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Monday, May 14, 2012

Supporting Simpler Medical Care - Gawande Calls for a New Kind of Doctor? (What Does He Mean by "New"?)

"(Dr. Atul) Gawande has found reason to question the assumption that the most expensive care must be the best care. "What we're discovering is that the best care, the places getting the best results, are often among the least expensive," he said. In those places, doctors and nurses providing care function like teams."

I'm dating my "nursing-self" but recall when "operating room nurses" used checklists to be sure surgeons didn't leave instruments or sponges inside patients while they sutured!  Believe it or not, surgeons typically began sutures before the nurses finished the checklist!  Yup, you got it, patients were re-opened without their knowledge to find a clamp or sponge not counted in the checklist.  Although these incidents were rare, they happened often enough for me to report them in this blog.  Even one incident where a surgical utensil was left inside a sutured patient was (is) more than enough.

Lesson learned, reducing the incidence of surgical errors and post operative infections are directly correlated to how diligent surgeons are to counting utensils.  Does this preventive count bring down the cost of health care?  Yes.

Indeed, Atul Gawande writes about how the best care is often the least expensive.  This certainly isn't new information but it takes a physician of Gawande's respect and stature as a surgeon to succinctly communicate this message to his professional colleagues and, thereby, to the public.  Yet,  Hungarian physician Ignas Semmelweis (1818-1865) was largely ignored when he tried to convince his peers about the infection preventing technique of hand washing.

Physicians cringe when they're reminded how midwives figured out how to reduce the incidence and mortality of postpartum women who died of puerperal infections during the 18th and 19th century. Midwives routinely washed their hands between deliveries, thereby reducing the incidence of transference of deadly bacteria from one woman to another.  Physicians didn't believe in hand washing  until it was proven women who birthed with midwives didn't die as often from infection as those who delivered their babies in hospitals with physicians attending - specifically, physicians who didn't wash their hands.  Semmelweis identified the preventive procedure of hand washing as being associated with reduced infection rates, but his conclusions were largely ignored by his peers.

Did hand washing improve the outcomes of obstetrical procedures while bringing down the cost of care?  Yes.

Gawande is calling for a new way to improve clinical outcomes while reducing the cost of quality care.  He calls for medical professionals to work as teams rather than alone.  Although most patients consider their physicians to be the primary source of all their health needs, the fact is, no one physician knows everything there is about anybody or condition.

If two physicians and one nurse work together to develop a care plan based on a check list of priorities  identified for particular illnesses or procedures, the rate of error would certainly go down.

Let's look at airplane pilots, for example.  Even the smallest commercial airliner in the US has a pilot and co-pilot - and they use checklists, too!

Paying for two airplane pilots brings down the risk of pilot error, thus reducing the human costs of deadly accidents.

A medical team of providers, likewise, would have the same result.  Consider the patient's body to be an airliner - seated inside are hundreds of systems needing care because no single illness or injury is isolated to just one organ.  Indeed, an injury to a bone also interferes with muscles.  An infection in the skin will change blood white cell counts.  So, if a human body is as complex as a commercial airliner, then we need more than one pilot to navigate us through chronic illness, injury and diseases.

When I worked as an administrator for emergency medical services, we reduced pre-hospital errors by implementing protocols for all common procedures.  At the time, the emergency medical services providers called it "cook book EMS", but it worked to improve patient outcomes.  In other words, more people lived to receive medical care in a hospital rather than needing resuscitation.  We measured this with quality improvement data taken from pre-hospital run sheets tracked over time.

Obviously, as a nurse, I applaud Dr. Gawande's work educating his peers about improving medical practice.  His vision of a "new" way to practice medicine is rooted in the tradition and oath: "First Do No Harm".

I'm reasonably sure Dr. Gawande appreciates a nurses point of view on his good work!

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