Trust and Safety in Medicine: Part 2 by Matthew Waitner M2 Georgetown

Perhaps, as Terry Fairbanks said yesterday, we should look not to our individual pursuits but the healthcare system that is in place.  Individually, we are each committed to the reason we put on the white coat – to cure, heal, and do our best to care for each of our patients.  And yet collectively as a system we are failing to provide that very goal.  How is it possible that such dedicated individuals are systemically failing – it would appear to be impossible, and the numbers certainly show that its more than just a few bad apples.  Perhaps our system needs to be overhauled.

I was struck at the insight that Dr. Fairbanks shared.  As a human factor engineer he explained that every other system in the world accounts for the natural errors in humanity.  There are fail-safes embedded in most systems to catch the errors before they cause undue harm.  Such fail-safes are not present in the culture of healthcare.  While every hospital is claiming to be patient-centered, we often fail to see the humanity within ourselves.  I am firmly convinced at this point that a systemic culture change is the only solution to our never-ending problem of patient safety.  Dr. Fairbanks made it clear that skill-based errors (or better put, automated errors) are the key to controlling our out of control safety issues.  In fact, as a first year medical student we learned in our neuroscience course about types of memory: short-term, declarative (semantic and episodic), procedural, priming, associative, and non-associative.  The last of these (non-associative learning) is when someone is habitually exposed to the same event over and over again that the event is done by rote.  This should sound familiar, as it’s the same as skill-based tasks that require automation or limited cognitive input in order to be achieved.

From my class example, this is when you live over a flight path (which I actually do), and you tune out the sound of the overhead planes because you hear them every few minutes.  Every once in a while a plane will fly lower causing a louder that normal event that triggers you to notice them again, and again with habituation it disappears from your thoughts.  So it is clear that our mind can become habituated by automated responses that require little cognition, and it is only when there is a difference that your routine is noted.  Hence is the case discussed today of the NICU heparin incident – habituation caused major medical errors.  I am fascinated by the idea that this system error could have been avoided if there had been a slight difference (a different shaped vial, a different drawer, any change from the expected norm).  Dr. Fairbanks would argue that this is how well-meaning, caring professionals make simple mistakes that cost lives – and it is not the individual practitioner, it is the system involved regardless of how mindful we may be.  That same error was noted in the book “Why hospitals should fly” when the flaps were not engaged yet 3 people confirmed a 15,15 green (indicating the flaps were extended) – it was the expected result and therefore it was what was seen.  These sorts of systemic errors are where the most margin for improvement can occur – because like any job, medicine becomes routine and we become habituated, and our brains are physiologically wired to become habituated.

To say this conference has been insightful would fall short of its true meaning in my eyes as a future medical professional.  These past two days have shown me that our profession is far from perfect (even though each of us strives for such), and requires some major safety overhaul before the public catches wind of our missteps.  In fact, I’m not sure how much longer we can pull the wool over their eyes before they catch us red-handed, and I’m not exactly sure how we have been fooling them for as long as we have.  The numbers are out there, the mistakes make headlines, and yet we are still more trustworthy than a stranger on the street, and we deserve no such pride.  As medical professionals, its time to put egos aside and start doing what we swore an oath to do: do no harm.

Trust and Safety in Medicine: Part One by Matthew Waitner M2

George_WashingtonI have been participating in the Telluride East conference taking place in Washington, DC since August 1. In the whirlwind two days I have been barraged by information, struggled through leadership, boggled by safety concerns, and simply overwhelmed by my own emotions.  To put it bluntly, this is the most interesting two days I have spent all summer, and even though I am exhausted, I am beyond stimulated by the experience of this conference.  One minute we are hearing from Paul Levy on negotiations and the next we are working on teamwork and leadership in a teeter totter game with 9 teammates, a 2×8, a cinder block and 2 eggs.  Suffice to say this is truly a hands on and experiential learning experience like none other.

