Over at “Ohio Surgery” Buckeye Surgeon is not at all happy with the commencement speech that fellow-surgeon Atul Gawande recently delivered to Harvard Medical School’s graduating class. Today, Buckeye (a.k.a Jeffrey Parks, a general surgeon on the East Side of Cleveland, Ohio), summed up what he called Gawande’s “essential message”:
“Healthcare is far too complex for any one doctor anymore. So gear up to be an interchangeable part, a faceless drone who performs menial tasks according to checklists and algorithms. . . Don't be a Cowboy (in the romanticized, individualistic sense of a bygone era) . . . All that debt you've taken on to be a physician? It's so you can be an anonymous member of an integrated Team. Like a Pit Crew.”
No surprise, Gawande, who is a regular contributor to The New Yorker, makes his case in somewhat more eloquent terms: “The distance medicine has travelled in the [last] couple of generations is almost unfathomable,” he writes, comparing that span to the “vast quantum leap” his father made when he traveled “from his rural farming village of five thousand people [in India] to Nagpur, a city of millions where he was admitted to medical school, three hundred kilometers away. Both communities were impoverished. But the structure of life, the values, and the ideas were so different as to be unrecognizable. Visiting back home, he found that one generation couldn’t even grasp the other’s challenges. Here is where we seem to find ourselves, as well.”
Medical culture has been roiled by change, leaving some doctors who remain attached to the past dismayed. This was inevitable, Gawande says. In the past, physicians had only a handful of remedies. “Now we have treatments for nearly all of the tens of thousands of diagnoses and conditions that afflict human beings. We have more than six thousand drugs and four thousand medical and surgical procedures, and you, the clinicians graduating today, will be legally permitted to provide them. . .
“We in medicine, however, have been slow to grasp . . . how the volume of discovery has changed our work and responsibilities . . .” he added, “The rapid growth in medicine’s capacities is not just a difference in degree but a difference in kind . . . the reality is that medicine’s complexity has exceeded our individual capabilities as doctors.”
He told the graduates that In earlier decades, “The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. . . We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to ‘protocol’ the MRI.” '
Like many physicians who I have quoted on HealthBeat over the past four years, (Bob Wachter, Diane Meier, Jack Wennberg, Elliot Fisher, Don Berwick, Brent James, Peter Eisenberg, among others), Gawande explains that medicine is no longer a matter of “individual heroism.” It has become a ‘team sport.’”
In 1970 the number of clinical staff involved the care of a typical patient at Johns Hopkins hospital was 2.5 full -time clinicians, he reports. “By the end of the nineteen-nineties, it was more than fifteen. The number must be even larger today. Everyone has just a piece of patient care. We’re all specialists now—even primary-care doctors.”
But, Gawande warns, “a structure that prioritizes the independence of all those specialists will have enormous difficulty achieving great care.”
Nevertheless, “we still train, hire and pay physicians to be cowboys.” Med school students are not taught to collaborate with each other; they are flogged to compete. As for pay, when they graduate, physicians usually are reimbursed one by one, fee-for-service. The doctor who draws more patients and does more surgeries wins the game.
By contrast, health care reformers would like to see doctors paid as teams, with higher reimbursements going to those that work well together, achieving better outcomes for patients.
“Patient Ownership”
Buckeye, it seems, remains nostalgic for what he himself calls the “romanticized, individualized” model of the past–the doctor as Lone Ranger, a hero who takes full responsibility for his patients. Buckeye complains bitterly that in his commencement speech Gawande said “not a word about patient ownership”–as in this is my patient. (Never mind that this sense of “owning” the patient can undermine care. Some surgeons refuse to a let a palliative care team talk to “their” patients, reports Dr. Diane Meier, a pioneer in palliative care. Oncologists, too, may block a palliative consult, on the grounds that this is “my patient” and “she’s nowhere near that point,” i.e. death. “We’re planning on another round of chemo,” an oncologist once told Meier, referring to a cancer patient whose organs were shutting down in the ICU.)
This sense of patient ownership goes back to the days when there was just one doctor and one patient. And that one doctor knew what was best for his patient. To Buckeye a doctor’s “personal accountability” is all. It defines what it means to be a physician and “put your heart and soul into this noble calling.”
A More “Patient Centered” View of Medicine
Gawande’s view is less romantic and, I would argue, more “patient-centered.” He warns that a system which “prioritizes the independence” of each of those fifteen specialists caring for an individual patient “will have enormous difficulty” achieving excellent care. When fifteen independent private practitioners “consult” on one patient, they don’t necessarily consult with each other. Doctors who prize their autonomy just aren’t very good at coordinating care, or following guideline.
“We don’t have to look far for evidence,” Gawande adds. "Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It’s like no one’s in charge—because no one is. The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.”
As UCSF’s Dr. Bob Wachter has said, “teamwork is at the center of the patient-safety movement.”
Do Patients Really Need Fifteen Physicians?
Still, many hospital patients wonder: “Why are so many doctors involved in my case? Isn’t that part of the problem–too many cooks, not enough communication? Why can’t just one doctor take care of me? What happened to the idea of “my doctor?”
Yes, sometimes too many specialists are called in unnecessarily, and this can be a sign that a hospital is inefficient, “fishing” for a diagnosis, casting a wide net by running a dozen tests or more, rather than taking a careful patient history, actually listening to the patient, and narrowing down the possibilities before ordering the tests.
But the days of “my doctor,” the hero who I can count on to know everything are gone. The truth is that, given the complexity of 21st century medicine, a very sick patient may well need those fifteen pairs of hands, not to mention fifteen minds. As Gawande points out, no one health care worker can do everything; no one doctor knows enough to provide the best care. Physicians need to listen to each other, nurses and other health care specialists, respecting each others’ knowledge.
I recall what Dr. Peter Eisenberg, Medical Director at California Cancer Care, wrote in a wonderfully candid guest-post published on HealthBeat two years ago: “Do you want to go to a doc and be treated according to his treatment plan after an hour-long visit?” he asked. “Or would you rather that he present your case, along with the pathology slides and the imaging studies, to a group of other docs representing a number of disciplines (medical, surgical and radiation oncology, diagnostic radiology, pathology, nursing, social work, dietetics, pain control, pulmonary, gastroenterology, etc.) to be viewed and discussed?
“Smart docs are not afraid to consult with the smarter (or more experienced) docs at the university and even send patients there to get their treatment if the care is complicated and not well–known to us,” he added.
Better Care Means Physicians Collaborating In a “System”
Gawande ends his essay by declaring that physicians should be concerned about the “unsustainable growth in the cost of care.”
“Medical performance tends to follow a bell curve,” he observes, “with a wide gap between the best and the worst results for a given condition, depending on where people go for care. The costs follow a bell curve, as well, varying for similar patients by thirty to fifty per cent. But the interesting thing is: the curves do not match. The places that get the best results are not the most expensive places. Indeed, many are among the least expensive. . .And the pattern seems to be that the places that function most like a system are most successful.
“By a system I mean that the diverse people actually work together to direct their specialized capabilities toward common goals for patients,” he explains. "They are coordinated by design. They are pit crews. To function this way, howver, you must cultivate certain skills . . .
