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Since 1999, when the Institute of Medicine issued a report, To Err Is Human, exposing the epidemic of medical errors and injuries in American hospitals, patient safety—or the lack of it—has been a recurring theme of bad news. The report provided a context in which a number of physician-writers have explored how doctors can do better, both with curable and terminally ill patients. Critics have praised in particular Atul Gawande, Jerome Groopman, and Pauline Chen for their literary skills and compassion (Gawande and Chen are both surgeons; Groopman an oncologist). But it is their willingness to criticize their own profession that makes them such important commentators on the vexed question of how to improve the quality of patient care in the United States.
In How Doctors Think, Groopman examines the cognitive processes that lead doctors to make serious errors in patient diagnosis and treatment. Doctors’ thinking, he tells us, is influenced by (among other things) fear of failure, pervasive uncertainty, information overload, the role of money in medicine, and the tendency to jump to a particular diagnosis and ignore information that would contradict “a fixed notion.” He relates his frustrating attempts to find a physician who could treat his own serious hand injury. Although a well-known specialist, he was stymied like many patients by doctors who invented diagnoses when they didn’t know what was wrong, or displayed macho bravado and a penchant for action even if it might harm their patient. In his concluding chapter he suggests a number of questions patients should ask—“What else could it be? . . .“Is there anything that doesn’t fit? . . .” “Is it possible that I have more than one problem?”—to “expand the breadth of [their] dialogue” with the physician and “remove inhibitions that could hide clues.” The right relationship with the doctor will deliver the best outcome.
Gawande’s Better also starts with the physician’s mindset:
We [physicians] face daunting expectations. In medicine, our task is to cope with illness and to enable every human being to lead a life as long and free of frailty as science will allow. The steps are often uncertain. The knowledge to be mastered is both vast and incomplete. Yet we are expected to act with swiftness and consistency, even when the task requires marshalling hundreds of people—from laboratory technicians to the nurses on each change of shift to the engineers who keep the oxygen supply system working—for the care of a single person.
How they manage to fulfill these expectations—and go on to improve patient care—is the subject of his work.
Finally, Pauline Chen probes her initial training and later practice as she tries to understand why doctors flee their dying patients—often after subjecting them to cures worse than their diseases. She bravely describes her own resistance to the many patients who inevitably die of their diseases, and we witness the way doctors refuse to accept defeat.
Gawande, Groopman, and Chen’s books each benefit from an insiders’ view of medicine, but that same insider’s view also limits their vision. Unlike such narrative journalists as Tracy Kidder—who has examined in detail workings of institutions such as schools, nursing homes, and high tech companies—they remain rooted in professional self-centeredness. Though these doctors work in organizations that rely on cooperation and teamwork, they, like many others, fail to consider the role of non-physician actors in improving patient care and safety, or challenge the systems that prevent other players from participating fully.
This blinkered approach to their subject is hardly surprising. Doctors are socialized into a medical hierarchy in which they are at the top, and other clinical staff assigned the role of “physician extenders,” “allied” health professions, or ancillary occupations (allied with and ancillary to medicine, that is). The physician is viewed as the lifesaver in the system—the one with superior knowledge, who does all of the curing and most of the caring.
The heroic medical narrative—even when the hero falters—supports the medical hierarchy, making physicians the health care equivalent of the military’s now-jettisoned advertising campaign, an “Army of one.” Consider Groopman’s story. He begins his journey into “doctors’ thinking” by describing the terror that young doctors-in-training experience in their internships. On his first night in the hospital, Groopman realized that he “would be on call alone, responsible for all of the patients on the floor as well as any new admissions” (emphasis added). While he is “alone,” one of his patients begins to crash, and he freezes. Fortunately, the sudden appearance of a senior physician, whom Groopman characterizes without irony as a deus ex machina, kick starts his paralyzed brain so he can save his patient.
Gawanade forcefully articulates this same heroic, but misleading, physician-centered view of the modern hospital. Physicians do not marshal nurses, lab techs, engineers, or anyone else in the hospital, except perhaps physicians-in-training and those attendings on staff. Though doctors give orders that some other professionals execute, it is hospital departments with their own budgets that hire, fire, and manage non-physician employees. Based on their budgets, they determine workload, work hours, schedules, and duties of employees over which physicians have little or no control. Surgeons like Gawande sometimes only discover this reality when nursing shortages force ORs to close and surgeons to cancel procedures.
For Groopman, the patient/doctor dyad is singularly crucial to quality care. In discussing how cancer patients make the decision about where to get treated, he notes that many are swayed by the reputations of hospitals like Memorial Sloan Kettering in New York. But he quotes another oncologist, Karen Delgado, to refute this idea. “Fundamentally, it’s not about the hospital,” she says, “although there are those with better support services, better nursing, and more expertise in certain diseases. All of that matters, but what matters most is the doctor.”
