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.

The Rise of Desktop Medicine -- Wrong Terminology, But Right Thing to Do

A recent NY Times article, the Rise of Desktop Medicine, highlighted the use of technology in accessing information (desktop medicine) and how doctors were spending less time with patients (bedside medicine).  Many doctors were concerned about the change and longed for the old days.  Yet, the reality is that with more medical knowledge, doctors must retrieve information from clinical trials, calculate risk of heart attack or osteoporosis, rather than rely on intuition, particularly when data exists.

My biggest problem with this article really was with the term desktop medicine.  I don't like it.  Certainly over the past few decades, our understanding of certain illnesses has become more precise, the interventions and treatments more clear, and therapies more evidence based (precision medicine).  Other illnesses, however, still continue to be more challenging and determining the correct course of action less clear (cognitive or intuitive medicine). 

Precision medicine, a term used by Harvard Business School Professor Clayton Christensen, has simply occurred at the same time computers and the ability to rapidly access information developed.  Imagine if medical science knowledge had evolved but that there was no infrastructure or technology available to retrieve information like clinical trial outcomes quickly.  Doctors would still be treating patients based on intuition rather than science completely oblivious to the latest knowledge.  Research has shown it takes 17 years before outcomes from research studies become commonly practiced in the community.

No desktop medicine isn't the right term to describe the phenomenon in medicine.  It implies doctors are simply indentured servants to computers and technology.  Nothing could be further from the truth.  Generations ago, doctors had few tools and treatments.  When people developed pneumonia, we could do nothing but wait and hope because antibiotics were not discovered yet.  We simply comforted individuals and families.  Many people died.

Today we have more tools, more treatments, and a better understanding of many, but not all illnesses.  To say this additional knowledge and the ability to retrieve this information somehow erodes the doctor patient relationship is incorrect.  We can still be caring and use our technology to access information to make the care of the patient in front of us more precise and personalized than ever before.

No, the terms desktop medicine and bedside medicine are incorrect because they provide the wrong type of connotation.  The former term implies cold and impersonal.  The latter term suggests humanity and comfort.  Better terms with less emotional attachment would be precision medicine and intuitive or cognitive medicine.

I'm a big fan of the art of medicine and bedside manner.   I also love how my computer allows me to make care more convenient and more personal. 

The next generation of doctors must be experts at both bedside manner and using the vast knowledge of medical science to make care precise in areas we have good understanding.  For illnesses where we don't, we still do what we did generations ago, comfort and heal. 

No computer will ever replace that.

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.