Part II - What Doctors and Healthcare Can Learn from the New England Patriots

Although my team, the New England Patriots lost Super Bowl XLVI to the New York Giants in one of the most exciting and tense games in recent memory, reviewing both the pre and post game coverage provided even more learning for doctors and healthcare than my prior post. One can demand excellence and still fall short. When one fails to achieve the intended goals, the learnings can be as important if not more so than when one is successful. In the latter, you assume that you understand the reason for success. In the former, you must investigate to determine problems. It is the approach that matters.

CEO of the Patriots, Robert Kraft noted in a post Super Bowl conference that statistically every NFL team has a 6 percent chance of reaching the Super Bowl and consequently a 3 percent chance of winning. Over the past decade, the Patriots have been in half of them. An impressive statistic considering other teams have equally dedicated players and coaches who also are focused on success. So what makes the Patriots so successful?

One learning is the true meaning of teamwork. Sure football is a team sport, but are the players and coaches truly a tight knit team on the same page for excellence?  Prior to the 2002 Super Bowl, players were introduced onto the field individually by name. Hearing your name called out and then running out onto the field to a crowd of screaming fans undoubtedly is a thrill for every player, particularly when it is the Super Bowl. Yet for the Patriots that year, this was not the case. Earlier that season at an away game, a mix-up in the team introductions had the team unprepared. Instead of the usual player introductions, the team instead raced onto the field as a team rather than individually.

Then 9/11 happened. For the remainder of the season, the Patriots found it fitting to continue dash onto to the field as a team as the nation came to grips of an unspeakable assault on our country.

Hours before 2002 Super Bowl kick off, head coach Bill Belichick notified his team that the NFL and television network required that the team be introduced as individual players. To come out as a team would be in violation of policy.

What did the team want to do?

They ran out as a team. The first time ever that has occurred. As noted on ESPN by former 49er quarterback and football analyst Steve Young, that tradition has continued to present day and shifted the focus back from the individual to the team, the right thing for football.

And perhaps this is the right thing for doctors and the health care system. How often do hospitals and health care organize themselves around having the "best" doctor? How often do people ask, who is the "best" surgeon, internist, oncologist, cardiologist. Is medical care really about one person or is it about having the right team? Dr. Atul Gawande, author, New Yorker writer, and surgeon, noted in his commencement speech titled, Cowboys and Pit Crews, at the Harvard Medical School in 2011 that today.

“[Medicine’s complexity] has exceeded our individual capabilities as doctors…
The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves... But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to “protocol” the MRI.”

“...We don’t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It’s like no one’s in charge—because no one is. The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.”

It really should be about the team and not the individual. This is particularly true when it comes to medical errors. When a wrong site surgery occurs or a medication is administered at a dosage that exceeds safe usage, the question in health care is - "Who is responsible?" As noted safety expert and UCSF professor Dr. Robert Wachter notes in a 2004 interview when a medical error occurs at a hospital -

"...people invariably point fingers at that place and person and lose sight of the systems failures that are really responsible. Look at it this way -- ask anyone if they've seen a medical error and they'll immediately tell you a story about one. Could it possibly be that all doctors and nurses are careless and stupid? Or, perhaps, does the ubiquity of the problem indicate that something deeper and far more interesting is going on?"

So in the true meaning of teamwork, should something happen, the team is accountable not necessarily the individual. The team owns the problem and does not leave the individual alone, unsupported, or in shame. Even after the most recent Super Bowl loss when many people picked up on individual player errors of dropped passes, including one from wide receiver Wes Welker, one of the most sure handed receivers in the NFL, which likely would have resulted in a Super Bowl win, no one from the team scapegoated him or others. As quarterback Tom Brady put it in the post Super Bowl press conference -

You win as a team and you lose as a team. Certainly it wasn't one play is the reason that we lost today. Everybody feels that we could have done more....

There was some missed opportunities.

When surveyed on the Boston Globe on who should be blamed most for the Super Bowl loss, quarterback Tom Brady, head coach Bill Belichick, the Patriots defense, or the receivers Aaron Hernandez or Wes Walker, the majority of votes distributed the blame evenly across the team. It was not just one person.

Yet in health care, we do a terrible job in supporting others when errors happen. We often assume the individual was at fault rather than a collective fault or system failure. Health care professionals who have dedicated their lives to saving lives are devastated. Some commit suicide after a medical error.

Finally the last learning is leadership, having a vision, and understanding what really matters. All season long as his young defensive unit was getting dogged in the press as being among the worst in giving up total yards to other teams, Belichick calmly noted that it wasn't about that statistic which mattered, but what was the win - loss column. Hard to argue with that as this team did make the Super Bowl.

Belichick is known to resist the status quo. He's a football coach, not a fashion model, yet was mandated by the NFL to wear Reebok sanctioned clothing on the sidelines to look nice. What did he do? He picked up the ugliest piece of clothing he could find, the hoodie.

There was no way to opt out of that deal so Belichick considered the fashion options laid out in front of him, and selected the most unstylish outfit, a grey hooded sweatshirt. He began wearing it each week. Only not before having the sleeves cut off to make it even less attractive.

“It’s comfortable,” Belichick said in explaining his fashion choice. “I carry my stuff in my pouch.”

What about chopping off the sleeves?

“I have short arms,” Belichick said.

