The NY Times Attack on Mil Med Continues
Another piece of investigative journalism slamming military medicine recently ran across the New York Times‘ headlines. The same journalists, Sharon LaFraniere and Andrew W. Lehren, who published the 28 June 2014 article provoking my initial response on GFM have published a new article titled Smaller Military Hospitals Said to Put Patients at Risk on the first of September 2014.
A similar pattern emerged paralleling the initial exposé in both premise and strategy. With headings like ‘Very Scary’ for Doctors, the sensationalism that sells newspapers (or web advertisement these days) is evident. Heavy on tragic anecdote and sparse of rigorous scientific analysis using healthcare quality metrics, the unsophisticated reader is left with a negative emotional reaction to military medicine, convinced that the U.S. Armed Forces are forced to receive the nation’s most mediocre medical care. As a matter of fact, very little new information is even presented and the reader of the previous article is left wondering how these two journalists convinced their editor to publish a new piece.
It is not that the independent facts presented are inaccurate as much as the article’s spin and premise seem misguided and unjust. Let us briefly review the article’s overarching but confused premise, followed by some of the problematic arguments employed by these two journalists.
THE NY TIMES POSITION
Similar to their initial NYT article, the premise of this piece implies:
- The quality of military medicine is uniquely inferior to all forms of healthcare in the civilian sector.
Let’s take a few moments to critically evaluate the foundations of this argument.
AN UNCONVINCING ARGUMENT
There are a number of problems that readily arise when one is able to restrain their emotional response to LaFraniere and Lehren’s words in favor of rational evaluation of the merit of their individual arguments. Below are a number of obstacles to convincing argument with which most journalists should have full familiarity.
The Plural of Anecdote is not Data
Roughly 2,265 of the recent NY Times article’s 4,828 total words were used to explicitly detail particular anecdotes that could have been plucked from any medical facility across the country. This is an unfortunate, but sadly true fact. Reports of medical errors are ubiquitous and spare no hospital. The fact that over half of the content of the article is devoted to tell a handful of tragic stories is evidence that the authors hope to falsely convince the reader this is representative of all experiences in military medical systems. This could not be further from a scientific approach to build convincing arguments. The section on Naval Hospital Lemoore was particularly guilty of ad hominem attacks with almost no objective evidence presented. A short list of anecdotes describing poor outcomes mixed with a number of employee testimonies does not a guilty conviction gain. If this type of evidence were able to convict a hospital in the courts of American media, then there is not a single healthcare facility safe from attack. Medical errors are widespread across healthcare systems, regardless of military or civilian status.
The initial June article was certainly guilty of cherry-picking metrics and benchmarks that attempt to confirm the author’s premise, while omitting or de-emphasizing any evidence that would suggest otherwise. This article repeats the fallacy. At worst, these journalists are purposefully highlighting or omitting data to prove a predetermined argument. At best, they are unconscious victims of their own confirmation bias. In my previous post, I discussed a number of metrics proposed by the World Health Organization and the Commonwealth Fund used to measure, quantify, and compare healthcare quality. Similarly, every medical specialty has particular benchmarks that are tracked and reviewed by The Joint Commission. Rather than taking the more scientific approach of first listing all quality metrics, and THEN reviewing performance of military medicine and civilian medicine, the authors of this article seem to scan thru a large list of data, only reporting the metrics that cast military medicine in a uniquely dismal light. Their choice of metrics seem arbitrary and unrelated.
Lack of Control Group
Who exactly is the Times comparing military medicine to? This question is not easily answered, because the authors do not bother to tell us. Early in the piece, the authors argue that compared with leading civilian hospitals, more than half of domestic military hospitals — including the five with the busiest maternity wards — performed poorly on one or more measures of harm to mothers or babies in 2011 and 2012. Is it really fair to compare military treatment facilities (to include some of the smallest military hospitals) to ‘leading civilian hospitals’? Is the expectation that federal funding budgeted for the Department of Defense should create a healthcare network that rivals the Mayo Clinic, John Hopkins, or the Cleveland Clinic?
Instead of the approach the Times takes, if they want to argue that military medicine is objectively worse than their civilian counterparts, they should compare apples to apples. It would be quite easy to place the variety of military hospitals into categories by size and compare their outcomes to the thousands of similarly sized hospitals in the civilian sector. But instead of taking this more rational approach, they compare all military treatment facilities (including the very smallest ones) to the ‘leading civilian hospitals’. Why don’t the authors go after all healthcare in Montana in this spirit, as I am sure most of the hospitals in our nation’s least densely populated areas will also not fair well against Harbor UCLA General Hospital or Harvard’s Brigham and Womans Hospital.
Small Hospitals are Unique to the Military
At one point the Times reports that Two-thirds of the hospitals last year served 30 or fewer inpatients a day — less than a third as many as the typical civilian hospital. How is a ‘typical civilian hospital’ defined? From where is this information acquired? The Center for Disease Control (CDC) publishes a massive report on health in the United States every two years. Included among the ocean of health statistics presented in the report is a table that categorizes all hospitals across the nation by size (number of beds) and their occupancy rates. This data can be found in Table 106 in the 2012 Report. Several interesting pieces of information are gleaned from these data tables. The NY Times article argues that small military medical treatment facilities are:
- Unique to the military
- Should be uniformly closed for patient safety concerns
- Closures are not happening at the necessary rate or scope
A quick glance at Table 106 should quickly assure the viewer that small hospitals are not at all unique to the military. Federal hospitals presumably include both military and Veteran Affairs facilities. Unfortunately, the tables do not break down subcategories of which hospital size are civilian or federally-managed, but conclusions can still be drawn. For example, in 2010 the United States was found to have 5,754 hospitals in operation, of which 213 were federally managed. The report states there were 424 hospitals within the category of hospitals with fewest beds (6-24 beds). Even assuming ALL federally ran hospitals were of this size (clearly not true), the civilian sector would have to account for the remaining 211 smallest hospitals in the nation. The two smallest hospital categories (hospitals with 6-24 beds and hospitals with 25-49 beds) together make up 1,591 of the nation’s 5,754 total number (27.7%). Again, assuming that all of the federally ran hospitals fall within these categories, the remaining percentage of super small hospitals in the civilian sector is (1,378 divided by 5,541) 24.9%. Between one quarter and a third of civilian hospitals are from these two smallest categories. Shocking. Do the same severe arguments pointed at small facilities in military medicine transfer to the thousands of similarly sized institutions in the country?