Yet countless studies document the role of hospital organization in what is known as “failure to rescue”—a hospital’s failure to prevent patient deaths due to avoidable complications. We know that when hospitals do not hire sufficient RNs to staff units, patients suffer many such preventable complications. Pharmacists, respiratory therapists, and others play central roles in a patient’s recovery. Patients can have the smartest, most experienced doctors in the world, but they will be in trouble if those doctors do not collaborate and communicate well with a raft of educated, experienced nurses and many other clinicians.
Indeed, the more we learn about how to “enable every human being to lead a life as long and free of frailty as science will allow,” particularly if those human beings are in hospital beds, the more we discover the importance of communication within collaborative health care teams. As in other high-risk industries, the majority of errors and failures stem not from a clinician’s lack of technical or diagnostic proficiency, but breakdowns of communication. However, unlike others in high risk industries like aviation, physicians are not taught to solicit the opinions of those they consider to be their inferiors. This was clearly documented in a study in the British Medical Journal, which compared the attitude of pilots to those of doctors: pilots were more likely to include subordinates in decision-making than physicians, and more likely to admit that stress, fatigue, and personal problems affected performance.
The aviation industry has learned this lesson and health care is beginning to take note of the progress in passenger safety. But many physician-writers—including Gawande, who recently wrote about one such lesson in the New Yorker—continue to tell a story that obscures an essential ingredient of effective teamwork. Teamwork demands that all players, no matter what their positions in the hierarchy, recognize the importance, knowledge, and skills of the others. It requires that players at all levels in the hierarchy advocate, inquire, and assert themselves, and that team leaders actively solicit and attend to everyone’s insights.
The books never depict—even really gesture at—this critical component of quality care. Even when a knowledgeable nurse is mentioned, the rules of medical hierarchy remain. In his first book, Complications, for example, Gawande describes the case of a surgeon whose penchant for overwork puts his patients at risk. In spite of stress and fatigue, the doctor could not cut back on the number of procedures he performed. Many of those working with him recognized that he had become a danger to his patients, but they could not do anything about it. Why?
As is often the case, the people who were in the best position to see how dangerous [the surgeon] had become were in the worst position to do anything about it: junior physicians, nurses, ancillary staff. In such circumstances, the support staff will often take measures to protect patients. Nurses find themselves quietly directing patients to other doctors. Receptionists suddenly have trouble finding openings in a doctor’s schedule. Senior surgical residents scrub in on junior-level operations to make sure a particular surgeon doesn’t do anything harmful. In this case, the surgeon was stopped only when other physicians acted.
Gawande never reflects on the prohibition against anyone of “inferior” status challenging, and thus shaming, the physician. That subordinates might urgently warn their leader of danger—an intervention now officially sanctioned in commercial aviation—is beyond imagining.
Exploring why many doctors flee the dying, Chen cites a famous 1995 study, SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment), published in The Journal of the American Medical Association (JAMA). The study tracked the experiences of 9105 dying patients in five major medical centers over five years. To help patients die with less aggressive treatment and in greater comfort, doctors were provided with up-to-date information on patient prognoses. Expert nurses communicated with patients and families and relayed information about patient wishes to physicians. Great attention was paid to pain control. Yet the results were abysmal: physicians did not understand or heed patients’ wishes; too many patients spent too much time on ICUs, and too many died in pain.
Why did the project go wrong?
According to Chen, “physicians cannot bear to undermine a patient’s optimism and will continue aggressive therapy in order to maintain a glimmer of hope. Another reason may be the increased specialization of our medical system; since dying patients are often under the care of myriad specialists, no single physician is ultimately responsible for facilitating end-of-life choice.” She also surmises that there may be “financial or legal reasons.”
Maybe. But Dr. Bernard Lo, who wrote a JAMA editorial on the study, told the media (and one of the nurses involved in the study confided to me) that the real reason the study failed was that the doctors would not listen to the nurses. Even when information about patients’ wishes was collected and relayed to doctors by nurses, it was, in most cases, ignored.
Like Gawande, Chen can acknowledge nurses’ concerns about the conduct of physicians. She relates the story of an infant born with a serious defect in his abdominal wall. His physicians refused to give up and subjected the infant to more than half a dozen gruesome surgical interventions during his few short months of life. Finally, the baby died:
I mentioned Max’s death to the head operating room nurse. Jamie was a pragmatic woman, a brilliant nurse who possessed more insight into our patients and hospital politics than most of the physicians. She looked at me flatly when I told her the news, pausing for a moment and then returning to her work.
