review the history of patient safety and how advances in this area of medicine have been incorporated (or not) into military healthcare.

 

A Brief History of Patient Safety

To Err is Human - 1999 IOM Report

To Err is Human – 1999 IOM Report

The origins of patient safety in medicine traces its roots to the very earliest written texts in the discipline.   One of the most famous ancient texts on the subject of medicine, The Hippocratic Oath, emphasizes the safety of the patient about all else.  Unfortunately, like most academic and philosophic disciplines, brilliant ideas lacked power and scope until the development of the scientific method.  Although allopathic (and ultimately osteopathic) medicine slowly embraced the techniques of empiric science in the 19th and 20th centuries, individual variation of clinical reasoning persisted.  Patient safety was not a codified part of most clinical practices or healthcare facilities even into the 1990’s.

In November 1999, the United States’ Institute of Medicine issued a shocking report.  This report titled ‘To Err is Human‘ shed light on the overwhelming number of deaths and injury caused by medical mistakes.  This damning report suggested that at least 44,000 but possibly up to 98,000 people died each year due to preventable medical mistakes in American hospitals.  The publication ultimately prompted a hard look and reconsideration of patient safety by national and world leaders.  An incredible amount of subsequent reports, private industry, and legislation soon followed.  The 2001 report, ‘Crossing the Quality Chasm‘ reiterated the need for improvements in patient safety, but placed a larger emphasis on recommendations and solutions for doing so.  The Agency for Healthcare Research and Quality emerged from within the federal government’s Department of Health and Human Services (HHS) to “enhance the quality, appropriateness, and effectiveness of health services…” as a result of these reports.

The emphasis placed on patient safety in the early 2000’s was to interpret medical errors as a consequence of system failures and inevitable human error, rather than assigning responsibility to malicious or negligent behavior.  Many of the program improvements for patient safety were derived from the aviation industry and other highly reliable organizations.  These include:

Crossing the Quality Chasm - 2001 Report

Crossing the Quality Chasm – 2001 Report

  • Root-Cause Analyses
  • ‘Never Events’ Identification & Prevention
  • Risk-Management Investigations
  • Increased Hospital Accreditation Requirements
  • New anonymous Patient Reporting Systems
  • Near-Miss Reporting
  • Funding and Emphasis on Technology to diminish Human Error
  • A Call for Electronic Medical Records
  • Re-emphasis on Evidence-Based Medicine
  • Standardization of Clinical Care thru Guidelines & Checklists
  • Changes in Payment Collection Systems – Payment for Performance

It would be difficult now to find a hospital in the United States that does not have a Patient Safety office with dedicated employees who evaluate and attempt to carry out Hippocrates message to first do no harm.  The military is no exception.  Almost every new requirement for patient safety has been incorporated into the healthcare system that delivers care to the U.S. Armed Forces.

Has military medicine failed the last few decades attempts to improve patient safety or is it merely representative of the larger U.S. mosaic of healthcare networks?

 

How to Measure Healthcare Quality?

How can a high-quality healthcare system be defined?  Obviously there is no official list of metrics, but the variables that government organizations, NGO’s, individual researchers and think tanks generally emphasize are readily available  Some of the most commonly cited metrics are:

The Commonwealth Fund:  American Healthcare in Last Place

The Commonwealth Fund: American Healthcare in Last Place

  • Safety
  • Effectiveness
  • Preventative Health Services
  • Routine Care
  • Emergency Care
  • Timeliness of Care
  • Cost
  • Access
  • Innovation
  • Equity
  • Best Practices

There are a number of ways in which these metrics can be used to evaluate and rank healthcare systems.  One of the most noteworthy rankings of a nation’s healthcare delivery is performed every 4 years by a private organization called The Commonwealth Fund which is headquartered in NYC.  In the 2010 report, The Commonwealth Fund evaluated healthcare systems across 7 developed nations.  Surprisingly, the strongest and richest nation was determined to be in last place (7 of 7) when it comes to healthcare delivery.  In 2014, this exercise was expanded to include 11 of the world’s most developed and richest nations.  The report was titled ‘Mirror, Mirror on the Wall‘.  The United States’ healthcare system held onto its position at bottom of the pack, slipping from 7 of 7 to number 11 of 11.   Many readers who are not familiar with this organization and report, will likely be both surprised and defensive of the findings.  Many politicians share this sentiment.

The criteria used by the CF are Quality, Access, Efficiency, Equity, Healthy Lives, and Health Expenditure Per Capita.  The category of Quality is divided into 4 sub-categories:  Effective Care, Safe Care, Coordinated Care, and Patient-Centered Care.  Although the results of this report continue to be hotly debated, such as a recent podcast by The Economist, which points out that Innovation and Best Practice Strategies (traditionally strong characteristics of American healthcare) are omitted metrics; the overall statement this makes should not be readily dismissed.  In context to the NYT discussion, the U.S. was ranked 7/11 overall within the category of Safe Care.  This means our ability to keep patients safe is somewhere between the bottom third and quartile among the world’s richest nations.

