When
Hospitals Care Fails Us, Why Should We Not Blame?
Presented at A Writer's Evening, Vanni Bistro Café,
Berkeley, CA, 10/9/18
The Case of
Ilana Yurkiewicz's Father
Our text for today
appears in the July 2018 issue of Health Affairs:
A young doctor down
at Stanford, Ilana Yurkiewicz, recounts the medical misadventures of
her 68-year-old father during a two month hospitalization (not at
Stanford) following his cardiac arrest. Her dad was very lucky;
after a heroic resuscitation with 9 separate shocks over 20 minutes
with 6 cracked ribs, he survived. An intern at the time, Ilana and
her physician sister naturally responded by taking leave to be by his
side kat the hospital.
Like many other
doctors who have found themselves in this position, Ilana was shocked
not only at being at the periphery rather than the center of medical
activity, but also by the multiplicity of errors, instances of
careless care, and the obvious deficiencies of organization that the
hospital delivered to her father.
I'm going to review
the details of this interesting case, review what Ilana thinks it
should teach us, and then offer what I think it should teach
us, and why we should be very disturbed at the root causes of her
father's mistreatment.
Details of the
Case – What Went Wrong
As she sat by her
Dad's bed, she saw that “Details slipped through the cracks.
Preventive measures were overlooked. Complications happened, and
then they snowballed.”
On morning rounds
“three days after my father's cardiac arrest, his medical team
agreed that he should come off the ventilator.” By evening nothing
had happened, but “the covering doctor was busy. It would have to
wait until the following morning.”
Note: This is a
major error in care. Just as justice delayed is justice denied,
medical care delayed is often effectiveness denied. And in this
case, that's exactly what happened. Because the ET tube stayed in
and was irritating, he would have to be sedated overnight. The
doctors on the team had written the order to allow the nurse to use
her discretion in choosing the dose of the sedative.
This is another
error. They assumed the nurse would be competent to make a choice.
She wasn't. Ilana and her sister pleaded with the nurse to make the
sedation light so that extubation could be effected the next day.
But for some unknown reason the nurse elected to give the maximum
dose allowed, and as a result their father was zonked out for 5 days.
After his cardiac arrest his kidneys were not working well (as every
clinician would expect) and it took them a long time to clear the
sedative. Total time on ventilator, instead of three days – nine
days! Nine days ripe for further misadventures.
Note here what is
happening. There is a “medical team.” “Team” may
sound like an attractive idea with two heads being better than one
and someone always available who knows about the patient, but a team
also means a decrease in individual responsibility, extensive needs
for scheduling, coordinating, signing off and signing on, figuring
out who does what, and in many cases no one really knowing the
patient thoroughly. In addition, teams are composed of ICU doctors,
in-patient physicians called hospitalists (doctors who work for the
hospital for inpatient care), residents (doctors in training),
nurses, and other non-physician personnel. Many members of the team
are young and inexperienced. There is no one on the team who knows
the patient before hospitalization and no one who will know him
afterwards. When I hear “team,” I think: bureaucracy, with all
the protection from individual responsibility that bureaucracies
afford. It was a bureaucracy that missed the extubation because
nobody was responsible for it, and it was bureaucracy that scheduled
there to be only one on-call doctor at night, who then didn't have
time to execute the orders, and it was bureaucracy that over-sedated
Ilana's father because the team assigned a less qualified team member
who made a bad decision without review in real time.
Back to the text:
because the ET tube was in so long, Ilana's father's vocal cords were
swollen (I wonder if the tube had been properly placed and
maintained) and he needed a NG tube into his stomach for feeding.
