Doctor please, not in front of the patient: interdisciplinary teamwork in healthcare

In today's New York Times, oncology nurse and author Theresa Brown highlights the sometimes fraught and always complicated relationship between physicians and nurses.  By drawing attention to the "hierarchical" interaction between these intertwined but very separate professions, she exposes some weighty issues.  These are matters with real consequences - both for those who provide, and those who consume contemporary, high-tech healthcare.  I want to talk about what she leaves out.

But first, here's what I think this accomplished nurse is saying that physicians have to hear. Medicine, if it was ever a solo act, isn't one anymore.  The hospital is a dangerous place.  We need to "expect" one another to make slips and errors - not so we can excuse ourselves, but so that we can see these events coming - before they harm a patient, and help one another by heading them off.  This is the essence of teamwork on behalf of patient safety.  

Changing the culture of an organization is hard work, but changing that of a whole profession is like steering an ocean liner.  Where do we come from, as physicians?  A longstanding "culture of accountability" means that doctors expect perfection of themselves and their colleagues.  That they, alone, must shoulder the burden of hard decisions.  That making a mistake is not merely a technical problem, but also a significant moral failure.  We are in many ways so different from our nursing colleagues that we have trouble understanding one another. Physicians focus on the mechanisms of disease and fixing what is broken.  Nurses respond to the patient who owns the disease, and that individual's overall needs.  Hospital leaders expect nurses, nowadays, to "stop the line" for safety.  They rightly complain that some of us physicians never go the memo.

On the other hand, many hospitals and Health Systems like ours have embraced team training.  We study and practice the language and techniques of highly effective teams...we call "huddles," we use checklists, and check backs and safe words that mean "I think we have to pause and figure this out because we're not on the same page." This is a framework adapted from aviation, nuclear power and the military, and applied in the Emergency Department, Labor Suite and Operating Room.  It is slow work, but there is reason to believe that it is stemming the tide of medical errors, a little at a time.

 

In her Times essay, “Healing the Hospital Hierarchy,” Brown describes an intimating encounter with a senior physician who “seethed” at her, eyeball to eyeball, when she proposed that a bone marrow procedure be delayed until her patient’s potentially serious heart problem could be evaluated.  She adds that “there is no established way for a nurse to resolve” such serious concerns. 

But here’s what Ms. Brown has left out.  First, escalation procedures in many hospitals absolutely encourage and protect the professional who speaks up.  In fact, they demand as much.  Second, intimidating behavior by any team member is verboten.  As a matter of fact, our Code of Conduct refers to it in great detail.  Physicians in our facility have been disciplined for it and privileges have been revoked. 

Finally, mutual understanding must be, well, mutual.  What I mean is that just as doctors need to understand the nurse’s role and hear her perspective, so nurses need to appreciate that most physicians, like most nurses, really ARE there for the patient and that they are committed to doing the right thing.  Therein lies the path to real teamwork – respect all around, and the patient at the center.        

Can We Catch Up With Belize?

My adventurous, smart and idealistic wife - also a pediatrician - is planning an international medicine experience this spring in Central America; her destination is Belize.  Since I'm the one more comfortable with literature searches than safaris, I've been checking out the healthcare system that she'll be working in.  According to the World Health Organization, Belize is a country of just 318,000 with a per capita GDP just 1/7th of the US.  This is not surprising, but here's what is.

In Belize, 98% of children receive measles vaccine, while 95% are immunized against whooping cough and hepatitis.  In the US, those rates are just 92, 92 and 93%.  Looked at another way, in the US four times as many children are un-immunized against measles than in a third world country, when adjusted for population.

Does it matter?  Immunization is one of the best markers we have for the quality of child healthcare.  Besides preventing a variety of infections that threaten life and health, immunization is a good proxy for overall contact with preventive healthcare and a measure of the extent to which a society provides for its children.  And look at the results: in the US, over 18,000 whooping cough cases were reported in 2011.  As well as 222 cases of measles.  In Belize, the number was...zero.  And the previous year, also zero.  These data may not be perfect.  But they raise some very interesting questions.

