Thursday, November 17, 2011

What is your physician's medical batting average?

TEDxToronto - Dr. Brian Goldman - Redefining the Practice of Medicine 
He admits his mistakes, speaks truth to power. A respected medical journalist for CBC Radio, and Emergency Room (ER) Physician in Toronto's Mount Sinai.
This physician is an amazing person. If anyone can improve the healthcare system in this province, in this country, it is Toronto, Ontario, Canada's Dr. Brian.

His premise?
We need an environment that supports the admission of error, the correction of those errors, and a redefined medical culture, starting with one physician at a time.

*Dr. Brian admitted to several mistakes he made in his ER. And he tells us that they were not made in his first five years of practice, but spread out over his many years as an ER physician and a medical journalist.

Have you ever been in an ER?
The kids singing at the top of his lungs, the people coughing into face masks, the contractors holding a bleeding arm/hand up in the arm, while blood drips down to the ground. In inner city situations, I cannot fathom how patients can sit there watching the walking wounded file in.

I feel that an ER physician is a very different specialty than others. They must juggle the sublime, to the severe. From stitch that needs removal, to undiagnosed congestive heart failure, epiglotitis, appendicitis, many are faced in this same ER. All this faced with patients sitting watching their watches, pain, blood, children crying. Then comes the follow-up treatment plan, the medications, and a home care plan. Difficult to do when there is a 4-hour wait. This, too, is something best done by a GP, family physician, over time.

There are three ways, Dr. Brian says, in which ER physicians can show their measure as an ER doctor:
  • those who who make mistakes and those who cannot
  • those who can handle sleep deprivation and those who cannot
  • those who can handle failure and those who cannot.
Alone, ashamed and unsupported, a physician toils in the ER and may use addictions, and cover-ups to deal with the pain of failure, sleep deprivation and making mistakes.

In his 20 years of medical broadcasting, he has learned that errors are absolutely ubiquitous.
Errors in prescriptions of 1/10, hospital-acquired infections abound.
In Canada, this medical journalist tells us, something like 24,000 die of medical errors every day.

If you weed out error-prone healthcare professionals, there won't be any left, especially in the busy ER. We must improve patient safety by addressing the mistakes, working as a medical team where each member feels free to call up one another before a mistake is made, at the time. This, according to The Emergency Room Nurse, is something physicians have a hard time accepting.
Read 'When Nurses Write About Physician Bullies, Don't Shoot the Messenger'
These are the bullies, we've all faced them in the workplace. The people who have such a need for power that can can discount a wise nurse who speaks out in truth.

Now, my point is, that while some conditions present themselves, in an emergency situation, many issues can be prevented, and diagnosed before they become serious. If you wait until you are in such pain that you are in agony, the ER is a difficult place in which to sit. If we all had access to a physician, which isn't the scope of this post, we would have less-crowded rooms.

Dr. Brian feels that physicians who make mistakes sit alone, ashamed and unsupported.
The difference in Dr. Brian's practice, and other's, seems to be his statement, "I asked my colleague to reassess this patient." In these cases, mistakes were prevented by collaboration and consultation.
THIS is what will improve healthcare.

He talks about his mistakes, finds the still small voice that makes learning happen, and creates a climate where all those on the healthcare team can and must participate in patient care.

Healthcare practices in Canada Influenced by the USA's for-profit system
The system that we have completely denies mistakes. I have written previously that I believe I know where this culture of denial comes from. It is the US-based system of medical practice in which insurance companies cannot accept mistakes, where pre-existing conditions are denied medical reimbursement, and the terribly litigious world of US healthcare. Where US hospitals are rewarded financially, "Hospitals with best patient satisfaction to draw in reimbursements."
US healthcare where,

Blacks and Medicaid Patients at Higher Risk of Losing Their ERs in California

The US healthcare system is a for-profit system, although revamped, in which patients must sue in order to gain compensation, and reimbursement of the vast sums of money required to seek redress, therapy, and beds in long-term care, support from rehabilitation centres. In Canada, a sense of closure seems to arise when patients sue a doctor for malpractice, for incompetence. (CTV News - Brain-damaged boy's family sues health officials)

Mistakes or Incompetence
Fortunately, there is a difference between mistakes and incompetence. When we know better we do better. Truly, the College of Physicians and Surgeons must determine this difference and create learning opportunities for those who make mistakes, and curtail the practices of incompetent physicians. I reported my father's doctor to the College. I tried for nearly a week to get adequate pain management for my late father. This GP, attached to the LTC, was unreachable, and the Charge Nurse, whose job it was to make a call to him for morphine, told me to contact the doctor myself as he wasn't responding to them. The follow-up by the College was fabulous. I felt closure, and that lessons were learned.