"For one, you must acquire an ability to recognize when you’ve succeeded and when you’ve failed for patients. People in effective systems become interested in data. They put effort and resources into collecting them, refining them, understanding what they say about their performance.” (Here Gawande is suggesting that physicians take an interest in those “algorithms.” that Buckeye finds boring.)
“Second, you must grow an ability to devise solutions for the system problems that data and experience uncover. When I was in medical school, for instance, one of the last ways I’d have imagined spending time in my future surgical career would have been working on things like checklists. Robots and surgical techniques, sure. Information technology, maybe. But checklists?
“They turn out, however, to be among the basic tools of the quality and productivity revolution in aviation, engineering, construction—in virtually every field combining high risk and complexity. Checklists seem lowly and simplistic, but they help fill in for the gaps in our brains and between our brains. They emphasize group precision in execution . . . Making teams successful is more difficult than we knew. Even the simplest checklist forces us to grapple with vulnerabilities like handoffs and checklist overload. But designed well, the results can be extraordinary, allowing us to nearly eliminate many hospital infections, to cut deaths in surgery by as much as half globally, and to slash costs, as well.”
This, says Gawande, “brings us to the third skill that you must have but haven’t been taught—the ability to implement at scale, the ability to get colleagues along the entire chain of care functioning like pit crews for patients. There is resistance, sometimes vehement resistance, to the efforts that make it possible. Partly, it is because the work is rooted in different values than the ones we’ve had. They include humility, an understanding that no matter who you are, how experienced or smart, you will fail.” (“Humility” is a virtue that makes Gawande stand out as an exceptional physician. Read his first book, Complications where he discloses his own failures and close-calls, without blaming his superiors, his colleagues, or his patients.)
These new values also “include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures,” he adds. “And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy.
“Resistance surfaces,” he explains, “because medicine is not structured for group work. Even just asking clinicians to make time to sit together and agree on plans for complex patients feels like an imposition. ‘I’m not paid for this!’ people object, and it’s true right up to the highest levels.”
As for the use of the checklists that Buckeye Surgeon describes as part of the “menial tasks” that Gawande would assign to doctors, the author addresses this idea that checklists are somehow demeaning in The Checklist Manifesto: “It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us – or those we aspire to be – handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating." (For more on the need for checklists, scroll down to my May 24 post: “The Medicare ‘Crisis’: A “Shaggy Wolf Story” and search for “checklists.”)
Humility, a belief in teamwork, understanding that following evidence-based guidelines is essential. . . “These values are the opposite of autonomy, independency, self-sufficiency,” Gawande acknowledges. “Many doctors fear the future will end daring, creativity, and the joys of thinking that medicine has had. But nothing says teams cannot be daring or creative or that your work with others will not require hard thinking and wise judgment. Success under conditions of complexity still demands these qualities.”
He ends by congratulating his audience: “You are the generation on the precipice of a transformation medicine has no choice but to undergo, the riders in the front car of the roller coaster clack-clack-clacking its way up to the drop. The revolution that remade how other fields handle complexity is coming to health care, and I think you sense it . . . Two years ago, the Institute for Healthcare Improvement started its Open School, offering free online courses in systems skills such as outcome measurement, quality improvement, implementation, and leadership. They hoped a few hundred medical students would enroll. Forty-five thousand did. You’ve recognized faster than any of us that the way we train, practice, and innovate has to change. . .”
Do Ezra Klein, Paul Krugman, Goozner, and I Dislike Doctors?
Full disclosure: In his complaint about Gawande’s speech, Buckeye wrote: “Is it any wonder that Dr Gawande is the very Messiah of future healthcare delivery to people like Maggie Mahar and Ezra Klein?"
My response: First, I’m flattered to be compared to Klein, if only in a “guilt by association” context. Ezra and I don’t agree on everything, but I greatly admire his work both as a writer and as a reporter –insightful, often original, delving into complicated, controversial topics where many bloggers and journalists fear to tread. (I should add that in the past I have enjoyed Buckeye’s blog and have quoted him on HealthBeat.)
I am troubled, however, that some physicians seem to believe that journalists and bloggers who favor health care reform are “anti-physician." Last week , Dr, Kevin Pho (a.k.a Kevin MD) published a provocative column arguing that “there’s an underlying tension between physicians and health policy experts. Health policy experts take subtle jibes against physicians in their analyses, with many feeling American doctors are overpaid, which exacerbates health costs. They tend to be politically progressive, and generally dismiss the issues that most doctors care deeply about. Medical malpractice, tort reform and the cost of medical education, for instance.
“It’s a subtle physician-antagonistic response that policy wonks on the progressive side —Goozner, Ezra Klein, Maggie Mahar, and Paul Krugman, to name a few — occasionally make that only exacerbates the discord,” he added.
“And doctors can be antagonistic to policy experts,” Pho conceded. “As most wonks are not physicians themselves, doctors generally discount their opinions, since they haven’t gone through the rigors of physician training, and are shielded from the day to day realities of practicing medicine . . . But if we are to fix our health system, both sides need to come together.”
“Patients still trust their doctors,” Kevin concludes. “Which is why it baffles me when policy experts don’t give doctors many olive branches when making their health reform arguments. Given the rancor surrounding the debate, it seems that reformers could use all the support they can get.” Pho suggests that as peace offerings, Krugman, Klein, Goozer and I should argue for tort reform and drop any suggestions that physicians are overpaid.
Here, again, I am named in very good company– Krugman, Goozner, Ezra. I am not at all offended by Kevin’s remarks. I consider him a friend. He often cross posts HealthBeat pieces that Naomi or I have written on Kevin M.D. And I consider his one of the best health care blogs out there. I have invited him to guest-post on HealthBeat where, if he chose, he might debate me in areas where we disagree.
But I am disturbed that Kevin, like Buckeye, sees me and other “reform wonks” as “subtly antagonistic to physicians.” On HealthBeat, I have addressed many of doctors’ concerns, including the relatively low compensation for primary care doctors, geriatricians, pediatricians, palliative care specialists and others who spend most of their time practicing “cognitive medicine” (talking to and listening to patients.) I also have argued that the cost of medical education should be subsidized so that young doctors do not graduate bowed down by tens of thousands of debt.
I totally agree with Kevin’s argument that “to successfully reform our health system, doctors need to be at the forefront, not policy experts.” But I am puzzled when he says that health care reformers should offer “olive branches’ to physicians by supporting malpractice reform and nixing any notions about reducing doctors’ pay.
This suggests that Krugman, Klein, Goozner or I have had some input into health care reform policy. I don’t know about Goozner, but I’m pretty sure Paul Krugmn didn’t receive calls from the White House asking for advice while they were hammering out the Affordable Care Act. (I truly wish the president had named Krugman one of his top economic advisers. But Krugman was outspoken in endorsing Hillary during the primary. I greatly admire his courage and honesty. But his did not position him for a place in the inner circle.)
Nor have any of us ever claimed to be a doctor, or even, as they say, “played a doctor television”– not even Ezra, despite his considerable success on TV.
