December 16, 2021

Editor’s note: Michael L. Millenson is the President of Health Quality Advisors LLC, author of the critically acclaimed book Demanding Medical Excellence: Doctors and Accountability in the Information Age, and an adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine. He serves on the Board of Directors for Project Patient Care, and earlier in his career he was a healthcare reporter for the Chicago Tribune, where he was nominated three times for a Pulitzer Prize. We spoke with him about how patient safety efforts are shaped by the media and how the role of media has changed since our original discussion on the role of media in patient safety (published in October of 2009 (https://psnet.ahrq.gov/perspective/conversation-charles-ornstein; https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety)).

Kendall Hall (KH): Let’s start by having you tell us a bit about yourself and your relationship to the media and patient safety.

Michael L. Millenson (MM): I started working for the Chicago Tribune in 1980 as a financial reporter. I started down the healthcare path in 1982, covering big healthcare companies like Baxter and Abbott, but became hooked on reporting the way healthcare issues affected ordinary people after doing a story about poor people suffering because they couldn't get ostomy supplies when the state of Illinois was not paying its Medicaid bills. In 1986, I was awarded an Alicia Patterson Foundation Fellowship and went out into the field for a year to report on the widespread changes in American healthcare being caused by new federal payment rules and new technology. That is when I truly saw the difference between what I call “meeting room reality” and “in the trenches reality.” When you see what's happening in the real world versus what people allow reporters to see, it started to spoil me for a journalistic career.

This is also when I became interested in quality of care. After my fellowship, I wrote a series of articles about the underserved, managed care, and measuring care quality that was nominated for a Pulitzer Prize, and a few years later a series about using technology to improve quality and safety that was also nominated. (My third nomination, with investigative reporter colleagues, was on a completely different topic.) I was “hooked” on quality and had begun using health services researchers as sources. I wanted to go deeper and applied for a Robert Wood Johnson Foundation Investigator Award in Health Policy Research in order to write a book. I got the award, became a visiting scholar at Northwestern University, and left journalism.

The book that ended up being Demanding Medical Excellence: Doctors and Accountability in the Information Age was supposed to build upon my last newspaper series and be all about how doctors were using technology to improve care. Instead, I was truly shocked to discover the extent of medical error and, to me, the then-inconceivable fact that a problem being repeatedly pointed out in the medical literature didn’t automatically change clinician behavior. (This was when the evidence-based medicine movement had barely begun.) Writing that book changed my life and put me on a course to be an activist, writer, researcher, consultant, et cetera, about patient safety and quality of care. Since I was not an academic and not up for tenure, I could bluntly say truths that academics only whisper, but won't write about in the peer-reviewed literature. Since then, I have been adjunct faculty at Northwestern in various departments. My work focuses on improving quality, improving safety, and improving patient-centered care, all focused on the healthcare delivery system.

KH: I think that's a nice historical perspective that takes us to the article you published in 2002 about how the news media turned patient safety into a priority.¹ As you know, your article was referenced in 2009 by Dr. Bob Wachter in a previous AHRQ [Agency for Healthcare Research and Quality] Patient Safety Perspective.² So let's just start with that and ask how has the media's coverage of patient safety changed?

MM: Historically, the gatekeepers of what constituted “news” were the three TV networks, the major national newspapers, and various wire services such as the Associated Press (AP). Virtually every news organization in the world belonged to the AP. The AP did stories on its own, and any story from a member could be condensed by the AP and sent out to the world. That’s how a story in the Boston Globe detailing how a young reporter named Betsy Lehman who experienced a fatal medical error³ could instantly be “picked up” by other media outlets and, essentially, be read or seen by virtually the entire public. As I wrote in my 2002 article, it was media exposure that translated into public outrage—Washington Post coverage of Lucian Leape’s JAMA denunciation of physician inertia in the face of patient harm, an NBC exposé about anesthesia deaths, the coverage of the To Err Is Human report—that prompted the profession to act. Absent that media spotlight, the same facts would have led to the same inaction that had continued for decades.

