3 Mar
2013
Posted in: Health Care
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Thank You For Pointing Out the Mistake

One of the greatest accomplishments of the Aviation Safety Model (ASM), Crew Resource Management (CRM) has been the creation of what Schein and Bennis and Edmondson have called “psychological safety” in the airline industry.  Moving from a culture that was characterized by the authoritarian (rather than authoritative) exercise of power, to one in which it is safe to tell someone — even someone higher up — that they have made or are about to make a mistake, was central to the creation of airline safety.  As my co-authors airline pilot Patrick Mendenhall and medical educator Bonnie Blair O’Connor and I have written in our book Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety, creating a psychologically safe environment takes a lot of work — both initially and over time.   Because of this work, aviation culture has moved, as former Vice Chairman of the National Transportation Safety Board Robert T. Francis has described it from a culture in which the captain would convey, implicitly or explicitly that “I’m captain, I’m king.  Don’t do anything!  Don’t say anything! Don’t touch anything! Shut up!” to a culture where the message is “I’m captain, I’m king, please tell me if you see me making a mistake!” Read more >>

15 Feb
2013
Posted in: Health Care
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A Flight Tested Solution To Patient Safety Problems

News that hospital patients in Minnesota are no safer today than a decade ago comes as no surprise to those trying to reduce medical errors and injuries. The drive to make hospitalization less risky began in 1999, when a study by the prestigious Institute of Medicine estimated that more than 100,000 patients suffer from avoidable harm each year.

Since then, hundreds of millions of dollars has been spent on new patient safety initiatives of all kinds. Unfortunately, as The Star Tribune confirmed last month, hospitals are still the scene of too many botched procedures and preventable falls, infections, and misdiagnoses. What explains the persistence of failure that adds billions to our nation’s health care bill, costs many patients their lives, and leaves others with new medical problems?

Many well-intentioned safety efforts have fallen short because doctors, administrators, and other staff resist necessary changes in the hierarchical and often dysfunctional culture of hospital work. Patients get hurt or become even sicker when doctors, nurses, and other hospital staff fail to share information, don’t work effectively in teams, or ignore mechanisms – like hand-washing to prevent infection –designed to minimize human error. In too many hospital chains, fragmentation of care is an institutional shortcoming both endemic and unacceptable.

In our view, the quality of patient care in America won’t get better until the healthcare industry embraces the flight-tested model of teamwork training and workplace cooperation that has drastically reduced the dangers of commercial air travel.

In response to a series of horrific crashes four decades ago, the airlines didn’t just develop better safety checklists or new equipment to detect impending mechanical failures. The entire industry was compelled to adopt new safety protocols, known as Crew Resource Management. (CRM). As a result, flying today is safer than ever before—for airline crews and their passengers

CRM teaches those working in the cockpit, cabin, on the ground and in air traffic control how to communicate and cooperate. It requires everyone to solicit and listen to relevant safety information from other employees, regardless of their rank or job responsibility as well as to use standardized procedures that assure safety. Annual CRM training is now mandated for all flight personnel by the Federal Aviation Administration. Airline unions, like the Airline Pilots Association and the Association of Flight Attendants, have been heavily involved in the implementation and success of the program.

Whatever other job-related complaints they may have, any longtime pilot, flight attendant, or air traffic controller will vouch for difference that CRM has made in their industry. One of CRM’s leading advocates is Captain Chesley “Sully” Sullenberger, who arguably became the most famous pilot in America after his landing of a crippled US Airways jet in the Hudson River four years ago. Since retired, he is now helping hospitals incorporate CRM methods into their patient safety programs.

beyond_the_checklist_book“Not long ago,” Sullenberger says, “there were captains in out cockpits who acted liked gods with a little ‘g’ and cowboys with a capital ‘C.’ You questioned the captain’s authority at your own peril, even if you were a fellow pilot.”

When CRM first emerged, some captains worried it would undermine their authority. According to Sullenberger, “others, like some doctors today, felt they didn’t need to learn the ‘soft skills’ of better communication and respectful interaction with co-workers.” Yet the consensus today is “that our cockpit management decisions are far better when we have regular input and information from all members of our aviation team, in the air and on the ground.”

Even where hospitals have realized the need for more “inter-professional training,” few have created a similar environment in which staff members feel free to challenge a physician or complain to an administrator. In medical schools and on the job, most doctors are not encouraged, much less required, to consult with skilled and experienced members of the same health care team who may have life-saving in-put.