Physicians should recognize that the Affordable Care Act is based, almost entirely, on ideas developed, not by “health policy wonks,” or government bureaucrats but by doctors. “Shared decision-making;” “accountable care organizations;” the idea of “bundling payments;” “checklists” to reduce medical errors and infections; the need for “end-of-life counseling;” the warning that we are “over-testing” patients; the call to reduce “over-treatment”; the need for “systems” to improve patient care; the call for “Healthcare IT” to reduce errors . . . These were the brain-children of doctors–and not just ivory-tower physicians, as some opponents of reform claim–but of physicians such as Steve Woloshin, Lisa Schwartz, H. Gilbert Welch, Jim Weinstein, Nortin Hadler, David Kibbe, Peter Provonost, Ken Kizer, Diane Meier, Atul Gawande, and many others while they were working in private practice, in VA hospitals, in private hospitals, and elsewhere.
At the same time, I think Kevin M.D raises critical issues in his post. These days, physicians feel beleaguered. I understand that. Some who want to duck the most difficult problems in our health care system have begun to demonize doctors, fingering them as the culprits who have pushed costs skyward. In Money-Driven Medicine, I tried to explain that we all are implicated–patients as well as doctors, medical schools, hospital administrators and others. I am especially critical of those who run our for-profit medical industrial complex (drug-makers, insurers, device-makers, and some hospitals). Typically, they put shareholders’ interests and the interests of top management ahead of patients’ interests.
Finally, I agree with Kevin MD that "tension" between physicians and progressives who write about health care, advocating for change, can only hurt patients. We should talk to each other.
Buckeye said, “Healthcare is far too complex for any one doctor anymore. So gear up to be an interchangeable part, a faceless drone who performs menial tasks according to checklists and algorithms. . . . Don’t be a Cowboy (in the romanticized, individualistic sense of a bygone era) . . . All that debt you’ve taken on to be a physician? It’s so you can be an anonymous member of an integrated Team. Like a Pit Crew.”
Welcome to my world, Doc.
Personally, I find it grating that some doctors would set themselves up as the heroic Cowboy in the modern day and age.
Truth is, physicians have been part of a collaborative health care team for a long time.
Doctors can’t do their jobs without the input of nurses and other Allied Health specialties. They depend on us to identify patient issues that need attention. More than once I’ve seen a doctor stumped and say to the room, “I’m out of ideas. Anyone else have a suggestion?”
In my opinion, the hallmark of a strong physician is one who understands he can’t do it all, and that it takes a team to give great care.
I can understand the fear of being reduced to a “cog in a wheel,” of being expendable and replaceable. It’s something I have to live with in my profession.
But the days when the physician was “Captain of the Ship” are over, and that is something that must be understood. Even if health care reform had never happened, this is true. The industrialization of health care is already taking away that Captain of the Team status for physicians as more and more docs become part of group practices that are little more than franchises and that are being run under faceless corporate models.
The change from Captain to Pit Crew is happening regardless of what health care progressives do. If doctors are feeling demonized, they should look and be sure they themselves are demonizing the right people for this fact.
I’m all for Maggie’s opinion that progressives should have a dialogue with physicians who feel as Buckeye does. But talk is a two way street. It’s gotta come from the other end, too.
Panace–
Thanks very much for your comment. You write:
The industrialization of health care is already taking away that Captain of the Team status . . . .
“The change from Captain to Pit Crew is happening regardless of what health care progressives do”
This is very true.
I also agree that the strongest docs solicit help from others–including nurses.
Recently, there was an article in the New York Times about solo practioners. It quoted an older primary care solo practioner who was very unhappy, but wouldn’t want to join a large group organization because “they let nurse practioners so primary care alongside doctors,” and he wouldn’t want to work in that situation.
I understand why older solo practioners are reluctant to give up their independence, but this seemed a particularly weak reason not to want to be part of a large group.
All good as long as the “pit crew” take ownership of the issues regarding the patient and works to address them.
I think Buckeye surgeon, having read his columns in the past, is of the opinion that once he performs surgery on a patient, he takes full ownership in making sure they recover fully. It does not mean that he goes it alone or is a cowboy; it simply means he is the one who takes responsibility for the care and recovery of the patient. In my world as a primary care doc, I find this to be an atitude that is fading in the 9 to 5, I don’t want to be totally wedded to my job atitude that seems the new paradigm. Which would you prefer as a patient? The surgeon who performs his task and leaves the post op care to the “team”, or the one who stays actively engaged from beginning to end? It does not mean that he may not seek appropriate consutation if situations evolve requiring help. It does not mean he is not a “team player”.
Every team needs leadership as well and it is not clear to me in this new world how the health care wonks view and construct this team. Every team needs potentially a differnet set of team members, but who guides and directs the team? Primary care?
This is the confusion we in medicine are experiencing on the front lines as we are dictated what the ideal health care system looks like. I for one am not opposed to change, but I would sure like to see some clear proof that this change will yield better outcomes. What I see is that ideas are being thrust at us that are not clearly rooted in good solid evidence as to their effectiveness. There are systems where the supposed team approach yields good results. There are also systems where this paid employee of the corporation type relationship does not exist and good care is also given. No one has shown conclusively that the huge expenditure on electronic medical systems is that beneficial, but still we are told we need to have one.
Give us some solid evidence that these changes will produce a better health care system, and not simply a way for for profit companies to increase their revenue or for the payers to increase their profit. Thats all we ask!
you don’t have to be a physician to have valid ideas about health reform. trust is vital to a doctor-patient relationship, but counsel to “trust, but verify” is as relevant in medicine as it is in other fields. one nagging issue is the need for dealing with large populations. some older doctors tend to argue both against cookbook medicine, which suggests there’s an optimal basic approach to any problem and allowing non-physicians to help author the cookbook if there is to be one. bottom line is that they’re no more welcoming to change — and probably no much more resistant — than the rest of us.
Here’s what I don’t understand….
I went to a medical school form 1995-1999. Half of every day in my first 2 years were spent in a class called “Patient-Physician-And society”. We read poetry, discussed the humanities, and talked abouit what things felt like from a patients perspective.
I trained in a very good medical center. We were taught to provide aggressive care and communicate with our fellow doctors. We rounded with the different teams. Touched base with our consultants every day. Made team decisions.
Now I am in private practice and I practice team based care. I interact with the nurses every day (I even teach the nurses a weekly class on patient care in one of the nursing homes).
I spend more time on the phone then in the exam room. Talking to specialists over and over again…coordinating care. talking to nurses. Talking to family members. Many of them hve my personal cell phone.a
ACO’s, ACA, PCMH, EMR…none of this actually means patient centered care. Actually I have seen some of these things detract from patient care and lead to more disjointed connections all together.
I think when Buckeye talks about “owning” a patient…what he means is taking responsibility for that patients care. That means chasing down the other specialists….coordinating palliative care….having family meetings, etc.
What I see in the new medical graduates is that they don’t “own” up to patients care. They have a team based belief that if they don’t take care of it someone else will…afterall it’s right there on the emr for anyone to see.