The irony is the “BB hooded sweatshirt” became a hot seller. It was so bad, it was cool. It now comes in all sizes and colors, even women’s versions. They sell for about $80

As a coach and leader, he knows what really matters: putting his players in a position to win. This is what leaders do and what players and analysts noted repeatedly up to the game. Belichick does everything possible for them to succeed. Near the end of the game, Belichick understood that the Giant offense had a high probability of scoring a touchdown and he needed to give his future hall of famer quarterback Tom Brady time to score. So he asked his defense to let the go ahead touchdown to go through to allow maximum time on the clock.


Good move? Well the outcome and the win for the Patriots didn't happen. But, it was the right leadership decision and recognized by Giants quarterback Eli Manning, who "had ordered [Giants running back] Bradshaw to take a knee."

Do we in health care have these leaders who can create environments that allow doctors and other care providers the opportunity to be successful? Do we have leaders who truly have vision and know what really matters?

Even without a Super Bowl win, we can still learn a lot from the New England Patriots. A true culture of teamwork matters and exists when we can still support each other not when things go smoothly, but when things don't. We need to have leaders who not only have vision, but also the discipline to do the right thing and challenge conventional thinking and the status quo.

Only then can health care truly transform and be what Americans want and deserve. 

Though I look forward to next year, there obviously is much unpredictability in which team reaches the Super Bowl. I'm certain the Patriots will have another successful year.

Congratulations to the NY Giants and their team, coaches, and leadership.

Unlike football, where there is next year and they need to perform for a game at a time, for us we need to get a win with every patient everyday at every moment. Our performance can never lapse.
 

Physician Autonomy, Professionalism, and Protocols – Mutually Exclusive?

Doctors are professionals.  But are doctors cowboys or pit crews?  Recently, physician writer, Dr. Atul Gawande, spoke about the challenges for the next generation of doctors in his commencement speech titled, Cowboys and Pit Crews, at Harvard Medical School.  Gawande notes that advancement of knowledge in American medicine has resulted in an amazing ability to provide care that was impossible a century ago.  Yet, something else also occurred in the process.

“[Medicine’s complexity] has exceeded our individual capabilities as doctors…
The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. One needed only an ethic of hard work, a prescription pad, a secretary, and a hospital willing to serve as one’s workshop, loaning a bed and nurses for a patient’s convalescence, maybe an operating room with a few basic tools. We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to “protocol” the MRI.”

Despite all of the advancements in medicine, the outcomes and consistency in treatment and care are not as good as they could be.  Doctors are not doing basic things.  The fact that Gawande, author of The Checklist Manifesto, spoke at one of the finest medical schools in the country indicates how much more the profession needs to go. 

“We don’t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It’s like no one’s in charge—because no one is. The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.”

So what is the issue?

Doctors usually bristle when facts of failure are mentioned.  When solutions are offered, a variety of reasons of why they won’t work often occur.  Doctors deal with patients and illness.  Medicine is different from other industries like aviation or auto manufacturing in their experience with providing a highly consistent and reliable service or product.  In many ways, this is true.  Patients are unique in their genetic makeups, personalities, backgrounds, and experiences.  Yet, the understanding of many illnesses has evolved to the point that doctors understand how to prevent, screen for, and treat these maladies which often afflict patients in similar ways.  When understood at this level of detail, this knowledge can be codified into protocols and workflows.  As research studies demonstrate what works and what does not, these can be refined further.  Analysis of medical errors borrow the same processes and tools from other organizations dealing with complex systems to determine underlying problems and more importantly solutions to avoid similar outcomes in the future.

The creation of standardized workflows, checklists, and protocols causes doctors to bristle even more.  As Gawande notes, the training of doctors today is essentially unchanged from generations ago which valued physician autonomy.  When asked to follow protocols, doctors often feel this freedom to practice medicine is threatened.  A natural tension exists between physician autonomy and adherence to protocols.  Many will argue that the two are mutually exclusive.  Both, in fact, can co-exist only if we look at the problem through a different lens.  It is about the difference between what Professor Clay Christensen, Harvard Business School professor, and author of the Innovator’s Prescription, calls intuitive medicine and precision medicine. 

It is also about professionalism.  Are doctors professionals or cowboys or pit crews? 

What Professor Christensen refers to as intuitive medicine is essentially how the public and doctors view themselves.  As a result of the medical training, history, and tradition, doctors are thinkers.  Patients present themselves with a set of symptoms or signs that they want doctors to solve.  Because the body only has a certain limited number of ways to manifest an illness (note that for a dermatologic disorder, the skin turns red and can blister due to a burn, drug rash, autoimmune disorder, or contact dermatitis), clinching the right diagnosis required doctors to ask questions, think, use pattern recognition, and experimentation.  Until the relatively rapid learnings over the past century, doctors did not understand the specific mechanisms, pathophysiology of diseases, or the appropriate treatments.   

An example of intuitive medicine was an illness that humbled American medicine just three decades ago.  It afflicted mainly young gay men.  Aside from the observations of a low T cell count and unusual opportunistic diseases affecting these patients, doctors were at a loss of what to do.  How did the illness occur?  How was it transmitted?  How as it treated?  The fear among the public was palpable.  During that time, doctors tried a variety of treatments that invariably failed though through some experimentation and observation, some patterns began to emerge.  The reasons for a few successes became better understood when HIV was discovered and doctors had a better understanding of AIDS.  As a result, the course of illness and then the development of therapies, treatment, and prevention programs occurred which now allow individuals with HIV to live productive lives.  

When scientific understanding of maladies becomes so clear that prevention, screening, and specific therapeutic options can be written down into steps, protocols, and workflows, Professor Christensen refers to this type of medicine as precision medicine.  Many medical problems, like diabetes, are in this category.