Although the NYT reports that half of military hospitals sustain higher than expected rates of surgical complications, they fail to say where this ranks the military hospitals among American hospitals.  This is an important point.  If this finding is emblematic of most hospitals in the United States, it may be more of an indicator of the overarching healthcare system in which the military operates rather than a failure of military medicine itself.  It should also be pointed out that the other half of hospitals not emphasized by the article had complication rates markedly less than what is expected.  Taking this data point alone, it would seem the military healthcare system is merely representative of a healthcare system that ranks 7 out of 11 when it comes to patient safety.  With half of the military hospitals on one side of the normal curve and the remainder on the other, the paper seems to only point out that military healthcare delivery is as safe as the average healthcare system in the United States.

 

The NY Times’ Arguments against Military Medicine

Anecdote of a Tragedy

Anecdote of a Tragedy

A quick glance at the referenced NYT article leaves the reader fully convinced that military healthcare is a substandard form of medical care.  However, the critical reader is left with many more questions about this argument than the authors seem to answer.  Below are some crucial problems with the arguments that the NYT proposes:

Victim Anecdotes 

Although each of these stories are tragic and those experiencing the described events are clearly worthy of empathy, these anecdotes are sadly not unique to military medicine.  These same stories can be found and delivered from any patient population from any hospital across the nation.  It must be restated that multiple anecdotes is not equivalent to data.

Deserts of Statistics

“The Times’s examination, based on Pentagon studies, court records, analyses of thousands of pages of data, and interviews with current and former military health officials and workers, indicates that the military lags behind many civilian hospital systems in protecting patients from harm.”

– What does this mean?  Does the military also out-perform many civilian hospital systems?  Without quantifying this statement, it is actually meaningless.  

“Avoidable errors can and do occur at the best of hospitals. But the military’s reports show a steady stream of the sort of mistakes that patient-safety programs are designed to prevent.”

– Again, admission that similar errors happen at the very best American hospitals.  Do these mistakes happen at a statistically significant greater rate at military hospitals?

Surgical Complication Rates at DoD Hospitals

Surgical Complication Rates at DoD Hospitals

“Malpractice suits can also be a rough indicator of risk. From 2006 to 2010, the government paid an annual average of more than $100 million in military malpractice claims from surgical, maternity and neonatal care, records show. It would be paying far more if not for one salient reality of military health care: Active-duty service members are required to use military hospitals and clinics, but unlike the other patients, they may not sue. If they could, the Congressional Budget Office estimated in 2010, the military’s paid claims would triple.”

– Would triple this number be more than is paid out for malpractice by civilian medical institutions?  Again, numbers are lacking.  

“The military health system is split into three major branches, with the Army, Navy and Air Force each controlling its own hospitals and clinics. The Pentagon’s Defense Health Agency also runs the Walter Reed National Military Medical Center and Fort Belvoir Community Hospital, both outside Washington. Any systemwide change involves a carefully calibrated consensus of three equally ranked surgeons general, as well as the Defense Health Agency. Dr. Woodson, who oversees the system, cannot order the surgeons general to act. He can only recommend.”

– How easily are massive changes in civilian healthcare made as a comparator?  

A Convenient Choice of Variables

“For example, their rate of infant mortality was equal to or lower than that of civilian hospitals in the most recent data analyzed by the National Perinatal Information Center, a private group with a Pentagon contract. In routine vaginal births, the rate of injury to the mother has consistently been below the national average.”

“In 40 percent of the military hospitals, mothers were significantly more likely to suffer hemorrhages after birth than at the civilian hospitals tracked by the perinatal center. The hemorrhages can lead to hysterectomies or even death. About 2,500 cases were recorded in military hospitals in 2012, roughly 760 more than if the military had met the civilian benchmark.

If doctors used instruments such as forceps to assist the delivery, mothers in military hospitals were about 15 percent more likely to be injured than mothers nationally, the most recent data shows.

Throughout this article, the authors dismiss areas in which military medicine outperforms its civilian counterparts, yet strongly emphasize those where they fall short.  Of course, anyone could cherry pick data sets that serve the purpose of any argument.  There is a scent of confirmation bias here.  It is like the graph and accompanying caption that points out half of military hospitals have surgical complication rates that exceed expected benchmarks, but failing to mention the other half of military hospitals who have significantly lower complication rates.  

