Once Again Status Trumps Patient Safety
The other day I was interviewing a physician who is an expert in patient safety and who teaches medical students and residents at a major teaching hospital. We were discussing the virtues of various safety models both inside healthcare and in high reliability industries outside of healthcare. As usual, the physician gave a thoughtful but by now typical commentary on the relevance of the aviation safety model to healthcare. He argued, as so many do, that healthcare is so much more complex than any other human endeavor that it is difficult to adapt a model that has been developed for another industry to healthcare. He then proceeded to catalogue the variables that are outside of the physician’s control. These included variations in the patient’s anatomy, physiology, genetics, and thus response to treatment. He went on to talk about patients’ different personalities, social circumstances, family, etc. His list also included the fact that so many people — so many more than in any other endeavor apparently – are involved in healthcare that it is difficult to control all of them as variables. The list went on and on. Added to it, of course, there are the stakes in healthcare, which include harm – or death – to the patient or patients.
From there, we went on to discuss a number of tools that have been developed to improve and enhance patient safety. About most of these, he was also deeply skeptical. One of those that came up in the conversation was TeamSTEPPS, the teamwork training developed by the Department of Defense (DOD) and the Agency for Healthcare Research and Quality (AHRQ). The physician had some interesting things to say about the training. Notably that it involved too many concepts and protocols that too many trainers had not adequately practiced and were thus ill equipped to teach. Similarly, too many institutions in which TeamSTEPPS was implemented failed to give adequate time to present TeamSTEPPS concepts or practice TeamSTEPPS techniques. (All of which I agreed with). Then the physician/teacher said something very relevant, indeed, deeply significant that helps us understand why we have not advanced enough when it comes to patient safety.
When our TeamSTEPPS conversation turned to the SBAR technique for communication between those who work in healthcare. SBAR stands for Situation, Background, Assessment, Recommendation and is a very important attempt to help people present information to one another so that they can create common goals and a shared mental model – which is dependent on people speaking the same language. It is a totally commonsense tool that is, in fact, the way most people talk to each other when they want the other person to understand what’s going on. Nothing particularly radical here. But apparently it is too radical for healthcare.
This very astute physician told me that SBAR was not used in his medical school because the physicians and residents don’t like it. Why, I asked? Because that’s the way the nurses talk. It’s the formula which nurses are taught to use to communicate information and since we’re physicians and above nurses we don’t want to talk like they do. (He didn’t say that, but that was clearly what he meant).
When I suggested that it didn’t really matter what doctors “like,” it matters what makes it possible for those who work in healthcare to speak the same language, share the same mental model and goals, he gave what I consider to be a Mediterranean shrug (no disrespect to those who eat the Mediterranean diet in a Mediterranean country) which is meant to convey, “you’re right but what can we do about it.” In fact, he pretty much said that. Yes of course, he said, but doctors don’t like it and that’s reality.” Apparently reality that is immutable.
I left his office and, as is my wont, started to reflect. Actually, I was pretty outraged. Here is a physician who is really, really smart and who simply asserts that if physicians don’t like something, then no one has to do it. What he described was the behavior of kindergarteners on the playground. If some of them don’t want to play a certain game because someone they don’t like or value is playing that game, well, neeneenee nee, we won’t play it. With kindergarteners, hopefully, the grownups tell them to share, to play cooperatively with others, etc, but in the case of medicine, the grownups had all left the playground. (Just in case physicians think I am picking on them, one could – and I have – find examples that are in other disciplines, like nursing or pharmacy or PT. Of this, I am totally certain).
What I am beginning to conclude is that the problem with patient safety and healthcare is not the complexity of the endeavor, but the fact that no one is willing to take the bull by the horns and tell it it has to change. The fundamental difference between aviation and healthcare is not that one activity (flying planes) is simple and the other (taking care of patients) complex. The fundamental difference is that in one, the people in charge – CEOs of airline companies, regulators, unions, researchers – finally said to pilots and particularly to captains, that they could no longer get away with behavior that jeopardized passengers, aircraft and themselves and their crew. Believe me, when they told pilots and captains that they had to change their ways those people did not like it. But the folks at the top did not give in. They held their ground and waited it out until finally, most captains– — as happened in 1989 with the Sioux City crash and Al Haynes— began to realize that they didn’t lose anything by adopting different behavior and actually gained quite a lot.
In healthcare, with some notable exceptions, the people in charge – of medical school and residency training, of hospitals and hospital systems, of Medicare and Medicaid, of insurance companies, of nursing and other health professional schools – have not said that enough is enough (enough being patient deaths and harm) and instituted programs and maintained them over the long term. They have not told professors in health professional schools they can no longer humiliate their students and apprentices. They have not told physicians-in-training that they have to just get used to it and talk the same language as nurses and explained that the consequences of siloed language are the same as siloed practice – patients die. They have not told RNs to stop belittling LPNS and nursing assistants. The problem in healthcare is not complexity, it’s enabling. Too many people are enabling people to maintain toxic hierarchies that kill and harm patients.
I wanted to ask that physician why he didn’t ask his residents whether they thought it was worse to sound like a nurse or harm a patient through poor and ineffective communication. I probably shound have, but as happens so many times in healthcare, it seemed almost impossible to intervene when hierarchy and status trump safety.
As I was further reflecting on this encounter, one of the other things I thought was, well if you are right and healthcare is so complex, and has so many out-of-control variables, why wouldn’t you want to eliminate as many as you possibly could. Since poor communication among the professions and occupations is one thing you actually can do something about (SBAR is, after all, not only commonsensical but evidence based) why wouldn’t you want to use that to standardize at least one element of the process that could be standardized? Which is also the argument for CRM and other techniques used in high reliability industries. In other words, if your particular industry has so many out of control variables then my goodness you should welcome, not reject, any and everything possible that you can do to make things less complex and less variable.