How Your Doctor Can Provide Safer, More Effective and More Efficient Care: The Role of Clinical Decision Making

During the last decade, health policy experts have devoted much thought to faulty "systems" and their influence on healthcare quality.  The idea is that even very qualified and devoted professionals will fail if the infrastructure of the healthcare system fails to promote effective information management, communication and coordination, while creating safety nets for high risk situations - like surgery and medication delivery - that keep inevitable human errors from actually harming patients.

This represented a significant departure for the medical profession, which for generations had focused single-mindedly on the individual physician as the unit of quality. However, as we confront run-away costs and uneven quality at a level that constitutes a national crisis, our focus must shift once more.   The safety agenda circa 2000 was about executing on the physician's plan of care.  Now we must re-direct our attention to the way physicians create that plan, and indeed to the way physicians diagnose and treat.  We need to think about thinking.

The "Medical Student Write-Up" was the place where past trainees (like me) first practiced diagnostic thinking and patient management.  It begins with a series of steps which, truth be told, physicians practice and, one hopes, improve upon over many years.  The patient arrives with "complaints" - like fever and abdominal pain - and the physician decides what other information is necessary to narrow the list of possible causes.  These "hypotheses"are then tested against the physical examination which may reveal findings (like right sided tenderness) that increase the likelihood of some diagnoses while ruling out others.  It is only at this point that additional tests, if any, are considered.  The thoughtful practitioner selects each test because the result - whatever it may be - materially changes the relative likelihood of one diagnosis as opposed to another. Additionally,  tests are prioritized based upon the urgency of the particular diagnosis under consideration (appendicitis, for example), the invasiveness of the test (like radiation from a CT scan), and, possibly, but not usually, its cost.

Here's the thing.  Busy, experienced practitioners see patients with certain complaints often enough that the sequence of steps becomes (somewhat) predictable.  And if the test is done often enough in a particular setting, it becomes a "standard of care" whether for the doctor individually or at the level of his peer group.  Sometimes this is a good thing, especially when the benefit of a test easily exceeds its risks and costs. There is a problem, however.  The more often such decisions are placed on "automatic pilot," the more removed the physician becomes from engagement with the facts of the case, hypothesis testing and critical thinking.  Over-use, diagnostic errors, over-exposure to harmful studies and excessive cost are ALL side effects of over-reliance on the "automatic pilot".

How do we know when doctors are on auto-pilot?  The fact is that it can be hard to tell.  And the reason for that is that many physicians have fallen away from the habit of recording their thought process in medical records.   Production pressure is one reason for this. Another is a misplaced notion that writing less is protective against medical malpractice (it isn't).  And paradoxically, the advent of electronic health records has made the situation worse, at least temporarily, as practitioners try to figure out how to use a combination of point-and-click, drop-downs and "free text" to replace what they once wrote with a ball-point pen.

The next time you see your doctor with a problem that needs diagnosing and she orders a battery of tests, ask the question.  What will this blood test or that MRI tell us?  Will it change the treatment?  Good diagnosticians have a reason for every test they order.  So if the answer is that "these are just the routine tests we do," think about another physician.  One who can share her thoughts and has thoughts to share.

      

Getting through the storm

Superstorm Sandy.  The waters have receded and the roads are (mostly) cleared.  But our homes are still largely dark and cold, and many have been rendered homeless.

I am writing this evening from the Riverhead, NY residence of my very generous father-in-law, who has opened his home to my wife and me, my mother and several friends.  Meanwhile, back at the hospital, nurses and physicians, ancillary staff and administrators are still working round the clock in the face of high volume in the ED and an overcrowded facility.  Why?  We can't discharge patients to unsafe conditions at home.  We can't discharge patients to long-term facilities and nursing homes that won't accept them, because their facilities are dark and their workers stranded.

Gridlock.

I have to say that like many, I have done my share of eye rolling when, in previous weeks and months, our COO called special meetings about disaster preparedness.  When the facility is humming along, the skies are blue and a dozen other challenges call out for attention, preparing for hypothetical catastrophes just doesn't seem like a good use of limited time.  We all feel differently now.

There have been positives.  On a personal level, I have been gratified to have opportunities to spend time with people one-on-one that I would not ever have had otherwise.  (Having spent Monday morning to Tuesday night in the hospital through the heart of the storm, I found many chances to engage my colleagues in discussions we would never had had under other circumstances...)  And then there was the camaraderie, the high spirits despite fatigue and the sense of shared purpose.  When every thing is going well we can be pretty self-centered.  The sommelier telling us that the Pinot Noir is unavailable becomes A BIG DEAL.  It takes a little disruption to set us straight.

There was one other lesson.  We have been conversing as a healthcare community about the issue of waste.  Unnecessary CT scans,  unwarranted consultations, inappropriate consultations. Under conditions of duress, these problems are magnified.  When the scanner is down, it MATTERS that we not order tests thoughtlessly.  And so, at a recent meeting of hospital leaders, I suggested that we keep this experience in mind when the dust settles, and get busy with the problem of eliminating waste from healthcare.  More on that next time.

To those of you in the path of Sandy, please accept my most sincere wishes for a safe recovery.  Keep the faith.