Many tragedies could be averted and patient care improved if health care fully applied the lessons of aviation teamwork and safety. In our hospitals, it’s time to go beyond the checklist and actually reduce the terrible financial and human toll of avoidable medical errors.

Cross-posted at the Beyond the Checklist blog

14 Feb
2013
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More on The Difficult Patient

People have made some very interesting and important comments on my latest post.  I want to add something here and also reiterate that I am not talking about patients who are truly abusive, or in other ways very difficult to care for.  That said, I want to add something about the conditions that may lead Health Care Professionals (HCPs) to view patients with legitimate needs as difficult.

One barrier is, of course, workload and fatigue.  Whether it is in the hospital or any other workplace, like primary care, people who are too tired, who have not eaten, and who have too much work tend to be irritable and have trouble attending to others.  In healthcare settings, professionals and other staff are constantly expected to act in a professional manner when, as Lucian Leape and his colleagues argue, their institutions do not treat them respectfully and ask them to work too hard and too long. Read more >>

13 Feb
2013
Posted in: Health Care, Uncategorized
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The “Difficult Patient”

Today it’s hard to find a health care professional who doesn’t want to “put the patient first,” practice “patient centered care,” or make the patient “part, or even the center, of  the healthcare team.” Bring up current problems with clinical practice (be they managerial, insurance company, or regulatory) and you will inevitably hear health care professionals talk about the importance of the doctor/patient, nurse/patient relationship.

Nurses, in particular, are adamant that they are members of THE Caring Profession and that their fundamental role is to be THE patient advocate. (This formulation does nothing enhance teamwork since it drives physicians, PTS, OTs and other non- RNs crazy. “What does that make me?” they may retort, “The patient’s enemy?”) Patient-centeredness, and the sanctity of the patient/clinician relationship is  the talk everyone is talking.

When you start actually probing and physicians and nurses (as well as others in health care) describe the real life patient (rather than the patient as abstraction), things start to get a bit more complicated. It’s amazing how quickly so many of these patients – who were absolutely revered a few minutes earlier — suddenly become “difficult,” when clinicians start discussing actual patient encounters. Read more >>

7 Feb
2013
Posted in: Health Care
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About Amour and Aging

From Jacobin/ a magazine of culture and polemic

On Our Own or All Together?

2.7.13

The troublesome question of aging.

All_Together

“It’s strange. We plan for everything. We insure our cars, our homes. We even insure our lives. But we don’t give a thought to our final years.”

— Jeanne, a character in the French film, All Together

Depending on who you ask or what you read, aging and retirement are the best things that could ever happen to you (considering the alternatives) or an over-hyped stage of life that’s actually filled with social isolation, economic insecurity, and mounting health problems. These bi-polar depictions are both reflected in the burgeoning popular literature about how to navigate the “new old age” — that period of life 78 million U.S. Baby Boomers just began to enter, with varying degrees of enthusiasm or trepidation.

Given this huge demographic, it’s not surprising that more movies now focus on the tribulations of the old. They include the moving, but terminally grim, Amour, its more uplifting French cousin, All Together, and a charming U.K. import (by way of India), The Best Exotic Marigold Hotel. Although none of these films are set in the U.S., they explore, very accurately, many of the same social, economic, and health care dilemmas facing millions of people in our country, due to increased longevity.

When the Oscar-nominated Amour opened near Berkeley, we joined a privileged slice of our generational cohort to find out what might be in store for us, several decades down the road. Statistically speaking, of course, not everyone currently in their sixties will still be collecting Social Security checks twenty years from now, even if they’re white, affluent, and feeling rather chipper today. For anyone counting on being alive and kicking in their seventies, eighties, or beyond, director Michael Haneke’s film is quite the reality check. In fact, it’s what used to be called, in The Sixties’,  “a real bummer.”

Not Aging Gracefully

Amour is the twilight tale of a long-married French couple, Georges and Anne, a retired teacher of concert pianists. He is played by 82-year old Jean-Louis Trintignant and she by 85-year old Emmanuelle Riva. (Riva is the oldest Academy Award nominee for best actress in a leading role and deserves to win on Feb 24.)

Georges and Anne are “aging in place,” but not gracefully. They haven’t moved into a retirement community or long-term care facility, of the U.S. or even French type. They have a distant relationship with their off-spring, who live or work much of the time abroad. They seem to have no close friends. So their social contact is limited to the concierge in their building, his helpful wife, and infrequent visitors, like their self-absorbed daughter or a successful former student of Anne’s. As Anne becomes disabled by a series of strokes, their gloomy, high-ceilinged apartment becomes their own private geriatric ghetto.

