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.
The winter virus season is fast approaching, bringing with it the old dilemma of what to do about infants and toddlers who wheeze. Last year I noted that we had no specific treatment that worked.
A few months after my post, investigators in Canada published a large study that compared two of the standard treatments traditionally used for wheezing infants and toddlers: oral steroids and nebulized (inhaled) epinephrine (or albuterol). The randomized, placebo-controlled study compared children who came to the emergency department for breathing difficulties. They received either, both, or none of those therapies. The endpoint the researchers studied was how many of those children progressed to get sick enough to need admission to the hospital during the subsequent week.
The results showed that maybe — maybe — there was a slight beneficial effect of both treatments together in keeping kids out of the hospital, but neither treatment alone helped. An accompanying editorial in the same issue pointed out the problem here: when infants and toddlers come with their first episode (or episodes) of wheezing, we don’t know if they are going to continue to have problems in the future (such as progressing to asthma) or not. These treatments clearly help asthma. So if we give them to all comers with wheezing symptoms there will be some, those who are destined to have asthma later, who will benefit. But that’s not at all the same thing as saying that these treatments (which are not risk-free) will help kids with bronchiolitis, by far the most common cause of wheezing in this age group.
Over the past year the authors of the study, probably a bit stung by the pooh-poohing of their findings, have churned through their data from a different angle. This sort of data-mining in search of positive findings is common, especially if the original findings were not earth-shaking (or even useful). After all, people’s careers in academic medicine may be at stake. Anyway, they’ve just published an article on the cost-effectiveness of of using the combination of inhaled epinephrine and oral steroids. They conclude that these therapies, which medically don’t help much, still save a little money — to society, not necessarily to the family. I don’t find that argument convincing, either.
So what do most of us do with wheezing infants and toddlers, especially those who have bronchiolitis? I think most of us give a trial of the inhaled medicine to see if it helps. If it does, we continue it; if it doesn’t, we don’t. If there is dramatic improvement with the inhaled medicine, we consider giving the steroids. The presumption is that kids who respond dramatically to the inhaled medicine are more likely to become asthmatic, so what we are really doing is treating early asthma, not bronchiolitis.
As a parent, what this controversy means to you is that the correct answer is still unknown, although the preponderance of expert opinion is that bronchiolitis — wheezing in small children — requires supportive care, such as help with feeding, clearance of respiratory mucous, and sometimes oxygen, but there are no good data showing the benefit of anything else.
Opponents of the current proposals in Congress for reforming healthcare have asserted that nearly all physicians are in opposition to these measures. I’ve even read claims that physicians will leave practice in droves if any of these bills pass, leaving America short of doctors. The highly respected Robert Wood Johnson Foundation recently surveyed physicians to see how we actually felt about reform. You can read the summary of their findings here. The bottom line — a large majority of physicians favor reform.
The survey found that 63% of physicians supported a public option — a system in which there was a government-funded alternative to private insurance. More radical than that, 10% supported a straight-up single payer system, such as Canada has. In sum, this is three-quarters of America’s doctors. In addition, a majority (58%) supported lowering Medicare eligibility to include 55-year-olds.
The survey does not address reasons doctors think this way. I think a majority of them, like me, realize our current non-system is unsustainable financially. I also think it is immoral socially, but I may be in the minority on that one.