Mini book review of Robert Pearl's Mistreated - SEPSIS

Mark Graber Mark.Graber at IMPROVEDIAGNOSIS.ORG
Fri Jun 9 15:17:56 UTC 2017


Thanks Ruth for the calling attention to Robert Pearl’s book and the sepsis problem.
For sure there is a great deal more to do, but sepsis is probably the leading example of a success story in terms of improving diagnosis.  Besides the enormous advances in tests to expedite the diagnosis, sepsis triggers and ‘bundles’ abound and substantial improvements in both timely diagnosis and mortality have been reported.  The Society for Critical Care Medicine sponsors the “Surviving Sepsis Campaign”, and sepsis awareness is the major focus of the Rory Staunton Foundation (responsible for the NY State laws on sepsis), the Sepsis Alliance (who cite statistics on awareness increasing from 15% to 55%) and the Sepsis Coalition, not to mention the Global Sepsis Alliance that sponsors World Sepsis Day (Sept 13) and the World Sepsis Congress (inaugural meeting in 2016).  So the congruence of better tests, growing awareness, and real changes in how care is delivered in hospitals has started to make a measureable difference.   We need more examples like this one !
Mark L Graber, MD FACP
President, Society to Improve Diagnosis in Medicine
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From: Ruth Ryan <ruth at RYAN-GRAHAM.COM>
Reply-To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Ruth Ryan <ruth at RYAN-GRAHAM.COM>
Date: Friday, June 9, 2017 at 8:28 AM
To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] Mini book review of Robert Pearl's Mistreated

Mistreated: Why We Think We're Getting Good Health Care -- and Why We're Usually Wrong, Robert Pearl’s 2017 book
He’s a surgeon and CEO OF Permanente Medical Group.
I’ve not seen any reviews of this in any medical sites.  It’s aimed at the general public and is an easy read, maybe that is why. He explains elegantly such concepts as homeostasis as background for the reader. It’s beautifully written.  Some citations are provided, not all.
But Verghese, Gawande, and Rosenthal wrote glowing blurbs for it—good enough for me to buy it.
There’s a section pp. 29-44 on diagnostic error and sepsis.  I am interested in this since my liability and case review background has showed me that many deaths have been classified as just people with infections who happened to code and die.  Until recently they were not even identified or categorized as death from septic shock.  Pearl gathers statistics: 1/6 hospital deaths are from sepsis. 210,000 people die of it annually.  Instituting the EGDT protocol cuts mortality 20-40% (true in Rivers study, and in subsequent cases where protocols were instituted institution- and system-wide on an ongoing basis).
About half of US hospital have a sepsis protocol of some sort, one quarter are “working on it”, and the other quarter—nothing.  He notes sepsis is an “orphan” disease owned by no particular specialty that takes charge and promotes protocols and has no equivalent Heart Association that sponsors fundraisers and raises awareness. He does an enlightening and thorough discussion of Kahneman/Tversky with respect to this diagnosis and the reasons evidence is not consistently followed in it.
I haven’t gotten to his recommendations yet, and he is boundlessly enthusiastic about electronic health record capabilities, while casually noting that many of those capabilities are not actually available or reimbursed yet. This book may be overshadowed by Elizabeth Rosenthal’s American Sickness at the moment, but it is well worth the airplane read.


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