But first, it is important to acknowledge that extreme poverty is not without consequence.  The children of Central America face serious issues about sanitation, clean water and access to advanced care.  Parasitic diseases are common. Educational opportunities are variable.  There are problems.

On the other hand, the Belizean people have decided that healthcare is a right.  All immunizations are paid for by the government.  Beyond this, the populace, being so very different than ours, have not fallen prey to the problem of "over thinking" their healthcare.  In the US, large numbers of children suffer from preventable infections because their parents became worried about rumored side-effects of individual vaccines, or just vaccines, period.  Perhaps the most pervasive involved a preservative, used for 70 years to prevent bacterial and fungal contamination of vaccine vials. More than a decade ago, this preservative, thimerasol, was removed from essentially all vaccines in our country.  This, despite the science which identified no relationship between the compound and any side effect, including that scourge, autism.  The anti-vaccine activists predicted that removing the preservative would result in a downturn in new autism cases, which would have been a wonderful and surprising thing.  What actually happened, sadly, was nothing.


(Well, not actually "nothing."  The incidence of autism continued to creep upward, while the cost of vaccine manufacture rose, creating yet another barrier to protecting our children.)

Alarmingly, a "coalition" of individuals opposed to thimerosal in vaccines is now seeking to extend the ban to developing countries.  Countries whose successful vaccination programs will falter and fail if these changes are enacted.  But I have faith that the WHO,  American Academy of Pediatrics and others will protect the Belizeans from well-meaning Americans.  If they can't, heaven help the children.

A Christmas Toast

Dearest family,

I am so thankful to be here with those I love.  It has been a difficult year and the messages of the months just past are grim, indeed.  We are embattled with Nature.  A "storm of the century" did unprecedented damage to our homes leaving too many of our Long Island neighbors without a place to stay.  Much of the repair and restoration still lies ahead and will take a long time.  But we will never restore the lives lost to the storm, and these also included some we know by name.  We have so rarely felt so vulnerable.  And what is worst perhaps is that this nightmare may be the "new normal,"  a result at least in part of human activity, an environmental injury to which each of us contributes every day.  

We are embattled as well with one another. I am reminded of the description a recovering addict once offered to describe how he reached bottom:  "I reached a state of degradation that surprised me by being even lower than my rapidly declining personal standards."  And so it was in Connecticut when twenty young children were murdered in a sudden, random and awful act.  No doubt mental illness played a role.  We must believe this because to believe that a sane human being could do such a thing would be to accept an account of human nature that is beyond our imagining.  

Too many Americans are following too many elected leaders toward a state of paleolithic tribalism fueled by the basest of instincts.  The marketplace of ideas is noticeably unpopulated.  Deliberation is out; ad hominim attacks are in. Take-no-prisoners politics has eroded our ability to respect divergent views, to find common ground, to solve problems together. 

We come together around this Christmas table despite these sorrows...to share what is still beautiful in our world -- this meal, a gesture of affection, your laughter, the Overture to Messiah, a December sunrise over Northport Harbor...and in doing so to stake a small claim to a different future, a better way forward.  Whatever the circumstances of the real, historical Christ child, we believe that He represented the idea that a single soul can re-create the world in ways that defy probability and common sense.   In our modern parlance, what I am describing, family, is your goodness going viral.  

As Andy Warhol noted "They say time changes things, but actually you have to change them yourself."  God bless us every one.

    

Whose body is it, anyway?

A study reported recently in the Journal of the American Medical Association found that three strategies for regulating long term asthma medications produced similar results.  One of these involved symptom diaries, while a second used sophisticated nitric oxide exhalation testing.  The researchers found that neither produced better results than a third strategy, which was simply to suggest that patients regulate their own medications based on symptoms.  

Two things struck me about this study.  One was that simple solutions turn out to be best more often than we may expect.  The second was what the authors said about their findings:

“The data from the study are reassuring that we’re doing no harm in allowing this flexibility.”