The pathophysiology of diabetes is known.  There are two types of diabetes, insulin dependent and non-insulin dependent diabetes.  The degree of blood sugar control can be determined with a simple blood test, HgbA1c.  If a patient has insulin dependent diabetes, the treatment must begin with insulin.  For non-insulin dependent diabetes, treatment can often start with weight loss, physical activity, and dietary changes.  Prescription medications, like metformin, and then later glipizide can be added in a stepwise approach based on a specific protocol should an individual patient’s blood sugar control require it.  The fact that the understanding of diabetes and development has occurred over the past few decades has benefited Professor Christensen greatly.  He has insulin dependent diabetes.  Had he been born a century ago, he would not have lived very long as insulin was not discovered until the early 1920s.

Yet, there are some areas in diabetes research which continue to evolve.  Intensive blood sugar and blood pressure control in patients with insulin dependent diabetes was found to decrease the risk of complications and death.  It was assumed and extrapolated that similar treatment would also benefit those with non-insulin dependent diabetes.  Recently studies have shown that older patients did not benefit and perhaps were harmed with this level of treatment.  As a result, the guidelines have changed.

Although the protocols and guidelines are good, they are not perfect.  They are only as good as the research available at that time.  They continue to be refined.  They are not static.  It is this element that opponents of using precision medicine shout out words like “cookbook medicine” which have significant negative connotation.  This simply denigrates the hard work and research that has allowed an illness to move from the realm of intuitive medicine to precision medicine.  The fact that these protocols are not perfect, should not be a reason not to use them. 

At the heart of being a professional and consummate physician is the knowledge and wisdom to understand when a patient’s illness or treatment of a condition fits a known workflow or protocol and when it does not.  The very best physicians follow procedures meticiously and thoughtfully whether placing a central line using the five critical steps as outlined by McArthur grant recipient and John Hopkins critical care specialist, Dr. Peter Pronovost, to eliminate risk of infection or taking seriously a surgical timeout to avoid wrong site surgeries.

Too often doctors will argue that blindly following protocols infringes on their autonomy.  That is true.  Blind adherence is a problem.  However, passively going through the motions is equally as disasterous.   Life saving treatment isn’t rendered.  Screening tests not offered.   Preventable medical errors still occur.  In November 2010, only six months before Gawande’s commencement speech, a wrong site surgery case was prominently profiled in the New England Journal of Medicine.  It occurred at one of the nation’s most prestigious hospitals, Massachusetts General Hospital.

In the end, it is the mindset of physicians which matter.  We aren’t cowboys.  We aren’t pit crews.  If analogies must be made, then we are like the pilots in flight crews who are professionals and despite the complexity of their roles provide ultrasafe travel.  Doctors are professionals.  It is what the public expects.  Using protocols, checklists, and standardized workflows are just as important as refining them to be even better.  Knowing when not to apply them, is just as vital as ensuring that those situations where they do apply that they are done - every patient every time.

Our patients deserve better.  We can and must do better.

Why Doctors Need To Be Less Like Chuck Yeager and More Like Captain Sullenberger

A recent medical error of a wrong site surgery that occurred in one of the country's best hospitals, Massachusetts General, reminded me why doctors need to be less like Chuck Yeager and more like Captain Sullenberger.  Growing up I always wanted to be a fighter pilot, years before the movie Top Gun became a part of the American lexicon.  My hero was World War II pilot Chuck Yeager, who later became one of the country's premier test pilots flying experimental jet and rocket propelled planes in a time when they were dangerous, unpredictable, and unreliable.  Much like the astronauts in the movie, the Right Stuff, Yeager and his colleagues literally flew by the seat of their pants, made it up as they went along, and never really knew if their maiden flight in a new aircraft might be their last.  They were cowboys in the sky wrangling and taming the heavens.

Fast forward to January 2009, when shortly after takeoff a one in a million chance, a double bird strike completely disabled a US Airways jetliner.  Captain Chesley Sullenberger with the help of his co-pilot Jeff Skiles ditch the aircraft in the Hudson River in under four minutes even as the nation surely expected a tragedy.  But not on that day.  Not with that pilot.  Though Sullenberger, an already accomplished pilot from being the top cadet at the US Air Force Academy, an aviation safety expert with his experience as a crash site investigator for both the military and civilian sector as well as an instructor for US Airways pilots, he credited much of the success to his training and his experience.  Sullenberger had studied why pilots and crews often failed in critical emergency situations.  He also mastered and understood the physics and performance aspects of the aircraft he flies (his wife calls him a pilot's pilot).  He also believes strongly and instinctively the need to follow checklists and protocols to ensure the right thing is done every time.  This was drilled in him in the military where the difference between life and death in a fighter plane could be simply a matter of feet and seconds.

Though the media dubbed the landing as the "Miracle of the Hudson" and named him America's hero, Sullenberger modestly noted he was simply doing his job, which only endeared him even more to a country looking for positive stories in a time of a new president, an unprecedented financial crisis, two wars, and an uncertain future.  Ask Captain Sullenberger, review the cockpit recordings, and you'll discover that he wasn't really flying by the seat of his pants but was very methodical, rational, and logical as he quickly evaluated his three options: return the plane back to LaGuardia, go to Teterboro, New Jersey, or ditch in the Hudson River.  While planning for a landing after the unthinkable, his co-pilot automatically did his job attempting an engine restart by cycling through the checklist seven times.  They landed the plane successfully with a little luck, a lot of skill, and a full understanding of how humans make mistakes in particularly stressful times and what mechanisms when put into place, checklists, protocols, and training, can decrease these to a minimum.  Frankly, no one else could have landed that plane except Sullenberger.

