The Devil Is In The Details

The US Institute of Medicine estimates that somewhere between 44,000 and 98,000 deaths in hospitals annually are due to medical errors Rachel Giese.  Most of these errors are preventable. 


But the modern hospital confronts elements that make it a veritable breeding ground for poor outcomes.  


Poor judgement on the part of doctors is an issue that requires attention but it is not pivotal.  The most pressing problems have much more to do with faulty operation systems, poor communication and the complexity and severity of today's hospital admissions.


For example, rather than being cared for by his/her family doctor, in this era of 'shift medicine', a patient is cared for by a number of hospital based physicians, who devote their time solely to outpatient care.


The personal physician's deeper Insights into the medical and social aspects of their patients' lives are more or less lost in the fracas of acute hospital care.  The communication between the hospital doctors is often done on the run causing changes, distortions and misinterpretations of the original message. Misunderstandings abound.  


Operational breakdowns abound too.  Just consider the number of departments (nursing, nutrition, mental health, speech pathology, social services, pharmacy) and consultants who regularly interact with patients and each other.  These caregivers appear not to have a lingua franca  and, as a result, frequently trip over each other. 


While team care has its merits it oftentimes looks like a bee hive without a queen bee. 


A queen bee is critical in medical care because she assures the kind of order, and ritual, necessary for safe outcomes.


Good care is not sexy, it is methodical.


The airline industry has famously recognized this and has reduced its fatality rate to nearly zero.  They didn't accomplish this with better pilots. They did it with check lists.  


On all flights it is required that the pilot and co-pilot evaluate together a list of safety questions.  It's the same form and the same questions every time.  Are the flaps up ( should they be)?  Is there ice on the wings?  Is the landing gear ready to go? 


The US Institute of Medicine and progressive hospitals have embraced  the checklist idea with many thousands of errors and deaths reduced annually.  The operating room list asks the team to review, among other things, the patient's identity, the nature of the operation, confirming, for example, that it is the correct kidney to be removed, skating clear of an intolerable 'oops'.


Another beneficial list deals with the placement of central venous lines, a major source of hospital infection, morbidity and deaths.  When they are placed willy nilly, going on instinct, based mostly on personal experience (often limited), errors soar.  Following the proven and battle tested lists technique can bring the error and complication rate to near zero. 


It seems inevitable that many more lists will be brought into hospitals and clinics.  Ones to eliminate errors in medication dosing at discharge are especially needed.


Doctors generally take a dim view of lists, at first blush, regarding them as an assault on their clinical hegemony.  Most are converted, however, by superior outcomes and a realization that clinical judgement remains an indispensable element of medical practice.


But clinical judgement will increasingly be sharing the spotlight with computers in what should be a promising relationship. 


Airlines have once again led the way, demonstrating that aircraft facing dire circumstances are sometimes more likely to escape disaster when following the dictates of the inflight computers rather than the most experienced pilots.


How could this be?    


The pilot may be sleepy, or hungover, or depressed.  The computer is not.  The pilot may be seasoned but unable to match the computer's storehouse of information dealing with successful or failed maneuvers in historically similar circumstances.


Going on automatic pilot then, checking the details and following repetitious patient care plans on the medical wards and operating rooms may not be scintillating, but doing so adds greatly to safety, reducing  both errors and mortality.  And not to worry, the importance of clinical judgement, wisdom and compassion will remain the most valuable coins of the realm.


So looking for a hospital?  If they have central line and operating room lists they are probably committed to safety and deserve your confidence as the days of do it my way, swashbuckling medicine are increasingly numbered.


In short, the devil remains in the details.

  

On Retirement

When it was announced that  I was retiring from medical practice (almost a year ago), well wishers came to congratulate me.  I thoroughly appreciated the good wishes, but didn't fully understand the congratulations part.

I was confused, thinking congratulations were generally reserved for individual feats such as winning the clinic hot dog eating contest or, say, reaching twenty years of sobriety, an act of courage.

Retirement didn't strike me as a feat but an inevitability, a kind of door closing.  So why all the back slapping?

In time,  I began to understand.  The congratulations were for going the distance,  for coming out of medical practice largely intact with an arsenal of cherished patients, colleagues and friends.

Good wishes were almost always followed by the same three questions:  what will you do with your time, where will you live and what travel plans did you have?   

When I smart-assly (I am one) responded that we had neither exciting travel plans nor any intention of moving, the predictable response was a mixture of sympathy and disappointment.

