(Tangentially related podcast here)
Here’s the thing: all this talk about arrogance in medicine is a red herring. It’s distracting us from the real question that we should all be asking: how do we improve quality medical care?
The personality of individual physicians is important, but not very, just as the medical mistakes of individuals have limited significance. As medicine has become more science-based, we have learned some important lessons about how to prevent and treat disease, and while the physician-patient relationship will always be important, as will the relationship between physicians and other professionals (see this discussion), implementing what we know about how to improve health care (and have known for years), will render much of it irrelevant.
Take the Keystone program. This simple program, developed at Johns Hopkins and piloted in Michigan, as well as a few other places, uses mandatory checklists for certain hospital procedures, and has been shown to reduce complication rates of these procedures. Unfortunately, bureaucracy threatened to strangle this program in the cradle, but that particular storm has apparently passed.
Quality medical care depends on many things (not the least of which is access, but that’s a topic for another time). It should be made to depend on individual personalities as little as possible. Let’s look at two areas where we can improve medical care.
There are two main types of medical errors: individual errors and systems errors. Human beings will always make mistakes. That is the idea behind, for example, cockpit checklists—the checklist helps to minimize any individual pilot’s ability to screw up.
In medicine, medication errors are common, and while it is easy to blame an individual, it is really a systems problem. As an example, let’s look at how drugs are given in a hospital, and potential errors at each step.
- 1) A doctor write an order, often by hand: may or may not be correct, legible, and appropriate.
- 2) A clerk delivers the order to the pharmacy: hopefully.
- 3) A pharmacist or tech verifies the prescription, fills it, and delivers it to the floor: hopefully. Remember that any error that has occurred in previous steps may be magnified.
- 4) A nurse receives both a valid order and a medication, then delivers the medication to the patient: That’s a tall order. What if the nurse picks up the wrong med, or sets it down and forgets it while someone is having chest pain?
- 5) A patient take the medication: whose?
As anyone who has taken basic science lab courses knows, the more steps you put into a process, the more error will be introduced. It’s inevitable, unless the system itself is fixed. Here are some basic systems fixes:
- 1) A doctor enters a drug order in an electronic prescribing system, which checks the patient’s other meds, allergies, kidney function, etc., and flags potential problems before the doctor can sign off on the order.
- 2) When the order is signed, it pops up on the pharmacists screen, who verifies it, and dispenses individually wrapped meds barcoded with the patients identity.
- 3) The medication is flagged for delivery on the nurses computer or handheld device. S/he is cued until the med is delivered.
- 4) The patient’s wristband barcode and drug barcode are scanned. If they match, the med is given.
The second system doesn’t reduce the error rate to zero, but it significantly lowers the chance of avoidable mistakes. This type of analysis can be applied to many aspects of patient care. Electronic health records (EHRs) would go a long way to helping reduce errors and make continuity of care more, well, continuous. At this point, however, there are no national standards for EHRs, nothing that requires them to be able to understand each other, nothing that subsidizes the huge costs to physicians and institutions for installing and implementing them. As an example, my three doctor private practice is planning to get an EHR, but the cost is tens of thousands of dollars. It’s taken us years to be in a place where we can (almost) afford it.
EHRs can help implement standards of care. Diabetes is a very common illness, one we’ve made great strides in treating. Science-based medicine has shown that certain interventions can reduce the complications of this disease. For example, ACE inhibitors given to diabetics with kidney disease can slow progression to kidney failure. Keeping systolic blood pressure below 130 reduces the risk of stroke and heart attack. Regular eye exams help prevent blindness, and foot exams prevent amputations. I use a pre-printed sheet to track these and other parameters in my diabetics. I also belong to a local physicians’ group that requires me to fill out a separate form on diabetics to track some of the same data. And Medicare has a new program called “PQRI” which also requires tracking of some of these data points. None of these systems is integrated, there is no one standard to allow doctors to simply enter the data and have it all go to the groups who want it. This is a huge disincentive to participating.
If EHRs were made available to all medical practices and institutions, all of these systems could be integrated. My diabetic data could be zapped to each of the organizations who wants it with the stroke of a key. This would allow easy implementation of standards tracking and free up more time to spend with patients.
We know how to deliver quality medical care. We have the data and we have the technology. We’ve simply decided as a nation not to do it. Quality care requires quality people, but personality is only one factor in medicine and becomes much less relevant once we use our knowledge to improve the system as a whole.
Of course a system that doesn’t cover everyone is a disaster waiting to happen. If you could carry all of your medical data on a card or flash drive that was readable by any physician, that would be great. What if you were “off the health care grid”? If you showed up at a hospital unable to speak, the staff would have to do a lot more guesswork and errors related to your care would rise. Imagine the difference in a natural disaster if we had access to a centralized data base of patient medical information.
Quality care isn’t about mistakes made by and to individuals. It’s about creating a health care system based on evidence. It’s about making data available and using it correctly. It’s something we can choose to do. Or not.