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Physician and Public Opinions on Quality of Health Care and the Problem of Medical Errors
Andrew R. Robinson, MD;
Kirsten B. Hohmann, MD;
Julie I. Rifkin, MD;
Daniel Topp, MA;
Christine M. Gilroy, MD;
Jeffrey A. Pickard, MD;
Robert J. Anderson, MD
Arch Intern Med. 2002;162:2186-2190.
ABSTRACT
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Background The 1999 Institute of Medicine report on medical errors proposed major
changes to the health care system and gained widespread media attention, yet
there is limited information on physician or public opinion regarding recommendations
from that report.
Methods Mail survey of 1000 Colorado physicians (n = 594) and 1000 national
physicians (n = 304), and telephone survey of 500 Colorado households to assess
agreement with several proposals and conclusions from the 1999 Institute of
Medicine report.
Results Most physicians believed that reduction of medical errors should be
a national priority (69.7% of Colorado physicians). However, physicians were
much less likely than the public to believe that quality of care is a problem
(29.1% vs 67.6%; P<.001) or that a national agency
is needed to address the problem of medical errors (24.1% vs 59.8%; P<.001). Uniformly, physicians believed that fear of
medical malpractice is a barrier to reporting of errors and that greater legal
safeguards are necessary for a mandatory reporting system to be successful.
Nearly all physicians (92.9%) believed that more training in how to handle
medical errors is needed, and 60.1% agreed that it is difficult to differentiate
errors due to negligence from unintended errors.
Conclusions There appears to be widespread concern among physicians regarding medical
errors, but only a minority in this survey believed that the problem is as
significant as the Institute of Medicine and the public believe it to be.
Our results suggest that physicians see several barriers to successful error
reduction including difficulty defining errors, the need for more training
in handling errors, and fear of malpractice litigation. Addressing these barriers
will be a necessary step to increasing physician support for many of the changes
proposed by the Institute of Medicine.
INTRODUCTION
OVER THE past decade, the quality and safety of health care in the United
States has become a major public health concern and the focus of significant
research. The 1999 Institute of Medicine (IOM) report on medical errors, To Err Is Human: Building a Safer Health System,1 reported "preventable adverse events as a leading
cause of death," and provided startling estimates of "between 44,000 and 98,000
Americans dying each year in hospitals as a result of medical errors."
While the accuracy of these estimates, which were based largely on retrospective
reviews of 2 observational studies,2-3 has
been widely debated,4-8 the
report has provided impetus for our health care system to accept the challenge
of improved reporting of medical errors and the reduction of preventable adverse
events. The IOM recommended that the federal government create a national
agency to research and monitor patient safety and advocated a nationwide mandatory
reporting system for serious medical errors.1 Furthermore,
the IOM acknowledged the potential problems facing those who report errors
and called for health care organizations to establish internal nonpunitive
error reporting systems in addition to national legislation to protect reporting
of nonserious medical errors.1
Since the release of this report, a number of national and private initiatives
to define the scope of the problem and to develop strategies for quality improvement
have arisen. The Agency for Healthcare Research and Quality along with the
Quality Interagency Coordination Task Force and the National Quality Forum
are among the leading agencies that have been designated to coordinate research
activity and implement standards for quality improvement. In addition, the
Joint Commission on the Accreditation of Healthcare Organizations has called
for the implementation of new patient safety standards and mandatory nonpunitive
reporting of serious medical errors.9
The public's opinions regarding the safety of health care are not well
understood. A 1997 National Patient Safety Foundation survey of adults reported
that 42% of respondents had been affected by a medical error, either personally
or through a friend or relative. In this same survey, respondents rated health
care as "moderately safe" overall, but it is not clear if or how public opinion
has changed since the IOM report was released.10
Despite the significant publicity given to these issues in both medical
and general presses, there is limited information about physician or public
opinion on the IOM's findings and recommendations. In view of the recent initiatives
to establish quality improvement standards in medical care and to reduce medical
errors, we believed it was important to ascertain physician and public attitudes
on the quality of health care and reporting of medical errors in the United
States, specifically addressing conclusions from the 1999 IOM report.