The Challenges of Military Medicine

The Challenges of Military Medicine

Unfair Comparisons

“While infighting held the military’s patient-safety programs in check, some civilian hospital systems cut death and harm rates. At Ascension Health and Kaiser Permanente, two of the nation’s biggest nonprofit systems, investigating workers’ reports was just a first step. The companies also analyze a vast array of data, including readmission and mortality rates.

Officials at Ascension and Kaiser say their hospitals have gotten safer. Ascension estimates that its safety measures have saved 1,500 lives in the last six years. Doug Bonacum, Kaiser’s vice president for quality, safety and resource management, said the mortality rate at Kaiser’s 38 hospitals had fallen more than 30 percent in the last four years.”

– Certainly there exist healthcare systems in the United States that are performing as well or better as those anywhere in the world.  These are our Best Practices.  Sadly, Kaiser, Ascension and our other Best Practices are not representative of America’s healthcare system as a whole.  It is unfair to compare the military’s medical delivery system with these programs.  Military healthcare is funded, managed, and executed by the federal government.  Scarcity is real.  Budgetary limits are daily obstacles.  Rationing at times is ordered.  There are other unique challenges to military medicine that cannot be appreciated by these large private organizations.  Military medicine does not make claims to be the VERY BEST facilities and systems within the United States, but most of us do believe that we provide care that is as good as or better than most of our civilian peers.

 

Military vs Civilian Healthcare in America

The importance of patient safety cannot be understated.  Maintaining confidence that you and your loved ones will be safe at a medical facility is vital to a  modern highly functioning health care system.  Although the NYT points out some concerning trends within the military related to safety, it does not at all discuss other important aspects of healthcare delivery.

Keep Calm &  Do No HarmAccess to care, timeliness of care, preventative health, and equity are all areas in which military healthcare likely exceeds its civilian competition by a long shot.  Preventive Health Services are provided and met at a rate unable to be replicated in the civilian sector.  All active duty members are required to have an annual physical health assessment.  This includes an annual dental exam and optometry when required.  Vaccinations are required for active duty members and are more difficult to opt out for children.  These services are provided equitably across all personnel and family as rank, ethnicity, and socio-economic status have no bearing on services received.  Although costs for the patients are significantly less (no copays or deductibles), the costs born by the payer (ultimately the DoD) are likely not much less than the civilian world, and may actually even be more.  That being said, however, the military as an entity has a much strong negotiating voice with pharmaceutical and medical supply companies, which may in fact translate into a more economic delivery of health service in the military.

The electronic medical record used in military medical facilities is antiquated and frustrating for providers.  However, this system allows patients to have their medical records viewable and editable across the globe.  Military providers have the ability to readily refer all of their patients to health and wellness centers for healthy living courses, mental health services for those with emotional or psychological struggles, or audiologist for those suffering early-hearing loss.  The list of services available to any military beneficiary is actually incredibly comprehensive.  Although similar, and possibly even better versions of these services are available to many in the civilian world, the biggest difference is that within the Department of Defense, these services are available to ALL of the beneficiaries.

Of course military medicine is no utopia.  There are many challenges that both patients and providers in the Armed Forces meet that are not shared in civilian life.  Physicians are usually young and relatively less experienced.  They also typically only serve for the duration of their commitment before leaving to pursue a career in civilian medicine.  The ones that do stay active duty eventually assume more and more administrative or leadership taskings, which distract from their abilities as clinicians.  Physicians and their families also have to move to new locations every 2-4 years, which disrupts continuity of care.  In the rare case that a physician does stay in one place for longer periods of time, his or her patients are the ones being shuffled about.  Continuity of care suffers.

Two concerning themes from the NYT article are the mediocre  patient safety marks when it comes to obstetrics and the pattern of missing safety investigations.  I cannot confirm the validity or degree of these problems, but the question surely deserves further attention.  And if we are in fact performing more poorly than our civilian counterparts, the source of the problems must be identified and addressed.  Of course, we can and must always do better.  For these reasons, a little taste of criticism across the headlines is actually a good thing.  Military medicine should be recognized for many of the strengths it offers and should in some ways be even emulated by the civilian sector.  However, in other areas of medical delivery, we still have a long way to go before we can call ourselves the best.  But, unfortunately, all this means is we have much in common with the greater American healthcare system.

 

References

1. The Hippocratic Oath.  4th or 5th century b.c. 
2. Sharon LaFraniere & Andrew W. Lehren. In Military Care, a Pattern of Errors but Not Scrutiny.  New York Times.  23 June 2014.
3. Institute of Medicine.   To Err is Human – Building a Safer Healthcare System.  Nov 1999.
4. The Institute of Medicine. Crossing the Quality Chasm – A New Health System for the 21st Century. Mar 2001.
5. The Commonwealth Fund. Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. 16 June 2014.