My standard response to the first question was that I planned to write a blog, take college courses and just knock around.  Nearly everyone seemed pleased and supportive until I got to the knocking around part, when smiles went missing, replaced by looks of incredulity and worry.   Lectures on the perils of inactivity and the rewards of a bulging calendar were numerous and mostly out of the same play book, leading me to want  to dive, head first, into the first available couch.


The message was clear - you are not living in an age of relaxation (notwithstanding the stampede of commercials for languorous cruises), you are  part of an age of competition and a technological culture of rapid fire updates, in which you spend considerably more time loading your musical files than listening to them. 


While the lectures and questions were indeed well intentioned they were so repetitive and predictable that I decided it was time for me to orchestrate a game changer.


So, resorting to fiction and whimsy, I emerged as Special Agent Blogspeak.

My shtick was to tell questioners, who wondered what I would do in retirement,  that  I was being heavily recruited by the FBI for a senior management position.  To my utter astonishment more than a few people seemed to believe it  possible that the FBI might want my services.  I was flattered and unrepentant.


Now well into my retirement, the special agent ruse  has come back to haunt me. The problem arises out of my college classes where  I have had almost no success in connecting with my classmates.  For example, no one has invited me to the Thursday night bar hopping nor was  I  invited on any of the spring break trips.  No one talks to me during class breaks.


My classmates apparently don't trust me, believing,  I suspect,  that I  must be an undercover agent for the Drug, Tobacco and Alcohol Bureau.  Why else, they might reason, would a gray haired, senior citizen come back to the classroom other than to snoop and snitch?


Determined to be accepted, I have thought about getting a tattoo, which just might win me some trust.  I'm told by experts that a neck location billboards best.  The inscription could be decisive.  For now, a catchy and convincing one might be 'anarchy now and forever'. 


If this works, I can confidently say my retirement is going well.  Among other things, I take walks, plunder the library for books, have hot chocolate dates with friends and have successfully deflected suggestions by family and friends that I get a personal trainer.

Too Good To Be True

Cliches get a bad rap for being worn out and unserviceable. Upon reflection, however, they are oftentimes brimming with common sense and wisdom. For example,"If it seems too good to be true, it probably is."


This cliche came to mind recently when I was reading an article published in The Lancet, a prestigious English medical journal, which suggested that even patients at low risk for cardiovascular disease would benefit from taking statins (a class of cholesterol lowering medicines), resulting in lives saved, and a significant reduction in heart attacks and strokes. 


Until this report, a risk of 20% or higher, defined by a standard measuring device, was the point at which statins, with ringing endorsements from the cognoscenti, were recommended. 


Now, the Lancet research suggests that anyone with a risk of 10% or greater is likely to benefit too.


What the authors of the paper are telling us is that individuals previously thought to be low risk are now thought to be candidates for statins.


With a wave of the wand, the total number of high risk, vulnerable individuals greatly increases, making it appear that cardiovascular disease is more rampant than ever.


Enter the treat everyone, 'put it in the water' school, trumpeting a message that thrives on the simple (and misguided) notion that we are all the same and benefit from the same management and treatments. 


Not too many years ago, followers of this same 'school' informed us that all women on estrogens needed to be on progesterones too. That idea turned out to be categorically false and based on flawed research.


They also issued warnings of late about the dangers of vitamin D deficiency, which they unassailably believed to be a big factor in everything from diabetes to depression to cancer to multiple sclerosis. As a result, no visit to the doctor was complete without a prescription for vitamin D.  Game on.


Enthusiasm for vitamin D supplementation,this latest edition of the fountain of youth, turned out to be uncontainable once the genie was let out of the bottle. Not surprisingly, the lower limits of normal have progressively decreased, drawing more and more people into the vitamin deficient category. 


And thanks to the idea that you can't get too much of a good thing dosages began to rise steadily.


As it turns out, the entire vitamin D epoch was the result of belief masquerading as fact, overlooking a fundamental quality of biology - its variability.  


Variability is the coin of the realm, promoting strength and sustainability in both plants and animals.


For example it's preferable that a garden have multiple strains of plants since a single strain would be much more vulnerable to blight, mutations and even extinction. That's why nature abhors sameness.


Humans are vulnerable to sameness too.  What happens, for example, if an unexpected, and severe, toxicity to, say, statins develops among a population where the drug is unnecessarily used by  large numbers of people? 


So when experts joke about placing a drug (not fluorides)in the drinking water, you can
be pretty sure that canonization of the treatment along with a pharmaceutical jihad are afoot,  unwisely exhorting everyone to dance to the same tune.


It is almost never the case (with the exception of toothbrushing) that everyone should do the same thing.


