Posts Tagged ‘Atul Gawande’
Some months back I read an interesting interview with Jonathan Skinner, a researcher who works with the group at the renowned Dartmouth Atlas of Health Care. More than anyone else I can think of, the people at the Dartmouth Atlas have studied and tried both to understand and to explain the amazing variations we see in how medicine is practiced in various parts of the country. It turns out that specific conditions are treated in quite different ways depending upon where you live. Atul Gawande documented a detailed example of the phenomenon in an excellent New Yorker article here. A major determinant appears to be local physician culture, how we doctors “do things here.” The disturbing observation is that patient outcomes aren’t much different, just cost. Of course it’s more than cost. Doing more things to patients also increases risk, and adding risk without benefit is not what we want to be doing.
Skinner is interested in something else, a phenomenon he calls “cowboy doctors.” By this he means physicians who are individual outliers, who go against the grain by substituting their own individual judgements for those of the majority of their peers. In theory such lone wolf practitioners could go both ways. They could do less than the norm, but almost invariably they do more — more tests, more treatments, more procedures. Such physicians not only may put their patients at higher risk, they also add to medical costs. I have met physicians like that and have usually found them to be defiant in their nonconformity. A few revel in it. They maintain they are doing it for the good of their patients, but there is more than a little of that old physician ego involved. There is also the subtext of what many physicians feel these days, especially old codgers like me who have been practicing for 35 years: it is the tension between older notions of medicine as an art, a craft, and newer evidence-based, team driven practice. Skinner describes it this way:
It’s the individual craftsman versus the member of a team. And you could say, ‘Well, but these are the pioneers.’ But they’re less likely to be board-certified; there’s no evidence that what they’re doing is leading to better outcomes. So we conclude that this is a characteristic of a profession that’s torn between the artisan, the single Marcus Welby who knows everything, versus the idea of doctors who adapt to clinical evidence and who may drop procedures that have been shown not to be effective.
Leaving aside outcomes and moving on to costs, Skinner and his colleagues were quite surprised to discover how much these self-styled cowboys and cowgirls were adding to the nation’s medical bills. They found that such physicians accounted for around 17% of the variability in regional healthcare costs. To put that in dollars, it amounts to a half-trillion dollars. That is an astounding number.
So what we are looking at here is a dichotomous explanation for the huge regional variations in medical costs. On the one hand we have physicians who conform to the local culture, stay members of the herd and go along with the group, even if the group does things in a much more expensive way that confers no additional benefit to patients. On the other hand we have self-styled mavericks who scorn the herd and believe they have special insight into what is best, even if all the research shows they’re wrong.
I think what is coming from all this cost and outcome research is that best practice, evidence-based medicine (when we have that — often we don’t for many diseases) will be enforced by the people who pay the bills and professional organizations. Yes, some will bemoan this as the loss of physician autonomy and the reduction of medical practice to cookbooks and protocols. I sympathize with that viewpoint a little, especially since I am the son and grandson of physicians whose practice experience goes back to 1903. But really, there are many things we used to do that we know now are useless or even harmful. An old professor of mine had a favorite saying for overeager residents: “Don’t just do something — stand there!”
For those who would like to dive into the data and see the actual research paper from the National Bureau of Economic Research describing all this, you can read it here.
Complicated medical procedures can be dangerous, even when done by highly skilled and experienced people. Why? Because, irrespective of the procedural risk itself, all of us are human and we can overlook or forget things, no matter how many times we have done the procedure. This was recognized many years ago in the airline industry. Flying an airplane is a complicated and potentially dangerous activity and their are many steps to go through and check before takeoff. This is why, as you board an commercial airplane, you see the pilot and copilot going through a standardized list of things even though the pilot may have thirty years experience. Missing something can be fatal.
This process of formal checklists entered medical practice some years ago, first in the specialty of anesthesiology. It is one of the main reasons, along with new monitoring devices, that anesthesia is much, much safer than it was several decades ago. This approach then spread to other areas of medicine, in large part because of the work of patient safety guru Peter Pronovost. The idea is simple: for every procedure, rather than just tick things off in our mind like I was trained to do, we should go through a formal checklist process to make sure everything is correct and in place. Many of these are pretty simple things. Do we have the right patient? Are we doing the correct procedure on the correct body part? Do we have all the stuff we need ready to go for the procedure? This may sound sort of obvious, even silly, but there are many sad examples of physicians doing the wrong operation on the wrong patient.
