FeuchtBlog

Below is an article that I wrote several years ago, that is now more true today than when I wrote it. At the time, we had a flamingly incompetent Chief of Staff (called Dr. Bigshot, since he remains very prominent in politics at our hospital) and the staff of our hospital was all given an article by Dr. Guwande from the New Yorker regarding the virtues of checklists in saving lives. My apologies for not being able to give you the exact reference for this article, as I threw it in the wastebin. I have no problems with checklists. I have a serious problem with assuming that checklists are what saved the airline industry, and that people would be saved if only we used checklists. So, I re-post my article. The next post carries on with the same theme, now written contemporarily. BYW, Dennis, I found most of my grammatical errors, but feel free to inform me of others.

Several years ago, tort reform became the cry of the medical profession. We felt that our profession was being destroyed by a litigious culture which was strongly supported by a government that seemed to thrive off of a healthy legal industry. We lost that battle. In return, the law industry laid claim that the health care industry was careless and did not attend properly to quality control or error reduction. In turn, we responded with multiple programs. There were state and national programs that were initiated, such as the 100,000 lives campaign (I await eagerly the 250 million lives campaign). Even in Pierce County, our medical society invited various quality control pundits to speak to us. The rallying cry was to become like the airline industry. After all, did not the airline industry take an intensely complex system, and produce methodological algorithms (such as checklists) to eliminate human error? As I learned in flight surgery school, the number one cause for airline fatalities was a loss of situational awareness on the part of the pilot. Checklists helped to reduce routine operational error, thus, decreasing the one aspect of fatal error.

The article by Atal Guwande in the New Yorker further fosters this idea that if only the health care industry model itself after the airline industry, then error reduction would significantly fall, and lives would be saved. I certainly agree with Dr. Guwande that checklists can serve some useful purposes in our profession. Yet, I also see certain problems with what he proposes. The first problem discusses differences between the airline industry and medicine, that disallow the airline model. The second details the evidence that Dr. Guwande himself provides claiming that checklists can solve many of our woes.

First, what are the differences between medicine and the airline industry? There are a number of issues that I can list.

1. We can?t control the circumstances. In the airline industry, if bad weather hits, the airlines shut down. We can?t do that. We “fly” in any circumstances. If a patient arrives in immediate need for surgery when the operating rooms are already filled and the patient already has multiple system organ failure, we aren?t allowed to “stop all flights (surgeries)” and wait, in order to get control of the situation.

2. We don?t aim for 100% survival. Ultimately, all of our patients will die, which is 0% survival. Unlike airplanes, we have a poor means of predicting personal survivability. We can quote population statistics, which do not apply to a given individual. Checklists or not, eventually everybody will die on us. In fact, we have very poor means of measuring when we are actually successful in medicine, as it is not necessarily survivability at low cost without complications.

3. We cannot set the circumstances for surgeons or health care personnel like we can with pilots and flight attendants, airline mechanics, etc.. I would love to have the same working circumstances as a surgeon as a pilot usually lives. There are strict controls of working hours, and time that a pilot is allowed in the cockpit. We have no such controls. Yet we know that human error is our biggest source of health care error, just like situational awareness is the biggest problem in the airline industry. Establishing mandatory retirement ages, mandatory work-hours, mandatory spontaneous drug testing would kill the industry. I have operated countless times high on antihistamines in the symptomatic treatment of seasonal URI?s, yet such drugs would have grounded me in the airline industry. Are we willing to have our health care personnel subjected to such demanding regulation as the airline industry has done? Why not? The object is to eliminate human error, and such airline regulations would accomplish that.

4. Human systems back-up cannot compare. A pilot has not only a second backup (the copilot) always at his side, but also the capabilities of autopilot. Generally, we virtually never have a second physician (with the same expertise) simultaneously participating on a case. Auto-doctors remain to be invented.

5. Which leads to brutally serious question…why have auto-doctors not been invented yet? Autopilots work because one can “figure out” most the systems issues and expected problems in the operation of an aircraft. The “machinery” (the human body) that we work with is infinitely more complex than the machinery (the airplane) that the airline industry works with, and the expected problems vastly greater. While Dr. Guwande tends to disparage the “art” of medicine, heralding the virtues of scientific medicine, it remains without question that the complexities of medicine demand both intuitive as well as methodological decisions, and the intuitive decisions cannot be check-listed. An equivalent comparison would be to devise an airplane that is so complex, the ground support personnel never really understand how the airplane works, or exactly what the proper procedures are to repair. The pilot could never be sure whether pushing the joystick to the right would move the appropriate wings or flaps in the proper direction, and would be told that any control panel action would have only an 80% or less response rate, as well as a highly unpredictable nature of whether all the monitors or gauges on the control panel were ever monitoring the correct information. Yet, we live with this all the time in medicine.