The resident – a doctor in training, remember – wrote the orders
for tube feeding and forgot to say that they should also give him
water. The “team” left the arduous task of writing the orders to
the junior member and didn't check them over in real time. Because
of no water, Ilana's father became thirsty, dehydrated, and delirious
– a diagnosis made by Ilana, it seems. Instead of just giving him
water to make up for the oversight, the hotshot ICU doc thought the
delirium might be because of his kidneys' failure to clear waste
products, so he had a catheter placed in his neck for dialysis –
very invasive, uncomfortable, with risks – and then after a few
days they found that the dialysis made no difference and it was time
to pull the line out. BUT, shades of extubation, this time the delay
in removal was because … it was the weekend! Can't do anything
over the weekend! Because, we don't staff our hospitals fully over
the weekend, because everyone knows that patients don't have the same
medical needs over weekends. Hey, let's all get some R&R! Maybe
the patients should go to the beach, too! Two more days of the
catheter.
I'll stop the
clinical course there; there were other problems but not so severe,
and luckily Ilana's father went home and is even back to work. What
a lucky man. And let's face it, even with service deficiencies,
modern medicine is great. Modern medicine is great.
Analysis - Hers
Ilona is a smart
young doctor, at Stanford via Harvard – smart enough not to stay in
the field of general medicine but to have now bolted to the specialty
of oncology, where her life will be more controllable – so as she
writes this up, she looks for root causes of the problems, as we in
medicine are taught that we should do. She assumes that her father’s
case is not atypical, because she has seen so much of the same thing
in her own experience, as have many others, including me. In fact,
many if not most people can recount their similar stories. There is
not much literature on the extent of errors (which is an interesting
and perhaps indicative fact in and of itself), but we know they are
extensive. For instance, perhaps 10% or more of the time doctors
miss the diagnosis.
Ilana has been
taught to search for root causes and not simply blame the on-call doc
for not being available, the nurse for ordering stupidly, the ICU doc
for missing the diagnosis, and whoever it is who shuts down the
hospital on weekends. But, although she is smart and an excellent
writer, she's young and not widely experienced, and not educated
about systems and organizations, so her list of lessons is short and
not terribly deep. She says that doctors should stop using the
passive voice (such and such happened) and instead take
responsibility, and appreciate that one error can then cascade, so
errors should not simply be excused. Noting that over two dozen
doctors participated in her father's care over two months, she says
that continuity of care should be honored more, so that the doctors
can better appreciate the details of the patient's course. She also
notes that technology should be better applied so that, for instance,
a warning should appear on the computer when too much sedation is
ordered, and feeding water with NG tube placement should
automatically appear on the order sheet. She notes that various
hospitals are pursuing doing just this (various hospitals –
what a national system, where there very few enterprise EHR
companies, but where solutions have to be developed separately!)
While they are
correct as far as they go, none of these suggestions is exactly earth
shaking. Importantly, she does not even mention the presence of or
actions by administrative leaders: supervisors, heads of service,
administrators, or the agencies that give quality grades to
hospitals. She seems simply to accept the existence and structure of
clinical teams, and the heavy patient loads that put doctors in the
position of having to make the difficult prioritization decisions
that screwed her father.
My Analysis
I've been around a
lot longer than Ilana, and unlike her, I'm reflexively critical and
paranoid rather than complaisant and obedient in the face of large
medical institutions. When they teach us not to be angry and
complain, but to understand that we are all striving for the same
ends, I don't believe them. I think they are trying to shut critics
up and preserve their own power, money, and priorities. In other
words, I'm realistic.
Are patients and
large medical institutions really striving for the same ends?
Patients want excellence in care, no question. So do doctors and
administrators. But doctors and administrators are the ones in
charge, and they want other things as well. Institutions need to
teach, so they include residents and students on the clinical teams,
which weigh them down and cause delays and errors. At the same time,
the use of students and younger professionals save the institutions
money by low or absent wages. Large medical institutions are very
concerned about profit, not a patient-shared objective. They care
about preserving their monopoly or oligopoly status, which actually
hurts patients. So, let's not whitewash the potential conflict
between the goals of patients and institutions.
Consider the large
medical institution as an organization. I like to break down
organizations into two types; blame organizations, where the most
important goal is to escape blame and not get in trouble, and
achievement organizations, where success in achieving progressive
objectives is paramount. A sports analogy might be apt. Some sports
franchises seek to be as profitable as possible; they keep the
payroll low and win as many games as necessary to attract a crowd.
