Atul Gawande, surgeon and staff writer for The New Yorker, is one of the most prominent voices speaking about patient safety in the United States. Thanks to his frequent contributions to The New Yorker, Gawande has a bully pullpit, and his ideas have become part of the current thinking about contemporary health policy and patient safety. In spite of the fact that it is now unarguable that teamwork is critical to patient safety and that most medical errors and injuries result from failures in teamwork and team communication –what I call lack of Team Intelligence — Gawande is both tone deaf and almost completely blind (I mix these metaphors deliberately) to the participation of non-physician actors to quality care. His early books, Complications, Better and Checklist Manifesto, place him firmly in the tradition of the heroic medical narrative, where physicians — usually acting alone — battle illness and death. In one particularly telling passage in the beginning of Better, Gawande states that:
“We (physicians) face daunting expectations. In medicine, our task is to cope with illness and to enable every human being to lead a life as long and free of frailty as science will allow. The steps are often uncertain. The knowledge to be mastered is both vast and incomplete. Yet we are expected to act with swiftness and consistency, even when the task requires marshalling hundreds of people – from laboratory technicians to the nurses on each change of shift to the engineers who keep the oxygen supply system working – for the care of a single person.”
What this neglects to acknowledge is that physicians don’t, in fact, marshall lab techs, or nurses, or shift engineers, nor does this personnel work directly for physicians. Hospitals pay these people and most of them do not conceptualize their work as working for physicians but working for and with patients. The kind of physician-centric view of the healthcare enterprise inhibits the kind of teamwork upon which safe patient care depends and instead turns hospital care into what I have called parellell play between intimate strangers.
In spite of the fact that Gawande is committed to greater safety and efficacy, his framing of healthcare activity ignores the fact that doctors are not an army of one but actually function as players on an inter-disciplinary team that includes multiple actors, each of whom has a contribution to make and ought to be consulted about quality and safety improvements. Healthcare, wherever it is delivered, requires what the linguistic anthropologist Edwin Hutchins calls “distributed cognition.” As Hutchins explains it in Cognition in the Wild, “All divisions of labor, whether the labor is physical or cognitive in nature, require distributed cognition in order to coordinate the activities of the partcipants. Even a simple system of two men driving a spike with a hammer requires some cognition on the part of each to coordinate his own activities with those of the other. When labor that is distributed is cognitive labor, the system involves the distribution of two kinds of cognitive labor: the cognition that is the task and the cognition that governs the coordination of the elements of the task. In such a case, a group performing the cognitive task may have cognitive properties that differ from the cognitive properties of the individual.” I have called those cognitive properties Team Intelligence — the ability of individuals working together to communicate, teach one another, think, learn, reason, critique, and cross-monitor together, irrespective of their position in the hierarchy.”
Gawande sadly seems unaware of the fact that other people around him actually may have something to contribute to both his individual performance or that of the entire team. This is made painfully clear in his latest New Yorker contribution entitled, “Personal Best: Should everyone have a coach?” The everyone in question here is, not surprisingly, the physician. In this well-written piece (everything Gawande writes is well-written, which is why his not so hidden assumptions are so disturbing and problematic), Gawande ponders the question of whether physicians like himself should have the kind of personal coaches that are routine in the world of competitive sport. In order to find out if he could improve his game, so to speak, Gawande asks one of the surgeons who served as his mentor during his training to come into the OR and observe him at work. The senior physician –retired general surgeon Robert Osteen –agrees and watches Gawande in the OR. When the two emerge, they debrief in the lounge and Osteen points to a number of small things that Gawande could do better. Although neither surgeon mentions the word, most of Gawande’s problems have to do with his interaction with the team. Acting as his usual army of one, Gawande has been oblivious to the fact that, “I had positioned and draped the patient perfectly for me, standing on his left side, but not for anyone else. The draping hemmed in the surgical assistant across the table on the patient’s right side, restricting his left arm, and hampering his ability to pull the wound upward. At one point in the operation, we found ourselves struggling to see up high enough in the neck on that side. The draping also pushed the medical student off to the surgical assistant’s right, where he couldn’t help at all. I should have made more room to the left, which would have allowed the student to hold the retractor and freed the surgical assistant’s left hand.” Similar observations, apparently abounded, including the fact that the surgeon had not noticed the patient’s blood pressure problems that the anesthesiologist was continually tracking.