We are producing doctors that take too little owenrship…and becuase of it care is following through the cracks…patients are suffering…and the job isn’t getting done. I suspect patient satisfaction with reform will be lower then expected.
Patient centerd care is Doc dependent…nothing about ACO’s or PCMH or ACA is going to fix that. You have to train the Docs that way….period.
I am very proud to say that I take ownership of my patients. All 2 thousand of them. And I think that Is actually why and how I practice team based care. I did this before EMR’s (although I have used one most of my professional career). And I did this before ACA.
This is what separates physicians and Policy Wonks. We feel they don’t understand this concept.
Just becuase you build it…doesn’t mean the physicianas will come.
In fact maybe they won’t…for just that reason.
Keith—
First, on the question of who leads the team? Some surgeons (and I believe Gawande is one of them) really take a much more egalitarian approach to the team. Anyone and everyone (including nurses) is suposed to speak up if they see a surgeon skipping over an item on a checklist,not washing his hands, or simply not noticing something that seems to be going sour with the patient …
In NYC we actually have an orchesetra without a conductor!!! This seems impossible, but a very good musician told me that it is a good orchesetra.
And at Mayo, the culture is extremely egallitarian. For example, after a few years, every doctor in a given specialty earns the same salary–whether they are world famous for their reserach or “just”
extraordinarily good clinicians (the requirement for being at Mayo.) They also have the same size offices, etc.
Finally, in the past, we have encouraged competition in medicine. The type of students admitted to med school tended to be extremely competitive. Often, they were “leaders.” Given the new collaborative model, many med schools are looking for “Indians” not
“chiefs.”
Women tend to be more comfortable with this collaborative model (this is what we were taught as children.–simply a matter of how we were conditioned.) Men are more likely to feel that someone must be “in charge.”
Buckeye Surgeon definitely sees it that way. In one post he wrote: “I operate, I own it. That’s the way I was trained. I run the show. I correct the electrolytes. I manage post op hypertension and pain. I write my own TPN. I order my own insulin drips. I make most of the critical care decisions for my sick patients in the ICU. That’s the way it is. My part doesn’t end when I take off my mask. Often, it’s only just beginning.”
I think it’s great when surgeon follow up, and I wrote about Buckeye’s post on HealthBeat (in a very positive way.) http://www.healthbeatblog.org/2008/06/the-buck-eye-su.html
At the same time, it seems to me that the surgeon should be collaborating with the intensivist in the ICU not calling the shots or “running the show.”
When I wrote about his post Dr. Chris Johnson ( a pediatric intensivist who spent many years at Mayo offered this measured comment:
“I have to say that, from my prospective Buckeye Surgeon , represents an example of the kind of problems I encounter every day. For those of us who work in the ICU, the irritation of dealing with surgeons who truly believe they know everything I know (as an intensivist), and they can do surgery, too. On the other hand, I do appreciate the kind of proceduralist, be it surgeon, cardiologist, gastroenterologist, or whatever, who stops by regularly after they have done whatever they needed to do to see how the patient is doing and if we need any more of their help. Patient families really appreciate this, too, since often they have questions the proceduralist is best suited to answer.
Johnson gives Buckeye credit –but makes it clear that Buckeye is Not an intensivist, and the attitude that he knows everything that an intensivsit does And can operate too is irritating. (Johnson created the pediatric intensive care unit at Mayo.) Buckeye’s somewhat macho language (I run the show) suggests that he is Not a team-player. He wants to be the captain–even when in the ICU. I’m also a little bothered by references to the patient as “it”–“ I operate, I own it.” There’s that theme of the doctor owning the patient again. Doesn’t seem to leave a lot of room for shared decision-making.
On Health IT We do have evidence that very good Health IT systems that are well-suited to the setting in which they are being used do reduce errors and improve care. (Here I’m thinking of the VA system and Mayo’s system.)
Unfortunately, some HIT systems that are designedby people who understand IT but don’t understand work-flow in the setting have not proven to improve care. In fact,they can be obstacles to better care.
It seems that the best systems were designed by doctors and nurses,or in close consultatoin with the doctors and nurses that will be using them.
Note I added nurses: if the IT doesn’t work for the nurses, it won’t improve care.
Buckeye Surgeon definitely sees it that way. In one post he wrote: “I operate, I own it. That’s the way I was trained. I run the show. I correct the electrolytes. I manage post op hypertension and pain. I write my own TPN. I order my own insulin drips. I make most of the critical care decisions for my sick patients in the ICU. That’s the way it is. My part doesn’t end when I take off my mask. Often, it’s only just beginning.”
I think it’s great when surgeon follow up, and I wrote about Buckeye’s post on HealthBeat (in a very positive way.) At the same time, the surgeon should be collaborating with the intensivist in the ICU not calling the shots or “running the show.”
When I wrote about his post Dr. Chris Johnson ( a pediatric intensivist who spent many years at Mayo offered this measured comment:
I have to say that, from my prospective Buckeye Surgeon , represents an example of the kind of problems I encounter every day. For those of us who work in the ICU, the irritation of dealing with surgeons who truly believe they know everything I know (as an intensivist), and they can do surgery, too. On the other hand, I do appreciate the kind of proceduralist, be it surgeon, cardiologist, gastroenterologist, or whatever, who stops by regularly after they have done whatever they needed to do to see how the patient is doing and if we need any more of their help. Patient families really appreciate this, too, since often they have questions the proceduralist is best suited to answer.
Johnson gives Buckeye credit –but makes it clear that Buckeye is Not an intensivist, and the attitude that he knows everything that an intensivsit does And can operate too is irritating. (Johnson created the pediatric intensive care unit at Mayo.) Buckeye’s somewhat macho language (I run the show) suggests that he is Not a team-player. He wants to be the captain–even when in the ICU. I’m also a little bothered by references to the patient as “it”–“ I operate, I own it.” There’s that theme of the doctor owning the patient again. Doesn’t seem to leave a lot of room for shared decision-making.
I have never practiced medicine, but my impression is that under the new model, a hospitalist would be the “co-ordinator”– who was in touch with everyone. This doesn’t make him the team leader. There is no leader. Different people lead in different spheres.
There is good reason to empower all members of the team to think of themselves as potentially the leader. Anyone who sees a problem must speak up, without worrying about crossing lines of command.
Finally, as for Buckeye, I have enjoyed a great number of his columns.B ut he often takes that somewhat ‘macho” attitude. I recall, for instance, a column where he writes about the poor and “woebegone” patients who are helped by a team that tries to keep them out of the hospital, in part by programming their health coach’s phone number into the patient’s cell phone when the patient can’t figure out how to do it.
Buckeye’s contempt for the patient and what he sees as “Nanny-state” medicine” (what he calls O-Mama care) is clear. No compassion for uneducated, poor, sick patients who can’t do something that he thinks “any adult” should be able to do. . . .
His column is here: http://webcache.googleusercontent.com/search?q=cache:HWNOgcx_OQoJ:ohiosurgery.blogspot.com/2011/01/gawande-and-o-mama-care.html+%22Buckeye+Surgeon%22+and+%22teams%22&cd=4&hl=en&ct=clnk&gl=us&source=www.google.com
Jordan–
I totally agree that physicians should “take responsiblity” for their patients.