PARTICIPANTS AND METHODS
POPULATION AND SUBJECTS
We conducted a mail survey of 1000 Colorado physicians, randomly selected
from the Colorado Board of Medical Examiners list of active practitioners
(N = 12 168), and of 1000 physicians nationwide, randomly selected from
a master list of practicing physicians, maintained by the American Medical
Association (N = 730 290); this list, which contains both members and
nonmembers of the American Medical Association, is the most complete list
of active practitioners in the United States. Response rate for physicians
was calculated by dividing the numbers of returned surveys by the number mailed
minus the number returned undeliverable. We also conducted a random digit-dialing
telephone survey of 500 Colorado residents. Public respondents were considered
eligible if there was a member of the household 18 years or older willing
to answer the survey. Nonworking and nonresidential numbers were omitted.
Response rate was calculated as the number of respondents divided by the number
of eligible households reached.
QUESTIONNAIRE
All respondents were asked to rate their agreement with selected statements
taken from the IOM report on a 4-point Likert scale, ranging from strongly
agree to strongly disagree. Physicians were asked to rate their agreement
with an additional set of statements that were not asked of public respondents.
Physicians were asked their age, sex, specialty, practice type and setting,
and whether they had personally been involved in a medical malpractice suit.
Public respondents were asked their age, sex, racial/ethnic background, income,
and level of education. The study protocol and survey instrument were approved
by the Colorado Multiple Institutional Review Board.
ANALYSIS
Statistical analyses were performed using SAS version 8.01 (SAS Institute
Inc, Cary, NC). Differences in agreement were measured between the Colorado
public and Colorado physicians and between Colorado and US physicians. Responses
were analyzed in 2 ways. First, agreement with statements was compared between
groups along the entire range of responses using the Mantel-Haenszel  2 test; second, agreement was analyzed as a dichotomous variable, with
responses of "strongly agree" or "agree" and "strongly disagree" or "disagree"
combined. Because there were no significant differences in the 2 analyses,
we chose to report the dichotomous agreement variables in the results to maintain
simplicity and clarity. Differences in agreement rates between physician groups
and between physician and public respondents, as well as demographic differences
within groups, were tested with 2 tests.
To compare the respondents to the larger populations from which they
were drawn, we calculated 95% confidence intervals (CIs) for the demographic
characteristics of physicians and the public in our samples. Public respondents
were compared with census figures for the state of Colorado11 and
Colorado Department of Housing figures for the year 2000.12 For
physicians, data on US physicians from the American Medical Association13 were used for comparison; no separate demographic
data on Colorado physicians is available. We considered demographic characteristics
to be significantly different from the larger population if the population
figures fell outside of the 95% CI for our respondents.
Multivariate logistic regressions were performed within groups (physicians
or the public) to determine adjusted odds ratios (ORs) for predictors of agreement
with each statement. For the public, variables included in the models were
age, race (dichotomized into white and nonwhite), education (dichotomized
by high school graduate or not), and annual household income (dichotomized
at above or below $35 000 [near the median income in Colorado]). For
physicians, variables included in the model were age, primary care, urban
vs rural, and previous involvement in a malpractice suit. Because age was
not found to be a significant factor in any model, age older than 65 years
was also examined as a dichotomous variable for physicians and the public.
RESULTS
In Colorado, 594 of 902 eligible physicians completed the questionnaire
for a response rate of 65.9%. In the national sample, 304 of 853 eligible
physicians completed the survey for a response rate of 35.6% (Table 1). Overall, Colorado and national physician respondents were
demographically similar to each other and to physicians nationwide. A slightly
higher percentage of both Colorado and national physician respondents practice
in rural settings compared with physicians nationwide; a slightly higher proportion
of Colorado physician respondents practice primary care.
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Table 1. Characteristics of Physician Respondents
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Six hundred ten eligible Colorado households were contacted to obtain
500 responses for a response rate of 82% (Table 2). Compared with the Colorado population as a whole, our
respondents were more likely to be female, more likely to have earned a college
degree, and less likely to be Hispanic. Respondents were similar to the adult
Colorado population with regard to income and median age.
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Table 2. Characteristics of Public Respondents*
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Table 3 compares physician
and public attitudes in Colorado regarding the quality and safety of health
care and the need for national solutions with the problem of medical errors.