One wonders why Gawande needed to have a senior surgeon present to uncover these team problems. Why didn’t anyone else in the room — medical student, surgical assistant, operating room nurse, anesthesiologist — mention these issues. The answer seems to lie in Gawande’s view that only another physician — and a senior one at that — could possibly give him any tips. As he puts it, “Yet the stranger thing, it occured to me, was that no senior colleague had come to observe me in the eight years since I’d established my surgical practice. Like most work, medical practice is largely unseen by anyone who might raise one’s sight. I’d had no outside ears and eyes.”
This is a truly amazing comment. Gawande here argues that during his entire career there were no “outside ears and eyes,” observing him, and that his practice was “largely unseen by anyone who might raise one’s sights.” In actual fact, there literally hundreds of people have been observing him — and very closely — and many of them could have raised the surgeon’s sights and acted as much needed “outside ears and eyes” — and I might add brains These people surround physicians and could help them make needed improvements. To surgeons like Gawande, however, these people literally do not exist. Surgical assistants whose access is blocked, med students who cannot help, nurses who have good ideas, these people are silenced by the kind of assumptions held by physician leaders like Gawande and others (for comments on Jerome Groopman and others, please see The Cure: Can Doctors Change How They Think, Boston Review).
In response to Gawande’s article, a former operating room staffer wrote a telling letter to the editor that should be required reading for those who read Gawande’s piece itself. He pointed out that,
“like all surgeons, Gawande operates with other members of a surgical team, and his piece doesn’t explore the shared experience of his team members, all of whom are vitally aware of the progress of a surgery. I once worked in a lowly position in an operating room. I was never consulted about how any aspect of a procedure, however minor, might be improved, until the hospital was faced with a malpractice lawsuit.”
Atul Gawande concludes that doctors, like athletes, should indeed hire personal coaches. I have a better idea. How about hiring team coaches, people who can help recognize that improving patient care not just about doing their “Personal Best.” Yes, Robert Osteen taught his star pupil to recognize his impact on those around him. What he did not do is help Gawande understand that patient safety and great performances are about how we all work, learn, think, and reason together.
On August 5, The New York Times Sunday Magazine ran an article on the changes in resident work hours. In “The Phantom Menace of Sleep-Deprived Doctors,” writer Darshak Sanghavi claims that the new changes in resident work hours has not, as it was intended, had a positive impact on patient safety. Residents may no longer be working 100 hour weeks, but patients, the author contends, are still experiencing significant harm. http://www.nytimes.com/2011/08/07/magazine/the-phantom-menace-of-sleep-deprived-doctors.html?pagewanted=all. In the article, the author focuses on the work of physician Christopher Landrigan whose studies of sleep-deprived doctors — like the death of Libby Zion in 1984 — helped to convince legislators and medical school accrediting bodies to limit the work hours of physicians-in-training. Sanghavi cites some of Landrigan’s studies http://www.nejm.org/doi/full/10.1056/NEJMoa041404as well as explanations of ACGME duty hours http://www.acgme.org/acWebsite/newsRoom/newsRm_dutyHours.asp.
The bulk of the article debunks the idea that there is a real correlation between sleep-deprived residents and patient harm. As the author puts it, “But this is where the neat story of the correlation between doctor fatigue and hospital error hits a wall. Landrigan’s research was compelling, but his study was small and controlled. In normal, day-to-day practice in hospitals across the country, medical errors didn’t fall when work hours were reduced. A massive national study of 14 million veterans and Medicare patients, published in 2009, showed no major improvement in safety after the 2003 reforms. The researchers parsed the data to see whether even a subset of hospitals improved, but the disappointing results appeared in hospitals of all sizes and all levels of academic rigor. “The fact that the policy appeared to have no impact on safety is disappointing,” says David Bates, a professor at the Harvard School of Public Health and a national authority on medical errors.” Landrigan, he says, was “dumbfounded” by this evidence and, painting the renowned researcher into a corner, he continues to assail the idea that changes in resident duty hours will positively impact patient care.
