At the end of the day

"How's your Tikker?"

A 37-year-old Swede named Fredrik Colting has invented a watch, aptly named "Tikker," that counts down the remaining years, months, hours, minutes and seconds of your life.  Well, not exactly of course, but with as much precision as can be created with actuarial tables and an algorithm which includes your age, gender, smoking habits and stress level.

Dubbed by its creator "The Happiness Watch," this instrument does for the millennial what a human skull on an otherwise bare desk did for medieval monks - which is to focus our attention on what's important by reminding us that life is fleeting.  For some, and sometimes, confronting mortality is liberating and refreshing and makes the world look brighter, and living more precious.   For others, it seems, the opposite occurs.  Terror of death provokes xenophobia, irritability and depression.  At least this has been the finding across many psychological studies looking at the effects of death consciousness on our minds. 

This makes me wonder: how does the constant confrontation with death affect physicians, nurses and other health professionals?  One doesn't have to look far to find burn out... do unconscious and unprocessed grief and fear take their toll unnoticed?  If so, this would make the case for reflective practices like writing that encourage us to explore and share our most difficult emotional encounters.  And what about the converse effect?  Can we catharse these sad experiences into love of life and an appreciation of the present? 

What do YOU think?

I opened some mail this morning from an investment firm.  It related to the estate of my late father-in-law and it contained a form which bespeaks...I'm not sure what.  Existential crisis? Tone deafness? A sense of humor?

The form is call "Change of Address As A Result Of Death."  (I'm not sure why there's a field for zip code.)

Very best wishes for a happy, healthy, life-affirming and meaningful 2014.

Approaching death with humility and care

I am recommending that every physician and nurse in our hospital read the cover story of today's New York Times Magazine "A right to die...the will to live" by Robin Marantz Henig.  The article describes in a way that is penetrating and analytic - but personal and humane -  the narrative of Brooke Hopkins, a bon vivant and English professor rendered quadriplegic in a cycling accident, and his loving wife Peggy Battin, who happens to be a bioethicist who has spent her career publishing on the right to die.

After years of philosophizing, legislating and teaching, our society - including its healthcare professionals - continue to struggle and suffer under the weight of decision-making at the end of life.  There are so many obstacles to getting this right.

First there is the legal clutter.  Thank goodness most physicians practice in only one state, because the hospital's role and the rights of the patient's "agent" all vary somewhat across state lines.  Then there is the evolving bioethical landscape.  How to understand patient "autonomy" and how this value balances with "beneficence" or the obligation of physician's to act always in the patient's best interest.  Additionally, there are our own biases.  There are those professionals, for example, who are so focused on death with dignity that they find it hard to understand that there are patients and families who want to fight for life.  And finally, there is intense pressure of time on nurses and doctors alike to ask the standard questions, populate the database and move on.

And so physicians in dialogue with families about the right next step are listening, inevitably, to a din of voices in their heads...the last Grand Rounds that talked about meanings of futility...Is it permissible to stop a life-prolonging treatment once started?   What if the family doesn't really know the patient's wishes?  What if the patient's healthcare agent believes that the ventilator should be disconnected but a younger sibling strongly objects?  Am I breaking a hospital rule? A law? A moral precept?

Reasonable persons can disagree sharply about what represents an authentic and autonomous decision of a patient at the end of life, whether to stop at the next intervention or to withdraw life-sustaining care.  I have heard it said that a patient who has asked not to be intubated in a formal declaration should not  be asked again at the time of crisis, because the sensation of air hunger (which probably feels like drowning) would cause many patients to change their minds.  How should we think about this?

There is hazard in all this uncertainty. I am concerned about doctors and nurses sidestepping the real issues while "normalizing" end-of-life discussions.  Populating the checkbox.  "Patient asked about appointing a healthcare proxy."  Check.  "DNR order."  Check, check.   This would be an abdication of our role and responsibility and a kind of abandonment.  What we need instead is a recognition of the fact that the end of life cannot be simplified and that there are no right answers.  Most of all we need honesty, humility and presence before the dying and those close to them.  This is the irreducible reality of our profession and what stands most starkly apart from the "business" of healthcare.
   

