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Nick Scobel posted a photo:
Crocodylus acutus
A pair of recent hatchlings take their first steps into the world in a remote estuary of Florida Bay in south Florida. Because of long term conservation efforts, this species was downgraded from Endangered to Threatened on the Endangered Species list in 2007. Today, more than 1,500 wild crocs are estimated to inhabit south Florida. Long term conservation and management plans are essential for the long term survival of this species moving forward.
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This story originally appeared on the Conversation and is reproduced here with permission.
A report published in May from researchers at the Johns Hopkins School of Medicine claims that medical errors are the third leading cause of death in the U.S., behind only heart disease and cancer.
According to the researchers, medical errors account for 251,454 U.S. deaths each year—and they regard this figure as an underestimate.
That's the sort of finding that makes headlines. Indeed, you might have read about this report in the newspaper or even seen it reported on the evening news.
But as we'll argue, the methods the researchers used to draw this conclusion are flawed, and that means the conclusion that medical error is the third leading cause of death is highly questionable.
When a report like this gets broad media coverage, it can foster unwarranted mistrust of medicine, which could prevent people from seeking needed care—a concern for everyone who takes care of patients.
A medical error can be defined as a decision or action that results in patient harm, one that experts agree should have been made differently given the information available at the time. But applying such a definition in reviewing patient records is fraught with difficulty.
The study's authors argue that death certificates should be redesigned to recognize that more deaths are attributable to medical error. That's a reasonable suggestion. But the implication of many media reports that these findings prove hundreds of thousands of people are dying each year due to medical errors is highly problematic.
First, the authors of the Johns Hopkins report did not collect any new data. Instead, they based their conclusions on studies performed by other authors. There is nothing wrong with that, in principle.
But in this case, the results are highly misleading because they are based on large extrapolations from very small data sets: The authors based their conclusions on four studies that included a total of only 35 deaths attributable to medical error—out of nearly 4,000 hospital admissions. Extrapolating from 35 deaths to a population of 320 million is quite a leap.
In addition, these studies frequently do a poor job of distinguishing between adverse events and errors. They are not the same thing.
An adverse event is defined as any undesirable outcome after a drug or treatment is administered to a patient. Every medical test and therapy, from antibiotics to surgery, is associated with some risk of an adverse outcome. Adverse events can include death, although that is rare. While every adverse outcome is regrettable, it does not prove that an error was made—that based on what was known at the time, a medical professional should have made a different decision or acted in a different way.
Physicians typically cannot know in advance which patients will experience such reactions, so attributing such deaths to error is misleading.
There is another problem with the Hopkins report: Two of the four studies it draws on use Medicare data, which generally include patients advanced in years, in relatively poor health, and being treated in the hospital. Sad to say, many such patients are at substantially increased risk of death to begin with. Many will die during their hospitalization no matter how well they are cared for. To attribute such deaths to error is to fail to account for the inevitability of death.
In fact, one of the studies on which the Hopkins report is based even includes a prominent correction factor. The author estimates the number of deaths due to medical error at 210,000. Then, based on the fact that the tools used to identify errors are imperfect, the author chooses to double his estimate of the number of deaths due to error to 420,000.
The sort of medical chart review used in these studies is radically different from caring for patients. The uncertainty and stress associated with caring for the very sickest patients are often invisible to hindsight. Seriously adverse patient outcomes are associated with a greater tendency to blame someone. When a patient has died, we want someone to be responsible even if every action taken appeared justifiable at the time.
This isn't the first study to try to assess how often medical errors can lead to death. Other studies paint a very different picture of the number of deaths attributable to error.
In one study responding to claims of very high death rates due to medical error, physicians reviewed 111 deaths in Department of Veterans Affairs hospitals by attempting to determine whether such deaths were preventable with “optimal care.” VA patients are generally older and sicker than the U.S. population, and thus somewhat comparable to studies based on Medicare data. Also, by using “optimal care,” the study may catch even more deaths than the “medical error” standards, resulting in a tendency to overestimate the number of deaths due to error.
At first, the researchers estimated that 23 percent of deaths could have been prevented. But when they were asked whether patients could have left the hospital alive, this number dropped to 6 percent. Finally, when the additional criterion of “3 months of good cognitive health after discharge” was added, the number dropped to 0.5 percent. Preventable deaths should be viewed in context, and there is a big difference between preventing death and restoring good health.
