When my segment on Why Hospitals Should Fly aired on Good Morning America on Monday, April 13th, it predictably stirred up some response - especially from people who had yet to read the book or understand the thesis regarding patient safety and service quality. One such response from a viewer who self-identified as "anonMD" was focused on the differences between aviation and medicine as if this was a repudiation of not only the book, but the entire subject of using human factors from one arena to apply to the other. The Doctor's first mistake is a typical one, saying that since pilots are the first to arrive at the scene of an accident, our buy-in with safety is somehow different than that of physicians. I've dealt with this misunderstanding for decades. The reality? Professional pilots never worry about their own mortality because our cockpits have never killed us any more than an operating room has killed a physician. We worry about loss of face and status, derision of our peers, possible suspension or firing for a gross mistake, and even the possibility of criminal prosecution in an accident if a prosecutor decides to abuse the law and bypass all civilized understanding of human failure. But we are not motivated in the commercial cockpit by some fear or personal death or injury, and in fact are motivated by precisely the same elements that push or pull at a doctor.
AnonMD also goes on to essentially misunderstand not only the book but what I said on air on the 13th with Dr. Tim Johnson about physician autonomy. Never will you find me wanting to strip physicians of their personal relationship with their patient or their ability and responsibility to make the best decisions on care for their patients. But acting as if only they can determine what is quality care and holding that imposing "Best Practice" standards on them is an undesirable evolution of American healthcare reflects the fact that most physicians have been trained to practice in a previous century (the 19th) when it comes to the difference between absolute autonomy and team medicine. We simply can't afford the mortality rates of the former.
The knee-jerk defense of absolute physician autonomy derives from 4,000 years of inertia beginning with the Code of Hammurabi in ancient
Another good friend and esteemed colleague, Dr. Jim Bagian - also a NASA Shuttle Astronaut, fellow U.S.Air Force pilot, and head of the Veteran's Administration office controlling the quality of medicine as practiced on our vets - tells of an early lesson in his surgical residency when a senior surgeon advised that "The only way..." to close a particular type of chest incision was a very precise and particular set of steps involving one type of suture material and one type of stitch. Several years later - left to close the very same type of incision - another senior surgeon essentially snarls at him that "The only way..." to close that very same incision is an entirely different set of steps and suture material. In other words, even in the late 20th century the variations in techniques and procedures, attitudes, use of medicines, and plans of care were so wildly variant from any uniformity that representatives from far more ordered industries run screaming from the room when presented with what amounts to cottage industry chaos. It is, in fact, the very battle over the past twenty years to bring some order out of this chaotic approach that has locked doctors in rather knee-jerk reactive resistance to increasing volumes of procedures and practices which we know, and can prove, are the best methods of everything from surgical procedures to courses of treatment.
Not everything can be reduced to an evidence-based best practice, but so much can that it borders on gross negligence in many cases for a hospital (which is ultimately legally and ethically responsible even for medical decisions made beneath its roof) to allow wild variations in medical care simply to bow to the ancient Hammurabian traditions of not interfering with a doctor's "right" to treat his or her patient any way that doctor sees fit. Again, I would be the last to say that some form of "Cookbook medicine" - where every procedure and decision in proscribed by black letter rules - is desirable. But why insist that the wheel needs to be reinvented with each patient, when there are proven methods that get proven results? It makes no more sense than to say that since I'm an airline captain, I get to ignore the best practice of putting the landing gear down each time I approach an airport and instead make the decision to use the gear or not based on my captain's autonomy.
I am not putting down anonMD's feelings or statements, but I would submit that his statements are premature, and I would invite the good doctor to read Why Hospitals Should Fly and THEN comment on everything Dr. Silverman has instituted in St.Michael's Hospital from the point of view of not only modified autonomy (giving way only to best practices), but also as to legal liability, which - alas - is grossly misunderstood by anonMD. Keep in mind that I am a licensed attorney (Texas) who is dedicated to disconnecting the tort system from what is mostly medical MISpractice (versus MALpractice). But as an attorney who is deep into these issues, I can assure the doctor that the difference is not between being employed and not being employed, the difference in degree of liability arises primarily from being aligned or not aligned with the acceptance and uniform use of the hospital's coordinated best practices. In other words, a doctor's greatest exposure is trying to practice with 19th century autonomy in the 21st century and refusing to use the amazing system of nurses, machines, pharmacists, and research that is there to support every physician.
I must also tell you that when the good doctor mentions that "...it is quite likely that they have weighed the risks..." he is largely incorrect. In most cases the slavish defense of autonomy and a doctor's rejection of evidence-based best practices is not a conscious or a well thought out decision, and one of the major problems across America is that most hospitals are too timid to require their independent physicians to do even the simplest and most important standardized procedures (such as the "Time-Out" presurgical checklists that all but absolutely prevent wrong site surgeries). In thousands of incidents every year, physicians should be immediately suspended from privileges for purposefully ignoring or violating those well-known and well-proven procedures, yet hospital boards usually do not step up to the plate and require compliance with procedures that the physician leaders themselves have mandated. That has to change, but anonMD's image of the thoughtful doctor put upon by a terrible legal system while everyone else runs scott free is simply incorrect - although I acknowledge it is a standard perception. Nevertheless, while I can prove beyond a shadow of a doubt that such a complete overstatement of legal risk is just that, the preception drives the reality, and this is, in fact, the way the majority of our physicians feel. In turn, that near-paranoic response to potential legal liability drives vital safety information underground and also drives trillions of dollars in wasted exams and tests - excessive tests ordered to protect the doctor and the hospital from potential, perceived liability. This is one of the major reasons why the tort system HAS to be removed from medical MISpractice in ways I'll discuss in a future installment.
One final demurrer: Nursing has not improved. Quite the contrary. The quality of nursing services continues to worsen, and most physicians are abysmally unaware of this truth. In fact, nursing is an endangered profession in which we have total confusion, depression, burnout, and incredible responsibilities heaped on women and men who are being daily pulled farther and farther away from true patient care.
I'm reproducing anonMD's comments as left on the GMA website below:
"The biggest difference between hospitals and airplanes? In airplanes, the pilot goes down with the plane. While individual physicians take on risk with every patient they treat, hospital administrators are immune by virtue of their corporate officer status. That's why corporate medicine used to be illegal.Kathleen, above, comments that patient safety boils down to teamwork but she is on a part of the team which is safe from risk. As nurses have become more activist over the last decade, physicians encounter situations where the staff refuses to carry out ordered treatments, or deliver ordered medications, on the basis of either professional autonomy or corporate policy. Yet they do so with little risk to their personal assets, while physicians face the risk of enormous, life-destroying lawsuits.On the flip side, physicians have always valued their autonomy and whether derived from ego, stubborness, ignorance or experience, the fact is that physicians sometimes fail to adhere to the "standard of care." They do so at their personal risk, and you can bet they know it, but it is quite likely that they have weighed the risks and benefits to both themselves and the patient while making those decisions. Today, physicians also run the risk of corporate punishment - loss of credentials, firing, and worse - and the loss of that autonomy is unfortunate.The Wall Street Journal reported today that medical costs have tripled as a portion of GDP over the last 50 years and that the size of the medical workforce has gone from 1% to 12% in the same period. Yet during that time, physician autonomy has been reduced and unhappiness with the system has risen. Nursing has improved, communication has improved, and doctors still take the risks. Meanwhile, insurers have grown, and hospitals are consolidating. Perhaps it's the corporations?"
Posted by: anonMD Apr-13
Leave a comment