Their life first takes this turn for the worse in a fashion familiar to many people over-65, who have the misfortune of being hospitalized and then discharged in worse shape than before. Failed surgery on a blocked carotid artery leaves Anne partially paralyzed. She is unable to walk, take a shower, get out of bed, or go to the bathroom by herself. After suffering a further stroke at home, she becomes totally bed-ridden, incoherent, incontinent, and dependent on the use of adult diapers. In one of her remaining moments of lucidity, Anne makes it clear to Georges that she does not wish to be hospitalized again, under any circumstances. Even after she has lost the ability to speak, she tries to communicate her “end of life” decision-making by refusing food and water.

Like many real-life spousal caregivers, Georges struggles with the physical and emotional burdens of round-the-clock care. Money for home health aides, who eventually become necessary, appears to be no object; but “good help” in that field can be hard to find. As played by Trintignant, the exhausted Georges is both tender and impatient, loving and uncomprehending. Faced with the prospect of even greater loneliness as a widower, he has trouble coming to grips with Anne’s desire to die in peace, rather than live disabled, disoriented, and in physical pain. How he resolves that matter is less than ideal.

Less Truthful Than Amour?

Directed by Stephane Robelin, All Together affects the light-hearted air of a French farce, a far cry from Amour. This apparently irked New York Times critic Stephen Holden when the film opened briefly in New York last fall, so he proclaimed it to be less “truthful about those final years” than Haneke’s “heartbreaking masterpiece.”

All Together can now be found on Netflix but, in truth, it has no shortage of its own age-related disability, disease, and death. These afflictions take their toll in a livelier set of French seniors, who are cher amis. The main characters include two married couples—Annie and Jean, Albert and Jeanne — plus their longtime bachelor friend, Claude. All have socialized together for years as part of the same comfortably bourgeois circle, with a shared interest in food, wine, politics, and ideas.

In one of the film’s early scenes, the police break up a Paris street protest led by an over-wrought Jean, still wielding a bullhorn like a young left-wing agitator. We learn that he and his fellow retirees are all veterans of campus activism long ago. Fittingly enough for a film with characters so inspired and a smooth French-speaking performance by Jane Fonda, a real-life Sixties’ radical, All Together conveys an important message: namely, that a sad, hermetic existence is not the only option for the old. Instead, these Gallic soixante huitards set out to prove (not for the first time) that “another world is possible.”

What triggers their late-in-life social experimentation is the hospitalization of 75-year old Claude.  He is an aging lothario once linked romantically to both Annie and Jeanne, unbeknownst to each other or their current spouses. Stricken with a heart attack, he lands in a French rehab facility that looks pretty nice by U.S. standards. Yet, when his friends come to see Claude, they share his dismay at the condition of other elderly patients. “This place is full of fossils,” one visitor says. “I’m not letting an old friend croak in this hole,” another declares.

On the spot, they decide to liberate Claude from the company of the palsied, demented, and wheelchair bound. They spirit him out of his chateau-like nursing home and move in together, at Annie and Jean’s many-roomed house, with a big garden in back. “Going hippy,” as Annie calls it, is not without inter-personal problems and tensions. Jeanne, the retired philosophy professor played by Fonda, has terminal cancer, a condition she attempts to conceal from her husband.  Albert’s worsening memory loss (and resulting absentmindedness around running water) leads to a damaging flood. To help them all cope, the communards hire younger live-in help, including a German graduate student who is studying the treatment of the elderly in different societies and becomes their in-house ethnographer.

The backyard is soon dug up and a pool installed, a move long resisted by the politically puritanical Jean. The expanded household is rewarded with the laughter and play of visiting grandchildren. When Jeanne dies in her new home, with her friends around her, Albert soon forgets that she has expired. He panics at the thought that she may have just become lost and tries to search for her. The now multi-generational intentional community rallies around him, in a touching display of solidarity. Aging in place, in collective fashion, looks a lot better than the institutionalized care that Claude narrowly escaped from or the lonely fate of Anne and Georges in Amour.

