Several days ago, I was asked to attend a meeting put on by the hospital in conjunction with outside consultants, seeking ways to improve the working environment in the hospital. The focus seemed to be directed at the operating rooms and surgeons. The consultants were ex-Air Force fighter pilots who now work in the private airline industry flying jets and running this consulting firm. The theme of the discussion was that by utilizing various organizational and procedural methods, the airline industry has been able to significantly cut back its accident rate, implying that the same methods can be brought into the health care industry to reduce the number of mistakes.
The discussion immediately began to focus on critical aspects of relations between physicians, nurses, and techs at GSH. There was a prevailing notion that the old behaviors and attitudes of surgeons would no longer be tolerated, as it was destroying the ability of nurses and techs to work constructively and contribute to the well-being of patients. Surgeons, so it is said, do not listen, and operate under behavior patterns that assure that mistakes will happen. Procedural techniques to fix this problem include creating pauses before cases and having debriefings after cases. During regular operations, hostile relations will be sought to be removed in order to allow the free interchange of information among all parties involved in patient care.
There is much good to this model. It realizes that the surgeon is not God and cannot have command of all aspects of things in the operating room or on the patient floors. It appreciated that various other disciplines such as nursing, dietary, physical therapy, and others have contributions that should be considered in the physician decision-making process. This model realizes that when there is a breakdown in comfort among various groups interacting in a hospital, mistakes are going to be made that were otherwise preventable. I raise absolutely no objection to these ideals and feel that GSH needs to recruit assistance from outside themselves to correct these relational issues. Yet, there is something missing from the discussion noted by the surgeons but nobody else. To that, I will address.
The grass was never greener in the past. Yet, it seems like the hospital is now trying to fix something that they spent the last twenty years destroying. I am not sure that the airline industry and the plethora of consultants have a grasp as to what is really broken. I recall the years when I would make rounds twice a day. During these rounds, I was usually accompanied by either the patient’s nurse or the charge nurse. Ideas were exchanged, thoughts on patient care discussed, and then some social exchange occurred. I knew the name of all the nurses on the surgical floor, as well as their hobbies, family situation, and length of time that the nurse had been at GSH. None of this occurs anymore. It’s not just the nurses’ fault. With declining reimbursement, I had to be busier to maintain a solvent practice, meaning that more surgical cases had to be performed, leaving me less time for other things. The tension between family, hobbies, and work usually meant that compromises had to occur at work. About ten years ago, I stopped doing evening rounds. At that time, nurses also stopped rounding with the doctors. Because the hospital had to cut back on employee costs, nursing aides were the first to go. This meant that nurses had no time to round. Then, electronic medical records came into being, which meant that nurses had not only less time with the physician but also less time with the patient.
Meanwhile, inappropriate behaviors by physicians had become of increasing importance to hospitals. All it takes is one mean-spirited, demanding physician in a bad mood, or, perhaps a kind but incompetent physician in any mood, to make life miserable for everybody in the operating room and on the ward. Oddly, throughout the 20 years of my time at GSH, there has ALWAYS been one or two physicians under extreme fire from the administration. Somehow, when one naughty physician is appropriately silenced or removed from staff, another physician rose to take their place. Often, this was a physician who may have had just slightly inappropriate behavior in the past, but then received the spotlight, which assured that the intensity of maladaptive behaviors would increase. The physician might have been sent to anger management training (no comment on that, watch the movie Anger Management!), or worse yet, sent to Seattle for psychological investigation and therapy. Should a hospital need to appropriately remove a physician from staff, lawsuits could be expected, unless the hospital had adequate documentation to support their claims of persistent and enduring physician misbehavior. Thus, the evolution of incident reports. Incident reports are written now for every possible behavior that might be interpreted as maladaptive, including walking onto the wards with crossed eyes. Any joke, any statement, any reference that might be overheard and misinterpreted by the hearer would lead to an incident report. When a real incident occurs, then the hospital will enquire of all employees as to comments or statements that might have been uttered by the doctor producing the incident. These are all kept in files outside of the purview of the physician. Oddly, the only person in this grand production that was not writing incident reports was the physician, regardless of the misbehavior of the employee toward that physician.
Not surprisingly, the ultimate result of this has been a widening rift between physicians and the hospital. Those physicians who are most dependent on the hospital, the surgical specialties, and OB/Gyn, have had the hardest time adapting. Surgeons have complained bitterly in the past about the widening rift between the surgeon and the hospital employees, but this has fallen on deaf ears. Thus, when the hospital shows an interest in correcting the alienation of surgeons with the rest of the hospital community, it represents a favorable move that hopefully is not too late in coming.
I had mentioned that surgeons and surgical subspecialties have been defined as having the greatest behavior problems at the hospital. What is it that is different about surgeons that make them bad boys? Is it that it takes a certain greater amount of ego and ambition to be a surgeon than other specialties of medicine? Only a select few wanted to go into surgery in the past since the training was extreme, and the risks that the surgeon would take were extreme. I saw many bright young doctors drop out of surgical residency in order to go into a specialty that possessed a tincture of sanity. The few that survived residency often went into fellowships, which were even more demanding on the person. After about 5-9 years of abuse in the training program, the young surgeon would be spit out onto the community in order to practice their trade. Their ability to do brutal things to a patient and yet have them survive could for the most part be attributed to ingrained habits, routines, and developed skills that occur automatically. Success in the operating room is possible when the techs and nurses mesh with the particular style of the surgeon. Of course, this is far more critical for large, complex cases than for small routine procedures. The stakes on complex surgeries tend to be huge, and the ultimate responsibility rests upon the surgeon to get the patient through. It is known that post-operative care is just as critical as intra-operative care, and so similar demands are placed on the nurses and ancillary personnel on the floor to perform commensurate with the expectations of the surgeon.