Compared with physicians, the public was more likely to believe quality and
safety of care are a problem, that error reduction should be a national priority,
and that a national agency is needed to address safety, and to support mandatory
reporting of serious errors. Rates of agreement between physicians and the
public were significantly different for all statements with the exception
of the IOM estimate of 44 000 to 98 000 deaths annually due to medical
errors. While 19% of both groups agreed with the estimate, 69% of public respondents
and 25% of physicians did not know if it was accurate (P<.001). For those who disagreed with the estimate, 29% of the public
respondents indicated that the number was too low, compared with 2% of physicians.
Conversely, 73% of physicians believed the estimate was too high, compared
with 2% of the public.
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Table 3. Colorado Physician and Public Agreement
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Table 4 compares Colorado
and national physician attitudes and perceptions about reporting and handling
medical errors. Nearly all physicians agreed that fear of medical malpractice
is a barrier to the reporting of errors and that greater legal safeguards
are necessary for a mandatory reporting system to be successful. A large majority
also agreed that the emphasis of reporting should be nonpunitive, and only
one quarter believe that the public should have access to error reporting
systems. Nearly 40% of physicians in both groups did not agree that all members
of the medical care team should be responsible for reporting errors. Nearly
all physicians reported that more training in how to handle medical errors
is needed. Physicians in the national sample were more likely than Colorado
physicians to agree that a national agency is needed (32.2 vs 24.1%; P = .01) and that malpractice litigation is a barrier to
error reporting (98.4 vs 95.5%; P = .03). Otherwise,
there were no significant differences in agreement between Colorado and national
physicians.
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Table 4. Colorado and National Physician Opinions
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Multivariate regression analyses found that physicians who were 65 years
or older were more likely to agree that quality is a problem (Colorado physicians
adjusted OR, 3.0; 95% CI, 1.7-5.4; national physicians adjusted OR, 3.4; 95%
CI, 1.6-7.3). Previous involvement in a malpractice suit was associated with
lower rates of agreement with mandatory reporting (Colorado physicians adjusted
OR, 0.7; 95% CI, 0.5-0.9; national physicians adjusted OR, 0.6; 95% CI, 0.4-1.0)
and with public access to reporting systems (Colorado physicians adjusted
OR, 0.6; 95% CI, 0.4-0.9; national physicians adjusted OR, 0.5; 95% CI, 0.3-0.9).
For public respondents, people were less likely to agree with the need
for a national agency to address the problem of medical errors if they were
white (adjusted OR, 0.3; 95% CI, 0.2-0.6), had attended some college or higher
(adjusted OR, 0.5; 95% CI, 0.3-0.9), or had a higher income (adjusted OR,
0.5; 95% CI, 0.3-0.8). Rates of agreement with the other statements did not
differ significantly by demographic characteristics.
COMMENT
The present study demonstrates that there is widespread concern in Colorado
among both physicians and the public regarding the problem of medical errors,
and a majority of both groups believe that error reduction should be a national
priority. However, it appears that a much higher proportion of the public,
compared with physicians, is concerned about the quality and safety of health
care. Although we did not ascertain the reasons for this difference in our
survey, it is possible that media attention given to the IOM report and to
isolated but horrific medical errors has affected public perception as well.
In a recent public survey, only 42% of respondents reported that they or someone
they knew had been affected by a medical error,10 yet
87% of respondents in our survey believed that error reduction should be a
national priority.
Another possible explanation for the difference between public and physician
opinion is that physicians are not as concerned about errors as they should
be.14-15 Most physicians (73%)
in our survey indicated that the IOM estimate of 44 000 to 98 000
deaths per year due to medical errors was too high, and only 21% believe that
the health care system has not matched the safety record of other industries.
It may also be that the inability to define errors or to determine if individual
errors truly are preventable4-5,8 has
led physicians to underestimate their frequency or not to recognize them at
all. It is also likely that the culture of medicine, which has not encouraged
physicians to openly acknowledge mistakes, has contributed as well.14-15 Further study is needed to clarify
the underpinnings of both physicians' and the public's beliefs.