System Errors
Not ferreting out the problems as we should.
Admitting the difference between a mistake or error, and incompetence. (Such as the incompetent pathologist, Charles Smith.)
In a hospital system where medical knowledge doubles every two years, it is impossible to know everything.
Failing to create a culture of collaboration for ALL STAKEHOLDERS, as well as inclusion of those who directly serve the patient (patient, doctor, nurse, family, hospital, caregivers).

 Human Errors
Sleep deprivation is a given, you must be able to cope.
Inability to deal with stress.
Cognitive biases during diagnosis in the ER; alcohol on the patient's breath, gender and socioeconomic biases, all serve to confound an accurate ER diagnosis.

My cyberfriend, an ER Charge Nurse says,

How a Resident Views Nurses at Triage

Yet I have to say, in my experience, the attitude that MDs must micromanage every element of patient care is slowly disappearing among physicians. Occasionally you get one who appears to have slept through the lectures on collaborative practice and the critical role of nursing on the health care team, but this is increasingly rare.

Framing the Discussion Around What’s Best for the Patient

These are the Charge Nurses who fight with, for or against a doctor or colleague for better treatment of those who are weak, vulnerable and at-risk.
These are the PSWs who work to provide care, who can speak of their residents issues without fear of censure by the nurses who may deride them for their ignorance.

It is the wise professional, nay, cancel that, it is the wise person who can admit a mistake, make reparation for it, and promise to do better, get retraining, therapy, help, and support.

Medical malpractice is based on crime, punishment, prevention and deterrence. The theory is that without patients suing doctors, they won't be inclined to improve their practice. According to opinion surveys of physicians, the system creates incentives to undertake cost-ineffective treatments based on fear of legal liability—to practice “defensive medicine” (Harris Interactive, 2002). 
The best professional strives, by promising to remember, to learn one thing from what happened that s/he can teach to someone else, in a loving, supportive way.

Defensive medicine can take two forms: positive and negative. Positive defensive medicine involves supplying care that is unproductive, not cost effective, or even harmful. Negative defensive medicine involves declining to supply care that could be beneficial; it also includes physicians deciding to exit the profession altogether.
Positive defensive medicine is driven by moral hazard from health insurance, which means that neither patients nor physicians bear most of the costs of care in any particular case. Negative defensive medicine is driven by two facts: that patients reap substantial surplus from medical care for which they cannot adequately compensate providers, and providers bear malpractice risk for which they cannot fully charge patients. 

We need to receive care in a culture of medicine that accepts that individuals make mistakes. For victims to be awarded millions of taxpayer dollars costs the Canadian system much. Prevention is much less expensive.
We need back-ups to catch mistakes, and must fosters places where all participants can call up and prevent mistakes, and honour those who speak truth to power.
Strive to learn one thing to pass on to other people.
I do remember...

Dr. Brian's video runs 19:37, but it is well-worth the viewing.

*Dr. Brian, and while we've broken bread together, and he interviewed me in my home, I use this designation with the dignity and respect he deserves, not that which he demands.

THIS  is incompetence

4 Hep C cases found after Ottawa clinic scare
Four former patients of a doctor accused of lax infection prevention practices have tested positive for hepatitis C after receiving a letter telling them to get tested, says the law firm heading a class-action suit against the doctor. more »

Health officials and the Ontario College of Physicians and Surgeons found that Farazli had lax procedures for disinfecting gastroscopy and colonoscopy equipment over a nine-year period from April 2002 to June 2011.

This is a mistake: 
The statement of claim alleges there was a surgical complication, as well as a complication with the anaesthetic because of Dylan's weight. The boy is about 5' 6" and weighs about 250 pounds.

Read more:
The family of a 12-year-old Manitoba boy who suffered severe brain damage, allegedly the result of a routine tonsillectomy, has filed a lawsuit against doctors, nurses and the Winnipeg Regional Health Authority.

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