Today I hope to make you think. Today I will rant against rampant subspecialization. Today I will make some readers mad.
Pauline Chen has a wonderful article in the NY Times – Learning to Keep Patients Safe in a Culture of Fear.
In this article she writes about the problems we have in improving patient safety in hospitals.
But a recent study indicates that current doctors-in-training may still be hesitant to document errors. Last month, The Joint Commission Journal on Quality and Patient Safety reported that the majority of residents have never written up an incident report. And according to a paper issued this week from a committee of leading experts in medical education and health care working with the Lucian Leape Institute of the National Patient Safety Foundation, young doctors are still going out into practice with little education or training in patient safety.
Changing a health care culture that undermines some of the most important principles of error reduction — trust, teamwork and communication — has proved to be much more difficult than a safety checklist would lead one to assume.
“Young doctors are being educated in a toxic culture,” said Dr. Lucian L. Leape, a leading patient safety expert at the Harvard School of Public Health who was chairman of the report’s committee. “The current environment is hierarchical, stressful for the individual, driven by the fee-for-service payment system and humiliating, all of which works against improving patient safety.” To ensure safer health care, doctors-in-training need time to reflect on their actions, a sense of community with colleagues and other health care workers, and the support to engage freely in disclosing errors.
Earlier this week the NEJM published a report on coronary angiography – Diagnostic Angiography Catches Few Cases of Obstructive CAD.
Now you are probably scratching your head now (if you are still reading this rant) and wondering how these 2 articles fit into one rant. Here is my hypothesis:
I believe that our rampant subspecialization has led to physicians focusing too much on disease and not enough on patients. As Osler reportedly said, "The good physician treats the disease; the great physician treats the patient who has the disease"
What has happened to medicine in the last 40 years? We have had an explosion of knowledge acquisition, primarily funded through NIH. NIH research focuses primarily on diseases and the biology of diseases. We have had the development of huge subspecialty divisions in internal medicine (and pediatrics, and ob-gyn, and surgery, …). These divisions have members who quickly focus on the diseases of that subspecialty and forsake their generalist training.
The power structure in academics exists either through NIH funding or bringing in "business" due to one's expertise in a specific disease. We have "product lines" in cancer, cardiology, liver disease, etc.
The focus on disease unfortunately can take the focus away from the patient and the process of care. The angiography example recalls the not funny joke that most non-cardiologists tell. What is the indication for coronary angiography? A groin (the catheterization starts in the femoral artery which is in the groin).
Those who focus on patient safety are considering the entire process of care, regardless of disease. They rarely receive grant moneys. They rarely get major publications. They merely work hard to prevent tragedies by understanding either tragedies or near misses.
I submit that our focus on disease (btw this is just as bad in community hospitals as in academic medical centers) leads to the culture that does not focus on the entirety of patient care.
I recently heard a story about a patient on multiple medications with multiple physicians who had altered medical status. One of the consultants insisted that his medications not be changed because he finally had the patient's disease under control.
Our job should focus on the patient and not the disease(s). If we focused on patients then we would all embrace safety. And we should.
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I live in the DC Metro area where the local subway system seems bent on destroying as much equipment as possible while also taking out employees and passengers.
Needless to say they’ve had an “audit.” The lead paragraph about the audit results was that the agency didn’t even have a “top 10 safety issues” list.
In support of your contention that blade-of-grass level views of system components leads systems to fail on the larger issues, I believe that a lack of system focus does contribute to safety laspes.
If everyone is focused on their tiny area, without even a clue as to what the overall risks are then safety is not a likely consideration.
How many health sector employees can rattle off the top ten safety issues in their workplace?
In support of your contention that blade-of-grass level views of system components leads systems to fail on the larger issues, I believe that a lack of system focus does contribute to safety laspes. There are many issues which should be care regarding the Patient’s care and safety.But the situation is changes, as the big hospital have different policies to affect the patient’s policies.If everyone is focused on their tiny area, without even a clue as to what the overall risks are then safety is not a likely consideration.
Have I told you lately that I love you?
It was be easy to come up with a punch line ribbing gastroenterologists like me to the inquiry, “What are the indications for a colonscopy’?”
We finally got my grandmother to a cardiologist after her second heart attack. She was willing to go see this doctor because she had met him once and he must be a good doctor since she had gone to school with his aunt. He looked at this frail 85yo who had no desire to try to live another 10 years, and who wouldn’t have survived the procedures necessary for that. He took her off most of the meds her GP had her on, which were doing very little except stressing her out because there were so many it was hard to for her to keep track of them. He also took her off the insanely restrictive (no salt, no fat) diet the GP had put her on after her first heart attack. His reasoning was that she probably only had 6 months or so to live, and she should be able to enjoy them. He didn’t treat her heart, he treated her.
We left the office saying, “He’s a good doctor”.
I don’t believe that the level of specialization correlates with focusing on disease while ignoring the patient. I’ve seen that happen with family practice and internal medicine physicians. Any physician can dehumanize patients; it’s just easier for subspecialists to do so.
The root cause of the problem is that our medical culture and training enables dehumanizing behaviors to thrive. These behaviors take root during medical school and usually worsen during residency. When third-year medical students talk about the “cirrhotic liver in bed 408A”, you know that our system is broken.
I taught clinical pathology to students and residents for twenty years, and, because pathologists rarely see patients, it was especially hard to instill a sense that we should think about the patient rather than the lymphoblast count or the diabetic ketoacidosis. I was rarely successful; and I recently quit my part-time teaching position due to continual frustration with residents who did not want to improve.
I disagree- blaming the “medical culture” is vague, self-defeating, and misses the target. I do agree (emphatically) that the practice of medicine has become progressive less “human” over my 3 decades of practice. My opinion is that we are to blame only to the extent that we, as physicians, have allowed our profession to be taken over by non-physicians.
The “cirrhotic liver in 408C?” Try referring to that poor soul by her name where someone might overhear. You will be called on the carpet by the local HIPAA enforcer. Ever try not adding on the medication recommended by the latest “guidelines” for that disease? There’s an enforcer for that, too. If your judgment is that the patient is too frail to have an angioplasty or colonoscopy or whatever, or should not be prescribed yet another $10 per day medication, the onus is on you to justify your management to the legions of Quality Mongers, mostly burned out RNs and other assorted bureaucrats who never met a guideline, task force recommendation, or unthinking mandate that they did not like (more justification for their never get hands dirty, 9 to 5, jobs). They are the ones who process the incident reports. They might occasionally find a junior nurse to fry if there is a need to be seen doing something, but otherwise it’s time to convene a committee meeting and discuss and produce findings which are never seen again.
Ever been in a hospital on the day of a surprise JCAHO visit? The administrators literally run through the halls after the doctors, beseeching them to sign this chart or that document. That’s all that matters- I have never seen them running after a colleague asking him or her to make more accurate diagnoses, close incisions better, or prescribe with more care. We already do that.
Then there are the legions of malpractice lawyers. Nuff said. If a patient’s bad outcome is sufficiently juicy to them, they are all in. If the potential payout is not sufficient, they encourage their client to complain to the state medical board. They need to be seen protecting the public, and are all too happy to make the hapless practicing physician’s life miserable to justify their existence.
If the bill passes tomorrow, it’s all over for us as a profession, and the poor patients, including the “cirrhotic liver in 408C,” will look at this as the good old days, when medical care was better that the treatment you get at the post office, DMV, or at the TSA airport security.
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