Is There a Leader in the House

Healthcare is steeped in  hierarchy, obsessed with leadership (as in everyone wants to be a leader and no one wants to be a follower/team member(but more on that in a later post), and very preoccupied with chain of command, as in not breaching it.  Problem is, many people who insist they are the leader of the team (which, in most places are teams in name only) want to be in command, not  in charge.  Consider the following story which an experienced RN at a major teaching hospital recently recounted.

The nurse, we’ll call her Joan Smith, was taking care of a gastroenterology patient who’d been admitted to have abdominal surgery.  Nurse Smith had taken care of the patient for twelve hours the previous day.  The patient had problems with chronic pain and the pain service  had prescribed a regimen of pain medications, which had been effective.  On the day in question, Smith came on to her shift.  She learned that the pain service saw the patient in the morning and the patient’s pain was well managed.  Three hours later, the patient had a significant spike in her pain and was in agony.  Smith knew the patient and that she was not “acting out,” or trying to “put anything over” on anyone – accusations which patients face all too often if they happen to have the misfortune to suffer from chronic pain.  Nurse Smith called the pain service to advise them of the change in the patient’s condition.  Rather than prescribe anything new, the pain service physician said she felt that the patient should be seen by the GI team since the pain level had altered.  Nurse Smith called the GI team but they did not return her numerous pages.    She then called a third year resident (R3) on the GI service and asked the physician-in-training to come and see the patient.  The R3 said that she was not on campus and that it didn’t seem like something for the GI team.  She told  Smith to call the pain service.  Smith said she had just called the pain service and they said to call the GI team, which she did, but the on-call didn’t respond and the patient was in serious discomfort.

The R 3 repeated that she was not even on campus anymore and said Nurse Smith should call the on-call resident.  Nurse Smith explained that she had just done that, several times, and did not get a response.  Nurse Smith tried to maintain her cool and kept repeating that the patient was in pain and that the priority should be to take care of the patient.  She said she would try to call the on-call again but again there was no response.

About twenty minutes after Nurse Smith talked to the R3, the young woman came in the room.  She examined her abdomen, assessed her condition, asked the patient some questions and then insisted that there was nothing she could do and she told Smith that she was leaving and was going to turn off her pager.

There are many possible morals to this story and if one did a root cause analysis, there would doubtless be many issues to highlight.  One is the widespread mistreatment of medical trainees, which impacts their ability to empathize with their patients and makes them cynical at best and callous at worst.  Another is lack of sleep, which is still a problem despite significant changes in resident hours.  Another is the long-standing problem between physicians and nurses which I have written about for years.  Then there is the tendency of physicians and nurses to disbelieve and write off patients who experience both chronic and acute pain.  There is also the issue of no team training in healthcare (there has been none at this major teaching hospital, in spite of its reputation for promoting patient safety and its many well known patient safety physicians.  I am sure there are countless other issues to highlight.

One of the things this story also spotlights is the fact that in too many instances there seems to be no leader on the healthcare team willing to take charge of the patient.  Whether in a teaching hospital where accountability for the patient is passed from one service to another, or from intern, to resident, to attending, or a community hospital where an RN calls an attending physician in the middle of the night and is told to call cardiology, or pulmonology or oncology – anyone but me, the one who is on the phone now – it seems that everyone wants to be THE BOSS, but no one seems to want to be in charge in the moment, particularly if it means more work for either the weary or the otherwise occupied.

When I heard this story – which is only one of many similar ones I have heard in the past – I was struck by several things.  First, I was stunned by how short our system memory seems to be.   Apparently the resident who blithely announced she was going to turn off her pager in the face of a patient in distress did not perhaps remember the terrible incident that happened in 2002 at Mount Sinai Hospital in New York. reminded me of the horrible incident at Mount Sinai when a man donating a liver to his brother died of an infection in part because no one could reach a resident who had turned off his pager when he left the hospital.

I was also struck by the lack of recourse of nurses, and even some doctors, in the face of their colleagues’ refusal to address significant patient suffering or safety issues.  Nurses constantly report this kind of issue.  But nurses aren’t the only ones who seem to have little recourse when the person in nominal charge of the patient refuses to take charge.  In his book Safe Patients, Smart Hospitals, world renowned physician Peter Pronovost recounts a  story in which he was forced to be a bystander, seemingly powerless to force the surgeon in command of taking charge of his patient.  The story, which we recounted  in our book Beyond the Checklist, went like this.  An otherwise healthy twenty-nine-year-old woman had been admitted for laparoscopic removal of a kidney. She quickly developed complications, and the surgical resident called Pronovost, who was at the time on call at home as an ICU attending. He told Pronovost that the surgeon in charge had requested that the patient be admitted to an intermediate care unit for extra nursing monitoring in spite of the fact that the surgeon insisted the surgery had gone well and the patient would be fine. Four hours later, at 2:00 a.m., the same resident called Pronovost to request the patient’s admission to the ICU with life-threatening problems.

