“The King Has No Clothes!” and Other Useful Truths in the Health Care Setting

Mike Tyson, Former Undisputed Heavyweight Champion of the World (Photo by Octal)

Two recent  articles in the Wall Street Journal’s Health Blog are well worth considering. The one article discusses the efficacy of the “aviation model” for medical practice safety. Noting that the surgical checklist is itself cockpit inspired, the article considers a report which questions whether other aviation safety models might be also effective in a health care setting. WSJ writes:

A paper published recently in the Milbank Quarterly, a peer-reviewed population-health and health-policy journal, suggests extracting even more lessons from the aviation world, offering 15 examples of error-reduction policies that aren’t always routinely used in the health-care setting.

The surgical checklist has proved effective. In a post entitled Surgical Checklist Said to Save Lives & Money, we noted the following:

The use of a basic checklist was shown to be associated with a substantial decrease in surgical deaths and complications. In what the A.P. referred to as a “a large international study of how to avoid blatant operating room mistakes,” researchers found a 47 per cent decrease in death and a more than one third decrease in complications-from 11% to 7%- concomitant with the use of a 19 point checklist designed by the World Health Organization.

A few aviation examples the WSJ noted in the article mentioned above involve communication and they, I believe, are worth considering for a moment:

The “sterile cockpit” rule. During certain critical phases of flight, pilots and crew aren’t supposed to chat idly or do anything else not essential to their jobs. Similarly, nonessential activities might be prohibited during certain phases of medical practice, which would depend on the practice (incision during surgery, for example.)

First-names only rule. Regardless of rank or seniority, cockpit personnel address each other by their first names in order to “flatten the social hierarchy” and “foster a culture in which colleagues feel more comfortable questioning one another,” the authors write. Doing the same for surgical or medical teams might promote a similar culture, though the issue is made “complex” by the fact that patients prefer “formality” in their relationships with their doctors.

These examples, much like the surgical checklist, stand out for being common sensical and one would imagine, relatively easy to implement.

Anyone involved in a moderately complex task should be able to relate to the benefit of a “no chatter zone” during the portions of the task which require greater concentration or present greater risk or more dire ramifications. Much of what I do on any given day, because I do it so often, is largely rote. But some moments are crucial; it helps to then not be listening to a co-worker recount the latest misadventure involving cute children, a puppy and some potato salad.

The First-names only rule is perhaps a bit more attenuated, but perhaps even more important. People make mistakes; it is crucial that one has colleagues or friends willing to point them out. The failure to be informed of one’s own errors can have critical impact. History and literature are filled with examples. Think of King Lear and his Fool–someone at court able to tell the King the truth– lest the ruler find himself, like that other famously fabled King, parading through town without clothes. A more modern, and real, example is President Kennedy, his Cabinet and the Bay of Pigs fiasco–a room full of men who thought better but engaged in “groupthink” to the point that they ultimately functioned as rubber stamp sycophants to the President– keeping their misgivings to themselves. After the disaster which was the Bay of Pigs, Kennedy removed himself from Cabinet meetings to allow his counsel to do just that. And for the boxing afficianado (boxing is not sport so much as life distilled– Classical Tragedy, with only the how and when to be resolved) it is an oft repeated tale in which after years of hard and driven work with a dedicated trainer a new Champion with new money is found by new friends–or “hangers-on” as they are most often called in the trade. These omnipresent “friends” with no visible means of support beyond the boxer tend to say things like “You’re right Champ” and  ”You’re the Champion Of The Entire World! You don’t have to train if you don’t want to.” The results are often brutal in their reckoning. Ask Mike Tyson.

But in a more recent article, “Report: Communication Breakdowns Lead to Hospital Errors,” the Wall Street Journal gives us other cause for concern–more concrete, more direct to the topic at hand. The Journal writes:

According to a two-pronged survey of operating-room and critical-care nurses conducted by their professional associations and VitalSmarts, a global training and consulting firm, 85% of 2,383 nurses surveyed said they’d been in a situation where measures put in place to reduce errors -  including checklists or hand-off protocols - warned them of a problem that would have otherwise harmed a patient.

That’s the good news. The bad is that 58% of the nurses said they’d been in situations where it was “either unsafe to speak up or they were unable to get others to listen.”