The Quartet Within

This weekend I discovered "A Late Quartet." Released in 2012, starring Christopher Walken (cello) and Philip Seymour Hoffman (violin), the film describes the creative process and the all-too human makers of music who comprise the (fictitious) Fugue Quartet.  And yes, there is a medical subplot involving a neurological disorder that affects one player (spoiler avoided, I hope) and therefore the unity of the ensemble.  But this isn't why we're exploring the film in this space.  I have another idea in mind.

But first, a little more about the characters.  Walken (an actor who so often plays odd or supernaturally-tinged roles that I have trouble watching him, and this is an unfair bias) is Peter Mitchell, the elder statesman of the Fugue.  His personal mantra is unwavering commitment to the music, into which nothing - and he means nothing - must intrude.  He is integrity personified, but on stage, he is not the star.  That role belongs to Daniel (played brilliantly by Mark Ivanir), as first violin.  This much younger man is the quartet's precision instrument.  When not engaged in relentless practice, he attends to the care of his instrument.  In a telling scene, he takes a student to the farm where he personally selects the horse hair that will become part of his bow.  It is that important, he tells her.  "Everyone says you're anal," she tells him.

Perhaps best known among cast members is Philip Seymour Hoffman, whose part is "second violin."  We become aware, however, that as in any string quartet, his role is anything but subservient.  He is surely no second fiddle.  Violinist Robert Gelbart is mid career, accomplished and passionate.  For him, a rehearsal without debate is empty, a performance without risk a waste.  He is the quartet's Freudian "Id,"its expressive force, and its soul.  Gelbart's wife Juliet, played with warmth and feeling by Catherine Keener, serves as violist.  She is the quiet one, the emotional glue (though privately tortured).  She is the conscience, the memory and a necessary counterweight to her husband's unbridled urgency.

I wonder whether any other physicians experiencing this film apprehended an extended metaphor for the doctor's mind and spirit, and indeed for our profession as a totality.  Or maybe not.  Is limitless commitment now out of style, replaced by a focus on work/life balance? Or passion, for that matter - has it been stifled by a healthcare "industry" which believes that physicians need monetary bonuses for adhering to scientific guidelines? I would argue that like the quartet that is the collective star of this thoughtful film, life and circumstance may intrude and threaten, but the guideposts endure.

Importantly, none of these characteristics - commitment to the work, the pursuit of perfection, passion, the drive to innovate or the centeredness necessary for personal and spiritual health - I say none are sufficient individually, yet all contribute to the harmony of self, and indeed to the creative urge which is at the authentic heart of music...and the medical profession.      

Don't Hurt Me, Don't Kill Me and Don't Make Me Suffer Needlessly

I have had a number of occasions to quote the gentleman who first wrote these words, but last week I finally met Roger Resar face to face.  Resar, a senior fellow at the Boston-based Institute for Healthcare Improvement and Assistant Professor of Medicine at Mayo, was addressing a room of healthcare leaders from North Shore LIJ Health System on the Global Trigger Tool, an innovative method for detecting, measuring and tracking adverse events, one that he helped develop.  Using it doesn't reduce harm, but it does make it detectable.  And this is a critical first step.

I had believed for a long time that the core issue in patient safety is identifying and preventing medical errors.  That view, I now think, is logical but wrong, or at least seriously incomplete, and this was Resar's message.  Patient safety is not principally about errors, he suggested, but about harm.   There are several reasons to defend this position. First, errors are generally hard to define and hard to detect. Additionally, studies confirm that most errors don't lead to harm.  It is simply not efficient to set our sites on the elimination of error from the hypercomplex environment of healthcare.  As a matter of fact, the pursuit of individual errors generally leads to interminable and vigorous debate about the relationship between the alleged error and the outcome.  Reputation and ego are often at stake.  Uncertainly prevails. This is a cul-de-sac and such discussions are mostly obstacles to progress.  Finally, when we focus on errors and away from harm, we tend to overlook many important opportunities to improve.  Today's "expectable" complication is an innovation away from the history books.