Pronovost understood that the patient’s problems could only be a result of a surgical complication and that she needed to return to the OR or she could die. The surgeon, the resident insisted, did not agree and refused to take the patient to the OR. Because the surgeon was in charge of the patient, neither Pronovost nor the resident could get the patient to the OR immediately. Pronovost called the surgeon, who continued to insist that his surgery had gone without a hitch. Holding his temper, Pronovost argued his case, and the surgeon finally retorted, “I am not going to the OR. I have to leave town. From now on talk to the surgeon on call.”

After additional delays, the woman was taken to the OR, and another surgeon discovered that during the first surgery the trocar, a harpoon-like rod used during laparoscopic surgery, had accidently punctured her intestine and pancreas. “Acci- dents like this happen: surgery is not a perfect science. However, if this had been discovered quickly the patient might have suffered less harm.” Because the surgeon did not tolerate cross-monitoring and was allowed even by a world-renowned colleague to refuse it, the patient who weighed 110 pounds on her arrival at the hospital ended up weighing 80. Instead of spending three days in the hospital, she spent six months and an additional year in a rehab facility. In addition, she lost both kidneys, was on dialysis, and needed a kidney transplant.

This incident did not happen at some remote or tiny hospital but at Johns Hopkins Hospital, several years after the Josie King incident when Hopkins had be- come a leading example of an institution devoted to patient safety.30 Josie King was a toddler who had suffered serious burns and was admitted to the hospital and died because of dehydration—something that could have been prevented by bet- ter teamwork and communication among staff and between the family and staff. The problem here is not a single medical institution but, as Pronovost himself explains, the “toxicity” of the medical system itself. In this kind of hierarchy, there is no two-challenge rule so that someone else can take charge of the patient when the captain of the ship is on a deadly course. Nurses who are concerned about patient safety in an urgent situation have to go up a cumbersome chain of command—charge nurse to nurse manager to clinical director and then–which rarely happens—to chief nursing officer, which could take more time than the patient has. She cannot call in another physician to oversee the case. In fact, even famous physicians like Pronovost cannot wrest a patient in danger from a surgeon or other physician’s control.

One of the things all of this points to is the need to have a meaninful two-challenge rule in healthcare in which nurses or physicians or anyone else can challenge the person in nominal charge when they see a patient safety problem that is about to cause serious or possibly catastrophic problems.  This is true in aviation and has prevented many disasters.  A first officer or someone else can challenge a captain who is about to endanger passengers and plane and can take over command of the aircraft if necessary.  Although such take overs are rare they do happen and have prevented tragedy.  In fact, if there is a crash or accident, or even near miss and it’s discovered that the subordinate did not speak up or take charge, they can be disciplined for having remained a passive bystander when it comes to safety.  When they do take over, they are thanked.

We need to do this in healthcare.  In the case recounted above, the nurse has to have permission – indeed, be expected, not only to call her nursing chain of command – a cumbersome and ineffective act in an emergency.  She – or he – has to be institutionally authorized to immediately go over the head of anyone she needs to to get to the person in charge, whether that’s the attending, the chief of service, whomever.  In the case of someone like Pronovost, the SICU attending has to be able to call another surgeon who can take the flight/patient to safety.  There has to be an accepted and expected procedure to do this and whoever does this, even if the call was wrong, has to be thanked.

I can hear the naysayers.  This will mean attendings, chiefs of service, CEOs, whoever, will be constantly being called by nurses and other underlings, woken in the middle of the night, interrupted at dinner, disturbed on the golf course.  Well guess what?  Maybe if a lot of attendings and chiefs and CEOS start getting disturbed more often they will do something to force the folks who want the power and authority to start using it in the service of  the patient.  Then rather than numerous  self-declared leaders we’ll actually have some real leadership in healthcare.