By contrast, other franchises have winning as the goal, while not
losing money is the constraint. With a large medical institution,
one must ask, what is the goal and what is the constraint?
If excellence in
care were really their top priority, they would measure it –
remember the old managerial adage, you manage what you measure. But
their measures of clinical excellence are very general and spotty –
e.g, they look at total patient days per diagnosis. Not one thing
that happened to Ilana's Dad would appear on a quality report,
and the length of his hospitalization would be rationalized by risk
assessments.
So what are we to
make of the priorities of large medical institutions that measure
profitability in exquisite detail, but measure quality of care
vaguely? It is important for these institutions to avoid being cited
as purveyors of bad care, and to be reputable enough to get enough
patients to fill the beds. In other words, as a rule, large medical
institutions seek to maximize profitability and view quality of care
as their constraint.
So, don't tell me
that we are all searching for the same thing, and it's simply a
technical issue of how to achieve it.
To go just a little
bit further down the chain of command, there are other priorities
besides profit and quality. How does a situation arise where there
are more patient needs than doctors available, as with night on-call
and weekends? It might be a question of personnel cost, but it might
also be a question of the convenience of the clinicians. Why did
more than two dozen doctors treat Ilana’s father? Ilana says that
the case details are missed that way, and she's right. But also
importantly – and note she doesn't even mention this – does
anyone ever get to know and care about the patient as a person with
this merry-go-round of clinicians? Certainly, patients are not
involved in scheduling. I’d say the providers schedule with the
needs of their own lives the first priority.
So, when
institutional officials say don't get angry, we're trying to get to
the same place you are, we're trying, I call BS.
Two more points.
The medical industry
also exhibits a curious discrepancy: the science of medicine is
advancing rapidly, but organizational experimentation and change is
slow and rare in medicine. (The invention of the hospitalist is an
exception, but it seems that needed reform is now too slow.) Why is
that? I mentioned earlier the bureaucratic nature of clinical teams,
and the fact that patients are begging for care on the periphery of
those teams. Are any serious efforts being made to restructure care
so there is caring for and about the individual and not just treating
the medical case? Are there any serious efforts to expedite patient
demands for care on the wards? Now that primary care doctors who
know and care about the patient have been kicked out of hospitals, is
there anyone to speak up for them, except for the occasional
physician family member, and we've seen how even doctors in the
family can be ignored. I haven't heard of organizational experiments
to change hospital care, and I doubt that there are many such
experiments. Why isn't someone messing around with our inpatient
system to get better results?
Knowing and caring
about the patient as a person is not only the essence of medicine
which being lost in current methods of inpatient care, it's also
instrumentally important. It's much harder to put off a procedure or
not review orders written by others for a patient you know and care
about, as against the arrest in Room 44.
Secondly, not to
beat a dead horse, but it bears repeating, a major reason for
inaction is that there is no money and no glory in discovering better
organizational actions. What's better for patients is not
necessarily what's best for the bottom line. My friend, Colleen
Kraft, currently the President of the AAP, until last year headed a
program at Cincinnati Children's Hospital that successfully kept many
patients out of the hospital by enhanced primary care – good for
the patients, good for cost. But when the hospital board got wind of
the program’s success, they took the only logical step a board
could take. They killed the program because it wasn’t serving
their prime objective, which was to fill up the hospital beds with
paying patients.
Common goals my
foot!
I'd like to discuss
various ways we could think of to introduce the strengths of primary
care onto the hospital wards, but I'm already over my word limit.
So, let me leave you with this well thought out conclusion:
IF YOU TELL ME THAT
INSTITUTIONS ARE DOING EVERYTHING THEY CAN TO PRODUCE EXCELLENCE OF
CARE WITH AS FEW MISTAKES AS POSSIBLE, THAT IT IS JUST TECHNICALLY
VERY DIFFICULT TO COORDINATE EVERYTHING, WHILE SOME OF THIS MAY BE
TRUE, BASICALLY, IT ISN'T, AND I CALL BS!
Budd Shenkin