But wait, we say.  What about wrong-site surgery?  Or the calculation error leading to massive overdose and death in the ICU? Clearly these front page news events are as real as the connection between the fateful error and the tragic outcome.  We must pay attention.

Indeed we must.  However, these events are anomalous, describing a tiny fraction of all harm that occurs in hospitals today.  More than a decade after the Institute of Medicine opined that 100,000 patients a year die in hospitals due to "preventable adverse events"  we are hardly any closer to winning the war on harm.  The best studies suggest that three of every ten hospital admissions is still associated with an event that causes temporary harm, permanent injury or death.  It is time to change tactics.

Everyday miracles in the ED

Earl is an "environmental service worker" in our Emergency Department.  His formal responsibilities include mopping floors and removing trash.  Wearing his tan, hospital-issued uniform, he is tall and lean with graying hair and would make one think of the actor Morgan Freeman. I have changed his name but the following letter and the events it describes are very real...

Dear Earl,

On the evening of Friday, May 10^th my father-in-law was brought by ambulance to the Emergency Department after a serious fall and spinal injury.  You were on duty that evening. 

I saw many things happen in the ER that night.  Few of my memories, however, are more vivid than those of your kind and very meaningful gestures, your expressions of empathy and words of consolation, not just for our family but for many others as well.  I have the sense that this is something you do every day.  I recall in particular when you went to the bedside and saw an anxious 19 year old girl, our daughter ______, leaning in and holding the hand of an older gentleman on a stretcher.  He was grimacing in pain and she was looking shell shocked, and you said “you must be so worried about your grandpa… It really is going to be OK.” 

Hospital leaders spend a great deal of time trying to promote a culture of caring.  This is true not only because measures of Patient Experience are now publicly reported, but because providing compassionate care is what we are all here for.  Thank you very much for being a true leader by making patients and families feel better, and showing all those around you how it is done.  We would be grateful if you would agree to attend an upcoming Administrative Meeting so that you can share your ideas with the hospital’s senior staff.

Please accept my most sincere thanks for everything you do.

Yours truly,

Michael B Grosso

Diagnosis: why checklists wont do the (whole) job

Perusing the National Patient Safety Foundation website this morning, I noticed a page for patients entitled "Checklist for Getting the Right Diagnosis."  If only it were so simple.

It shouldn't be surprising that a group like NPSF would focus on a "systems" approach to the problem of diagnostic error.  After all, a key learning of the patient safety movement has been that healthcare errors in general can best be understood not as the individual failure of a doctor or nurse, say prescribing or giving a wrong medication, but as malfunctions of our hyper-complex healthcare delivery system susceptible to improvement with more reliable processes, communication protocols and standardization.

So when leaders are confronted with the widespread problem of diagnostic error, it is tempting to fit this issue into the very same framework, and to start thinking about systems-based approaches to a fix.  Hence, the checklist for correct diagnoses.  Therein, patients are advised to be good and accurate historians of their ailment, to keep track of their own test results and, most significantly, to "ask the physician, as a matter of routine, 'could this be anything else?'"  (Presumably this mental jog is intended to influence the physician to think more broadly about the patient's problem, and consider alternate diagnoses.) Here's the problem.

Physicians frequently weigh several diagnoses based on the patient's history and physical examination, narrowing the possibilities as they go on.  This is not a cut-and-dried affair, however.  Common conditions, as a med school aphorism goes, occur commonly.  Uncommon explanations are generally reserved for situations where it is so important not to delay the rarer diagnosis that it is acceptable to consider it seriously until "ruled out" with further investigation.  A common complaint may also point to an uncommon diagnosis when the clues just aren't "adding up" to any of the garden variety explanations - as when the pain is too severe, the duration or tempo of the symptoms is wrong, or a physical finding (like an enlarged lymph node or a peculiar rash) just doesn't make sense in the context of the "usual suspects."

