Such outrage about awful healthcare! Too many mistakes, too many adverse drug reactions, hospitals making people sick, accidents in the operating room, arrogant doctors, costs going through the roof. What’s the matter? Everyone wants answers.
Why, when competitive business and even publicly-administered enterprises like airports and air traffic control are achieving near-perfect records of safety and economic performance is our healthcare so dismally bad? It’s not like we’re complaining about the dirty hallway floor or nurses not attending to us immediately when they’re called, we are talking danger here: people are dying!
How come? Many critics conclude it’s a lack of order and a failure of trust. There are big messy differences across regions and practitioners in operation performance, complication rates, and mortality. Doctors just decide what to do without reference to authority or science. But, these critics believe, all this is brought on by doctors and other healthcare people we have learned to believe in over half a century who are now apparently abusing our confidence.
What should we do? When in response to critical outrage our reasonable business-trained administrators (responsible for what kind of health care we pay for) look around for a model for success, they properly focus on air-traffic, airports, and the airline industry. It has succeeded through science and technology at making air travel unbelievably safe, by imposing consistency.
Why don’t planes crash? Because absolutely every tiny detail of the machine and everything anybody ever does from check-in to disembarkment is monitored, checked and rechecked, and meticulously documented. The margin of error gets squeezed down very close to zero. So why couldn’t we get rid of nearly all the horrible mistakes maverick arrogant doctors make by just forcing them in the same way to do their job exactly correctly, every single time?
In hopes of getting rid of at least some of our health care disasters, we have started to practice healthcare quality control through a similar surveillance of detail and enforcement of consistency of process. Whereas in the old days surgeons had ships’ captains’ control of the operating room (and when they made mistakes everybody looked the other way), now operations proceed according to protocol which is strictly enforced. Drug treatment is studied and the latest and best evidence gathered to produce prescribing guidelines from which there shouldn’t be any variation.
And all this has a hard paper trail so when things don’t work out, the personal injury industry can fix blame and impose punishment. Mandatory documentary consistency and legibility and our fear of random mistakes has led to health records that look increasingly like checkbox forms. And that’s okay, we think, because we believe that as long as we can successfully impose consistency, results will also be consistent.
I just came back from a meeting of nurses, doctors, and rehabilitation professionals trying to organize a protocol for safely returning frail elderly people who have come to the emergency room, back to their homes, once it’s clear that they have no serious problem that requires hospital admission. We looked at eight separate existing printed evaluation forms that are used in the emergency room, all of them with dozens of checkboxes, some with almost a hundred. Practically nowhere was there any space for written comments, concerns, or summary of evaluation. The forms, it seemed to be assumed, would (once correctly filled out) lead to proper procedures which would lead to best possible outcomes.
Our meeting group spent quite a bit of time trying to cut back redundancy in these forms, but there lingered over the meeting an unstated worry that the process we were trying to create and streamline might not be the best way to come up with a useful picture of an old person’s life that could get them safely out of the hospital and back home to their family.
I left the meeting wondering whether we are on some wrong track in trying to perfect our health care through exhaustive checklists as if it resembled making sure a plane doesn’t crash. A person is not an airplane, a hospital is not an airport and a surgical operation is not a takeoff or landing. You can nearly perfect a process that involves close-to-identical machines and procedures. But to try to perfect a world involving human patients and health providers has to be a little more difficult, doesn’t it? I thought to myself.
And worse, are we sending a clear though unspoken message to our health professional students that once they check every single box on the form, and are exhaustive and meticulous with all the detail they have discharged their responsibility to their patients? If so (and I see that kind of practice around me in hospitals) what a terrifying prospect to confront if you ever get sick and need help.
Of course the “outcomes” (crash? no crash?) in healthcare are infinitely less cut and dried than whether there is an air accident or not. Patients are never perfect. When we measure re-admissions, postoperative infections, return to pre-illness function, or even death, it’s still pretty hard to know whether someone would go back to the hospital again if they had the same problem, have the operation again given the choice, or try a drug treatment a second time knowing how the side effects really feel to them. Hard, in other words, to quantify and factor in the human element in balancing and understanding choice.
I wonder if a better way to fix health care is to return to valuing carefully thought-through problem-solving by experienced health professionals who balance science and evidence with clinical and human instincts. And who make sure they get vitally connected with the people looking for their advice, then tell those people what’s on their mind, ask them what they think, and listen to the answers.
Doctors and nurses have betrayed an old-fashioned trust, but we did it with some able assistance. In trying to clean up our procedures we and our administrative colleagues have washed the baby out with the dirty bathwater.
Anyone who reads posts on this blog will be wondering how many ways I can find to keep saying the same thing. They are correct of course. But I insist it is way past time to refocus on relationships, admit that we will always make mistakes, and that sometimes we will see our patients suffer even when we do our job close to perfectly. I think we should be very clear to ourselves, one another, and the people who depend on us that our decisions and opinions, whether they come from procedural guidelines, our instinct, or both, are tentative. And while we’re at it we should get a lot better at writing out our thinking process in the record in our own original honest language. Legibly.