But that does not mean that they cannot collaborate with other
physicians. They don’t have to “take charge” when working with other docs.
See my reply to Keith and what Buckeye has to say about being “in charge” when his patient is in the ICU. And see Dr. Chris Johnson (who is an intensivt)’s comment.
Johnson also “takes responsiblity” of his patients. He appreciates surgeons who follow up, and their input. But the notion that they know more about intensive care than he does (and can operate too!) is not helpful, and suggests an arrogance which can get in the way of good patient care.
Sharing responsiboity does not mean “passing off” responsiblity to someone else. It means that everyone is watchign out for the patient, and everyoone is watching each other’s back. Every doctor will at some point make a mistake, or miss something. If doctors and nurses are all taking full responsibity, they will catch another doc’s oversight–making patient care better and safer.
We have reserach (from peer-reviewed journals) showing how this works when doctors and hospitals decide to work together and infection rates, etc., drop.
Finally, ACOs etc were NOT created by health care reformers/policy wonks like me.
Dr. Elliot Fisher first dreamed up the idea of the ACO– and conined the term is his.
Dr. Ken Kizer made what many view as the first major breakthrough in good use of EMRS at the VA –when he was running it.
He showed that medical errors, medication mix-ups etc. can be reduced.
People like Dr. Brent James, and doctors at Mayo and Kaiser have been the pioneers inventing and refining the idea of multi-specialty group practice.
Everything I know about “patient-centered care,” I have learned from doctors like Jim Weinstein (who helped pioneer “shared decisoning” because, as an practicing orthopedic surgeon, he felt pateints were too passive when giving informed concent– tha they weren’t making an informed choice, that they didn’t undertand the risks. Instead, they woudl just say “I trust you doc.”
The Affordeable Care Act promotes “shared decision-making” and paying doctors for the time it takes.
On the need for palliative care teams working with patients as well as their surgeons, oncologists, etc., Dr. Diane Meier is one of the leaders. Docs who want to take full responsbioity for “their” patient often block a palliative care consult.
The “end of life counselling” that was originaly part of the ACA is something that Meier and other palliative care specialists championed.
It was not dreamed up by “health policy wonks.”
Many of the younger docs that I have met believe in taking responsiblity for the patient AND working together as a team. I think in particular of doctors who are members of
tne National Physician Alliance.
Of course, teamwork shouldn’t mean “I don’t have to worry about that. Soemone else will.”
That is hardly the attitudde at Mayo, Geisinger, INtermountain or many other centers that will serve as models for ACOs.
It sounds as if you are a very good doc–but,as you know, you are not the only good doc in the U.S. Other physicians–who have been invovled in shaping reform– as well as many younger doctors also are excellent, patient-centered physicians.
Finally, I frankly can’t think of an important provision in the Affordable Care ACt that wasn’t designed by physicians– whether the idea of moving away from fee-for-service, or cutting back on over-testing(Gil Welch, Lisa Schwarts and Steve Woloshin) were leaders here, by giving the Secreatry of HHS the ability to reduce fees for “overvalued services.”
Keith-
: On the question of who leads the team… Some surgeons (and I believe Gawande is one of them) really take a much more egalitarian approach to the team. Anyone and everyone (including nurses) is suposed to speak up if they see a surgeon skipping over an item on a checklist,not washing his hands, or simply not noticing something that seems to be going sour with the patient …
In NYC we actually have an orchesetra without a conductor!!! This seems impossible, but a very good musician told me that it is a good orchesetra.
And at Mayo, the culture is extremely egallitarian. For example, after a few years, every doctor in a given specialty earns the same salary–whether they are world famous for their reserach or “just”
extraordinarily good clinicians (the requirement for being at Mayo.) They also have the same size offices, etc.
Finally, in the past, we have encouraged competition in medicine. The type of students admitted to med school tended to be extremely competitive. Often, they were “leaders.” Given the new collaborative model, many med schools are looking for “Indians” not
“chiefs.”
Women tend to be more comfortable with this collaborative model (this is what we were taught as children.–simply a matter of how we were conditioned.) Men are more likely to feel that someone must be “in charge.”
Buckeye Surgeon definitely sees it that way. In one post he wrote: “I operate, I own it. That’s the way I was trained. I run the show. I correct the electrolytes. I manage post op hypertension and pain. I write my own TPN. I order my own insulin drips. I make most of the critical care decisions for my sick patients in the ICU. That’s the way it is. My part doesn’t end when I take off my mask. Often, it’s only just beginning.”
I think it’s great when surgeon follow up, and I wrote about Buckeye’s post on HealthBeat (in a very positive way.) http://www.healthbeatblog.org/2008/06/the-buck-eye-su.html
At the same time, it seems to me that the surgeon should be collaborating with the intensivist in the ICU not calling the shots or “running the show.”
When I wrote about his post Dr. Chris Johnson ( a pediatric intensivist who spent many years at Mayo offered this measured comment:
“I have to say that, from my prospective Buckeye Surgeon , represents an example of the kind of problems I encounter every day. For those of us who work in the ICU, the irritation of dealing with surgeons who truly believe they know everything I know (as an intensivist), and they can do surgery, too. On the other hand, I do appreciate the kind of proceduralist, be it surgeon, cardiologist, gastroenterologist, or whatever, who stops by regularly after they have done whatever they needed to do to see how the patient is doing and if we need any more of their help. Patient families really appreciate this, too, since often they have questions the proceduralist is best suited to answer.
Johnson gives Buckeye credit –but makes it clear that Buckeye is Not an intensivist, and the attitude that he knows everything that an intensivsit does And can operate too is irritating. (Johnson created the pediatric intensive care unit at Mayo.) Buckeye’s somewhat macho language (I run the show) suggests that he is Not a team-player. He wants to be the captain–even when in the ICU. I’m also a little bothered by references to the patient as “it”–“ I operate, I own it.” There’s that theme of the doctor owning the patient again. Doesn’t seem to leave a lot of room for shared decision-making.
On Health IT We do have evidence that very good Health IT systems that are well-suited to the setting in which they are being used do reduce errors and improve care. (Here I’m thinking of the VA system and Mayo’s system.)
Unfortunately, some HIT systems that are designedby people who understand IT but don’t understand work-flow in the setting have not proven to improve care. In fact,they can be obstacles to better care.
It seems that the best systems were designed by doctors and nurses,or in close consultatoin with the doctors and nurses that will be using them.
Note I added nurses: if the IT doesn’t work for the nurses, it won’t improve care.
Buckeye Surgeon definitely sees it that way. In one post he wrote: “I operate, I own it. That’s the way I was trained. I run the show. I correct the electrolytes. I manage post op hypertension and pain. I write my own TPN. I order my own insulin drips. I make most of the critical care decisions for my sick patients in the ICU. That’s the way it is. My part doesn’t end when I take off my mask. Often, it’s only just beginning.”
I think it’s great when surgeon follow up, and I wrote about Buckeye’s post on HealthBeat (in a very positive way.) At the same time, the surgeon should be collaborating with the intensivist in the ICU not calling the shots or “running the show.”