In reflecting on the past two days I have stumbled upon many thought trains (thanks Cliff), but one that my psyche continues to grapple with is the following conundrum: How can the medical community as a whole commit so many errors as to kill nearly 100,000 patients yearly (for at least 13 years according to the IOM), and still be considered one of the most trustworthy professions in the country?

All I have to say is, whatever PR firm is handling healthcare’s interest deserves some large bonuses for pulling off this feat.  Nurses, Pharmacists, and Doctors all top the list here in the US according to the most recent Gallup poll in November (http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx), nurses rank #4 and physicians #6 in Australia (http://www.readersdigest.com.au/most-trusted-professions-2013) and doctors rank #1 in the UK (http://www.gponline.com/News/article/1171314/Poll-reveals-doctors-trusted-profession/).  Seriously – this PR firm not only succeeded here in the US, but internationally as well.  I am stunned because on average (in the US) we kill 272 people per day due to medical errors which is the equivalent of two Boeing 737 crashing each and every day (total capacity per 737 = 137).

According to today’s presentation by Terry Fairbanks, we have a 1:616 adverse incident rate as a field – akin to bungee jumping in safety, while other professions soar in safety comparatively.  How could we possibly still believe then that healthcare professionals are still worthy of the patient’s trust? My only conclusion is that we as a profession do not deserve such accolades until we get our house in order and focus on patient safety.

What continues to be mind-boggling about this conundrum is that the population polled must have had some interaction at one point or another with the medical field.  Healthcare touches nearly every life in the country either directly or indirectly, and yet we are still given the distinct honor of being one of the most trustworthy professions.  This is even after Press Ganey scores (indicating mediocre treatment in the hospital, as any front-line employee will indicate), after outrageous hospital acquired infection rates (about 1.7 million yearly according to the CDC), and our dismal rate of iatrogenic death previously discussed.  Why are people not more outraged at these numbers?  As a future physician, these numbers are staggering and show that truly patients should not trust our professions.  So, truly, whatever PR firm is handling medicine must be doing one hell of a job and be making a killing in the process.  Seriously though, these numbers and our perception are at complete odds with one another and deserve to be honestly considered.

The only conclusion I have been able to draw from this analysis is that the healthcare profession has been given nearly implicit trust by our patients, by simply putting on a white coat, and we have done a horrible and dismal job of accepting that trust and caring for our patients safely.  Again I ask, where is the outrage?  Are people not doing the math? Where is the expose on 60 minutes or 20/20?  Frankly I’m surprised anyone trusts us at all, and if we are going to continue to receive such trust, we best make some changes fast to ensure that this trust is correctly placed.   From my perspective, somewhere in our profession, we have determined that while patients are the reason we exist, they are not to be treated as having such power.  Instead of being patient centered and safety conscious, we have turned healing into a business focused on doing more and caring less.  I am appalled as a future professional that this has been allowed to occur.  I, as many others reading this blog, came to this profession in order to diagnose, heal, and comfort people in their most dire need.  How could our profession have lost sight of our reasons for entering the profession in the first place?

Stay tuned for Part 2…

Slowing down to Speed Up

Day one reflection–Telluride East

by Scott Emory Moore

“We don’t run in the ER.”  

Early in my career as a new graduate nurse in a Level 1 Trauma Center, I remember hearing these words.  I do not remember why the nurse said this to me at the time, may not quite be the same reason as it comes to mind now, but it is a valuable lesson none-the-less.  In reflecting on my first day at Telluride East, it is evident to me that one person’s hasty actions can have tremendous impacts on outcomes and patient experiences.

Often in the healthcare industry we are quick to focus on speed and time rather than diligent and deliberate precision in the execution of the interventions.  Getting caught up in the fervor of the emergent situation does no good for us, rather it is when we slow down and take a full account of the situation that we are able to serve our patient’s best interests.

Slow down in order to speed up…

The Lewis Blackman story is a great example of the need to really take our time to ensure strong work and safe outcomes for patients.  Intentional focus on safety must be at the center of our work as healthcare professionals.  The stories of patient loss like Lewis Blackman must pave the way for improved hindsight, insight, and foresight surrounding patient safety.