What is dumbfounding is the fact that anyone would think that changing one variable in health care would have a revolutionary impact on patient safety. I completely agree with Landrigan’s conclusions and applaud the changes in resident duty hours. But let’s face facts. Fact number one, moving to 16- hour days instead of 20- hour days or even 36- hour stretches at a time is hardly a revolution. We know that errors go up after eight hours on the job, so how can we expect them to be dramatically reduced if people are still staying up for 16- hours at a stretch. What is more significant, however, is the fact that resident duty hours are only one of the slices in the Swiss cheese that lead to patient harm. What do I mean by Swiss cheese. I am referring here to James Reason’s Swiss cheese theory of error which explains that catastrophic errors occur not because of the actions of individual actors but because of system problems. Each layer of the Swiss cheese has to line up perfectly in order for an error to occur — in this case for a patient to fall through. Doctors, whether in training or not, are only one slice of the package of cheese. Unfortunately, neither journalists like Sanghavi nor his editors seem to understand that fact. Looking at health care through the prism of the heroic medical narrative, they see only the medical actors on the health care stage.
The reality is far more complex. For example, today in hospitals, nurses are now working 12 hour plus shifts. Sometimes back to back. Residents used to be the ones who were sleep-deprived. Now nurses, who used to be the safety net in teaching hospitals, may be too tired to pay attention to catch an error that has been made by an novice physician. Nurses also shoulder higher and higher patient loads and in their haste to run from one patient room to ano0ther, may not have time to attend to the details –like the a medication error. Increasing hospital through-put has also increased the load of both novice and expert doctors. We know that interrupted labor is a hazard. If residents are now caring for more and more patients, they will face more interruptions. Ditto for attendings. Which is why Landrigan’s work, which appears in a book I have just co-edited with Ross Koppel entitled First Do Less Harm: Confronting Inconvenient Problems in Patient Safety — is so important.
I read stories like this and want to weep. Our societal and journalistic failure to understand that health care really is delivered by teams leads to coverage like this. It’s a shame because it denigrates important innovations like changes in resident duty hours. We need more of those changes not less but we’ll never get them until we get the fact that just as it takes a village to raise a child it takes a village to care for the sick.
I have just written this article for the great blog Beyond Chron that Randy Shaw edits out in San Francisco. Here it is,http://beyondchron.org/news/index.php?itemid=9532 but check out Beyond Chron. http://www.beyondchron.org/news/
Here’s the article
To Control Health Care Costs, Put Docs on a Different Pay Scale
Mention escalating health care costs and how to control them and most people, including many health care activists, focus on the administrative overhead that comes from having an employment/private insurance based health care system. Or the high cost of pharmaceuticals or the misuse of technology – like having an MRI machine on every block. Turns out another huge factor in our out of control health care spending is physician fees. According to a new study in the journal Health Affairs, the US spends more on physician fees than any other industrialized country (and our health care outcomes are often poorer). The study, by Miriam J. Laugesen and Sherry A. Glied documents that physicians, whether paid by private or public insurers, are paid and thus earn a whole lot more than docs in Australia, Canada, France, or Germany.http://content.healthaffairs.org/content/30/9/1647.abstract
Go to a primary care doctor in any of those four countries and a public payer will pay 20 percent less and a private payer 70% less than in the US. For a hip replacement, American orthopedic surgeons are paid between 20 and 70% more from public payers and 120 % more from private ones than their counterparts in those four other nations. Not surprisingly, American physicians also earn more. The average income for a PCP in the US is $186,582 and for an orthopedist it’s $442,450. To put this in perspective, in 2006, the average US median income for a family of four was slightly over $50,000.http://en.wikipedia.org/wiki/Household_income_in_the_United_States
Most physicians argue that their medical school debts justify the fact that they earn from between three to almost ten times as much as a family of four. Medical school is indeed more costly here than in the four countries listed above or in any other country with a national health care system (which will also probably have free education). The average physician leaves medical school with $158,000 or more in debt. So does anyone with a graduate degree. And people like myself who studied French Literature or Social Work or Nursing don’t have a prayer of earning the kind of money a physician earns when they enter into practice. Physicians, however, have made themselves a special case and we are supposed to pay them a whole lot more than doctors earn in other countries because of their so-called financial sacrifice. While I have little sympathy with people whose earning power far outstrips the average person who invests in their higher education, the fact is that physicians have turned their medical school debt into a powerful stick and have effectively used it secure higher and higher incomes.