Which brings me back to the medical error noted in the New England Journal of Medicine.  Dr. David Ring, after a day of many carpal tunnel surgery releases erroneously performed the surgery on a woman who was supposed to get a trigger finger release.  Though he has been praised by many to be courageous to publicly acknowledge the error, what was quite disturbing was his one comment:

"I no longer see these protocols as a burden. That is the lesson."

His insightful comment should not be seen as an anomaly.  Dr. Ring should also not be ostracized.  He speaks the truth.  Doctors today still see themselves as cowboys, the heroic individual who despite whatever obstacle or hardship can just get the job done.  Somehow, we are too smart to rely on surgical timeouts, checklists and protocols.  Instead, we refer to the entire process "cookbook" medicine and go through the motions just to appease regulators and administrators.

It is this arrogance and hubris that pervades our profession that is quite disturbing and equally disappointing.  A March 2010 report found that medical schools are not doing enough to prepare future doctors on how to develop the mindset for patient safety.  Yet for much of medicine, we understand the precisely the science of how to do things better.  No central line infections occur when all doctors abide by a simple 5 point checklist developed by John Hopkins intensivist Peter Pronovost.  Merely having every surgical team member introduce himself before surgery as noted by New Yorker writer and general surgeon Atul Gawande improves communications so that the team is more likely to function better in times of crisis.  Even a singular phone call by Dr. Gawande to the blood bank to hold blood on standby for a "routine" surgical procedure, which he had done many times before and never needed the blood, ended up being critically important.  On that day with that routine surgery, his patient had a tear which required 30 units of blood.  If Dr. Gawande hasn't called for blood on standby before the operation started, his patient would have died.

We know much more about medicine since the development of antibiotics, antiseptics, and best practices, yet we act no differently than 150 years ago.

"In 1852, the Massachusetts General Hospital was featured in a New York Times article detailing a series of events that led to the death of a young patient. Under the care of the surgeon, Dr. John Collins Warren, the patient had received chloroform instead of the usual chloric ether anesthesia. The event that we describe here, more than 150 years later, is a sad reminder that despite expert and well-intentioned providers, our patients continue to face risks caused by human fallibility and systems that do not fully support our efforts to provide safe care."

It's time doctors stopped acting like the cowboy test pilots of Chuck Yeager's era and adopted the mindset of Captain Chesley Sullenberger and doctors Pronovost and Gawande.  Protocols and checklist exist for the safety of our patients and to ensure highly reliable outcomes everytime.  Until doctors all adopt this mindset, medical errors will continue to happen despite policies and regulations because somehow our profession still believes we are infallable.

Navy Investigates Murtha's Death - CNN's Elizabeth Cohen Reports Unhelpful Advice

Nine days after my post wondering if the late Rep. John Murtha's death after an elective gallbladder surgery was a result of a preventable medical error, CNN and the Washington Post report that the Navy is now opening an investigation.

"The review is being conducted to determine if Murtha died due to a preventable surgical error and whether any action against those who performed the surgery is potentially warranted." according to the CNN article.

While this is good news, what I found rather disappointing was CNN's senior medical correspondent Elizabeth Cohen thoughts on how Murtha might have acted differently to avoid this unforseen outcome.

"You really have to be an aware and empowered patient because in those two days it's likely that he likely felt something that he felt some discomfort or felt a bit ill and, of course, we aren't trying to blame the patient but if you feel anything at all strange following a surgery you have to go back to that surgeon."

While I suspect she is trying to be helpful, the advice she offers isn't particularly meaningful. Who doesn't feel a little discomfort, feel strange, or a bit ill after having surgery? What other past life experience provides a reference point on whether this post-operative recovery will turn out fine or be completely disastrous?

The reason she would say such a thing is because our healthcare system is not as good as it must be in preventing medical errors and eliminating missed opportunities for prevention and screenings. Patients don't want to constantly worry about being an "aware and empowered patient". They don't want to be burdened with the responsibility of being vigilant for bad outcomes. They would rather can focus on healing and getting better.

Our healthcare system must continue to focus on improving patient safety.

So, in the end, was Murtha's death preventable? While I don't have any specifics of his case, my sense is that unfortunately his death was the result of a known risk and surgical complication and not due to gross incompetence or negligence. Let's be frank the Navy's review of Murtha's death is only because of his status as a very visible Congressman. Had this occurred to someone else, I doubt a death after gallbladder surgery would have received this level of scrutiny.

If this review is done objectively, then I don't expect anyone to be reprimanded or fired.

His death, however, does serve as important reminder. Only have surgery if it is absolutely necessary.

Could Rep. John Murtha Have Died from a Medical Error or Omission?

While the news reports that Representative John Murtha of Pennsylvania died after complications from gallbladder surgery, the question no one is asking is whether his death was a preventable one or simply an unfortunate outcome. According to the Washington Post, Murtha had elective laproscopic gallbladder surgery performed at the Bethesda Naval Hospital and fell ill shortly afterwards from an infection related to his surgery.

He was hospitalized to Virginia Hospital Center in Arlington, Virginia, to treat the post-operative infection. His care was being monitored in the intensive care unit (ICU), a sign which suggests that not only was the infection becoming widespread but also that vital organ systems were shutting down.

Was his death preventable or simply unavoidable? One reference notes that when gallbladder surgery is performed electively that "the mortality rates are very low. (Even in the elderly, mortality rates are only 0.7 - 2%.)" Perhaps Murtha was one of the unlucky 2 out of 100 to have died from this elective surgery.