6. The economics are different. If the airline industry is asked to institute an industry-wide change, they would raise rates to passengers to pay for that. We cannot do that any more in the health care industry. In fact, our pay would either remain stagnant or cut, in spite of elimination of error.

7. Training and retraining. We call retraining CME, yet CME only remotely pertains to our practice of medicine. A flight-simulator has never been invented for the health care industry, probably for reasons explained in #5. Our expertise comes solely from experience, coupled with the maintenance of an innovative mindset. When we increase physician educational demands and demonstration of competence through increased testing, the net result is not increased competence among physicians, but a decreased number of physicians, who drop out rather than re-test. This doesn?t mean that we can?t learn from the airline industry. It only means that we need to be very cautious in selecting what methodological algorithms we acquire from the airline industry, and then be highly selective in exactly which circumstances or activities would be well served by these algorithms. It is possible that some systems in medicine would actually be harmed by blindly applying the airline industry methodology of error prevention.

What about Dr. Guwande?s claims that checklists can significantly reduce error in medical care? Dr. Guwande discusses his thesis with unbridled enthusiasm. In a most unscientific manner, he fails to discuss multiple variables that should have been examined, especially since his thesis of the virtues of checklists are now being mandated throughout hospital systems in the USA. Which variables did Dr. Guwande follow? Survival? Costs? Turnover rates of health care personnel? Patient and family satisfaction? Days of hospitalization? His studies of checklists were limited to highly specific and controlled circumstances, such as the management of central lines. This is a relatively non-complex system compared to many systems seen in medicine. Does he propose that all operational systems will be helped by check-listing? Does he have evidence for that? Newly enacted checklists tend to eventually breed familiarity, that in turn lead to loss of effectiveness. Dr. Guwande has only short-term follow-up of his check-list system, so it is not surprising to see short-term improvements. What do you suppose we will see after ten years of checklisting and familiarity itself leads to error? I suspect it will lead to even more detailed check-lists, probably orchestrated by a computer program, rather than a human, such as the nurses that Dr. Guwande used in his catheter study. This in turn will not only drive up the costs of medical care, but also the depersonalization of medical care.

Outside of checklists, the failure to communicate has been identified as the other great sources of medical error. There is a great amount of truth to this, and check-lists certainly serve the function of forcing a brief episode of communication among the team, many of whom often don?t even know each other?s name, let alone the most rudimentary facts about the other people on the team in the room. But, we don?t dare tread on that. We must remain scientifically impersonal. Yet, when I work with a team that has known me for years, typically, minimal communication ever occurs about the patient or medical care we are rendering, save for occasional teaching points for the team (we do talk about other things!). We know how each other does things, and we expect things to be done that way. This is true for nurses and techs in the OR or recovery room, as well as experienced nurses on the wards. Sadly, regimented communication cannot fix the problem of operational harmony, something that only time and experience with each other as a team can fix. Which is why “teams” are probably more important than check-lists. Another communication issue, handwriting, was fixed thirty some years ago with computer-order entry, quite the norm in Chicago, IL where I trained, but still unknown in these parts.

Dr. Bigshot comments that resistance to checklists is an “ego” issue. I doubt it. True, there are ego issues when one has a nurse policing the doctor. Not even the airline industry has stooped that low, having a stewardess tell the pilot to push the rudder right rather than left when the airplane is going down. But that is exactly what is happening in medicine. You can escape hierarchical disorientation by being independent, which is exactly what Dr. Bigshot has done. Hospital bound doctors like surgeons and intensivists don?t have that luxury. Is it ego-istic to ask questions pertaining to the efficacy of checklists? I don?t think so. Many of us could have easily gone into research rather than clinical medicine. Our training teaches us to ask questions, look for alternative solutions, explore the unthinkable, to agonize over a solution that doesn?t exist in a textbook, journal article, or on a check-list. Yesteryear, that made you a good physician. Now-days, it makes you a non-team-player, radical, disruptive, or perhaps, worst of all, egoistic.

We will turn to checklists. We will love them with religious devotion. The Joint demands it. We will comply. Yet, it feels like we are driving just another stake into our coffin. R.I.P.

In Feuchtblog, I will be publishing several articles regarding healthcare and medicine. This article, as well as several to follow, will be short reflections of mine regarding the status of medicine in our country.