Culture Change? Which One?

By Garrett Coyan, University of Kansas Medical School

The last week I spent at Telluride was very eye-opening for me. I was glad to be surrounded by so many other healthcare professionals that had the same desire to provide the safe and high-quality patient care experiences as I do. Reinvigorated with ideas for improving communication and decreasing risk to my patients, I couldn’t wait to get back to my institution and start implementing change. However, as I returned to the hospital today, I was quickly reminded of the main reason why this goal will be so difficult. Not only does cultural change need to occur in the hospital, but I would argue that even more importantly, cultural change needs to occur in the education of health professions students. This was made evidently clear by a conversation I had with one of my recently graduated colleagues who is staring his internship in a week. At our school, we take a one month class in our fourth year about public health, health policy, and healthcare practice. A few days of this class are slated to discuss patient safety and quality improvement. When I asked my friend about the content of this lesson, he told me frankly he couldn’t remember, because he and most of his classmates thought the information was either common sense or not really applicable. He related that most of this lesson was simply going over “bundles” of different types, and maybe 15 minutes was spent on communication between providers. The material was never really tested, and apparently didn’t stick with this particular colleague of mine. This, of course, was rather startling to me after the experience I had just had in Telluride!
In order to change the safety culture of the hospitals and health systems we work in, we need to create providers who are trained, knowledgeable, and willing to implement the changes needed to provide quality, compassionate, and safe care to our patients. It is for this reason that I will be speaking with my dean, director of quality improvement, all of my mentors, and as many of my classmates that will listen about making this information a mandatory and testable portion of our curriculum. It is only then that we can hope for young medical students, residents, and physicians to be competent and comfortable enough to speak up when medical errors are made, and confront them head on and honestly with our number one partner in healthcare: our patient.

I suppose the hardest part of the Telluride experience was not being involved in the intense and productive discussions that took place, but coming down from the mountain (literally and figuratively). It’s time to get to work. Culture change will not occur until we start demanding it!

Getting to 50

By Nicole T. Jiam, Johns Hopkins University School of Medicine

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About a month ago, I was sitting in on a clinical correlation led by an aneurysm neurosurgeon and his patient at the Johns Hopkins Hospital. These clinical correlations are incredible opportunities for medical school students to learn directly from the patients themselves by hearing their story and then asking them questions.

During this particular clinical correlation, the neurosurgeon discussed the importance of informed consent and the decision making process that stretches over several weeks. The decision to undergo a surgery and which neurosurgeon requires deliberation and time.

At one of the meetings prior to the operation, the Johns Hopkins neurosurgeon candidly told his patient: “One of the most important ways of evaluating physician competency is case volume. You want to pick a surgeon that has a huge wealth of experience doing this procedure.”

To which the patient responded by asking, “So… how many aneurysms have you done?”

During our clinical correlation, the patient recounted the neurosurgeon getting onto his computer. After a few minutes or so, the physician replies, “You will be my 537th.”

In the clinical correlation Q&A, a classmates asks the neurosurgeon, “What number determines competency?” It, of course, varies due to a number of factors, but 50 was thrown as a minimum number.

My classmate then re-raises his hand.

“Well… how do you get to that 50?”

It was a very legitimate question. One I had asked myself.

In these past couple of days, I have witnessed what happens when physicians fail to uphold their responsibility to their patients. Michael Skolnik was a young teenager that died unnecessarily because a neurosurgeon did not provide true informed consent. He did not disclose to the Skolniks that he had only done two cases prior to Michael’s. Furthermore, the neurosurgeon did not take the time to discuss the risks of the surgery and alternatives to the craniotomy. To Skolnik’s neurosurgeon, informed content meant a mere signature and 15 seconds of his time. A life was lost because of this missed conversation.