It is also equally likely that he died of a medical error or omission. As Dr. Atul Gawande notes in his newest book - The Checklist Manifesto - a simple list helped prevent less than optimal surgical outcomes. One item on the list is whether or not IV antibiotics were given at the time the surgeon begins the opening incision. You would think this would be obvious, yet in the operating room, there is a surgical team which as a group is responsible for the patient's care. Do they work as a highly functioning team? Are there clear lines of communications between the surgeon, anesthesiologist, nurses, and surgical techs? Sadly, communications are not as clear as they need to be. As Gawande notes, a simple two minute checklist not only forced communications (something as basic as an introduction to the surgical team - "Hi, I'm Dr. Gawande general surgeon") but also verified that critical tasks were completed. As a result, the checklist decreased the complication rates by 36 percent and death rate by half. Disappointingly only 20 percent of American hospitals have adopted these types of checklists.

The Leapfrog Group rates hospitals on their processes to keep patients safe. Bethesda Naval Hospital being a government institution isn't listed and is not part of the survey. (Leapfrog Group was founded by large employers, who purchase health insurance, to evaluate the care their employees receive from hospitals).

Virginia Hospital Center, where Murtha was hospitalized, didn't submit any information either even though it is listed in the Leapfrog Group database. Specifically, Virginia Hospital Center declined to respond to the survey on how they are doing to keep medical errors from occurring. Questions include whether there is adequate ICU staffing, processes to reduce ICU infections, and steps to prevent harm. Gawande notes in his earlier New Yorker piece that even intensive care units errors of omission and missed opportunities happen which can be avoided with checklists.

In other words due to lack of transparent information, both hospitals are black boxes - Bethesda Naval Center because it is a government run hospital and Virginia Hospital Center because it didn't submit any data. There is a good chance that Murtha's death was possibly avoidable. This doesn't mean that doctors aren't working hard or trying to do their best. I believe that getting medical care must be as safe as it is humanly possible. Having witnessing near misses in medical care with my family and understanding what it takes to make patient safety as routine as other highly reliable organizations, I recognize that there is still much to do.

In the mean time, what does this mean for you? Surgery is never routine. If you need to have an operation, check out the hospital and how it rates to keep you safe at The Leapfrog Group. Not listed there? See if you can get surgery at a hospital that is recognized by Leapfrog.

Book Review -- The Checklist Manifesto - Checklists and Team Communications Make Us Better

I’m a huge fan of Dr. Atul Gawande ever since meeting him at a patient safety conference in 2005, and then subsequently reading his books and following his New Yorker articles. Perhaps because I’ve been following his works closely or maybe because I’m a practicing doctor diligently making the healthcare system better is why I didn’t find his latest work the most compelling.

Dr. Gawande makes two points, checklists and clear communications among teams, are absolutely required to decrease errors and problems and increase the chances of absolutely the best outcome, whether in constructing buildings, flying airplanes, and performing surgery. We aren’t perfect. Systematic approaches make us better.

Only the last two chapters, “The Hero in the Age of Checklists” and “The Save”, which highlight the “Miracle on the Hudson” landing of US Airways flight 1549 by Captain Sullenberger and his crew and Dr. Gawande’s experience in the operating room of adverting a near catastrophe respectively, were the most gripping.

Ultimately, despite his points the irony will be that the healthcare system will not adopt these ideas, which are accepted as expectations in the aviation industry, because doctors still feel that we are somehow smarter or above checklists or teamwork. This failure to do what we are truly capable of is disheartening. As a result, individual patients will be the ones responsible in taking care of their health and asking questions. A good easy to read book or “checklist” in ensuring you get the right care every time is at Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System.

Although I wasn’t bowled over like his other works, nevertheless, I have my own checklist and that is to continue reading and learning from Dr. Gawande and many others who toil in making healthcare better and safer.

Near Misses by Air Traffic Control Still Better than Healthcare System

ABC News reported that two regional jets nearly collided before Thanksgiving near Denver when an air traffic controller accidentally told an approaching aircraft to make a u-turn into the other.

The error was both unbeknownst both pilot crews of the airplanes as well as the air traffic controller. Only 200 feet apart in altitude and less than 2 miles away, these planes flying at hundreds of miles per hour were within seconds of catastrophe.

What prevented this disaster so that it was simply a near miss? Two critical factors.

Computers in both cockpits alarmed imminent collision and advised immediate course of action. Pilots trained to trust the safety systems built to identify threats and problems and not question them.

Although human error is to blame for the near miss, it is clear that technology can assist to improve safety. Also, more importantly is that those using the systems need to have a mindset of trust and act accordingly even if it isn't immediately obvious why the action must be taken. As a result, the aviation industry is the leader when it comes to safety.

When it comes to patient safety, the healthcare system could do much better. Approximately 100,000 Americans die annually due to these preventable medical errors or errors of omission and missed opportunities. However, since these typically only occur one death at a time throughout the country no one seems to notice.

100,000 Americans is about 250 Boeing 747 jumbo jets filled to capacity. Imagine if that many crashed in a year. Would that get your attention?

These errors and omissions occur because doctors and hospitals lack the basic information technology for making patients safer. The vast majority of healthcare providers still use paper charts and handwritten prescription pads. Without a comprehensive electronic medical record which would help identify drug-drug interactions, avoid dispensing the wrong medication or dosage due to illegible handwriting, suggest the lab tests due for specific medical conditions, or prompting both doctors and patients when to get important screening tests done, all of us instead depend on our doctors and pharmacists never to make a mistake.