Allowing this flexibility?  First, I hope these academics know that patients regulate their own medications - for asthma and a host of other conditions - with or without permission.  Second, and more fundamentally, this inadvertent expression of paternalistic medicine sounds weirdly out of synch with the contemporary movement toward collaboration between care providers, families and patients.  After all, the person with a chronic disease will only enjoy the best possible health if she becomes as expert in her own care as her physicians.  Or more so.

Which is not to say that I favor the practice of laying out a smorgasbord of choices for those who come to us for care.  (Back pain?  Tell me what you'd like - an X-ray?  An MRI?  Referral to a chiropractor?  How about a nice spine surgeon?)  While this latter approach, which has become common in some quarters, seems to empower the patient and support her autonomy, it deprives the person seeking care of what is most helpful, and that is the thoughtful and informed opinion of the physician.  

But some raise an objection here.  Bioethicist Robert Veatch has suggested that since literally every medical decision is value-laden, and for the most part physicians do not and cannot understand their patient's values, it is impossible even in principle for the physician to make medical judgments in the "best interest" of the patient.   One treatment carries more side effects but the alternative costs so much that I'd need to sell my house.  What textbook tells my doctor which one is "right for me"?

When I pick a primary care physician to supervise my health I want him to have the right knowledge, skill set and dedication to do a really good job.  I'll also want to make sure that he's flexible enough to work with me when I need to call the shots,  but confident enough to tell me what he thinks is best.  It's a tall order.

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.

By my side

The federal Center for Medicare and Medicaid Services has enacted new rules for hospitals to ensure the right of every patient to have someone - such as a spouse, relative or friend - to help them make medical decisions and to provide emotional support.  This is a very good thing.

The experience of serious illness carries with it not only the crisis of confrontation with our own mortality, but also, all too often, alienation and a sense of powerlessness.  Our hospitals and medical profession have, in the past, done much more to exacerbate this kind of suffering than to address it.  From Doctor's Orders to Visiting Hours, it is no wonder that in his role as a terminal patient in "The Bucket List" Morgan Freeman's character talks about "busting out" of the hospital.  Indeed, leaving "Against Medical Advice" is as unsanctioned (and liberating) as a jailbreak.

Persons receiving hospital care have the right to appoint a "representative." The healthcare team, led by the physician-of-record, communicates with this individual just as it does with the patient himself, and so allows the patient the opportunity to share decision-making with another trusted person.  The new rules also provide for a "support person" who may or may not be the representative.  This person helps with visitation, ensuring that anyone the patient wants to visit can do so while also helping to protect the patient's privacy by limiting visitation in accordance with the patient's wishes.  

Among the traditions that may be most offensive to the autonomy of hospitalized patients is that when certain procedures are undertaken, the patient's visitors - even a spouse - may be asked to step out.  This goes on regardless of the patient's wishes.  A variety of explanations are offered: the procedure will be too upsetting for the visitor, or the visitor may faint, or the staff will be distracted.  None have ever been studied scientifically, and to the extent that unrestricted visitation has been evaluated, we know that it is helpful to patients.  Moreover, it is their right.

When I need the services that can only be provided in an acute-care hospital, I will want my wife or my children there.  I will understand that the number of visitors may need to be limited if I have a room mate, although I think that double rooms are a questionable practice and need to be abolished.  I will probably ask my wife to be there if I need a tube inserted into my stomach or chest, unless I am asleep for the procedure.  If I have grandchildren at that time, I will decide with my wife whether it is in their best interest to come into the hospital, and not leave that decision to hospital staff.  And if I become unable to make decisions on my own behalf I will expect my physicians to treat the decisions of the person I have pre-appointed as though they were my own.

Surely not all patients will want the same things or decide in the same way.  This is very much to the point.  But every patient will have the right to decide how they decide and how they live within the walls of the hospital, walls that we can hope will represent not incarceration, but patient-centered care.