The Off-Shoring of Old Age

The British expatriates thrown together more randomly in Best Exotic Marigold Hotel are played by an ensemble cast better-known to American audiences than Fonda’s fellow actors in All Together.  Directed by John Madden, the film features Dames Judi Dench and Maggie Smith (both age 78), Bill Nighy, Tom Wilkinson, and Dev Patel, the 23-year old Anglo-Indian actor who played Jamal, the upwardly mobile prize-show contestant in Slumdog Millionaire.  Like Holden in The Times criticizing All Together, Boston reviewer Allen Stone dismissed Madden’s work as “a fairy tale for old people—an anodyne against the cruel reality.”

In fact, the film unfolds against a very realistic backdrop of economic crisis, the fiscal squeeze on pensions, dwindling personal retirement savings, and what Patel’s character, Sonny, calls the “out sourcing of aging,” a trend that has sent more than a million Americans abroad, to places where their fixed incomes can go further.

The disparate retirees who land in Jaipur have, with one exception, never set foot in India before, so the culture shock is extreme. They include a quarrelsome married couple just fleeced out of their retirement nest egg. (Nighy plays the harried husband who decides to stay behind when his spouse evacuates to England). Other Marigold guests are divorced, never-married, or recently widowed singles with their own personal and financial baggage or romantic agendas. Among them is a closeted gay judge, now retired from the bench (played by Wilkinson), a middle-class widow (Dench), whose recently deceased husband left her unexpectedly penniless, and a newly laid off household servant for the rich (Smith), who has been unhappily dispatched to India for an outsourced hip replacement, to avoid waiting in line at the National Health Service.

All are unsettled to discover that the retirement paradise advertised, on-line, by Marigold’s hyper-kinetic young manager (Patel) is more of a shambles than a jewel of the Raj. Fortunately, their humid, dumpy quarters are right in the middle of Jaipur’s teeming, colorful street life, to which the new residents react in varying ways. Wilkinson’s character is briefly re-united with his one-time Indian lover, now a middle-aged married man; he soon expires, peacefully and happily, of heart failure in a Marigold Hotel easy chair.

Smith’s bitter and distrustful former maid overcomes her racism, bonds unexpectedly with a family of Dalit “untouchables,” and rebounds from surgery to become Sonny’s much-needed bookkeeper. Like millions of real-life seniors also forced back to work to support themselves, Dench’s character snags a part-time job in a local call center. There, she coaches young Indian telemarketers on how to communicate better with cranky old U.K.-based customers like the one she used to be.

Out of their individual and collective struggle to find a place for themselves as strangers in a strange land, the guests of the Marigold—or those who don’t die or defect—manage to forge a new sense of community. They work together to rescue their residential hotel from impending bankruptcy.  The down-market Marigold gets a big makeover and becomes, in the words of their host, Sonny, “a home for the elderly so wonderful they will refuse to die.”

Life Imitating Art?

Now, cynical reviewers may continue to object that the happier endings of All Together and The Best Exotic Marigold Hotel are simply not “real,” (a legitimate point since neither is a documentary). Yet both films do accurately reflect the aspirations of many older Americans — particularly those influenced by the politics and counter-culture of the Sixties. They are wary of traditional long-term care arrangements, at home or in an institutional setting. And they sure don’t want their own life to become a sad, impoverished replay of Amour, if that can be avoided.

So, instead, many U.S. Baby Boomers, at all income levels, are engaged today in an urgent quest for alternative forms of old age living. These range from cross-generational co-housing projects to natural occurring retirement communities (or NORCs), where neighbors help each other out, to “life care” facilities located on or near college campuses to new retirement villages organized around shared politics, musical tastes, or sexual identity. And then, of course, there’s the Marigold Hotel option in the form of lively, multi-cultural retiree colonies like San Miguel de Allende in Mexico and its counterparts in Costa Rica, Belize, and elsewhere.

Despite its rich and very relevant social content, the current crop of international films on aging may prove to be a mixed blessing. Given the copycat instincts of Hollywood, more Americanized remakes of Marigold or Amour may soon be slated for production. And if The Bucket List or Stand Up Guys — the new buddy film about the last hurrah of three old gangsters — is any indication, they are likely to be pretty awful. Meanwhile, the humor, pathos, and communitarian striving so well captured in All Together and Best Exotic Marigold Hotel will continue to play out in real life, here and abroad, where it really counts after all.


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Steve Early and Suzanne Gordon are Bay Area journalists collaborating on a book about how Baby Boomers — particularly those politically or culturally influenced by the Sixties — are dealing with aging and retirement.

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