This is of course impossible.

So why doesn't the healthcare system do better?

Two simple reasons. First, the implementation of technology like electronic medical records is costly and no one wants to pay for it. For a doctor to implement an electronic medical record can easily cost $30,000. If it prevents a drug drug interaction or stops from having the wrong prescription dispensed, the patient benefits. Does the doctor or pharmacist benefit?

Second and perhaps the biggest challenge is in changing the mindset of doctors. Pilots and flight crews are trained to communicate and speak up regardless of their rank. Doctors, however, operate in a world with a set hierarchy and perspective that impedes safety. The pecking order still is medical student, intern, resident, fellow, and attending physician. Medical assistants, physician assistants, nurses, and doctors. Attending doctors tell residents what to do. Residents tell medical students what to do. Doctors tell support staff what to do.

As a result, the mindset becomes one of self reliance and a top down approach rather than one that values collaboration and team orientation. Rules, regulations, and computerized systems aren't going to tell a doctor what to do. This perspective explains why wrong side surgeries still occur and surgical instruments are left in patients even though surgical timeouts and checklists have been implemented in hospitals. Despite built-in safety systems and reminders in electronic medical systems which could help doctors provide better and safer care, doctors balk at the hassle factor of being slowed down or being prompted by a computer even though using paper charts they have more potential for serious harm.

The aviation industry takes safety seriously. When two Northwest airline pilots were using personal laptops in the cockpit which resulted it distracting them from their duties, being out of contact with air traffic control for 90 minutes, and resulted in them missing their destination airport, the airline suspended the pilots immediately while the FAA revoked their license.

The healthcare system says that it takes patient safety seriously, but do we? If doctors don't wash their hands routinely before every patient and every time, should physicians be suspended? Watch your doctor next time you see him. If he doesn't wash his hands, a simple yet important ritual to avoid spreading germs, then what other important steps might he be skipping?

The healthcare industry still has a long way to go in regards to patient safety. Until the mindset changes where doctors embrace systems and teamwork to prevent adverse outcomes which will invariably occur due to human errors and flaws, you'll be far safer flying than staying overnight in a hospital.

Healthcare That Puts a Computer on the Team

The New York Times is increasingly a reputable source for medical information that is timely but also relevant to the discussion about healthcare reform and asking ourselves as a society a simple question - are we getting value for our healthcare dollars?

The series - the evidence gap - is an excellent forum to review. Its article about how information technology / computers is improving the delivery of care is important to understand what the American healthcare could look like if all doctors and patients were hooked up as easily as we do now with email, web surfing, and blogging.

As someone who works at one of these organizations, I will never go back to paper-based records. The computer helps me review data quickly, share them with patients online, in the office, or over the telephone, and permits me to spend more face to face time.

Frankly, I despise reviewing paper charts, particularly for new patients joining my practice, not simply because of the amount of paper shuffling I need to do to find important clinical data to keep them healthy, but because a lot of their doctors have illegible handwriting, which alone jeopordizes patient safety.

Medicare Restricts Reimbursement for Anemia - Better Patient Care?

A recent FDA advisory committee recommended that anemia medications, Procrit, Epogen, and Aranesp be not used in patients with breast cancer, head and neck cancers and used in patients with incurable cancers. These anemia medications are typically used to support cancer patients, who develop anemia, as a result of chemotherapy. This most recent FDA recommendation follows research studies which reported last year that these medications may have caused more deaths and contributed to tumor growth.

From the article:

• In its efforts to overturn Medicare's new reimbursement policy, Amgen Corp. spent more than $16 million on lobbying last year and nearly $700,000 on campaign contributions, according to the Center for Responsive Politics. Amgen manufactures all three of the anemia drugs involved — Aranesp, Epogen and Procrit. Johnson & Johnson markets Procrit.
• The aggressive lobbying campaign succeeded in generating numerous letters and speeches from lawmakers denouncing Medicare's actions and in legislation that would have voided the rule if passed.
• Many doctors and consumer groups joined in the criticism last year when Medicare made its decision to restrict when it would pay for treatments. Amgen and J&J argued again Thursday that the safety problems cited by FDA have been inconsistently reported across dozens of studies. And they pointed out that only studies involving higher-than-recommended dosing levels showed significant safety risks.
• The two drug companies have asked for more leeway from Medicare to reimburse doctors for maintaining hemoglobin levels up to 12. The Congressional Budget Office estimated that overturning CMS's decision could increase government spending by as much as $5.3 billion over the next decade.

What is fascinating isn't the science behind this, but the outcry from doctors, lawmakers, and the public when Medicare decided last year only to reimburse doctors if the medications were administered to patients with a hemoglobin of 10 or less (hemoglobin is a measure of the amount of red blood cells). A hemoglobin of 10 was derived from the research that suggested patients given these medications with higher hemoglobins did worse. Although the manufacturers argued that perhaps doctors were administering the medications at higher than recommended levels, doctors generally don't change practice behavior based on medication label warnings as quickly as they do when reimbursement is decreased or no longer covered.

Naturally everyone has a financial stake in seeing this ruling overturned. The pharmaceutical companies will see sales of their medications decrease as there are fewer indications (note their consumer-directed ads about these medications). Doctors will have their reimbursement decreased because they also will have fewer patients to give this medication to, even though the science suggests that many of these patients not only shouldn't get this medication but also that they could do harm. Patients, aligned with their doctors, will see this as a takeaway. Lawmakers, focused on getting re-elected would rather be seen on the side of their constituents, patients and doctors, and lobby against the FDA or Medicare as again taking a valuable benefit away.

