Monday, July 21, 2014
Acceptable Miss Rate
The acceptable miss rate is a concept that realizes even in the best of hands with all the available data accessible, there still will be some errors. The question is whether society can tolerate without retribution aka law suits a reasonable attempt to keep this below 1% for most significant diagnoses. The cost of achieving unobtainable perfection is rampant in our medical system, where depending the risk adverse psychology of the provider, the price tag goes from linear to exponential.
In the article The Acceptable Miss Rate, Dr. Jeffery Freeman states the typical psychology of most providers, "What are the odds that if I follow my instincts and send this patient home without any further tests that he'll seize and die, and I will spend the next five years defending my instincts as a defendant?" The researchers among us may confer analytically on false negatives, prior probabilities, and Bayesian theory, but we all know what it means at a more visceral level. But, in fact, most physicians do not spend cognitive energy calculating an acceptable miss rate. Indeed, if the perceived odds re non-zero, it is quite likely that some justifiably preventative - defensive - action might be taken.
Medicine is a combination of art and science that rarely achieves 100% accuracy. The provider trying to be an excellent clinician, following evidence based guidelines, and providing good follow-up care can still be sued, especially if there is a bad outcome. Malpractice has on the one hand a financial cost, but on the other it also has a serious psychological cost. This latter overhead is one that can have significant impact on the ability of the sued provider to continue delivering care while a case is defended. Anticipatory prevention, then, leads to defensive medicine, and thus to unnecessary testing, more hospital admissions, and care that stays mired in process, without improving over time.
By establishing an acceptable miss rate protocol, it would allow physicians to use evidence based protocols with their experience to provide reasonable, inexpensive care. These protocols could reflect reality of a 1-2% miss rate per specific diagnosis even in the best of circumstances. The cost saving would be astronomical. Moreover, the parallels between the practice of medicine and baseball will take one more step toward being acknowledged. In baseball the batter aka provider steps up to the plate. The patient aka pitcher throws him the ball. The provider can watch it go by or take a swing- there really are no other options unless it is a wild pitch. But in baseball, when a swing is taken, even those on a full team are allowed a certain percentage of errors. Why not physicians, too? We have yet to see a perfect baseball player or a perfect physician.