Following my heart procedure and then subsequent Sabbatical, I’ve had time to think about medicine and what is different about my profession from when I began as a private surgeon in 1992. The opportunity of being away from medicine for a year has been especially helpful in delineating what seems to bother me about the “New” Medicine.

1. The feminization/effeminization of medicine: The percentage of physicians that are female have sharply increased, so that in many medical schools in this country, there are now a majority of females. This is especially true in surgery, where the shift toward female doctors have taken a sharp upward turn. As a female, different expectations are held toward the profession. It is often the activity that conflicts, rather than supports family life. The female psyche of being more a nurturing person changes the approach to the patient. Oddly, this feminizing effect on medicine has affected even males. They are no longer supposed to be aggressive. They must be gentle and never lose their temper or raise their voice. They must now approach their patient as an advocate, friend, sympathizer, rather than as the authority and aggressor against their illness. As we have seen the effeminization of male movie stars, who previously were masculine and tough, Clint Eastwood types, but are now boyish girly men, male doctors have had a tendency to become girly men in the ways mentioned above.

2. The foreign-ication of medicine: I will be the first to comment on my absence of objection for foreign doctors. I believe that foreign physicians stimulate thought and provide wonderful new perspectives to American medicine. My favorite doctor of all time ever, Dr. Das Gupta remains a role model and mentor, though he was born outside of the USA. Yet, I can’t help but think that there is a problem when greater than 50% of our physicians are foreign medical graduates, and not necessarily assimilating into the American cultural belief systems. Besides religion, they differ in such drastic things as how they view the nature of science, medicine, and life itself. Many come here, assuming that wealth and lifestyle will be an automatic given, and often end up frustrated or disappointed when that doesn’t happen.

3. The accelerated gentrification of physicians: we see both an effect on the older physician, and a response that older physicians are giving to their profession in this gentrification. First, modern technology demands rapidly changing practice patterns in order to keep up on the latest-greatest. This often results in ping-ponging of management, that is, certain techniques or management methods are forbidden, then encouraged, and then later forbidden again. Otherwise, newer technologies or treatment plans come in that are often demanded by the patient, but offer no distinct advantage, are far more expensive, but take seemingly forever to discover the errors in their thinking. We see physicians retiring early, or, as soon as possible. They simply don’t wish to put up with the arrogance of younger doctors and competing technologies that seem to be more hot air than distinct helps to the physician or patient. We also see a loss of respect for the older physician. They tend to be out-dated, not with it, hopelessly lost in the past. It takes years to make the best physician judgements, yet these older physicians are no longer respected. A most functional medical community would allow the older physicians to slow down, and work with younger physicians to help them develop skills. This is not happening, and an increasing generational gap happens between younger and older doctors. In times past, the older doctors were able to hone their practice to allow for their decreased ability to be as physically agile or supple as the younger doc. It is more difficult to stay up at night, to have great physical strain in caring for sick patients, yet, there is no reprieve for the aging physician. Thus, for an aging physician, it only makes sense to get out asap.

4. Economic and legal dis-incentivation of physicians– The cost of medicine continues to rise. Prices on medical commodities continue to inflate at standard or accelerated rates, rent and employee costs continue to rise, taxes fail to go down, all of this eating away at physician profitability. Meanwhile, reimbursements continue to fall. When one subtracts costs from reimbursements, you get a number that is essentially your profit. If you divide that profit by the hours that you work, you get an essential pay rate. Currently, when accounting for inflation, I made more as an apprentice typographer than I am currently earning as a physician. Ultimately, physicians will deem the effort not worth it, and consider an employed situation, volunteering, or switching professions. Worst of all, many physicians will remain in their trade, while playing other trades such as gambling with the stock market or real estate investments in order to make a reasonable income commensurate with ones’ education and overall “sweat factor” to get where one is. Remember, most physicians started as quite competitive throughout high school, college, and even competed seriously in medical school, if one desired a more challenging specialty. Residency could be quite variable, but usually seriously limited ones’ lifestyle in years past. As an example, I spent essentially 16 years in “school” past high school to get to a point of being able to earn a living, and all the while accrued hefty school loans. Meanwhile, friends who started to work after high school were able to establish families, purchase homes, and become quite established. Others, who enlisted in the military or worked government jobs immediately after high school were 4 years from retirement by the time I was able to earn my first dime. I don’t pull out too many Kleenex when people complain about doctors’ earnings. But, what about legal dis-incentivation? It is not infrequent nowadays to see articles in surgical journals lamenting that certain surgeries are safer at high volume centers, and even though one may examine their own track records and see competitive  morbidity and mortality rates, the pressure is still extreme to transfer those patients on. When deciding to tackle a more complicated case, the reimbursement is no higher than a simpler case, yet the amount of time spent could be quadruple to ten-fold. At the same time, one is not legally protected for medical “heroics”, but could always be faulted for assuming care of certain patients. Thus, there is every reason to stick with simple cases, and transfer off more complicated, high risk cases. This does a terrible service to many patients, where travel away from families and known surroundings and a known medical community makes life more difficult, and often increases the risks to the patient. I have often seen where patients go off to these “centers of excellence” only to receive vastly inferior care to what would have been provided back home in a smaller hospital. The legal climate offers me no incentive to attempt to retain these patients.

