A Call to Address the Public Health Crisis of ‘Medical Error’
After decades of experience in public health, holding credentials from the UCLA School of Public Health and serving in leadership roles from middle management to the C-suite across various U.S. health systems—both non-profit and proprietary, including academic medical centers—I have come to a resolute conclusion. The mandate before medicine and healthcare ‘leadership’ is unambiguous: medical error is a public health emergency that demands immediate and concerted action.
The NMP Culture: A Deep-Rooted Issue in Academic Medicine
One of the most pervasive issues plaguing our healthcare system, particularly within academic medicine and tertiary medical centers, is the ‘NMP’ (Not My Patient, Not My Problem) culture. This ‘risk avoidant‘ attitude in a highly litigious (shame and blame) culture not only undermines patient care but also exacerbates the incidence of medical errors, contributing to what is now recognized as one of the leading causes of death in the United States. According to a study published in the BMJ, medical error is estimated to be the third leading cause of death in the U.S., trailing only heart disease and cancer—a staggering statistic equivalent to the crashing of multiple jumbo jets every single day!
A Personal Tragedy: The Loss of Anthony John Masters
My commitment to addressing this issue is deeply personal. In June of 2023, I experienced the most profound tragedy of my life: the loss of my healthy 38-year-old surfer, boarder and skateboarding son, Anthony John Masters, while under the care and custody of what were purported to be ‘world-class clinicians and administrators.’ Having witnessed this avoidable loss firsthand, powerlessly unable to advocate for him at bedside, I have spent the last 15 months grappling with an overwhelming sense of despair, anger, and disabling depression including periodic thoughts of suicide. This period has been marked by an endless loop of each phase of grief described by Elisabeth Kübler-Ross in her seminal work on death and dying.
My Professional Journey: From Supporting Physicians to Advocating for Systemic Change
Throughout my career, I have dedicated myself to working closely with and supporting physicians in nameplated U.S. hospitals or parent health systems. I was privileged to be one of the first ‘lay’ individuals in the country appointed as ‘Director of Medical Affairs‘ for a regional medical center in Colorado, a newly minted title and role attributed to the Estes Park Institute’s Medical Staff/Board retreats. In this role, I became intimately familiar with the inherent tensions and dysfunctions within the required collaborative governance structures characteristic of acute hospital settings—often likened to a ‘three-legged, wobbly stool‘ comprising the board, the medical staff organization, and the administration.
Many years later, I am horrified by the ‘normalization‘ and too often ‘code of silence‘ fear-based denial or reliance on litigation associated with medical error and preventable death claims in our healthcare system. This unacceptable reality propels me to take action (never underestimate the determination of a grieving father!). It is past time to confront and dismantle the unaccountable ‘NMP’ culture and to advocate for systemic change that prioritizes patient safety above all else. Too often the psychology – if not confirmation biased thought process – flows as follows. To determine if this situation is per se ‘my patient and thus my problem‘, the discernment decision tree is: is this patient on my service and therefore within my professional skill sets or specialty? If the answer to that question is ‘no’, absent an organizational commitment and culture embracing team-based leadership and ‘patient safety’ as the prime directive, the conclusion typically is: ‘it’s not my problem‘. This is unacceptable, period!
Looking Forward: A Vision for Change
As I recover the strength, clarity and determination to prevent other fathers, mothers, brothers, sisters, friends or colleagues from experiencing the horror I witnessed at bedside, I am committed to building or supporting initiatives aimed at eradicating medical error and fostering a culture of patient safety, accountability and compassion in our over-engineered ‘cathedrals of medicine‘. Often revered institutions surrounded by ‘moats and silos‘ (physical and psychological) constructs of provider centric vs. patient centric separation. It is my hope that by raising awareness, driving policy to enable team-based workflow and underlying cultural change, we can prevent other families from experiencing the same heartbreak the Masters family endured.
Anthony, ‘sea you again‘.
Love, Dad
References:
Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. BMJ, 353, i2139. Available at: BMJ Article
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