When a single approach is universally promoted, know that the idea defies common sense and the variability of nature.


Above all, dust off and brandish that trusty cliche - if something appears too good to be true, it probably is.










                   

On Selecting A Physician

Finding a new doctor can be a daunting experience, especially with hospitals and clinics going all out with media campaigns to corral new patients. So, if you are unable to find a doctor, it's more than likely that one will find you. 

A favorite method to capture patients is to circulate filmed interviews of doctors that can be widely seen on television, the internet and DVDs.

The clinicians are asked in the filming to reveal their values, interests and style of practice; giving the patient a brief look under the hood.  

Somehow, most of the interviewed seem to say more or less the same things: they like to take walks (by a lake is best),  read books, drink fine wines, bicycle and play with their Labradoodles.  None have yet referenced pub crawling or pick pocketing as forms of recreation and fulfillment.  Their style of practice is relentlessly collaborative - a partnership, whether you want to be a partner or not. 


Altogether a picture of sameness and similarity emerges from the interviews, right out of the Big Mac playbook, which seems to make choosing a new doctor less burdensome, less of  a choice.

The interviews suggest clinical competence which should be true for the vast majority of doctors.

Still, sniffing out a good doctor from advertisements can be perilous, especially at a time   when medicine has evolved from craft, to profession, and now to commodity.

So what strategies exist as an alternative to the media blitz?

One tried and true method is word of mouth recommendations, which generally expose the fakers (uncommon) and bloviators (not so uncommon).

Nurses, moreover, are excellent referral sources as they, more than most, get to see physicians with the mask off.  Most doctors I know are flattered when a patient is referred to them by a nurse.

Furthermore, don't hesitate to take the measure of the doctor yourself by scheduling a getting to know you appointment.  Your intuitions and observations can be telling.

And don't forget the medical assistant.  If they are bruised, the doctor probably is and you, by fallout, might be too.  If the assistant cares about whether your dog recovered from his accident, the doctor probably does too.  If the assistant seems out of control, the doctor might well be out of control too.

The point is that the assistant's manner and style often reflects the doctors, giving a sense of how the doctor's practice is run, a key variable in picking a doctor (read does it take four days for the doctor to return phone calls).

Finally, advice from George Bernard Shaw, who counseled patients to acquire a doctor whose father was rich, believing such a caregiver would order tests and procedures in a more measured way and might be able to spend more time with patients.

Outrageous, of course.

Worth a thought, of course.

Not So Fast

Dear Reader -

The link which follows is to an important and welcome article in the New York Times.  Nine premier medical societies have joined forces and endorsed frugality in the ordering of forty-five commonplace tests, scans and medications.

For example, sinusitis is rarely improved with antibiotics and MRIs of the back are much overused.

Some of us, brought up in the more is better school, might want the targeted tests regardless, believing they are an unmitigated good, especially attractive for individuals with health insurance.

Misguided use of monies is a big concern, but an even bigger one is that inappropriate testing can lead to errors of thought and judgement which can cause significant harm.

What you will read in the article has been known by the majority of physicians.  The issues have remained under the radar for a number of reasons, none more compelling than the staggering profitability of testing.

So here is the link Link NYT Article.

Your opinions and comments are hoped for.

On Starving and Smuggling

At the beginning of my years of practice, I noticed that there was a certain number of patients hospitalized for heart failure, who remained resistant to treatments, especially to diuretics, the main weapon at that time. Rigorously low sodium diets were standard as even tiny amounts of salt will oftentimes sabatoge the effectiveness of diuretics.  Nonetheless patients who seemed like they should respond did not.  It was a puzzlement.

It was while interning at a predominantly Jewish hopsital that the explanation for this became apparent. One day I walked into a room to find heart patient Irv, surrounded by his loving family, with his oxygen mask off, wolfing down a bagel with lox and cream cheese.  With the normal heart this is one of life’s great pleasures, with a weak heart lox, suffused with salt, is toxic.

Irv and his family turned out to be the tip of the iceberg, many families, upon investigation, were smuggling in salt laden food, a mainstay of Jewish cuisine.  The contraband poured into the hospital despite regular alerts to families regarding the dangers of salt for failing hearts.

Given the ubiquity of tasteless and ropey hospital cuisine it is therefore not  at all surprising that food came into the hospital, under the radar, giving pleasure where it was otherwise in short supply, while hopefully harnessing the magical healing powers of mother’s chicken soup.

In some cases where there was marginal heart function this trafficking in salt was tantamount to “killing with love” and shows that dietary retrictions can be very important.