With the internet, any story from any source can go anywhere, but the ability to make an impact is diluted by the sheer amount of content we deal with today and the splintering of the audience. Stories can be either more or less impactful. It’s more hit or miss. Perhaps even more important is the loss of reporters in large and medium-sized cities who had healthcare “beat” expertise. That has largely, although not entirely, gone away as newsrooms have radically shrunk.

As for TV, they cover medical news in 30- to 60-second sound bites (except in the midst of a pandemic), and the content usually originates from official sources such as articles from medical journals and tend[s] to be the “medical miracle” stuff, as opposed to what’s happening in the healthcare delivery system. Patient safety issues are more amorphous and complex than talking about a brand-new drug or procedure that’s going to provide new hope of curing some disease. When you start to get down to things that are more complex like patient safety, it's more difficult to report.

KH: Why is it more difficult? You have things like the Betsy Lehman story from Boston and some of the other high-profile stories that are easy to report. For patient safety issues, there can be a large volume of representative data. Doesn’t the large volume of similar events have the same collective effect as an individual high-profile story?

MM: That’s a great question that highlights a key difference between the medical literature and the news media. We humans are wired to listen to genuine stories, and that’s what the news media does. Articles in the medical literature may be stories, but mostly they’re about facts, provided within a very strict structure. They need to be true, not necessarily interesting or even conclusive. A patient safety story with a clear victim (Betsy Lehman) or hero (a Harvard professor sounding the alarm) is easy to tell. Particularly today, if you want to cut through the noise, you need a compelling storyline.

KH: In your 2002 article you referenced the often-cited sound bite from the 1994 article published by Lucian Leape that the death toll from medical mistakes was equivalent to “two 747s crashing every three days” and described how it was picked up and lit a fire in the field.

MM: Yes, there was the article from Lucian Leape and the editorial written by David Blumenthal⁴ published in JAMA near the end of 1994. George Lundberg was JAMA editor-in-chief at the time. As he wrote in his book, Severed Trust, “I wanted to publish the paper for the profession, but feared that I would lose my job if the media hit hard on it.” The solution was to place the article in a late December issue, since “typically holiday issues are the least read and covered.”⁵ However, the article was picked up by National Public Radio and then the Washington Post and got a lot of publicity. That helped set the stage for the high-profile case of Betsy Lehman, which was uncovered by investigative reporting, based on documentation and interviews.

Betsy Lehman was a young mother in a Harvard-affiliated hospital being treated for breast cancer when she experienced a fatal medication administration error. That error occurred even though she was an “empowered patient” as a medical columnist for the Boston Globe and even though her husband was a researcher at the hospital where she died. So now you have a story that resonates with the general public—and the profession—because Lehman is young, well-educated, engaged in her care and is being treated at a prestigious hospital—and if something like that happens to her then it can happen to anyone. Under other circumstances though, perhaps her death might not have been so high profile.

Next comes the Institute of Medicine (IOM) report entitled To Err Is Human,⁶ and here the media is absolutely crucial. The report included names of actual patients harmed by errors, including Betsy Lehman, and it can do that because they are citing newspaper stories about error that the Lehman case helped bring out of the woodwork. They do that very deliberately, the same way they use a sound bite-ready estimate of 44,000 to 98,000 preventable deaths in hospitals each year. They planned to get news media attention, and they succeeded beyond their wildest expectations. Although the studies upon which the estimates were based were not new, the packaging, the prestige of the IOM, and the media attention resulted in their being part of a press conference on the White House lawn just two weeks later!

In 2001, when the IOM actually has an even more compelling story about quality of care throughout all of medicine, they publish the Crossing the Quality Chasm report.⁷ Here the IOM doesn’t include references to actual patients but rather includes only data. Their sound bite is great, but it’s a generalization, i.e., there’s not just a “gap” but a “chasm” between the quality of care we have and should have. I vividly remember this getting a few paragraphs in the Washington Post at the bottom of page 3 because it was just data and did not include real people who were affected—it lacked the human-interest component. (On the other hand, it was perfect for PowerPoint use by healthcare people.)

Now, if we fast-forward to 2015, the National Academy of Medicine (formerly the IOM) publishes its report Improving Diagnosis in Health Care,⁸ where they included case studies, but the names were semi-shrouded, without last name (though you could easily find them via an internet search), and the full case studies were buried in the appendix. The report did not get a lot of media attention. The lesson is, you have to tell a clear human-interest story that resonates.

