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BACK TO THE FUTURE
In June 1964, while preparing to start my internship on the medical service of the Yale-New Haven Hospital, I received a welcoming letter from the chief resident advising that the new interns begin their orientation by reading a recent article, “The hazards of hospitalization” by Elihu Schimmel.1 This now classic report was the product of Schimmel’s year as chief resident at Yale in 1960–1 when he designed a research project to involve all 33 members of the internal medicine house staff. While Robert Moser had earlier coined the term “diseases of medical progress” and a previous study estimated a 5% rate of “major toxic reactions and accidents” on a university medical service, the Yale study was the first prospective assessment of these risks. Adverse events were identified from report forms that were attached each day to the front of patients’ charts and were filled out by the attending house officers. Importantly, episodes were included in the analysis if they “arose from acceptable diagnostic or therapeutic measures deliberately instituted in the hospital”, and complications “were excluded if they arose from inadvertent errors by physicians or nurses”. The startling discovery that 20% of patients admitted to the medical service had one or more complications, even in a leading teaching hospital, was told and retold many times to succeeding generations of that hospital’s house staff.
The Schimmel report, largely forgotten except by physicians who trained at Yale in the 1960s, now appears as a landmark in the measurement of the quality of care. When this paper was published, Weed’s problem oriented medical record and Donabedian’s taxonomy for quality were still in the future, Lown had only recently introduced electrical cardiac defibrillation, and hospitals did not yet have intensive care units. The issues addressed in the Schimmel report were not rooted in concerns about the cost of health services—the cost of a day in the hospital at that time was something less than $70. Medical errors and mistakes were also not a particular focus; indeed, the belief that the quality of medical care in this facility was exemplary lay behind its power.
The impetus for the Schimmel report undoubtedly owed much to the singular leadership of a remarkable department chairman, Paul Beeson, who, while nurturing a large academic department emphasizing basic science, used his charisma and mystique to model humanism and caring in medicine. Beeson exemplified humility, graciousness, and diligence that are sensitively portrayed in his biography by Rapport.2 In his own work Beeson had called attention to the hazards of the urinary catheter that sometimes caused infections that were difficult to treat and advised that there should be good indications for its use.3 (Yale house officers were advised wisely to avoid the use of a urinary catheter unless absolutely necessary.) Beeson was distressed by the risks of adverse outcomes that frequently result from even the best care. His background was unusual in that he had actually spent several years in general practice with his father and brother in Ohio before beginning his academic career. As a towering leader in medical education extending over four decades, including his appointment as the Nuffield Professor of Medicine at Oxford and recognition as an Honorary Knight Commander of the Most Excellent Order of the British Empire, he played a central role in promoting the hospice movement in the US, served as a driving force in the new field of geriatrics, and became an ardent member of the Physicians for Social Responsiblity.
One of Beeson’s initiatives at Yale that followed the publication of “The hazards of hospitalization” and that was motivated by his increased concerns about the conditions of patient care resulted in a book by Duff and Hollingshead “Sickness and Society”,4 published in 1968, that was highly critical of hospital care. In a review, Beeson himself criticised the book for its sensationalist style and other deficiencies after it was described in an article in McCall’s magazine entitled “Hospital. Enter at your own risk.” Beeson’s ambivalence—he conceded that “there are bases for many of the things the authors deplore”—parallels and resembles the responses of many thoughtful physicians today to the 1999 Institute of Medicine report “To Err is Human: Building a Safer Health System” and the resulting flap in the lay media.5 The Schimmel report, in contrast, was not accompanied by press releases and attracted little attention—perhaps because, in 1964, the media had not yet discovered the public’s appetite for medical news.
Sherwin Nuland, a Yale surgeon and gifted medical writer, noted that the Schimmel study provoked a great deal of thought but little else, certainly no demonstrable changes, either at Yale or elsewhere.6 The rate of injury in the 1960–1 study may even have been higher if adverse events due to inadvertent errors had not been specifically excluded. A similar study at Boston University Medical Center nearly two decades later in 1979 found an even higher rate of iatrogenic illness (36% of 815 patients admitted to the medical service).7 These investigators also did not report events due to errors and believed their criteria for injury to be conservative. How are these high rates of injury determined prospectively 30–40 years ago to be viewed in relation to the lower rates (3.7% and 2.9%, respectively) from implicit reviews of medical records in the retrospective New York State and Utah-Colorado studies in 1984 and 1992, respectively?8,9 These more recent studies included only injuries that prolonged hospitalization or caused disability at the time of discharge, but the results are more broadly representative of hospitals in general owing to the random sampling methods used. It is striking that many, if not most, of the adverse events in the Schimmel study were due to now outmoded drugs or procedures, factors that sharply limit its modern relevance. Interestingly, Schimmel found that 10.4% of patients had episodes of moderate or major severity—that is, using definitions similar to the New York State study. Is the rate declining or are the risks actually increasing for our most ill patients? The answers to both these questions are probably “yes”. There is a clear opportunity for an ambitious investigator to redo the Schimmel study in a contemporary hospital.
In the 1960s the Schimmel report had a clear message for the house staff. Physicians became more aware that the risks of hospitalization had to be factored into the decision to admit patients for hospital care. However, the changed nature of hospital care over the past several decades—leading to earlier discharges, shorter lengths of stay, and increased home therapy—as well as ageing of the population, more immunocompromised patients, and more aggressive treatments and surgical procedures, has both reduced and complicated the recognition of hospital related adverse events and expanded the nature of adverse events to include all episodes related to health care, regardless of venue.
A lesson from the Schimmel study for the current concerns about patient safety and medical error is the need to monitor adverse events continuously as the foundation of injury prevention and for this process to take place as a normal procedure at the patient’s bedside by the caregivers themselves. The Yale study was based on voluntary reporting by a committed and dedicated house staff and shows that this process can work quite well with the right kind of leadership. This report was the work of insiders at the sharp end of patient care, often overworked and tired house officers. It is disappointing that this lesson has still not been learned. External mandatory reporting has not worked well.10 There is now great interest in developing new voluntary reporting systems, and Schimmel showed one way such a programme can work.
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