What happens when the system breaks down? Complications occur, patients die, and fingers get pointed in all directions as to responsibility. Physicians become angry, nurses and techs become frightened or despondent, and further disruption of the system into a fatal spiral occurs. The hospital responds with checklists and policies. Niceness is enforced. Feel-good sessions are enacted. The root problem is ignored.
The surgeon used to be considered as captain of the ship. The airline pilots who were consulting for GSH acknowledged the importance of having a captain on an airplane. The pilot of the airplane has sole responsibility and is allowed the final decision for matters of concern that occur on an airplane in flight. Because of the breakdown in relations between surgeons and nurses/techs, there is no captain of the ship in a hospital. Decisions are made during my meetings and multiple consults. Everybody deserves an equal say in the decisions. If a nurse or other employee feels the physician to be in error, they have the hospital support to correct that decision and change the physician’s order or not fill the doctor’s order. This has happened to me many times and has happened many times to other physicians that I know of. To respond in an emotional manner would generate an anger management recommendation to the doctor.
The airline equivalent is appropriate here. In order to keep things totally safe, we should spend the rest of our life taxiing our airplanes around on the tarmac. The stewardess (now called flight attendant) would have a chance to drive the plane on the tarmac once in a while. Everybody will feel warm and fuzzy.
It is hard to compare the world of the airline pilot and that of the surgeon. The example of following protocols is often given of Captain Scully landing the AirWest plane in the Hudson. It was a tremendous decision. Oddly, he didn’t call a case management conference. He didn’t hold a discussion of options. He didn’t worry about offending the co-pilot, who happened to be flying the plane at the time. He immediately took total control of the plane. He would have not tolerated a stewardess protesting his decision and might have even acted in anger if the stewardess had the audacity to do such a thing. Surgery is always operating under an adverse event. Things are never normal, which is the reason for surgery. Much is not predictable. The human body is not a finely tuned aircraft whose every part and function is known. If we really had to compare the airline and health care industry, then we should force the Airline industry to operate mainly in inclement weather, with a 30% unreliability placed into all the instruments. The pilot could never totally trust his instruments. I really don’t think we’d see the same industry-wide track record for the airline industry. We might see more pilots forced into anger management classes for failing to respond properly to extreme stress.
Physicians used to be the orienting factor for quality health care. Many of the great clinics, such as the Mayo Clinic, Oschner Clinic, Cleveland Clinic, Virginia Mason Clinic, and others were created around a single surgeon who attracted patients. These physicians set the tone of excellence for the entire clinic. Today, hospital advertising tends to promote first-class facilities and techniques such as laser surgery or robotic surgery. Doctor names are rarely ever mentioned. When doctors are illustrated, it is typically a room with either a team of physicians and nurses and ancillary people or a group of physicians together. In a sense, this is understandable. But, it is like advertising an orchestra while focusing on the second violins and never mentioning the conductor. The second violins are vital, but nobody really cares who is playing second violin if the conductor is von Karajan.
The old paradigm of private practice medicine tended to keep the physician stable in the community. Now, physicians tend to be employed by hospitals or large physician groups, and their life situations tend to be far more mobile. As an example, hospitalists have been at GSH for at least 7-10 years, with 10-15 physicians in the group, yet only three of the hospitalists now at GSH have been at GSH for over 2 years. It becomes hard to build functional teams when most of the physicians and employees on the team are transient. Worse, without a stable physician base, it can be challenging for hospitals to promote physicians on their teams. Thus, the public focus is on things that do not promote quality, such as new hospital buildings, new computer informatics systems, and new gizmos in the operating room.
My solution to this whole problem was somewhat novel and required a Sabbatical to realize. After returning from Sabbatical in 2009, I decided that the safest solution was to never, ever do a complex case again. My patient outcomes at GSH historically have been superlative for thoracic cases, hepato-biliary and pancreatic surgery, gastric and esophageal surgery, and complex oncologic cases. Regardless, with a system that I viewed as broken, I was uncomfortable having my patient risk the hospital experience under my responsibility. I do not feel that the hospital has yet allowed surgeons to be the lead driving force for quality improvement. Therefore, I have advised complex surgical cases to go to the university for their surgical treatment.
The system is broken between physicians and the hospital and its employees, and I’m delighted to see the hospital taking a preliminary move toward identifying the problem and trying to fix it. I do NOT want to be misinterpreted as implying that this is a problem limited to my hospital. It is a problem that exists in most hospitals in the US and represents the changing culture of health care. For my hospital, it is most vital that they respond quickly to an ever-deteriorating condition of dysfunctional relationships. Thus, my strong support for bringing in an outside agency to help restore a workable dynamic in the hospital.