This is where some of the great work I’d like to see featured in the media becomes invisible. The individual whose life was saved by care being safer doesn't know they weren’t harmed. It’s the plane crash that doesn’t happen. And part of the problem is that the hospitals I admire that have truly gone toward zero harm in terms of adverse events have not gotten any publicity for it in the general news media because it's really difficult to go to your local newspaper and say, “You know what? We’re hurting fewer people.” That’s not a story your lawyers or executives want you to tell. There are definitely heroes when it comes to patient safety and medical error prevention, but it's difficult to tell those stories.

KH: So it sounds like you're saying that a high-profile case still could have the same effect on patient safety as it did in the past.  

MM: Absolutely. Yet publicity doesn’t magically solve the problem of resistance to change by many in the medical profession. The excuses we heard then we still hear today, if more muted: the number of preventable deaths was exaggerated; the individuals who died were already very sick and would have died anyway; we’re doing everything we can.

Ten years after the IOM’s report To Err Is Human, the medical literature made it clear that care had not become significantly safer,⁹ much less met the IOM’s goal of cutting the toll from medical error in half. I wrote in the Health Affairs blog in 2010 that the problem is due to the three I’s: invisibility, inertia, and income.¹⁰ Invisibility is what happens when medical errors kill a few people at a time, spread out over many hospitals, and the deaths come among those who were already very sick. They become, in a real sense, invisible. Inertia is the resistance to adopting practices that are known to reduce errors out of fear that adopting them would highlight weaknesses or that mortality reduction is already optimal—and that problem remains strong. Finally, and the least spoken about publicly, is income, which represents the belief that complications bring additional income to the hospital and sometimes to individual clinicians, such as surgeons. I wrote a piece in December of 2019 about the danger of the business case for safety where financial motivations might prevent implementation of inexpensive steps known to improve patient safety.¹¹

KH: We’ve been talking about patient outcomes that wind up on the front page. What about presenting performance issues with structural or process measures and how that performance ultimately affects patient safety?

MM: The problem with that story is that it’s technical; nobody wants to read it unless you can connect it with a human face. Remember that the public expects hospitals to follow protocols and provide good care. If you were going to write a “doing things right” story, you would have to show why it's special and not ordinary, which would require a hospital that's willing to go public about what it had been doing and what it was doing now. Not impossible, but difficult to share with the general public as opposed to the trade press.

More broadly, there's an ongoing debate inside the quality movement about whether providers don't have the tools to make care safer or don't have the willpower. Again, if you were going to put that into a newspaper or television news story, you would have to show places where they don't have the tools or the motivation—perhaps because they think care is already pretty good—and find somebody willing to state those things on the record. Again, really difficult. Journalists need multiple corroborative sources. Sometimes people believe that they're the victim of an error when they weren't, and sometimes, they believe they got great care when they didn't. So you can't always just go by the testimony of an individual.

KH: So is it possible to use the media to drive safety efforts anymore like we did in the past? And if so, how can we use the media in that way? We kind of talked a little bit about that, but it requires people divulging some of the inner workings.

MM: Yes, if people talk to journalists. Going back to the 1999 IOM report To Err Is Human, the media had already done the reporting based on egregious errors, and the authors of the report were smart enough to use what the media had already done and then add a catch phrase that they knew would be picked up. If you want to report on good hospital performance as we talked about earlier, where some of the hospitals have done superb work, ultimately you put yourself in a difficult position. If you're reporting that a specific hospital is giving care that is safer than other hospitals, you have to have good data to demonstrate that claim. It's not a story to say a hospital is providing safe care unless there is some sort of contrast. So, for example, if there is a big patient safety scandal, reporters might turn to hospitals with great Leapfrog scores to show that things can be different. Contrast.

KH: Let’s turn the conversation a bit to other forms of media, particularly social media and what they are reporting.

MM: Online health news organizations provide a lot of information. That’s not quite social media, but because everything is now searchable, it does help with being more influential in telling patient safety stories. With the internet, even if you tell a story to a small news organization, it becomes searchable by everybody. It doesn’t have to be in a major news organization. I think that's important to emphasize.