“Maybe it was a good thing, huh?” She said as she switched the suction tubing from one canister to another. She walked out of the room, and I could hear her asking aloud, “I mean, how much can you do to a person?”
But when Chen describes nurses’ observations, the nurses are relegated to the sidelines, condemned to making terse asides in the OR or hinting that maybe, just maybe, a doctor’s conduct or attitude is a problem. She never entertains the idea that creating a medical team—not only of physicians but nurses, social workers, and members of other disciplines—might expand the outlook of physicians and save some patients from harm.
Why can these doctors, otherwise critical of the state of medical education and practice, not imagine more profound changes?
Part of the explanation may lie in the inadequacies of medical training. Neither medical students nor residents are taught that other professionals can help doctors think better. They are rarely tutored on the role of nurses and other groups they consider to be ancillary. For example, doctors, who spend about five to ten minutes a day with a hospitalized patient, do not know when their patients are in trouble if nurses are not there to detect it. And doctors—particularly doctors-in-training—rely heavily on nurses and pharmacists to help them decide what medications they can safely prescribe. A recent study of 334 medication errors that took place in two hospitals over six months confirmed the critical role nurses play in preventing mistakes injurious to patients. A nurse, who had the time to check, was the health care worker most likely to discover a medication error made by a physician, clerk transcribing the physician order, or pharmacist dispensing that order. In this study, RNs intercepted 86 percent of errors made by other professionals.
In one chapter of How Doctors Think, Groopman relates the story of Rachel, a woman in her late forties who has worked as a financial manager in an academic institution. A member of Groopman’s synagogue, Rachel decides to adopt a Vietnamese baby, but as soon as she and her new daughter, Shira, arrive in Boston, Rachel realizes that the baby is very sick. Shira is admitted to Boston Children’s Hospital. Because she is seriously immunodeficient, physicians initially fear that she has AIDS, then decide she has severe combined immunodeficiency disorder (SCID), a rare inherited disease. They recommended a bone marrow transplant.
A well-informed advocate for her adopted child, Rachel becomes “convinced that Shira had something else,” and suggests to Groopman that the baby has a nutritional problem that is compromising her immune system. Searching online, Rachel had discovered that nutritional deficiencies common in third-world orphanages could produce many of Shira’s symptoms. Unfortunately, the child’s doctors did not agree even though Shira’s condition had improved markedly as she became better nourished. Doctors insisted she was an “atypical case of SCID;” her recovery would only be temporary, and they told the distraught mother to plan for a transplant. Rachel begged the resident in charge to retest Shira’s blood, but he refused. Finally, she told the resident, “If Shira is an atypical case . . . then an ambitious scientist might be able to publish a paper on her. He could look more closely at her cells, get more data on why they don’t function.” He retested Shira’s cells and, much to his surprise, the resident found they were “working perfectly.”
Groopman attributes Rachel’s persistence to her religious faith. In fact, it was not faith but a privileged social position (as a high-level manager with a sister who is a physician) and Internet savvy that allowed her to influence the course of her daughter’s treatment. Only the most sophisticated health care consumer—what used to be called a patient—could cause a physician who is convinced he or she is dealing with a mettlesome mother to reverse course.
More importantly, by focusing on Rachel’s faith, Groopman discounts her role as a rational and knowledgeable player in her child’s treatment. By treating her case (clinician-style) as a unique story, he misses the lessons about teamwork and knowledge of social context. Groopman analyzes the resident’s faulty thinking, but does not suggest that it might have been important to call in a nutritionist or nutritional specialist (if one was consulted, we’re not told about it). Furthermore, the health problems associated with third-world adoptions are now quite well known—Rachel was able to find relevant information on the internet.
If doctors were taught how to be leaders of real teams, they’d recognize that their job is to solicit all of the available information from all of those who might have it (including patients and their families), and to make decisions based on all of that information. Today, doctors (as well as members of other health care disciplines) conceptualize themselves as members of teams that include their discipline and no other. Education in health care needs to change so that doctors learn alongside of, not in isolation from, other professions. And in the organizations in which they work, an infrastructure supporting teamwork must be built brick by brick. Only then will contemporary exhortations that “teamwork is what counts” be more than ritual slogans to ward off the evils of patient harm.
Patients would do a great deal better and doctors might learn to think differently if such influential physician-writers started to challenge toxic medical hierarchies by writing narratives that include more of the players who help patients heal, cope, and die with dignity. If physicians want to pass their final exams, it behooves them to learn, as one airline captain recently told me, that “it takes a team to make sure the plane doesn’t crash and a team to make sure patients don’t either.”
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