5. The rise of public medical pseudo-professionalism with de-professionalization of physicians–Patient empowerment is a good and a bad thing. It is good when a patient comes to a true specialist and then gets a more complete picture of their current illness or situation. It can be bad when patients determine that they are more knowledgeable than the physician. I wish to add one caveat here. Patients always know themselves best, so that a decision for or against a medication or a surgical procedure is something that they need to choose in their own mind, and it is not good for a physician to force a treatment plan on a patient against the patients’ better sense, no matter how wrong it may seem to the physician. Contrary, when a patient attempts to force the hand of a physician for a treatment that the physician feels to be wrong, you could expect only trouble if the physician gives in. Much public pseudo-professionism is a result of a combination of the internet and big Pharma direct patient marketing. Another way in which pseudo-professionalism manifests itself is with the “2nd opinion”. In the past, a second opinion was often required by an insurance company. Now, many websites encourage seeking a second opinion. The problem with the second opinion is that a patient will never be able to adequately and critically choose between two doctors without a large amount of personal health care experience. Rarely is second opinion thinking correct. I have had patients turn me down because their second opinion physician gave them a kinder hug at the end of the session, or had a slicker office, or had better name recognition from advertising. When I discover that I’ve just wasted an hour or more with a highly anxious patient who just saw me as a second opinion and now is even more anxious in needing to decide between physicians, I will ask them for what criteria they would be using to determine who would be the best physician for them–typically, their answer betrays the other physician promising false security or over-rated expectations of what is physically or humanly possible. Therefore, I refuse to see second opinions, and will immediately cut off a second opinion visit unless the patient swears that they intend to stay under my service. I am not an entertainment committee to amuse the curiosity of needy patients. They can watch a medical soap on television for that.  Meanwhile, while patients become the “professionals”, physicians are rapidly loosing their concept of “professionalism”. I already railed about physician advertising, the loss of a true moral creed for physicians, and increasing dishonesty with physicians. Since the advent of the 80 hour residency workweek, personal time and comfort has taken a strong priority over the care of the patient. I was taught that one always sacrificed personal time when a patient needed your care. Residency meant almost never planning an event, since your primary responsibility was for your patients, and not the movie or restaurant you would be attending that evening. It was considered immoral to be an employed physician, as that meant confused loyalties. All of that is gone, and physicians have become nothing more than highly intensively trained plumbers or electricians. We are no longer professionals, but sophisticated and highly educated blue-collar workers. In return, we no longer have the right to expect to be treated like professionals.

Concomitant with these changes among health care professionals and patients, are changes that are occurring throughout our society, which influence medicine and the attitude of physicians.

1. Loss of personal integrity. I am called by the chart reviewer and asked to up-grade a person’s admission for no reason other than increased reimbursement by Medicare, and Medicare would allow it. The whole idea seemed quite dishonest to me, or at least encouraged serious inconsistencies, that would leave us physicians always wondering from moment to moment whether we were being “honest” rather than violating some crazy medicare rule. Physicians no longer desire integrity as a supreme quality. Efficiency and profitability come first.

2. De-personalization of others. While walking home one day recently, I passed a number of people, and would usually smile at them and either nod my head or say hello to them. The typical response was for the passerby to walk on, head slightly turned away from me, and not even acknowledge the presence of another person. De-personalization has affected medicine in many similar ways, so that people have become more and more fragmented, consisting of lungs and livers and intestines. This attitude has been true of the past, but distinctively truer now, and more obvious on the wards.

So, where does that leave me? In a sense, I dread being back in the bathtub of medicine, since the water now has become quite filthy. The next feuchtblog will talk about who is responsible for breaking medicine. I might eventually write a blog about my thoughts regarding what could be done to fix the healthcare crisis that we are in.