Patient safety: when doctors are the problem
We’ve always know that hospitals can be dangerous places for patients. In a landmark study some years ago, the Institute of Medicine, a part of the National Academy of Sciences, demonstrated just how dangerous they can be; anywhere from 50,000 to 100,000 people die annually from preventable errors. How are we doing at reducing that grim statistic? The answer is that we are making some progress, but there remain serious roadblocks.
The deaths studied by the Institute of Medicine came from a whole host of causes, and many of these causes are complex and difficult to address. But it turns out that one cause — serious infections from central venous catheters — can be easily improved. We can’t prevent all of these infections, but we can dramatically reduce them. The way to do this is absurdly simple and the lowest of low-tech: use a checklist that ensures basic procedural steps are followed in the correct order. Hospital safety guru Peter Pronovost demonstrated this some years ago. Checklists for all sorts of procedures are useful. Well-known medical author and surgeon Atul Gawande had even written a best-selling book about them. So what’s the problem? The answer is that the problem is often doctors and our medical culture. A recent editorial by Dr. Pronovost helps explain why. (The editorial is from the Journal of the American Medical Association, which requires a subscription. If anybody wants a copy, let me know.) Here’s the crux of the problem, as described by Dr. Pronovost:
“Although most physicians and hospital leaders genuinely want to prevent harming patients, and many physicians practice good teamwork, this view of not questioning physicians is pervasive. Physicians are often rushed, sleep deprived, and overworked and are offered limited training about teamwork and conflict resolution. The practice setting is not always conducive to completing recommended practice and anything that takes extra time for one patient (eg, searching for supplies) detracts from the care of others. Physicians also may not receive feedback on individual performance or hospital infection rates. Social, cultural, educational, and financial differences between physicians and nurses also may inhibit some nurses from speaking up, even when physicians may welcome such feedback.
Moreover, many physicians have not accepted that fallibilities are part of the human condition. Thus, when a nurse questions them, it causes embarrassment or shame. Clinicians are sometimes arrogant, believing they have all the answers, dismissing team input, responding aggressively when questioned. The line between autonomy and arrogance is fine and nuanced. Society has benefited tremendously from physician autonomy and innovation, producing new drugs, devices, therapies, operations, and anesthetics. Therefore, autonomy and innovation must be continued. However, autonomy becomes arrogance when actions are mindless and not mindful, when something is done simply because a physician demands it, when a clinician does not learn from mistakes, and when experimentation occurs without a clear rationale or testable hypothesis. Too often autonomy is mindless and driven by arrogance. When placing a catheter, reliability not autonomy is needed.
As Pogo said many years ago: “We have met the problem, and he is us.”