Applying the rates from the VA study to U.S. hospital admission data, medical error would drop down to No. 7 of the top 10 causes of death in the United States. Applying the additional criterion of three months of good cognitive health, medical error would not even rank in the top 20. Of course, doing so runs the same risks as the Johns Hopkins study; namely, extrapolating from a small study to the entire U.S. population.
To produce a truly balanced account of medicine's role in causing death, it would be necessary to account not only for the risks but also the benefits of medical care. Many patients with heart disease, cancer ,and diabetes whose deaths such studies attribute to medical error would not even be alive in the first place without medical treatment, where its benefits vastly outweigh its risks.
Looking at medicine from this point of view, we are fortunate to be living in an era of unsurpassed medical capabilities, when the profession is doing more to promote health and prolong life than at any time in the past.
Perhaps the strongest evidence that such studies overestimate the role of medical error is that the fact that, when causes of death are ranked by authoritative organizations such as the U.S. Centers for Disease Control and Prevention, medical error is not even included in the top 10. Would adding medical error to death certificates change this? We doubt it.
There is no doubt that mistakes occur in medicine every day, and if we take appropriate steps, error rates can be reduced. But inflated estimates of the number of deaths associated with error do nothing to advance understanding and may in fact make many patients more reluctant to seek care when they need it. A blinkered focus on error without corresponding accounts of medicine's benefits contributes to a distorted understanding of medicine's role in health and disease.
Nick Scobel posted a photo:
Crocodylus acutus
A hatchling explores a mangrove estuary on a remote key in south Florida.
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While grocery shopping one day, I realized I'd spent close to 30 minutes just in the produce section, meticulously choosing the best-looking apples, bananas that were ripe, but not spotted, ears of corn with perfectly aligned kernels. I admit, I'm picky about my produce. But I bet I'm not the only one that rejects the slightest bruise, blemish or mark on my fruits and veggies.
How did we get this way? Could it be because we are living in a society where everything is filtered, where beauty is rewarded, where supermarkets reject foods that don't adhere to a certain standard, where everything is shiny and bright?
I've also seen how my pursuit of perfect produce has impacted my kids. When I pack their lunches, I make sure to include the plumpest tomatoes, crispest blueberries, cucumbers without any dents or scratches. But one day when my daughter refused to eat an avocado that was turning slightly brown, I knew I had to change my ways. I realized I was unconsciously raising my children to accept society's norms of perfection and that these perceptions can have a devastating impact on our environment.
In the U.S, up to 40 percent of food produced is wasted every year. Most of this waste ends up in landfills that create dangerous greenhouse gases. Around 20 percent of food waste is produced directly at the farm because this so-called ugly food may not meet certain cosmetic standards set by grocery stores, yet are still perfectly consumable. Meanwhile, 48 million Americans live in food-insecure households.
On a recent night in San Francisco, I attended a dinner party to raise awareness about this growing problem. The event was called the Salvage Supperclub and it is the brainchild of food waste activist Josh Treuhaft, who decided to create a unique, immersive experience as a conversation starter around food waste. It was an intimate gathering of 16 people dining on a table made from reclaimed wood, all within a cleared-out dumpster. The chef, Pesha Perlsweig, prepared a six course meal with food that would have otherwise gone to waste.
Perlsweig sourced some of the evening's ingredients from Imperfect Produce, a delivery subscription service that specifically sells “ugly” fruits and vegetables. Boxes of produce might contain organic crooked carrots or knobbly sweet potatoes for 30 to 50 percent of the price that one might pay at a traditional market.
I was blown away by Perlsweig's creative dishes made from food the industry considers trash including stuffed wilted kale, ugly eggplant and squash ratatouille, and a delectable banana doughnut made from the actual peel of a banana. Before each course, Perlsweig offered guests tidbits and tips about how we can reduce our food waste. Did you know that if you cut off the end of a limp carrot or celery stalk and place it in water it will become firm again?
After the evening's dinner, I became inspired to rethink the way I shop for and consume food, to embrace the imperfect, the ugly, the unique. My actions have inspired my daughter to think differently as well. One morning, while she was helping prepare her school lunch, I noticed her choosing a handful of cherry tomatoes with slight blemishes. “They're special,” she said.
Here's hoping these small changes in our perception might make a big impact on our world.
Watch more of Laura Ling's reports on Seeker. Follow her on Twitter @lauraling.
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Sumatran Tiger habitat were pushed away by oil palm plantation and poacher.
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