When I wrote about his post Dr. Chris Johnson ( a pediatric intensivist who spent many years at Mayo offered this measured comment:
I have to say that, from my prospective Buckeye Surgeon , represents an example of the kind of problems I encounter every day. For those of us who work in the ICU, the irritation of dealing with surgeons who truly believe they know everything I know (as an intensivist), and they can do surgery, too. On the other hand, I do appreciate the kind of proceduralist, be it surgeon, cardiologist, gastroenterologist, or whatever, who stops by regularly after they have done whatever they needed to do to see how the patient is doing and if we need any more of their help. Patient families really appreciate this, too, since often they have questions the proceduralist is best suited to answer.
Johnson gives Buckeye credit –but makes it clear that Buckeye is Not an intensivist, and the attitude that he knows everything that an intensivsit does And can operate too is irritating. (Johnson created the pediatric intensive care unit at Mayo.) Buckeye’s somewhat macho language (I run the show) suggests that he is Not a team-player. He wants to be the captain–even when in the ICU. I’m also a little bothered by references to the patient as “it”–“ I operate, I own it.” There’s that theme of the doctor owning the patient again. Doesn’t seem to leave a lot of room for shared decision-making.
I have never practiced medicine, but my impression is that under the new model, a hospitalist would be the “co-ordinator”– who was in touch with everyone. This doesn’t make him the team leader. There is no leader. Different people lead in different spheres.
There is good reason to empower all members of the team to think of themselves as potentially the leader. Anyone who sees a problem must speak up, without worrying about crossing lines of command.
Finally, as for Buckeye, I have enjoyed a great number of his columns.B ut he often takes that somewhat ‘macho” attitude. I recall, for instance, a column where he writes about the poor and “woebegone” patients who are helped by a team that tries to keep them out of the hospital, in part by programming their health coach’s phone number into the patient’s cell phone when the patient can’t figure out how to do it.
Buckeye’s contempt for the patient and what he sees as “Nanny-state” medicine” (what he calls O-Mama care) is clear. No compassion for uneducated, poor, sick patients who can’t do something that he thinks “any adult” should be able to do. . . .
His column is here: http://webcache.googleusercontent.com/search?q=cache:HWNOgcx_OQoJ:ohiosurgery.blogspot.com/2011/01/gawande-and-o-mama-care.html+%22Buckeye+Surgeon%22+and+%22teams%22&cd=4&hl=en&ct=clnk&gl=us&source=www.google.com
Jim–
I think you are right that most doctors are like the rest of us– resistant to change (they too, are human), but at the same time welcoming i.
Most of us us realize that something must be done, the system is in crisis, but many are wary about what it will mean for them, personally.
The model that I most embrace for the doctor of the future is that of coach or teacher.
THE MOST IMPORTANT RECENT revolution in medicine is the democratization of medical information through the miracle of the global worldwide web. This gives rise to co-decision-making between doctor and patient.
Dr.Atul Gawande, whom I admire greatly, works in a very high-tech hospital in a very high-tech medical specialty. No wonder his good book is about checklists which is very understandable and necessary in his practice environment.
I see these types of high-tech high-cost hospitals diminishing in power and resources as primary care,prevention and public health re-emerge as the inevitable dominant forces in the future of Medicine.
Respectfully,
Dr. Rick Lippin
Southampton,Pa
Dear Dr. Rick,
As you know, I usually try to be hopeful about the future. As one of my favorite poets wrote: “To hope, till hope creates, from its own wreck, the thing the thing it contemplates.”
But today,as I look at the “wreck’ of the U.S. economy, and the politics and prejudice wrecking our society, I can’t help but throw a little cold water. (Apologies. No doubt, tomorrow,I will once again be in a more hopeful fighting mood.)
But right now, there are some realities that I think we all should face up to. We can’t really fight for change unless we recognize just how bad things are.
I, too, would like to see primary care and prevention dominate our health care system.
But that will never happen as long as so many Americans are poor.
As I have written in the past, there is a limited amount that primary care docctors can do for the poor.
Preventive care doesn’t solve the problems of stress, depression, anger, and the self-medication that follows. Sub-standard housing, poor nutiriton, no place to exercise and sub-standard public schools all go hand in hand with poverty.
The biggest healthcare problem in the U.S., is chronic disease. A huge percentage of those suffering from chronic diseases are poor.
If primary care docs become political activists, they could help fight poverty in their communities. But ultimately, all of us would have to be involved– agreeing to pay the higher taxes needed to create the better schools, housing,nutrition and social safety nets found in other developed countries.
As you know, in the U.S. more childeren are living in poverty than in any other developed country in the world. Even if they get their shots when needed, and see a good primary care doc, they will die six years earlier than wealthier kids.
And many of them will be physically ill and/or mentally ill (deperssed etc.) for most of their adult lives. Even if they somehow break out of poverty, get an education, and do everything “right:”: eat right, dont’ gain weight, exerise, etc., the scars of childhood poverty will cause them to die sooner. They’re also more likely to have miscarriages
When we let children grow up poor, we condemn them to tough lives.
Finally, I agree that, in theory, the most important thing that primary care docs can do is to be teacher/coaches and teach patients how to help manage their own chronic diseases and keep themselves healthy.
I say “in theory” because this is likely to work only with relatively well-educated upper-middle class patients (families living on joint income above the median of roughly $63,000)
But the half of all Americans who are not in that bracket are, by and large, not terribly well-educated . (This is in large part thanks to the fact that our poublic schools have traditionally been financed by property taxes. If you grow up in a wealthier neighborhood, your public school will have more resources. )
Meanwhile, for the past 20 years, middle-class incomes have remained relaitvely flat. Those in the middle class struggle with economic problems. Increasingly, they cannot afford to send their kids to college, buy a home–or keep up with the mortgage payments if they do. . Unemployment hovers, as a real threat. Healthcare is becoming more and more unaffordable.
Like the poor, those living at median income or below are stressed. They’re depressed.
They’re not good candidates to learn how to manage their chronic diseases. If eating is my one consolation in life, why should I cut back on the comfort food –or the beer?
Meanwhile the poor have even less education , are even more depressed,and are living the chaotic lives that come with poverty. The chances that they will able to learn how to control their chronic diseaes are slim to none.
Finally, for the foreseeable future, Cancer will continue to be a major problem. I recently discovered that as of 2010, in the U.S. “ one in two men and one in three women will be diagnosed with cancer in their lifetime.
Of these, approximately half will die of cancer or related complications .”http://www.physorg.com/news187960866.html
The media’s upbeat stories about cancer cures totallly distort how successful our war on cancer has been. (Why so unsuccessful? In large part due to ” money-driven medicine.” Too much compeition (for profits and glory) –not enough collaboration and sharing of information. Drug companies setting the research agenda.
Misplaced prioriites: pouring money into wide-spread testing of well, low-risk people leading to unnecessary treatments. Too little money put into smoking cessation, eliminating environmental causes of cancer. Too little money put into cancers that can be cured –particularlly among children, especially poor, uninsured or underinsured children.. Too much money put into incurable cancers that affect older relatively affluent Americans –The truth is that, today, if you have metastatic solid tumor cancer your chances of a cure are roughly “zero’ as two very candid oncologistis report in the most recent issue of the NEJM. .