 

 

 

 

 

 

 

 

Healthcare is deeply hierarchical, obsessed with leadership (as in everyone wants to be a leader and no one wants to be a follower (but more on that in a later post), and deeply preoccupied with chain of command, as in not breaching it.  Problem is, even though physicians insist they are the leader of the team, in actual practice, most health care teams are not only teams in name only but also leaderless.  Everyone, it seems, wants to be in command, but in many situations, no one seems to want to be in charge.  Consider the following story whichh an experienced RN at a major teaching hospital recently told me.

The nurse, we’ll call her Joan Smith, was taking care of a gastroenterology patient who’d been admitted to her floor for abdominal surgery.  Nurse Smith had taken care of the patient for twelve hours the previous day.  The patient had problems with chronic pain and the pain service was also involved in care and had prescribed a regimen of pain medications, which were working.  On the day in question, Smith came on to her shift and the pain service saw the patient in the morning.  Three hours later, the patient had a significant spike in her pain, and was in agony.  Smith knew the patient and that she was not “acting out,” or trying to “put anything over” on anyone – accusations which patients face all too often if they happen to have the misfortune to suffer from chronic pain.  Nurse Smith called the pain service to advise them of the change in the patient’s condition.  Rather than prescribe anything else, the pain service physician said she felt that the patient should be seen by the GI team since the pain seemed to be new.  Nurse Smith called the GI team and they did not return her numerous pages.    She then called a third year resident (R3) on the GI service and asked the physician-in-training to come and see the patient.  The R3 said that she was not on campus and that it didn’t seem like something for the GI team and that Smith should call the pain service.  Smith said she had just called the pain service and they said to call the GI team, which she did, but the on-call didn’t respond and the patient was in serious discomfort.

The R 3 said she was not even on campus anymore and said Nurse Smith should call the on-call resident.  Nurse Smith explained that she had just done that, several times, and did not get a response.  Nurse Smith tried to maintain her cool and kept repeating that the patient was in pain and that the priority should be to take care of the patient.  She said she would try to call the on-call again but again there was no response.

About twenty minutes after Nurse Smith talked to the R3, the young woman came in the room.  She examined her abdomen, assessed her condition, asked the patient some questions and then insisted that there was nothing she could do and she told Smith that she was leaving and was going to turn off her pager.

 

There are many possible morals to this story and if one did a root cause analysis, there would doubtless be many issues to highlight.  One is the widespread mistreatment of medical trainees, which impacts their ability to empathize with their patients and makes them cynical at best and callous at worst (http://www.gme.medsch.ucla.edu/chiefresidents/Eradicating_Medical_Student_Mistreatment___A%2099583.pdf).  Another is lack of sleep, which is still a problem despite significant changes in resident hours.  Another is the long-standing problem between physicians and nurses which I have written about for years.  Then there is the tendency of physicians and nurses to disbelieve and right off patients who experience both chronic and acute pain.  There is also the issue of no team training in healthcare (there has been none at this major teaching hospital, in spite of its reputation for promoting patient safety and its many well known patient safety physicians.  I am sure there are countless other issues to highlight.

What this issue really highlights is the fact that in so many instances there seems to be no leader on the healthcare team willing to take charge of the patient.  Whether in a teaching hospital where accountability for the patient is passed from one service to another, to a community hospital where an RN calls an attending physician in the middle of the night and is told to call cardiology, or pulmonology or oncology – anyone but me, the one who is on the phone now – everyone wants to be THE BOSS, but no one seems to want to be in charge in the moment, particularly if it means more work for either the weary or the otherwise occupied.

When I heard this story – which is only one of many similar ones I have heard in the past – I was struck by several things.  First, I was stunned by how short our system memory seems to be.   Apparently the resident who blithely announced she was going to turn off her pager in the face of a patient in distress, did not perhaps remember the terrible incident that happened in 2002 at Mount Sinai Hospital in New York. reminded me of the horrible incident at Mount Sinai when a man donating a liver to his brother died of an infection in part because no one could reach a resident who had turned off his pager when he left the hospital. (http://www.nytimes.com/2003/03/22/nyregion/mount-sinai-may-resume-a-liver-transplant-program.html)

