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.
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!