Yet, when all is said and done, the heroes in the process, those that are protecting patients by altering doctors' behaviors to comply with the latest in research and those that are protecting the taxpayers by assuring that we are paying for the right care, are buried by massive lobbying and public relations campaigns. Perhaps this is why our healthcare system is in crisis because at the end of the day it isn't about the science, but about where the money goes.

Newer Isn't Better - Cholesterol Medication Not Effective

A report found that Merck's cholesterol lowering medication, Zetia, did not show any benefits.

While this report was surprising, it illustrates an important fact. Newer medications aren't necessarily better than previous therapies. The active ingredient in Zetia, which is also found in Vytorin, lowers cholesterol, but the released clinical trial showed that it didn't slow the clogging of arteries. This is why clinical trials need to be done to prove therapies are effective. While one can assume that lowering cholesterol can improve clogging of arteries, one needs to have proof.

If you go to the ZETIA website, there is the following disclaimer.

• Unlike some statins, ZETIA has not been shown to prevent heart disease or heart attacks.

So, when your doctor prescribes you a medication, particularly if it is one that has been heavily marketed, ask him the following.

• Why this particular medication?
• Is this one proven to save lives (i.e. lowering cholesterol isn't as important as preventing heart attacks).
• Are there others that are less expensive and proven?

Try not to ask your doctor about medications that you saw on television. Research shows that doctors more often than not will prescribe it for you.

Caveat emptor - Let the buyer beware.

Chinese Herbal Supplements Not Safe

The FDA found that an erectile dysfunction herbal supplement had the active ingredient from the prescription medication Viagra. The herbal supplements is available under the names Super Shangai, Strong Testis, Shangai Ultra, Shangai Ultra X, Lady Shangai and Shangai Regular.

This unfortunately is not surprising. Due to loopholes in the current legislation, manufacturers of herbal and dietary supplements are not obligated to prove to FDA that their products are safe or effective. Manufacturers do not need to register with FDA that they will market a new product. Companies also must make sure that their marketing plans are not misleading. The laws that regulate herbal and dietary supplements is far different than those covering over-the-counter medications and prescription medications.

What does this mean to you? Be very careful when taking a herbal or dietary supplement as manufacturers are accountable to no one. Check with your doctor. Consider finding out more about potentially dangerous herbals at Consumer Reports, the Natural Standard database, and at Medline Plus.

A Simple Checklist - Can It Save Lives?

Atul Gawande, a surgeon at Harvard as well as staff writer for the New Yorker, has penned a couple of excellent books, Complications: A Surgeon's Notes on an Imperfect Science and Better: A Surgeon's Notes on Performance. His most recent piece, The Checklist, is no exception. Improving the delivery of care isn't so much about overhauling it with radical changes, but simply looking at how to little steps enhance the process of delivering that care.

Excepts from his most recent article:

• A decade ago, Israeli scientists published a study in which engineers observed patient care in I.C.U.s for twenty-four-hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just one per cent of these actions—but that still amounted to an average of two errors a day with every patient.
• Here, then, is the puzzle of I.C.U. care: you have a desperately sick patient, and in order to have a chance of saving him you have to make sure that a hundred and seventy-eight daily tasks are done right—despite some monitor’s alarm going off for God knows what reason, despite the patient in the next bed crashing, despite a nurse poking his head around the curtain to ask whether someone could help “get this lady’s chest open.” So how do you actually manage all this complexity? The solution that the medical profession has favored is specialization.
• Substantial parts of what hospitals do—most notably, intensive care—are now too complex for clinicians to carry them out reliably from memory alone. I.C.U. life support has become too much medicine for one person to fly.
• In 2001, though, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it a try. He didn’t attempt to make the checklist cover everything; he designed it to tackle just one problem, the one that nearly killed Anthony DeFilippo: line infections. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years.
• Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.
• The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary...The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.
• Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.

Don't Tell

Doctors are human after all, so perhaps the findings from the Annals of Internal Medicine titled, "Professionalism in Medicine: Results of a National Survey of Physicians" isn't that surprising. A summary from Reuters illustrated the following:

• 46 percent of physicians surveyed admitted they knew of a serious medical error that had been made but did not tell authorities about it.
• 96 percent of those surveyed said they should report all instances of significant incompetence or medical errors to the hospital clinic or to authorities.
• 85 percent of most doctors said they should tell patients or relatives about significant errors.

the reality was far different.

• Forty percent of the doctors said they knew of a serious medical error in their hospital group or practice but 31 percent admitted they had done nothing about it at least once.

The article also found that nearly a quarter of the 1600 doctors surveyed didn't feel that periodic certification was desirable.

Conclusion? Doctors are human as well and naturally do things in their best interest. Is the lack of reporting due to a medical culture where error and omissions aren't openly talked about? Why would a good number of doctors oppose periodic re-certification? Medicine changes constantly and what was good a few years ago is no longer the standard of care. Concerning but perhaps not surprising. This behavior needs to change for significant improvement to occur in patient safety.

Too Many Drugs?

The New York Times article titled "The Poisonous Cocktail of Multiple Drugs" illustrates a fairly common occurance for many patients, taking multiple prescription medications. Known as polypharmacy, patients have many different medications prescribed by multiple doctors who don't know what the other one wrote. As a result, these patients, unfortunately, are at higher risk for having medication side effects or interactions.

As people live longer with more chronic illnesses, their care becomes more complex. This is why patients may find it valuable to have one primary care doctor coordinate care and ensure that the treatments rendered by various specialists are compatible with each other. The other is having technology like the free web-based eRx Now system to help busy doctors check different medications for drug interactions and track a person's treatment.