I was also struck by the lack of recourse of nurses, and even some doctors, in the face of their colleagues refusal to address significant patient suffering or safety issues.  Nurses constantly report this kind of issue.  But nurses aren’t the only ones who seem to have little recourse when the person in charge refuses to take charge.  In his book Safe Patients, Smart Hospitals, world renowned physician Peter Pronovost recounts a terrifying story in which he was forced to be a bystander, seemingly powerless to force the surgeon in command of taking charge of his patient.  An otherwise healthy twenty-nine-year-old woman had been admitted for laparoscopic removal of a kidney. She quickly de- veloped complications, and the surgical resident called Pronovost, who was at the time on call at home as an ICU attending. He told Pronovost that the surgeon in charge had requested that the patient be admitted to an intermediate care unit for extra nursing monitoring in spite of the fact that the surgeon insisted the surgery had gone well and the patient would be fine. Four hours later, at 2:00 a.m., the same resident called Pronovost to request the patient’s admission to the ICU with life-threatening problems.28

Pronovost understood that the patient’s problems could only be a result of a surgical complication and that she needed to return to the OR or she could die. The surgeon, the resident insisted, did not agree and refused to take the patient to the OR. Because the surgeon was in charge of the patient, neither Pronovost nor the resident could get the patient to the OR immediately. Pronovost called the surgeon, who continued to insist that his surgery had gone without a hitch. Hold- ing his temper, Pronovost argued his case, and the surgeon finally retorted, “I am not going to the OR. I have to leave town. From now on talk to the surgeon on call.”

After additional delays, the woman was taken to the OR, and another surgeon discovered that during the first surgery the trocar, a harpoon-like rod used during laparoscopic surgery, had accidently punctured her intestine and pancreas. “Acci- dents like this happen: surgery is not a perfect science. However, if this had been discovered quickly the patient might have suffered less harm.”29 Because the surgeon did not tolerate cross-monitoring and was allowed even by a world-renowned colleague to refuse it, the patient who weighed 110 pounds on her arrival at the hospital ended up weighing 80. Instead of spending three days in the hospital, she spent six months and an additional year in a rehab facility. In addition, she lost both kidneys, was on dialysis, and needed a kidney transplant.

This incident did not happen at some remote or tiny hospital but at Johns Hop- kins Hospital, several years after the Josie King incident when Hopkins had be- come a leading example of an institution devoted to patient safety.30 Josie King was a toddler who had suffered serious burns and was admitted to the hospital and died because of dehydration—something that could have been prevented by bet- ter teamwork and communication among staff and between the family and staff. The problem here is not a single medical institution but, as Pronovost himself explains, the “toxicity” of the medical system itself. In this kind of hierarchy, there is no two-challenge rule so that someone else can take charge of the patient when the captain of the ship is on a deadly course. Nurses who are concerned about patient safety in an urgent situation have to go up a cumbersome chain of command—charge nurse to nurse manager to clinical director and then–which rarely happens—to chief nursing officer, which could take more time than the patient has. She cannot call in another physician to oversee the case. In fact, even famous physicians like Pronovost cannot wrest a patient in danger from a surgeon or other physician’s control.

One of the things all of this points to is the need to have a two-challenge rule in healthcare in which nurses or physicians or anyone else can challenge the person in nominal charge when they see a patient safety problem that is about to cause serious or possibly catastrophic problems.  This is true in aviation and has prevented many disasters.  A first officer or someone else can challenge a captain who is about to endanger passengers and plane and can take over command of the aircraft if necessary.  Although such take overs are rare they do happen and have prevented tragedy.  In fact, if there is a crash or accident, or even near miss and it’s discover that the subordinate did not speak up or take charge, they can be disciplined for having remained a passive bystander when it comes to safety.  When they do take over, they are thanked.

We need to do this in healthcare.  In the case recounted above, the nurse has to have permission – indeed, be expected, not to call her nursing chain of command – a cumbersome and ineffective act in an emergency.  She – or he – has to be institutionally authorized to immediately go over the head of anyone she needs to to get to the person in charge, whether that’s the attending, the chief of service, whomever.  In the case of someone like Pronovost, the SICU attending has to be able to call another surgeon who can take the flight/patient to safety.  There has to be an accepted and expected procedure to do this and whoever does this, even if the call was wrong, has to be thanked.

I can hear the naysayers.  This will mean attendings, chiefs of service, CEOs, whoever, will be constantly being called by nurses and other underlings, woken in the middle of the night, interrupted at dinner, disturbed on the golf course.  Well guess what?  Maybe if a lot of attendings and chiefs and CEOS start getting disturbed more often they will do something to force the folks who want the power and authority to start using it in the service of  the patient.  Then maybe we’ll have some real leadership, rather than just a bunch of unattached leaders, in healthcare.

