16 August 2010

Involving patients in checklists

Since graduation season in June I've noticed links to commencement address transcripts (e.g. Jeff Bezos's brief but heartwarming address to the Princeton Baccalaureate, synopsis: 'OK, be clever, but also be kind, have a little humility').

On a different scale (but, actually, a related topic as, I suppose, all such addresses must be), Atul Gawande's address to Stanford medicine graduates considers the knowledge demands and ethical dilemmas doctors now face. He puts the increasing complexity of current medical decision-making  into context:

When penicillin was discovered, in 1929, it suggested that treatment of disease could be simple—an injection that could miraculously cure a breathtaking range of infectious diseases. Maybe there’d be an injection for cancer and another one for heart disease. It made us believe that discovery was the only hard part. Execution would be easy.

To emphasise the difficulty of execution he cites examples of a medical procedure being overlooked in complex cases (administration of antibacterial vaccines after splenectomy), with dire consequences for patients. These are cases (and he alludes to others) where patients have complex conditions that are handled across different medical teams. So I suppose it is likely that the checklist approach that appears to reduce error in decision-making would be difficult to apply here. But, actually, Gawande has also written positively (in 2007) about the potential of checklists, for which he interviewed Peter Pronovost, who initiated their use in medical settings. Pronovost's comments reflect Gawande's train of thought at Stanford:

The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.

There's another resource here, too, the neglect of which might also be described as outrageous: the patient (if capable) or their family, the people who know the patient best and care about them most as a whole person, rather than a collection of medical problems. I'm not saying doctors don't care, and don't consult families but that families are not drawn on as a support to reduce medical error. There are shining examples of patient and family involvement in medical care, especially in non-acute settings such as childbirth, treatment of chronic illnesses etc. But if they had the right kind of empowerment and information, patients and their families, could also prevent omissions and error in acute settings.Medical dramas frequently portray interfering families who have to be rebuffed by inspired physicians who must make critical decisions that, in the end, win the day. That stereotype comes from somewhere.
My own limited experience, for example, has been that it's worthwhile checking a radiographer knows which side of your body they should be x-raying (there are worse stories, real, not apocryphal, of surgery carried out on the wrong side), that doctors are looking at your x-ray and not that of someone who shares your name, that doctors really have checked through any contra-indications of any drugs they might prescribe. I'm sure many people have similar errors or near-errors to report. In the power relations, even of a non-critical medical context, these can still be difficult things for a patient to feel comfortable about checking (although there's some encouragement to do so here). How much more pressure there is to assume (and, indeed, hope) the doctors haven't missed any details when things get critical: these are clinical procedures, the experts' exclusive domain...

...unless checklists become an open tool for communicating beyond the professional team and (back to Bezos) there's humility enough to embrace them.

[Bezos address via John Naughton]

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