It was a heart wrenching story, and I felt ashamed for my profession. Telluride Patient Safety Roundtable forced us scholars to face these necessary truths. That lives are lost when we view informed consent as an annoyance rather than a responsibility we owe our patients.

But alas, we revisit the question – how do residents achieve that level of competency without endangering a patient’s life? Someone’s going to have to be number 1…

The Johns Hopkins neurosurgeon answered the question with this:

It is important to be honest with your patient. When a patient comes to me and tells me, “I don’t want a resident touching me”, I will ask him what does he mean by touching. If the patient means draping and prepping, etc., then I will let him know Johns Hopkins is a teaching hospital and that it would be better for him to seek care at a private hospital. But if he means the aneurysm/core of the case, I tell them that I will only let a resident that can do the procedure as good, if not better than me, “touch the patient.”

Residents have been frustrated with me in the past, saying I don’t let them do anything. But that’s because they cannot do the procedure at the standard I demand [...] I do believe some residents can become as good as me. They may not be able to do it as quickly but they can certainly achieve the same level of proficiency [...]. Aneurysms are not for everyone. I’d be happy to refer to them to a career counselor.

When I first heard his response, it was with mixed emotions. I understand how dangerous aneurysms are. But wasn’t that a bit harsh to imply a career change?

After hearing Michael Skolnik’s story, I recall this answer with fresh perspective and humility. This Johns Hopkins neurosurgeon demanded a standard of care we all owe our patients. How would I feel if a neurosurgeon killed my little brother by refusing to acknowledge his shortcomings? Yes, we all have to learn – but not when lives are at stake.

And if we’re not good enough, maybe we shouldn’t be holding the scalpel in the first place.

We Can Do Better: Telluride Reflections by Madeline Rovira #TPSER9

Wow.  I’m not even sure how to reflect on the amazing day we had today.  From the horrors of the Michael Skolnik case video, to the excitement of being the first group ever to save Stewie (our egg ‘patient’),  to the heartbreaking story that Carole courageously shared with the class, today has been emotional and eye-opening.

So many moments today, as we listened to and became engrossed in the narratives being shared, I found my face scrunched up or my mouth falling open wondering how we could possibly treat our patients and families in some of the ways that we do.  I like to believe that people are good and generally do the best they can.  And yet, hearing about health care providers who ignore and belittle a mother worried about her child, or administrators who threaten a mother who just lost her child to medical neglect, or a physician who performs a surgery he is not qualified to perform, or hospitals that hide medical records containing the truths that could give some closure to a family, I find myself faced with conflicting pictures and refuse to believe that this is as good as we can do.

I am not satisfied with the response that we only know how to prevent the egregious actions taken by the hospital after the appalling death of Carole’s daughter, and that the events prior are just much more complicated and since they are medically related they somehow become less preventable or less in our control.  If this was the case, none of us would be where we are.  I will not, I cannot, settle for this status quo as good enough.  We know better and we have to do better.  The excuse that patients are just so much more complicated and medicine is inherently dangerous is a poor excuse for the suffering and pain we routinely cause.

For as long as I can remember, I dreamed of being a doctor – someone who cures the sick, heals the injured, and returns loved ones to their homes.  In recognizing the chasm between my childhood view of medicine and the reality I am learning more about, I think I am finding the reason why work in quality improvement and safety is so exciting to me, and why I am comfortable not knowing what field of medicine I will practice as long as this is a piece of it.

Thank you Carole for your story – your daughter’s story.  Your courage and resilience is inspiring.

Reflections on Telluride experience

By Karen Mitchell

I first met Sorrell King at a Bioethics event sponsored by my hospital. When she was leaving to fly home, we asked her to return. She said she would come back if we filled an auditorium with students, and we did – nursing students, medical students, and other practitioners.  She believed that educating students was critical to improving patient safety.  This week has validated the seed she planted in me.  I hope that each of us return to our homes and our work and schools knowing that the power of one is amazing. We can each make a difference in the lives of patients and families and in the culture of our institutions. Keep the conversations going.

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