 

Healthcare is deeply hierarchical, obsessed with leadership (as in everyone wants to be a leader and no one wants to be a follower (but more on that in a later post), and deeply preoccupied with chain of command, as in not breaching it.  Problem is, even though physicians insist they are the leader of the team, in actual practice, most health care teams are not only teams in name only but also leaderless.  Everyone, it seems, wants to be in command, but in many situations, no one seems to want to be in charge.  Consider the following story whichh an experienced RN at a major teaching hospital recently told me.

The nurse, we’ll call her Joan Smith, was taking care of a gastroenterology patient who’d been admitted to her floor for abdominal surgery.  Nurse Smith had taken care of the patient for twelve hours the previous day.  The patient had problems with chronic pain and the pain service was also involved in care and had prescribed a regimen of pain medications, which were working.  On the day in question, Smith came on to her shift and the pain service saw the patient in the morning.  Three hours later, the patient had a significant spike in her pain, and was in agony.  Smith knew the patient and that she was not “acting out,” or trying to “put anything over” on anyone – accusations which patients face all too often if they happen to have the misfortune to suffer from chronic pain.  Nurse Smith called the pain service to advise them of the change in the patient’s condition.  Rather than prescribe anything else, the pain service physician said she felt that the patient should be seen by the GI team since the pain seemed to be new.  Nurse Smith called the GI team and they did not return her numerous pages.    She then called a third year resident (R3) on the GI service and asked the physician-in-training to come and see the patient.  The R3 said that she was not on campus and that it didn’t seem like something for the GI team and that Smith should call the pain service.  Smith said she had just called the pain service and they said to call the GI team, which she did, but the on-call didn’t respond and the patient was in serious discomfort.

The R 3 said she was not even on campus anymore and said Nurse Smith should call the on-call resident.  Nurse Smith explained that she had just done that, several times, and did not get a response.  Nurse Smith tried to maintain her cool and kept repeating that the patient was in pain and that the priority should be to take care of the patient.  She said she would try to call the on-call again but again there was no response.

About twenty minutes after Nurse Smith talked to the R3, the young woman came in the room.  She examined her abdomen, assessed her condition, asked the patient some questions and then insisted that there was nothing she could do and she told Smith that she was leaving and was going to turn off her pager.

 

There are many possible morals to this story and if one did a root cause analysis, there would doubtless be many issues to highlight.  One is the widespread mistreatment of medical trainees, which impacts their ability to empathize with their patients and makes them cynical at best and callous at worst (http://www.gme.medsch.ucla.edu/chiefresidents/Eradicating_Medical_Student_Mistreatment___A%2099583.pdf).  Another is lack of sleep, which is still a problem despite significant changes in resident hours.  Another is the long-standing problem between physicians and nurses which I have written about for years.  Then there is the tendency of physicians and nurses to disbelieve and right off patients who experience both chronic and acute pain.  There is also the issue of no team training in healthcare (there has been none at this major teaching hospital, in spite of its reputation for promoting patient safety and its many well known patient safety physicians.  I am sure there are countless other issues to highlight.

What this issue really highlights is the fact that in so many instances there seems to be no leader on the healthcare team willing to take charge of the patient.  Whether in a teaching hospital where accountability for the patient is passed from one service to another, to a community hospital where an RN calls an attending physician in the middle of the night and is told to call cardiology, or pulmonology or oncology – anyone but me, the one who is on the phone now – everyone wants to be THE BOSS, but no one seems to want to be in charge in the moment, particularly if it means more work for either the weary or the otherwise occupied.

When I heard this story – which is only one of many similar ones I have heard in the past – I was struck by several things.  First, I was stunned by how short our system memory seems to be.   Apparently the resident who blithely announced she was going to turn off her pager in the face of a patient in distress, did not perhaps remember the terrible incident that happened in 2002 at Mount Sinai Hospital in New York. reminded me of the horrible incident at Mount Sinai when a man donating a liver to his brother died of an infection in part because no one could reach a resident who had turned off his pager when he left the hospital. (http://www.nytimes.com/2003/03/22/nyregion/mount-sinai-may-resume-a-liver-transplant-program.html)