The report focuses on what causes this type of communication breakdown, including three concerns that are rarely discussed by health-care teams: dangerous shortcuts, incompetence and disrespect. Among respondents to a separate survey of 4,235 nurses, 84% reported working with people who take potentially dangerous shortcuts, such as not washing hands for long enough, with 34% saying shortcuts had led to near misses and 26% saying they caused harm to patients. Some 19% say incompetence or lack of required skills have harmed patients and 20% say that disrespect is making them seriously consider leaving their profession.

Despite all this, concerns “are often left undiscussed,” the report says.

A Sokal Hoax for Docs

Via Ezra Klein, a revealing anecdote about the power of “thought leadership:”

In the early 1970s, a group of medical researchers decided to study an unusual question. How would a medical audience respond to a lecture that was completely devoid of content, yet delivered with authority by a convincing phony? To find out, the authors hired a distinguished-looking actor and gave him the name Dr. Myron L. Fox. They fabricated an impressive CV for Dr. Fox and billed him as an expert in mathematics and human behavior. Finally, they provided him with a fake lecture composed largely of impressive-sounding gibberish, and had him deliver the lecture wearing a white coat to three medical audiences under the title “Mathematical Game Theory as Applied to Physician Education.” At the end of the lecture, the audience members filled out a questionnaire.

The responses were overwhelmingly positive. The audience members described Dr. Fox as “extremely articulate” and “captivating.” One said he delivered “a very dramatic presentation.” After one lecture, 90 percent of the audience members said they had found the lecture by Dr. Fox “stimulating.” Over all, almost every member of every audience loved Dr. Fox’s lecture, despite the fact that, as the authors write, it was delivered by an actor “programmed to teach charismatically and nonsubstantively on a topic about which he knew nothing.”

It’s one more rationale for more disclosure of sources of influence in the medical profession . . . and ostensibly more objective, “algorithmic” authorities.

Originally posted at Concurring Opinions. Photo credit, Jerry Angelica.

Doctors, Patients and a Failure to Communicate

“What we have here is a failure to communicate.”  Fans of Cool Hand Luke (and who is not?) will recall the phrase in graphic detail–and for those of you without that memory, the video will provide.

A recent study highlighted in the Wall St. Journal’s Health Blog points to both a discrepancy in perception between hospital doctors and their patients and a failure to communicate.

The study was conducted by Douglas P. Olson, MD and Donna M. Windish, MD, MPH. The authors noted as “Background” in the study abstract that:

Hospital surveys indicate lack of patient awareness of diagnoses and treatments, yet physicians report they effectively communicate with patients. Gaps in understanding and communication could result in decreased quality of care. We sought to assess patient knowledge and perspectives of inpatient care and determine differences from physician assessments.

The results of the study were derived from two validated questionnaires given to inpatients treated by “house doctors” over a course of roughly eight months at one hospital.The corresponding doctors were also queried. Eighty-nine patients and 43 doctors participated.

According to WSJ:

The survey — which the authors note is limited by its reach (one institution), patient characteristics (older, indigent and less-educated than average), and general responses, rather than one-to-one-patient-physician comparisons — is published in the Archives of Internal Medicine.

The results? From the abstract:

• Only 18% of patients knew their main doctor by name.
• Sixty-seven per cent of doctors believed their patients knew them by name.
• Fifty-seven per cent of patients knew their diagnosis.
• Seventy-seven per cent of doctors believed their patients knew their diagnosis.
• Fifty-eight per cent of patients thought that physicians always explained things in a comprehensible way.
• Twenty-one per cent of doctors stated they always provided explanations of some kind.
• Sixty-six per cent of patients reported receiving a new medication in the hospital, 90% noted never being told of any adverse effects of these medications.
• Ninety-eight per cent of doctors stated that they at least sometimes discussed their patients’ fears and anxieties.
• Fifty-four per cent of patients said their doctors never did this.

Interestingly enough,the WSJ article notes that the

responses didn’t significantly differ by sex, age, race, language or payment source, for the patients, or level and type of training, for the doctors.

Only 57% of patients knew their diagnosis? Which is to say that 43% did not? 90% not told of potential adverse reactions to new medication?

Res Ipsa Loquitur.