Social media can also be important when we talk about patient safety, but you have to look closely at context. Is an adverse drug reaction a safety issue that could have been prevented or not? A lot of the social media stuff gets publicity because it’s easy to find. But the people who get medical care tend to be sick and older. How many people like that, if they have a problem with their care, turn to Twitter? How many people want to tweet out personal medical experiences?  Social media like Facebook can be influential in the stories it tells. Twitter, Instagram, TikTok not so much.

KH: But if you see enough similar stories, you could use Twitter, Instagram, Facebook, etc., to find trends and potential safety concerns.

MM: Facebook and similar social media can certainly serve as tip sheets for journalists. Somebody can tell a story through there that goes viral in the mainstream media, no doubt about it.

KH: I’m thinking about it as a patient safety tool, like using it to identify clusters of events, or identifying systemic causes of events. So, use it not to get the story into the mainstream, but as a tool, similar to how web data can be used for syndromic surveillance.

MM: I think that could get people's attention. Social media is evolving as the ways of listening to the patient's voice are evolving. Suppose you say, “I've been tracking the last year of medical data on my wearable device (or implanted device), and I can show what happened.” It becomes documented. I believe that as we move to a data-driven world, the patient's voice will be amplified. We now have OpenNotes¹² and federal rules against information blocking, so the role played by patient involvement could radically change over the next five years.

KH: This gets back to my original question. Do you think it's viable to use the media to drive patient safety efforts and to be demanding of hospitals to get to zero errors?

MM: Yes, providing we can tell the right stories. Suppose on World Patient Safety Day you had women who had lost a child to a medical error show up at different local TV stations and say, “My child died at this hospital, and they paid me a settlement, and I know that they're trying to improve, but we need to hold them and others accountable to do more.” That would be a powerful story—or someone who lost a spouse or a parent. It would not be a scandal, but it would be real people pushing for accountability in a public way, as opposed to working “within the system” quietly, which is mostly what happens now. Although, to be fair, patient advisory councils could also be a general news media story if they could point to a real and significant impact.

KH: So what is the overall takeaway regarding media’s influence to drive change? Is it holding up the mirror to the medical community and saying, look, you’re not doing well, and confronting them with that?

MM: After the IOM report, the medical community changed for two reasons: political pressure and public pressure. Thomas Kuhn famously wrote that paradigms do not change until the defenders of the old way can “no longer evade the anomalies that subvert the existing tradition.”¹³ Let's be clear: I don’t believe any provider is deliberately giving unsafe care. And so, if people believe that the care they're giving is already safe, they will not change unless you hold up a mirror that does not allow them to avert their gaze from the evidence of how the “old ways” are failing patients.

Media coverage provides a motivation, and often an urgent one, to have a discussion about patient safety. It’s not a topic coming out of the blue. It’s what “people are talking about.” All of us have issues in our life that take our attention. Patient safety will not be a priority until we can show the public, emotionally and economically, that it matters to their lives, that they should care. The Betsy Lehman case made the point emotionally. Government regulation and payment rules are making the point economically.

Professionalism alone won't do it, and has never done it, as physician leaders in this field have openly acknowledged. It’s not because doctors are uncaring, it’s just that with so many other pressures, this is not seen as pressing. Economic incentives alone won't do it, either, for many reasons. But if you can mobilize professionalism plus economic incentives, we can and will get change. And that's where the media comes in. Media coverage affects us in a deep way, in terms of how we want to be seen by others. The reflection in the media motivates change.

Consider, for instance, the chief medical officer who can't get a physician volunteer to take over responsibility for patient safety, not because the doctors don’t care about safety, but because the situation generally seems acceptable. However, if there were a high-profile safety event either locally or nationally that received a great deal of publicity, filling that patient safety improvement role would become a lot easier. Now the problem has salience. That’s just human nature—the squeaky wheel gets the grease. We need the news media to make the noise that will make this issue one that the general public cares about. That’s how the good people who urgently want to drive us to zero medical errors will have the leverage they need to do just that. It's that simple.