I was also struck by the lack of recourse of nurses, and even some doctors, in the face of their colleagues refusal to address significant patient suffering or safety issues.  Nurses constantly report this kind of issue.  But nurses aren’t the only ones who seem to have little recourse when the person in charge refuses to take charge.  In his book Safe Patients, Smart Hospitals, world renowned physician Peter Pronovost recounts a terrifying story in which he was forced to be a bystander, seemingly powerless to force the surgeon in command of taking charge of his patient.  An otherwise healthy twenty-nine-year-old woman had been admitted for laparoscopic removal of a kidney. She quickly de- veloped complications, and the surgical resident called Pronovost, who was at the time on call at home as an ICU attending. He told Pronovost that the surgeon in charge had requested that the patient be admitted to an intermediate care unit for extra nursing monitoring in spite of the fact that the surgeon insisted the surgery had gone well and the patient would be fine. Four hours later, at 2:00 a.m., the same resident called Pronovost to request the patient’s admission to the ICU with life-threatening problems.28

Pronovost understood that the patient’s problems could only be a result of a surgical complication and that she needed to return to the OR or she could die. The surgeon, the resident insisted, did not agree and refused to take the patient to the OR. Because the surgeon was in charge of the patient, neither Pronovost nor the resident could get the patient to the OR immediately. Pronovost called the surgeon, who continued to insist that his surgery had gone without a hitch. Hold- ing his temper, Pronovost argued his case, and the surgeon finally retorted, “I am not going to the OR. I have to leave town. From now on talk to the surgeon on call.”

After additional delays, the woman was taken to the OR, and another surgeon discovered that during the first surgery the trocar, a harpoon-like rod used during laparoscopic surgery, had accidently punctured her intestine and pancreas. “Acci- dents like this happen: surgery is not a perfect science. However, if this had been discovered quickly the patient might have suffered less harm.”29 Because the surgeon did not tolerate cross-monitoring and was allowed even by a world-renowned colleague to refuse it, the patient who weighed 110 pounds on her arrival at the hospital ended up weighing 80. Instead of spending three days in the hospital, she spent six months and an additional year in a rehab facility. In addition, she lost both kidneys, was on dialysis, and needed a kidney transplant.

This incident did not happen at some remote or tiny hospital but at Johns Hop- kins Hospital, several years after the Josie King incident when Hopkins had be- come a leading example of an institution devoted to patient safety.30 Josie King was a toddler who had suffered serious burns and was admitted to the hospital and died because of dehydration—something that could have been prevented by bet- ter teamwork and communication among staff and between the family and staff. The problem here is not a single medical institution but, as Pronovost himself explains, the “toxicity” of the medical system itself. In this kind of hierarchy, there is no two-challenge rule so that someone else can take charge of the patient when the captain of the ship is on a deadly course. Nurses who are concerned about patient safety in an urgent situation have to go up a cumbersome chain of command—charge nurse to nurse manager to clinical director and then–which rarely happens—to chief nursing officer, which could take more time than the patient has. She cannot call in another physician to oversee the case. In fact, even famous physicians like Pronovost cannot wrest a patient in danger from a surgeon or other physician’s control.

One of the things all of this points to is the need to have a two-challenge rule in healthcare in which nurses or physicians or anyone else can challenge the person in nominal charge when they see a patient safety problem that is about to cause serious or possibly catastrophic problems.  This is true in aviation and has prevented many disasters.  A first officer or someone else can challenge a captain who is about to endanger passengers and plane and can take over command of the aircraft if necessary.  Although such take overs are rare they do happen and have prevented tragedy.  In fact, if there is a crash or accident, or even near miss and it’s discover that the subordinate did not speak up or take charge, they can be disciplined for having remained a passive bystander when it comes to safety.  When they do take over, they are thanked.

We need to do this in healthcare.  In the case recounted above, the nurse has to have permission – indeed, be expected, not to call her nursing chain of command – a cumbersome and ineffective act in an emergency.  She – or he – has to be institutionally authorized to immediately go over the head of anyone she needs to to get to the person in charge, whether that’s the attending, the chief of service, whomever.  In the case of someone like Pronovost, the SICU attending has to be able to call another surgeon who can take the flight/patient to safety.  There has to be an accepted and expected procedure to do this and whoever does this, even if the call was wrong, has to be thanked.

I can hear the naysayers.  This will mean attendings, chiefs of service, CEOs, whoever, will be constantly being called by nurses and other underlings, woken in the middle of the night, interrupted at dinner, disturbed on the golf course.  Well guess what?  Maybe if a lot of attendings and chiefs and CEOS start getting disturbed more often they will do something to force the folks who want the power and authority to start using it in the service of  the patient.  Then maybe we’ll have some real leadership, rather than just a bunch of unattached leaders, in healthcare.