The only way to deal with this particular cost escalator is to take that stick away once and for all. How can we do this? By making medical education free. And by this I don’t mean that a few select docs can get free education by promising to work on an Indian reservation for a couple of years. What I mean is that we make graduate medical education free for every doctor and then insist on payments that are in line with the international standard. (If we had a national health care system, patients would also be less inclined to sue for malpractice because they would be assured of the care they needed after a medical injury. That would take away yet another excuse used to rationalize higher fees).
If physicians did not have to pay thousands for their medical education, then perhaps doctors would claim that they deserve higher fees because they put in years of residency training before they can reach their full earning power. This too is a bogus argument, since doctors-in-training do not work for free but are paid (albeit modestly compared to their future earnings) throughout their apprenticeship training.) Those who put the most years into training earn the most – way more than that average family of four.
The place to begin the work of removing physician fees as a healthcare cost escalator is with primary care physician education. We now have a catastrophic shortage of primary care physicians in America. Only about 15 % of medical students show an interest in going into primary care. Again, medical school debt is a disincentive. So if we really want more primary care physicians, make their education free, if that is, they pledge to work as PCPs not for just a few years, but for most of their career. Once we’ve established this precedent, then we can move on to the orthopedists, neurologists, and other specialties. Until we can the debt issue off the table, doctors will continue to justify the unjustifiable and we will continue to have the most costly and inefficient healthcare system in the industrialized world.
I just want to alert readers to a wonderful new book that my series at Cornell University Press has published called Out of Practice: Fighting for Primary Care Medicine in America http://www.amazon.com/Out-Practice-Fighting-Medicine-Politics/dp/0801449766/ref=sr_1_1?s=books&ie=UTF8&qid=1310582734&sr=1-1. It is written by primary care physician Frederick Barken and details why so many physicians are going out of practice — not choosing to become primary care physicians or leaving primary care practice far earlier than they ordinarily would have. It’s really a must read. It’s a great memoir but also details all a serious look at the policies and financial imperatives that make primary care medicine in this country so unrewarding. We need primary care doctors. Many more of them, but only about 20 percent of medical students are choosing to go into primary care. Why? Read Barken to get a real understanding of how deep and critical this crisis is.
Several weeks ago, the New York Times ran an article detailing a program started by Medicare to hire “mystery shoppers to call the offices of primary care physicians to see if they were talking new patients or patients, how long waits are, and how they respond to patients who have private insurance or patients with public insurance like “Medicaid.” Physicians, not surprisingly, have responded with outrage, and CMS quickly abandoned the program.http://www.nytimes.com/2011/06/27/health/policy/27docs.html?pagewanted=all
The program was started to help tfigure out how to deal with the primary care physician shortage and to make sure that the 30 million new patients covered by the soon to be implemented (hopefully) PPACA (Patient Protection and Affordable Care Act), which depends on primary care, will actually be able to find a primary care physician in a country with a notorious shortage of people going into primary care.
I have no problem with the government trying to collect data about physician willingness or ability to take new patients or on whether they discriminate against people on Medicare or Medicaid. Since the government — and that means us the taxpayers — are a huge funder of graduate medical education, I’ve always wondered why we’ve allowed physicians of any sort to refuse to accept patients with public rather than private insurance. But all of this begs the fundamental question. If we want more primary care physicians, why don’t we just get over it and pay their medical school tuition, with the obligation that they will have to pay back the cost of their education if they don’t remain in primary care for a significant number of years (and I don’t mean two years in the military or working on an Indian reservation, both of which are certainly worthy endeavors but hardly pay back the investment we, the taxpayers, have made in them.
Consider the math — which I would like to actually check on. The average graduating doc, has $100,000 or more in medical school debt.http://www.studentdoc.com/medical-school-loans.html. So if the government shelled out $100,000 for their education, this would be like giving them a $100,000, compounded with interest over a period of years, or wisely invested (even today) the return on this investment would be significant. If education for PCPs was free or at very low cost, maybe that would go a ways to ending the catastrophic shortage of primary care doctors.