The checklist concept really took off with Atul Gawande’s widely read book (it was a New York Times bestseller) The Checklist Manifesto: How To Get Things Right. The groundswell to establish checklists before and during procedures has now reached most hospitals. I know in my practice things have changed. In the past when I needed to do a procedure on a patient I just gathered up the personnel and equipment I needed and got started. Now we go through a checklist. An important part of the process is that any member of the team who has questions or issues is encouraged — mandated, really — to raise them. Now that I’m used to it, I like the new way better than the old one.
But the big question, of course, is if this increased role of formal checklists before procedures has done anything. Are rates of, say, wrong patient, wrong site, or other bad things improved? There are data showing that complications from at least one procedure, placement of central venous catheters, are reduced by checklists. But what else do we know? A recent article and accompanying editorial in the New England Journal of Medicine examined this question. The upshot is that things are murky.
The research study is from Canada. It looked at 3,733 consecutive patients at 8 hospitals that had implemented checklists for operative procedures. The bottom line was that there was no improvement in measurable outcomes. But hold on, observed the author of the editorial. As he saw it, the problem was that the checklists were foisted upon the operating room personnel without any preparation. There was apparently some resistance at the novelty of them, accompanied by gaming of the system — “dry-labbing the experiment,” as we used to say in the laboratory. The author’s point is that we really don’t know if the demonstrable success of checklists in some aspects of patient care can be generalized to other things. We hope so, but we don’t know for sure. The editorial author’s explanation for the findings of the research study is simple:
The likely reason for the failure of the surgical checklist in Ontario is that it was not actually used.
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.”
Healthcare researchers have known for some time that there are large regional variations in the cost of medical care. The well-respected and long-running Dartmouth Atlas of Health Care project has documented this for years. A recent widely read article by Atul Gawande in the The New Yorker highlighted some particularly astounding examples of how the same healthcare can cost much more in one place than in another, even if the demographics of those two places are virtually the same.
Most analysts think there are huge amounts of money to be saved by trimming back the expensive places. Not surprisingly, some of these places have pushed back, asserting that their costs are higher because their patients are sicker. After all, one person’s excess cost is another person’s revenue stream. In claiming this, however, they ignore the fact that the Dartmouth research has been corrected for case mix to eliminate that possibility as an explanation for the cost differences. A recent editorial in the New England Journal of Medicine labels this defense “the reverse Lake Wobegon effect,” after the fictional town devised by humorist Garrison Keillor, a place where “all of the children are above average.”
Anybody who looks at the data recognizes that it is a lame defense — in these expensive places the care is just more expensive, not better. Sometimes the more expensive care is even worse care.
Much of the discussion about healthcare reform seems to presume that we need to break everything we have into little bits and start fresh. In a recent New Yorker piece, Atul Gawande points out the problems with this notion. At the most practical level, our medical care system (such as it is) needs to function 24/7, all the year round. We can’t just stop it for a while, put the whole country on hold, as we introduce a new way of doing things.
But beyond that, Gawande brings up another fascinating angle to the question. Anyone who has read about the issue knows that Britain, France, and Germany, for example, have established systems that differ from each other in fundamental ways. Only in Britain does the government run everything. Gawande asks the question: why have these countries done things differently? The answer, it turns out, is that each of them built upon the system (and citizen expectations) that already existed in that country. In no case did anybody tear down completely what was there and erect a totally new way of doing things.
Gawande concludes that whatever we do will necessarily be built upon what we already have. This will offend some people deeply, particularly partisans from both sides of the political spectrum. It will not at all be a system that a dogmatic purest of any ideological stripe would plan from scratch. Rather, it will inevitably be a series of compromises and tinkerings with the way we are doing things now. And we will need to be willing to trim our sails if needed, modify the system, when it is clear one or another aspect of it is not working.
Change will come, one way or another. We cannot sustain the rate of rise of medical care costs, which already consume 16% of our GDP, far more than any other nation.
Medicine is in many ways a black art. It is not a science; it is an art guided by science. The guidance the science offers varies considerably from, for example, bone surgery to psychiatry, but the uncertainty is always there, even in the high-tech surroundings of the PICU. Our complicated machinery can mask the fact we occasionally are unsure about what we are doing and why. Sometimes we have almost no idea what is going on with our patients, a circumstance some doctors have trouble admitting both to themselves and to patients’ families. It is a difficult thing, at least the first few times you do it, to talk to a family when much of what you say describes your ignorance. With practice, though, it gets easier, especially when you know — really, truly know — that you can always do something to make a sick child more comfortable.
If you want to read more about an in-the-trenches account of how physicians deal with uncertainties, I suggest Atul Gawande’s book Complications (Picador, 2002).