 

 

Healthcare is deeply hierarchical, obsessed with leadership (as in everyone wants to be a leader and no one wants to be a follower (but more on that in a later post), and deeply preoccupied with chain of command, as in not breaching it.  Problem is, even though physicians insist they are the leader of the team, in actual practice, most health care teams are not only teams in name only but also leaderless.  Everyone, it seems, wants to be in command, but in many situations, no one seems to want to be in charge.  Consider the following story whichh an experienced RN at a major teaching hospital recently told me.

The nurse, we’ll call her Joan Smith, was taking care of a gastroenterology patient who’d been admitted to her floor for abdominal surgery.  Nurse Smith had taken care of the patient for twelve hours the previous day.  The patient had problems with chronic pain and the pain service was also involved in care and had prescribed a regimen of pain medications, which were working.  On the day in question, Smith came on to her shift and the pain service saw the patient in the morning.  Three hours later, the patient had a significant spike in her pain, and was in agony.  Smith knew the patient and that she was not “acting out,” or trying to “put anything over” on anyone – accusations which patients face all too often if they happen to have the misfortune to suffer from chronic pain.  Nurse Smith called the pain service to advise them of the change in the patient’s condition.  Rather than prescribe anything else, the pain service physician said she felt that the patient should be seen by the GI team since the pain seemed to be new.  Nurse Smith called the GI team and they did not return her numerous pages.    She then called a third year resident (R3) on the GI service and asked the physician-in-training to come and see the patient.  The R3 said that she was not on campus and that it didn’t seem like something for the GI team and that Smith should call the pain service.  Smith said she had just called the pain service and they said to call the GI team, which she did, but the on-call didn’t respond and the patient was in serious discomfort.

The R 3 said she was not even on campus anymore and said Nurse Smith should call the on-call resident.  Nurse Smith explained that she had just done that, several times, and did not get a response.  Nurse Smith tried to maintain her cool and kept repeating that the patient was in pain and that the priority should be to take care of the patient.  She said she would try to call the on-call again but again there was no response.

About twenty minutes after Nurse Smith talked to the R3, the young woman came in the room.  She examined her abdomen, assessed her condition, asked the patient some questions and then insisted that there was nothing she could do and she told Smith that she was leaving and was going to turn off her pager.

 

There are many possible morals to this story and if one did a root cause analysis, there would doubtless be many issues to highlight.  One is the widespread mistreatment of medical trainees, which impacts their ability to empathize with their patients and makes them cynical at best and callous at worst (http://www.gme.medsch.ucla.edu/chiefresidents/Eradicating_Medical_Student_Mistreatment___A%2099583.pdf).  Another is lack of sleep, which is still a problem despite significant changes in resident hours.  Another is the long-standing problem between physicians and nurses which I have written about for years.  Then there is the tendency of physicians and nurses to disbelieve and right off patients who experience both chronic and acute pain.  There is also the issue of no team training in healthcare (there has been none at this major teaching hospital, in spite of its reputation for promoting patient safety and its many well known patient safety physicians.  I am sure there are countless other issues to highlight.

What this issue really highlights is the fact that in so many instances there seems to be no leader on the healthcare team willing to take charge of the patient.  Whether in a teaching hospital where accountability for the patient is passed from one service to another, to a community hospital where an RN calls an attending physician in the middle of the night and is told to call cardiology, or pulmonology or oncology – anyone but me, the one who is on the phone now – everyone wants to be THE BOSS, but no one seems to want to be in charge in the moment, particularly if it means more work for either the weary or the otherwise occupied.

When I heard this story – which is only one of many similar ones I have heard in the past – I was struck by several things.  First, I was stunned by how short our system memory seems to be.   Apparently the resident who blithely announced she was going to turn off her pager in the face of a patient in distress, did not perhaps remember the terrible incident that happened in 2002 at Mount Sinai Hospital in New York. reminded me of the horrible incident at Mount Sinai when a man donating a liver to his brother died of an infection in part because no one could reach a resident who had turned off his pager when he left the hospital. (http://www.nytimes.com/2003/03/22/nyregion/mount-sinai-may-resume-a-liver-transplant-program.html)