Our survey also found a difference of opinion between physicians and
the public on how to deal with the problem of medical errors. The public was
substantially more likely than physicians to agree with the designation of
a national agency to lead initiatives in reducing medical errors, with almost
60% of the Colorado public supporting such an agency. It appears that public
support of government's role in reducing errors has increased since 1997,
when a national survey reported that majority of respondents (53%) believe
that federal and state governments have a negative or no effect on patient
safety.10
There was also a large difference between physician and public support
of a mandatory reporting system for serious medical errors. Even though the
majority of physicians support the idea of mandatory reporting, most also
see significant barriers to such a system. Among the barriers identified were
difficulty in defining errors, deciding who should be responsible for reporting
them, deciding who should have access to the results of reporting systems,
fear of malpractice litigation, and the need for greater legal safeguards.
This issue has been similarly raised in a recent report from the American
College of Physicians–American Society of Internal Medicine on the State
of the Union's Health Care,16 which called
for Congressional support of a uniform, voluntary, and nonpunitive reporting
requirement for medical errors with individual confidentiality protections.
The American College of Physicians–American Society of Internal Medicine
also called for broader reform of the medical liability system with enactment
of legislation to protect peer review and individual confidentiality prior
to implementation of either a voluntary or mandatory reporting system. Our
survey found that most physicians agree with these recommendations and reinforces
the notion that the current medicolegal environment must be changed before
more substantial reforms recommended by the IOM can be enacted.
Our survey has several limitations. We used different methods to administer
the survey (a mail questionnaire for physicians and a telephone survey for
the public). While we believe this was the most efficient way to ensure an
adequate response from each group, the different modes may have affected responses,
with nonresponse bias being more problematic with self-administered questionnaires.17 The use of a telephone survey excluded those without
telephones, and thus those of lower socioeconomic status are more likely to
be underrepresented. However, our proportion of those with annual household
incomes less than $20 000 was similar to the state as a whole, so we
believe this potential source of bias has been minimized. Response rates for
physicians were lower than those for the public, which also may lead to nonresponse
bias, and limits our ability to generalize these results to the larger population.
For Colorado physicians, we believe the response rate was adequate, and while
the response patterns of physicians in the national sample were comparable
with Colorado physicians, the low response rate in the national sample does
not allow us to generalize our findings to physicians nationwide.
Our survey of the public respondents only included Colorado residents.
Colorado residents are slightly younger, more educated, and have a higher
median income than the nation as a whole, and Colorado has fewer African Americans
and more Hispanics. Thus, our results cannot be generalized to the public
outside of Colorado. Also, our survey of the public was likely to have included
people who do and do not have regular contact with the health care system.
Such contact may be an important predictor of views regarding the quality
and safety of health care, but we did not gather this information from our
respondents. Also, the definition of "quality" is multifactorial, and we cannot
infer that respondents' concerns about the quality of health care in the United
States are necessarily related to safety or errors.
In summary, we found that the Colorado public agrees with many of the
conclusions made by the IOM and is likely to support many of the changes they
have proposed to improve safety and decrease medical errors. In contrast,
physicians are less likely to agree with the IOM's conclusions or to support
their recommendations. Without physician support, effecting such changes will
likely be more difficult. Our survey found several areas of concern to physicians
that may need to be addressed to increase physicians' support of changes and
improve their effectiveness. The IOM acknowledges the legal barriers to effective
error reporting systems, and our survey confirms that physicians nearly uniformly
concur. Improvement in training of providers in how to handle medical errors
appears to be needed as well. Better understanding of the differences in public
and physician attitudes and attempts to address the barriers to change may
help facilitate improvements that are acceptable to all involved groups. Physicians
should also be aware of public perceptions regarding the quality and safety
of health care and how they may affect both their patient interactions and
public policy.
AUTHOR INFORMATION
Accepted for publication February 13, 2002.
These results were presented in part at the Society of General Internal
Medicine National Meeting, San Diego, Calif, May 3, 2001.
Corresponding author: Andrew R. Robinson, MD, 1719 E 19th Ave, 5C
East, Denver, CO 80218 (e-mail: arobinson{at}health1.org).
From the Division of General Internal Medicine, HealthONE Presbyterian/St
Luke's Hospital, and University of Colorado Health Sciences Center, Denver.
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