Without either of these interventions, the case of the 78 year old lady who passed out from a stomach ulcer due to the combination of aspirin, ibuprofen, and Celebrex, will undoubtedly continue.

Health Insurance - Odds 1 in 3 Yours Isn't Doing Everything to Keep You Well

One hundred million insured or one in three Americans have no idea if their health insurance plan is doing everything to keep them healthy. This ignorance could cost them their lives. This is the conclusion from the recently released 2007 State of Health Care Quality report by the National Committee for Quality Assurance, a non-profit organization which for over a decade has accredited health insurance plans for their performance. NCQA rates health plans on their ability to provide their enrollees with basic and proven preventive treatments, controlling high blood pressure, diabetes, cholesterol, among many others, consistently and routinely. While the industry has made significant improvements, much more needs to be done to save lives.

When NCQA started reviewing the quality of care delivered, it found that in 1996, on average only 62% of heart attack patients were getting beta blocker medications. These medications have been proven to decrease the risk of future heart attacks and prescribing them to these patients has been the standard teaching in medical schools for years. Over the past decade on average 98% of the time heart attack patients in health plans accredited by NCQA receive this treatment.

Unfortunately, health plans that didn't submit information for review did less well with 94% of patients getting the prescribed medication. Although it most situations this would be good enough, each drop in percentage translates into lives that could have been saved with a simple proven intervention.

Because this and many other effective preventive treatments weren't done to the level recommended by expert committees, 75,000 insured Americans died prematurely. Had these individuals accessed high performing health plans they would be alive today. If the entire industry performed as well as the top plans, $3.7 billion spent on hospital costs would have been avoided. Preventive care saves lives and money when done consistently and regularly. The problem is that within the healthcare system this is far from the case.

Part of the problem is that the most popular insurance plan, the PPO plan, does not have the same level of scrutiny when it comes to performance or accountability like a HMO plan. Until last year, no PPO plans provided NCQA any information on how well they did to keep you well. This year, those plans that cover one hundred million Americans still have not committed to submitting information for review. This lack of transparency has California's insurance commissioner developing a report card rating PPOs, much like the current system which lists HMOs, available to consumers by 2009. Until then, you have a one in three chance that you are in a plan that answers to no one and that the care you receive is not ideal.

Fortunately you aren't powerless. With open enrollment, now is a good time to see if your choices whether HMO or PPO include a NCQA accredited program by going to www.ncqa.org. If not, ask your human resources department to consider one for next year. Take the same amount of time and diligence you would do researching for your next car. It's your money. Don't you deserve the best care possible? With buying a car, if you purchase a lemon, you always have another chance to get another one. With your health, the stakes are higher. Choose wisely. The information is available. Act on it. Next year tens of thousands won't be around to rectify their mistake. Make sure it isn't you.

Enough Flu Vaccination to Go Around - Just Do It

The Centers for Disease Control announced that for the 2007 - 2008 flu season, there are plenty of vaccinations to go around. According to CDC:

Every year, flu infects up to 20 percent of the population, causes the hospitalization of 200,000 people and kills 36,000.

People 65 and older are most likely to get vaccinated, 69 percent during the 2005-2006 flu season, the latest count available.

But that's still well under the national goal of vaccinating 90 percent of seniors — even though Medicare provides flu shots for free.

Just over a third of 50- to 64-year-olds are getting vaccinated, and just 30 percent of high-risk younger adults, CDC found.

The vaccine is recommended for anyone over 50 or under 5; people of any age who have asthma, heart disease, weakened immune systems or other chronic illnesses; and pregnant women.

From personal experience this past season, I diagnosed more confirmed flu cases that in the past. The impact of flu vaccination became clear when I examined one patient, in his late 30s who was vaccinated, feel well in a day or two despite having the flu and then saw others in their early 20s, who weren't vaccinated, feel miserable, bed bound, and wanting to die (they didn't of course). On follow-up, the latter group all without hesitation planned on getting the flu shot this fall.

Perhaps you should to, especially if you are a health care provider.

Doctor, Retire the Prescription Pad and the Pen

A few months ago, a coalition of companies including Google, Cisco, Allscripts, Aetna, Wellpoint, among others formed an internet based electronic prescribing system. Known as ERx Now, it provides physicians, who register, the benefits of electronic prescribing for free. Benefits include a drug-to-drug interaction check, a check to see if you have an allergy to the prescribed medication, whether the medication is on your insurance formulary or if a generic equivalent is available.

Since the prescription is sent electronically to any pharmacy, you wouldn't have to drop off a prescription and wait for it to be filled or wonder when your doctor would call in the prescription. As long as he had internet access, a complete prescription could be written in the exam room. By the time you reached the pharmacy, it would be ready to go. No wait. No worries. Illegibility is not a problem.

It is a surprising fairly robust program given the fact that it is free. Physicians can access their patient's information, allergies, and medication information, past and present.

As someone who has been electronic prescribing for a couple of years, the ability to provide even safer care with automatic drug interaction and allergy checking, the ease of refilling prescriptions at a click of a button, and the option of accessing critical patient information anywhere there is an internet connection, allows me to deliver better care.

In the past, physicians could argue that installing systems that allowed electronic prescribing, among other features, was simply too expensive. Now, with this free internet program, there is NO excuse not to adopt this practice. The only reason your doctor could justify not getting rid of his prescription pad is if he (a) never heard about this program or (b) doesn't have a computer and/or internet connection. Even then, does that trump your safety?