I was also struck by the lack of recourse of nurses, and even some doctors, in the face of their colleagues refusal to address significant patient suffering or safety issues.  Nurses constantly report this kind of issue.  But nurses aren’t the only ones who seem to have little recourse when the person in charge refuses to take charge.  In his book Safe Patients, Smart Hospitals, world renowned physician Peter Pronovost recounts a terrifying story in which he was forced to be a bystander, seemingly powerless to force the surgeon in command of taking charge of his patient.  An otherwise healthy twenty-nine-year-old woman had been admitted for laparoscopic removal of a kidney. She quickly de- veloped complications, and the surgical resident called Pronovost, who was at the time on call at home as an ICU attending. He told Pronovost that the surgeon in charge had requested that the patient be admitted to an intermediate care unit for extra nursing monitoring in spite of the fact that the surgeon insisted the surgery had gone well and the patient would be fine. Four hours later, at 2:00 a.m., the same resident called Pronovost to request the patient’s admission to the ICU with life-threatening problems.28

Pronovost understood that the patient’s problems could only be a result of a surgical complication and that she needed to return to the OR or she could die. The surgeon, the resident insisted, did not agree and refused to take the patient to the OR. Because the surgeon was in charge of the patient, neither Pronovost nor the resident could get the patient to the OR immediately. Pronovost called the surgeon, who continued to insist that his surgery had gone without a hitch. Hold- ing his temper, Pronovost argued his case, and the surgeon finally retorted, “I am not going to the OR. I have to leave town. From now on talk to the surgeon on call.”

After additional delays, the woman was taken to the OR, and another surgeon discovered that during the first surgery the trocar, a harpoon-like rod used during laparoscopic surgery, had accidently punctured her intestine and pancreas. “Acci- dents like this happen: surgery is not a perfect science. However, if this had been discovered quickly the patient might have suffered less harm.”29 Because the surgeon did not tolerate cross-monitoring and was allowed even by a world-renowned colleague to refuse it, the patient who weighed 110 pounds on her arrival at the hospital ended up weighing 80. Instead of spending three days in the hospital, she spent six months and an additional year in a rehab facility. In addition, she lost both kidneys, was on dialysis, and needed a kidney transplant.

This incident did not happen at some remote or tiny hospital but at Johns Hop- kins Hospital, several years after the Josie King incident when Hopkins had be- come a leading example of an institution devoted to patient safety.30 Josie King was a toddler who had suffered serious burns and was admitted to the hospital and died because of dehydration—something that could have been prevented by bet- ter teamwork and communication among staff and between the family and staff. The problem here is not a single medical institution but, as Pronovost himself explains, the “toxicity” of the medical system itself. In this kind of hierarchy, there is no two-challenge rule so that someone else can take charge of the patient when the captain of the ship is on a deadly course. Nurses who are concerned about patient safety in an urgent situation have to go up a cumbersome chain of command—charge nurse to nurse manager to clinical director and then–which rarely happens—to chief nursing officer, which could take more time than the patient has. She cannot call in another physician to oversee the case. In fact, even famous physicians like Pronovost cannot wrest a patient in danger from a surgeon or other physician’s control.

One of the things all of this points to is the need to have a two-challenge rule in healthcare in which nurses or physicians or anyone else can challenge the person in nominal charge when they see a patient safety problem that is about to cause serious or possibly catastrophic problems.  This is true in aviation and has prevented many disasters.  A first officer or someone else can challenge a captain who is about to endanger passengers and plane and can take over command of the aircraft if necessary.  Although such take overs are rare they do happen and have prevented tragedy.  In fact, if there is a crash or accident, or even near miss and it’s discover that the subordinate did not speak up or take charge, they can be disciplined for having remained a passive bystander when it comes to safety.  When they do take over, they are thanked.

We need to do this in healthcare.  In the case recounted above, the nurse has to have permission – indeed, be expected, not to call her nursing chain of command – a cumbersome and ineffective act in an emergency.  She – or he – has to be institutionally authorized to immediately go over the head of anyone she needs to to get to the person in charge, whether that’s the attending, the chief of service, whomever.  In the case of someone like Pronovost, the SICU attending has to be able to call another surgeon who can take the flight/patient to safety.  There has to be an accepted and expected procedure to do this and whoever does this, even if the call was wrong, has to be thanked.

I can hear the naysayers.  This will mean attendings, chiefs of service, CEOs, whoever, will be constantly being called by nurses and other underlings, woken in the middle of the night, interrupted at dinner, disturbed on the golf course.  Well guess what?  Maybe if a lot of attendings and chiefs and CEOS start getting disturbed more often they will do something to force the folks who want the power and authority to start using it in the service of  the patient.  Then maybe we’ll have some real leadership, rather than just a bunch of unattached leaders, in healthcare.