Some cancers could be prevented if we fought poverty (which, in turn would reduce smoking and the number of poeple living in carcinogenic enviroments. We typicallly “dump” carcinogents in places where the poor or working class people live.)
But that still leaves a greatly many cancers that are not associated with poverty.
So Gawande, and hi-tech hospitals like his will still have their work cut out for them. Some cancer victims can survive–or at least go into remission and enjoy another 3, 5, 10 or more relatively good years. Or their lives can be etended and they will gain at least a couple of good years, playing with their grandchildren.
Bottom line: Gawande , the hospital where he works, and his version of cancer care will remain a v. impt. part of the equation for a long time to come. . .
Maggie:
When I look at what separates European healthcare systems from ours, the successes they have for much less money, I think the linkage with economic status is inescapable. The Ayn Rand worshiping, self-styled rugged individualists that too many Americans idolize are the problem — healthcare status is closely linked to economic status. The more poor and unemployed we have, the worse our healthcare statistics will be. Anyone interested in public health needs also to be interested in economic health.
The only conclusion I could draw from Buckeye Surgeon’s post is that he’s never actually taken the time to read The Checklist Manifesto or Dr. Gawande’s New Yorker article on the subject.
The straw man that he puts out there about checklists being handed down from on high doesn’t at all line up with Gawande’s approach to checklists, nor does it line up with what I see aviation safety experts teaching in healthcare – people who do the actual work need to write their own checklists. The checklists need to evolve with medical evidence. Checklists are NOT an excuse to “check your brain at the door” or such.
Buckeye Surgeon’s complaining about something that Gawande’s not even saying.
But then again, Buckeye Surgeon thinks the graduation address should have been 30 minutes of “y’all are awesome” congratulations.
Out of one side of your mouth you claim to want affordable healthcare for all, then out of the other side you excoriate a surgeon willing & able to provide the bulk of this care at no increased cost to the patient .
General Surgeons, because of their broad training, should be playing a key role in healthcare reform due to the amoumt of valuable patient
care they can provide per
dollar spent.
And why are you so opposed to someone willingly accepting
the leadership role in patient
care?
For the most common pathologies, a team of 15 is not needed. One point woman is
adequate with consults as
necessary. A team of 15 docs + allied health professionals for the majority of pathologies is akin to the state road
construction crew; the epitome
of inefficiency.
Regards,
PrecordialThump
Nice article, thanks for the information.
Chris, Mark, Pre-cordial
Chris–
Exactly.
Too many Americans associate health with inidivduals taking “personal responsibity” for themselves, ignoring all of the evidence which shows that people are healthier when they are wealthier and better educated.
It’s just much, much easier to take care of yourself if you have the resources to do so.
Economic inequality also correlates with mental illnesses such as depression,high anxiety, etc. Living in an unequal society is stressful– particularly when you’re at the bottom of the ladder.
We have higher rates of mental illness here than in most Western European countries.
That said, I’m all for the “wellness” movement, and docs like Dr. Rick can help many of their patients. I recall his coment that the two most impt. questions that a primary care doc can ask a patient in an annual physical are:
“HOw are things at home?”
“HOw are things at work?”
These are questions that may elicit more impt. info than most blood tests.
Though for the doctor to help the patient who admits to problems (divorce, alcohoism, constant fighting at home, Hating a bullying boss and loathing his job) the patient has to be in pretty good shape mentally and economically ( He must be able to find another job, financially able to afford divorce, have the internal wherewithal to try to quite drinking.
Mark–
Thanks for your comment.
Yes,it doesn’t seem likely that Buckeye has read The Checklist Manifesto or the New Yorker article about checklists.
The chekclilst, as you say was not created by a health policy expert. And the medical checklist was created by Dr. Peter Provonost, practicing at Johns Hopkins where a very young child died of a preventable infection. That inspired the checklist.
I’m afraid you’re right: “Buckeye Surgeon thinks the graduation address should have been 30 minutes of ‘y’all are awesome’ congratulations”
Well-put!
Pre-cordial–
Having one person “take charge” does not save money. Medical reserach shows that when doctors and others work together as a team,fewer errors are made.
Errors are very, very expensive.
What is important is not how many docs are involved but how many “doctor hours” are involved. In an inefficient hospital, it might take 30 “docotor hours” to diagnose a patient. In a very efficient place like Mayo, it might take 4 hours.
At Mayo eight people might be involved consulting with each other–all looking at the same electornic medical record, and ocmmunicating with each other effortlessly.
At the other hospital, one person might take “charge.” (Of course if no one has access to the notes he took when the too the patient’s history, no one is able to watch his back. He may have missed someting impt.
In terms of costs, –what’s impt. is the total hours spent.
This is how the Dartmouth reserach compares efficient and inefficient hospitals– in terms of units of doctors’ time. This is what hikes bills.
See Dartmouthatlas.org
http://www.dartmouthatlas.org/keyissues/issue.aspx?con=2939
Are you sure you linked the correct page? The first page I read agrees with my perspective & not yours….. It says that many people dont get basic care (like post MI beta blockers) and the MORE physicians involved, the WORSE the care. Thanks for helping to make my point that the team approach is light on patient ownership; dont worry, one of the patients 10
other docs will write a script
for that beta blocker.
Regards,
PrecordialThump
p.s. Who is responsible, in a team of 10, for forgetting the beta blocker?
P.p.s. Ive seen collaborative care work well for certain case, especially oncology. Theres a niche for it in medicine, but it aint
inspirational graduation
speech fodder.
Maggie said, “Though for the doctor to help the patient who admits to problems (divorce, alcohoism, constant fighting at home, Hating a bullying boss and loathing his job) the patient has to be in pretty good shape mentally and economically ( He must be able to find another job, financially able to afford divorce, have the internal wherewithal to try to quite drinking.”
This is so true.
I had a conversation with one of my nursing students along these lines today. She’s a heavy smoker, and was complaining how she had a hard time climbing stairs: this girl is 20 years younger than I am, and she can’t climb stairs because she gets short of breath.
Quit smoking, says I.
Too stressful, says she. Too much going on in her life between work, school, and her personal life. She has money worries and no health insurance (a poster child for universal health care if ever there was one). She couldn’t afford to go to the doctor and get on a smoking cessation program, or get a prescription for Wellbutrin.
OK, says I. Think of this. How much money do you spend a week on cigarettes?
About $100/week, says she.
I replied, for $100/week you could go on the patch, and save the money on cigarettes. At least then you’re not smoking and you have a plan to wean off the patch until you have quit. Worth a try at least, and you’re not out anything you wouldn’t have already spent.
The idea had never occurred to her before. But at least she was willing to consider it. Her complaint was, every time she saw a doctor, he “ordered me to quit smoking. He just didn’t get it.”
She’s right: he didn’t take the time to talk about HOW she was to go about doing this . . . just “do it.”