But not always.  Sometimes they are so Orwellian as to make compliance nearly impossible.  Consider the low sodium, low potassium diet, commonly deployed in  hospitals for cardiovascular and or renal patients.  For some of these patients the restrictions are key.  More often the dietary bans amount to painting by the numbers, producing dietary decisions that lack common sense and balanced thought.

Sometimes caregivers will bend, but there are a good many who strictly follow the rules.  The result is that a number of patients find their diets so objectionable that they choose not to eat.  After drawing on, and depleting, sugar and starch stores, protein is marshalled by the breakdown of muscle, leading to profound weakness, which compromises healing, decisively at times, along many fronts.

So there are times where we, despite the best of intentions, starve patients by not allowing them foods they enjoy or can tolerate.  When it comes to this, smuggling pastrami, raisins, bananas and avocados into the hospital just might be life-sustaining and certainly humane.

Professor Motherbleeper

The setting for this blog posting is a neighboring university where, in my retirement from medical practice, I am auditing classes.  Names, places and scenes have occasionally been fictionalized.  This piece is dedicated to my classmates who have unwittingly provided most of the material for this essay.  They treat me well though more than a few seem to think I just might be a senior undercover agent for the drug and alcohol bureau.

My professor was droning on about a political figure prominent during the Civil War, and I felt myself slipping into what promised to be a satisfying nap.  But as the shades were just about to be closed down around me, I bolted up in my seat hearing my teacher say, "and he was a motherbleeper."  I quickly scanned the lecture hall and discovered, to my amazement, that his word selection seemed to have gone unnoticed by everyone but me.

I attended college in the early 1960s where we freely used the expression everywhere on campus with the exception of the library and the classroom.  The faculty never deployed the word in the classroom, or we imagined, anywhere else.  If they did, especially in front of students, they almost certainly would have been censured, or worse, by the Dean, because motherbleeper did not mix well with veritas and similarly high-minded words commonly carved into the facade of university libraries across the country.

Upon reflection, I felt that the professor had conveyed, with clarity, just what kind of guy this politician was.  The meaning of the expression was unambiguous, a linguistic victory.  While a teacher and practitioner of bleeping words might be asked to tone it down by their Dean (who would snitch other than someone like me?), my lecturer's word choice is arguably covered by principles of academic freedom and even freedom of expression as guaranteed in the first amendment.

But if racy language has gained a seat in the classroom, then it should be called upon judiciously, a light garnish rather than the main course.  

One might intuit whether or not a word is obscene by its purpose.  If it is meant to injure or diminish someone then it is probably obscene and should remain locked up. Motherbleeper did not injure the long dead politiican, but did paint him as a rather unsavory character.  Mission accomplished.

Altogether, the motherbleeper episode reminded me of just how much the college experience has changed since my graduation in 1965.  Salty language is just one element.

For one thing, students seem to talk to each other as little as possible so as not to interfere with text messaging and other social media chores, such as making sure that everyone of your nearly fifteen hundred facebook friends (of whom they personally know, say, two hundred) hear about the new shoe polish you discovered that decreases scuffing by at least twenty percent.

Walk into the typical university building and you will likely find lines of students, waiting for their next classes to begin, silent, with necks flexed, eyes locked on tiny screens, thumbs galloping, gathering information on movies, celebrity news and shopping tips.  During lectures some students continue text messaging with their smartphones strategically placed below the table, again with the neck in a tell-tale flexed (bent forward) position, feigning headaches, exhaustion or perhaps a spiritual awakening. 

It is this flexion of the neck which worries most as, who knows, it might just lead to a permanent flexion in adulthood, opening the possibility that  today's college students will lose the capacity to see far, even when standing on the shoulder of giants.

While conversation is increasingly rare so is visual contact.  Mired in  tiny smartphone screens, students seem not to see one another.  While this  ironically provides relief for many women who resent  being objectified by up and down staring, it is curious that young men seem uninterested in looking at, or innocently flirting with, young women.  Why is this?  Could it be that students of both sexes have such easy sexual access to each other, that the mystery and magic of sexuality becomes hobbled and looking is subverted by texting?

On another front, there is a growing sense that more and more people are developing romantic and sexual ties to their computers and social media devices, rife with pornography, well suited for people with many time constraints, who favor efficiency over intimacy, and prefer, as it were, to fly solo.

So college life has indeed changed greatly in the past half-century, as have  our cultural norms, charged and fueled by a ubiquitous technological revolution in which the internet and social media define our times. These changes make colleges more fascinating places to be in than ever.  The challenge for today's college students is to find ways to stay connected, both digitally and personally.  

Either or falls woefully short of the mark.