The occupancy rates are also provided and point to further problems in the Times’ line of argument. The overall occupancy rates of federal and civilian hospitals are nearly identical with 65.3% occupancy in federal hospitals and 66.6% in the civilian sector. It is true that occupancy rates steadily increase with increasing hospital size, but this would be expected to be uniform across both civilian and military facilities and as stated above, a majority of these small hospitals are operated by private institutions.
In regards to hospital closures, the CDC’s tables again offer insight. Both the total number of federal hospitals and bed numbers in these hospitals has decreased dramatically since 1975. The number of federal hospitals has decreased by about 10% for every 5-10 years, but leveled off between 2007 and 2010. Though, during this period total number of beds in these hospitals did continue to decrease.
Clearly, the NY Times’ journalists do not seem to equitably distribute their criticisms to the civilian sector even when the application is obvious.
In summary, the Times‘ argument that the quality of military medicine is in some way uniquely inferior to civilian healthcare only ignores the more important $3.8 Trillion elephant in the room. Almost all of the allegations aimed at military medicine in these two articles are easily applied to the greater American healthcare system (or non-system as it is often called). The authors correctly point out that the military hospital system is actually less a system than a collection of hospitals that, with a few exceptions, are run separately by the Army, the Navy or the Air Force. However, they fail miserably in pointing out that the military system is actually a much more robust and considerably more standardized system than that seen elsewhere across the United States (aside from maybe the other federally-managed Veterans Affairs system). At least all three services, which operate on almost every continent across the globe, use a similar medication formulary and electronic medical record, ensuring that providers within the ‘system’ can access a patient’s vital medical information regardless of geographic location. There is simply nothing like this across the hundreds and thousands of small, fragmented provider partnerships, competing medical centers, complex health insurance configurations, and overall medical mosaic which spans from Atlantic to Pacific.
It is true that the military struggles with a handful of healthcare facilities and an abundance of physicians who do not see enough patients or perform enough procedures to remain a competency parallel to counterparts in busy urban centers. BUT THIS IS FAR FROM A UNIQUELY MILITARY PROBLEM. It is one of medicine’s dirty little secrets that doctors and surgeons who have not performed a high volume of a particular procedure recently will have higher rates of complications. This is also true for basic maneuvers in aviation. Recent time and volume in experience is critical for both initial mastery and maintenance of complex skills. But just as you have no way of knowing how many landings the pilot of your commercial flight has performed over the last 30 days, patients will not easily discover their surgeon’s total or recent number of similar operations performed. This is true across all healthcare systems everywhere.
CHALLENGES AND SOLUTIONS IN MILITARY MEDICINE
Of course, the military has unique challenges and obstacles not experienced in the civilian sector. A diversity of pathology and disease is not always observed since the military tends to have a population that is much younger and healthier when compared to the general population. For this reason, there may be times when zebras (uncommon medical conditions) will at times be missed. The many additional requirements that being an enlisted member or officer in the military entails distracts medical providers from their primary duties of clinical care. A lack of level one trauma units and other specialized medical centers leave gaps in continued medical education for certain military providers. The military’s budget is a constant limitation to what it is capable of doing. We are often continually asked to do more with less. The Pentagon needs to continue to look at which infrastructure is cost-prohbitive or has a superior economic substitute in the civilian sector. However, any of these discussions of reducing unnecessary infrastructure quickly become mired in the political meat grinder of local special interests. This is a HUGE problem not shared by for-profit civilian hospitals that close when they became economically insignificant, replaced by a more competitive, higher quality and more profitable alternative (assuming a perfect economic model in the absence of market failures).
However, many of these problems are known and creative solutions are being proposed and enacted. Many military physicians are required to work in civilian settings to maintain their unique skill-sets. For example, a training program called C-STARS, which requires providers to rotate through one of 3 world-renknown civilian hospitals (St Louis University, Shock Trauma at University of Maryland, or University of Cincinnati) is a requirement for particular types of medical providers. When new legislation or health policy is mandated, the military’s tight hierarchy and command structure allows implementation of new programs to be completed without delay or debate.
Of course, military medicine has ample room for improvement. And if there are specific metrics in which we perform more poorly than similar facilities within our civilian counterparts, this must be addressed and creative solutions proposed. If the NY Times’ efforts are truly towards the admirable goal of improving military medicine, they need to first determine which civilian healthcare facility is a good benchmark for comparison and then do so in a consistent and fair manner. Ultimately with this goal in mind, they may be better served focusing their attention and efforts on the greater healthcare non-system spanning the United States. By making ALL healthcare a more comprehensible, safe and functional system; military medicine will gladly comply and share these benefits.
1. SHARON LaFRANIERE and ANDREW W. LEHRENSEPT. Smaller Military Hospitals Said to Put Patients at Risk. The New York Times. 1 Sep, 2014
2. SHARON LaFRANIERE and ANDREW W. LEHRENJUNE. In Military Care, a Pattern of Errors but Not Scrutiny. The New York Times. 28 Jun, 2014
3. CDC: Health, United States, 2012.