It’s that same “personal responsibiltiy” idea Maggie was talking about . . . the doctor gives his instructions, the nurse gives the patient education but everything else is up to the patient. That’s OK to a certain point . . . we can’t do it for them . . . but if we don’t even bother to find out what we need to tell the patient so that the instructions are REASONABLE and POSSIBLE, then the patient is just going to throw their hands up, say “they don’t get it,” and keep on with the same unhealthy behaviors.
It’s a vicious circle, and we won’t break it until we as health care professionals change our thinking and our approach towards patients.
Teamwork requires the resources to have a team. I have worked with great teams during my oncology career. In the past 15 years as a clinical educator in a community hospital that is much poorer than the neighboring university and private hospitals I have to play many of the “team roles” such as social worker,insurance filer, clinical pharmacist, IT worker as well as physician. For the uninsured or undocumented we have to beg for surgical and gyn support and keep patients going until insurance kicks in which can be weeks to years. Our support staff puts out fires when they can. The economics are critical to this discussion.
As a physician, I never perceived Money-Driven Medicine as having an ‘anti-physician’ stance at all.
Not only does poverty perpetuate bad health, but bad health often causes poverty……56% of bankruptcies (with many actually insured!), ruinous premiums, expensive drugs, etc., place millstones around our necks.
Always follow the money to find out the truth. Mayo MD’s are salaried and are known for regular case conferencing. Team integration is enhanced by having very effective EMR’s as well.
To All Readers:
At HealthBeat, (as on many blogs) we have a policy of deleting any comments that involve personal attacks, are rude, or are “rants” (often having little to do with the subject at hand).
Over four years we haven’t had many problems.
I’m very proud of the level of discourse on these threads.
But over a period of months one reader has repeatedly posted hostile or personal comments, and when they are deleted, he then posts comments stating that if people don’t agree with me, their comments will be deleted.
In fact, he is the only reader whose comments have been deleted in recent memory. I may be forgetting a random lunatic who showed up and accused me of being on Obama’s payroll, but I don’t think so.
We also delete comments by someone selling something (“Designer Handbags, etc.), but that’s a separate category of “spam” .
In any case, I wanted to reassure everyone:
As you can see, there are many comments disagreeing with Naomi or I on these threads.
We welcome rational arguments, ideally backed up with evidence.
Ruth, Panacea, Linda, Pre-Cordial
Ruth, thanks much.
And I agree that EMRS can greatly enhance team collaboration.
It’s also true that so much in our society can be explained by following the money. Poor health (and medical bills) does lead to poverty.
Panacea–
You gave your colleague excellent advice. I hope it works. Nicotine patches really are effective for many people.
And you are aboslutely write: ordering a patient, lecturing a patient, mocking a patient — none of this works. Though it is generally quicker than having a conversation with the patient, figuring out what might work for him or her. For example, a sedentary patient who needs to lose 30 pounds is probably not going ot respond to being told he should join a gym or go on a stringent diet. But he might respond to the idea of going for a walk after dinner every night with his spouse . . . Even if he doesn’t lose a lot of weight, it’s good cardio-vascular exercise.
Linda– An excellent point.
Many “safety net” hospitals don’t have the resources to create teams.
With health care reform, there will be many fewer uninsured and this should help safety-net hospitals.
And they will be eligble for funding to help them improve care and reduce costs.
But we still need to re-distribiute resources and make sure that wealthier hospitals are taking care of their share of poor patients, the immigrants, who will remain uninsured, etc.
Some non-profit private hospitals make the poor feel definitely unwelcome. So poor patients all go to the public hospitals two blocks down the street . .
You see this pattern in Manhattan.
Precordial Thump–
You’re misreading what Dartmouth is saying.
They are talking about hospitals where the specialists who come in to consult are not part of a team in an integrated health care setting.
They are in private practice, have “privileges” at the hospital, and often don’t communicate wtih each other at all.
I am a general surgeon. I am a female. I believe strongly that you cannot be a surgeon or a good surgeon without being the leader and having ownership over the patient. I also did a critical care fellowship. I would dare say that more harm is done to surgical patients by well-meaning intensivist who have no idea or clue about postoperative fluid and electrolyte management and shifts than many intensivist would like us to believe. Am I saying that surgeons should be a$$es? No. What I am saying is that surgeons do have to be the leader. I don’t want a pure follower operating on me, what happens if in the middle of my surgery he/she encounters something out of the ordinary? Who do you call then? You need to lead and know.
Kellie–
First do you have any reserach from peer-reviewed journals or data showing that patients in ICUs are harmed when intensivists don’t listen to surgeons? If this is a widespread problem, it must have been studied.
Seoondly, we’e not talking about surgeons consulting and collaborating with “pure followers.” We are talking about surgeons
a) paying attention when a nurse– or anyone on the scene– points out that the surgeon is making a mistake that could hurt the patient.
(The data on surgical errors suggests that this would be a good idea). I would urge you to read this book: The Checklist Mainfesto, written by a surgeon)
.
–and B) We’re talking about surgeons recognizing that when not on their own turf — the OR– but rather in an ICUs Rehab, a hospice, or a patient’s home where he/she is receiving hospice or palliative care, the surgeon really doesnt’ know as much as specialsts who have been traiend to tak to–and listen to– dying patients.
How often do you spend 10 or 15 hours talking to a surgical patient and familly about death and dying after you recognize that he or she is not going to live–and after you have given up on further treatments?
Are you of the belief that surgical training entails only the operative suite? Surgical residency is designed to educate and treat surgical pathologies encompassing preoperative, operative and post operative care to include critical care management of our patients. Your continued insistence that our realm of expertise ends in the or is wrong and insulting.
Dylan–
Yes, I realize that surgeon’s training extends beyond hte OR– as it should.
And good surgeons definitely follow their patients beyond the OR.
I think it’s great when surgeon follow up, and I wrote about another Buckeyes post (in a very positive way) focusing on that topic. See http://www.healthbeatblog.org/2008/06/the-buck-eye-su.html
At the same time, it seems to me that the surgeon should be collaborating with the intensivist in the ICU not calling the shots or “running the show” as Buckey suggests in this earlier post.
When I wrote about this post Dr. Chris Johnson ( a pediatric intensivist who spent many years at Mayo offered this measured comment:
“I have to say that, from my prospective Buckeye Surgeon , represents an example of the kind of problems I encounter every day. For those of us who work in the ICU, the irritation of dealing with surgeons who truly believe they know everything I know (as an intensivist), and they can do surgery, too. On the other hand, I do appreciate the kind of proceduralist, be it surgeon, cardiologist, gastroenterologist, or whatever, who stops by regularly after they have done whatever they needed to do to see how the patient is doing and if we need any more of their help. Patient families really appreciate this, too, since often they have questions the proceduralist is best suited to answer.
I think that Johnson gives Buckeye credit –but makes it clear that Buckeye is Not an intensivist, and the attitude that he knows everything that an intensivsit does AND “can operate too” is irritating. (Johnson created the pediatric intensive care unit at Mayo.)
Buckeye’s somewhat macho language (I run the show) suggests that he is not a team-player. He wants to be the captain–even when in the ICU.