This kind of thinking is dynamic and, one hopes, improves with the experience of the practitioner.  Doctors in training have trouble separating what's relevant from what's not, and so develop long lists of possible diagnoses, even for common complaints, where their supervising physician will quickly hone in on one or two.  As one might imagine, the process is potentially error-prone, which is what makes diagnosis the hardest part of medical practice.

I remember a day some three decades ago in the Pediatric ER at the New York Presbyterian Medical Center.  I was the senior resident, supervising an intern on a chilly January day.  He was presenting a perplexing case - fever, headache, and multiple organ system involvement - coughing, nasal congestion, joint and muscle pain, nausea and lack of appetite.  And yet, the patient's physical examination, beyond a clear nasal discharge, was "within normal limits."  He was clearly baffled. After he reviewed a series of arcane tests and investigations aimed at getting to the bottom of this,  I posed the question..."so why don't you think this is the flu?" 

On the other hand, physicians can go on mental autopilot and fail to recognize when the need exists to think outside the box.  Here's the challenge though - how to be sensitive to the rare bird without taking too many patients on chases of the wild goose, which cause their own problems.  Beyond the matter of cost, the diagnostic Sherlock Holmes will surely cause much unnecessary anxiety and mental anguish, and, from time to time, cause physical harm by aiming a machine gun of tests and treatments at problems when a fly swatter would suffice.

So here's my version of the one-size-fits-all diagnostic checklist.  One: did I remember to listen to the patient?  Two:  have I thought through the problem to the best of my ability?  Three: have I communicated my thoughts clearly to the patient and family?  And finally:  have I checked my hubris at the door?  Because being a good physician means never getting too infatuated with our own ideas and always being open to changing course if doing so is in the best interest of our patient.

Getting to Zero Harm

“There’s nothing in the high reliability literature that demonstrates how to move a hospital or health system from low to high reliability in the real world,” according to Mark R. Chassin, MD, FACP, president of The Joint Commission and the Joint Commission Center for Transforming Healthcare.

This is the second most challenging fact about patient safety in 2013.  We have no roadmaps, other than those we invent and test ourselves.  But the biggest obstacle is that it is hard for healthcare professionals to remember how lost we really are.

I have a love/hate relationship with the term "patient safety."  We tend to think of it as getting from good to great, like Volvo building better airbags to protect passengers in case of a high speed crash.  But there's a big difference.  Automotive safety protects passengers from threats "out there" - bad weather, another driver's error.  Patient safety is about protecting patients from the very healthcare we are providing.  A closer analogy would be Volvo announcing that it has reduced the number of times its cars spontaneously catch fire and explode, noting with pride that their vehicles now do so a bit less often then those of their competitors.  Imagine that.

That's how healthcare leaders have to see things if we are going to get to anywhere near zero harm from healthcare - making medication errors, hospital infections, "failure to rescue" events and wrong site surgeries problems of the past.   

In a recent monograph on high reliability in healthcare by the American College of Healthcare Executives (Healthcare Executive, Mar/April 2013), the author pointed out that we need to aim for the total elimination of "defects" (which in our world means harm to patients) if we are to really move the bar.  This admittedly flies in the face of "realistic" goal setting, given the difficulty of the work and our industry's track record to date.  

How do we engage our professional workforce - physicians and nurses, pharmacists and therapists, from housekeepers to hospital administrators - in a sustained, heartfelt rejection of the status quo and the heavy lift of transforming the way we do...everything?  As medical scientists, we like data.  But it is clear that data, business intelligence, report cards - call them what you will - are not nearly enough.  We need the human stories, and the closer to home the better.  We need the spirit of renewal and a vision of the possibilities before us.  And while on the topic of renewal and possibility, a happy Easter and Passover to all.