Certainly many procedures, tests and prescriptions
are based on legitimate need. But many are not.... This kind of treatment is a form of
defensive medicine, meant less to protect the patient than to protect
the doctor or hospital against potential lawsuits.
Herein lies a stunning irony. Defensive medicine is rooted in the goal
of avoiding mistakes. But each additional procedure or test, no matter
how cautiously performed, injects a fresh possibility of error.
With a quick aside in admiration of Peter Pronovost's approach to harm reduction and some other process improvements, he then says:
What may be even more important is remembering the limits of our power.
More — more procedures, more testing, more treatment — is not always
better.
And then, remarkably, he presents M&M conferences as a remedy:
One place where I have seen these issues addressed is in Morbidity and
Mortality, or M and M — a weekly gathering of doctors, off limits to the
public, which serves in most hospitals as a forum for the discussion of
mistakes, complications, deaths and unusual cases. It is a sort of
quality-assurance conference where doctors hold one another accountable
and learn from one another’s mistakes. They are some of the most candid
and indelible meetings I have ever attended.
Having a consistent gathering to talk about the mistakes goes a long way
toward that goal, and just about any institution, public or private,
could benefit from a tradition like M and M.
OMG. Dr. Gupta has inadvertently given us a wonderful exposition about a lack of understanding of the nature of quality and safety process improvement in hospitals. Most harm is not caused by a doctor making an error of commission, i.e., an extra test or an unnecessarily executed procedure. The number of reported adverse events from such instances is dwarfed by other forms of harm -- hospital acquired infections, falls, failure to rescue, pre-39 week induced labor. Many of these are not even reportable as harm.
Dr. Gupta's presentation reflects no knowledge about the science of process improvement. Peter Pronovost's check list is not just a good idea. Brent James' introduction of clinical protocols is not just a good idea. These are approaches that introduce the use of the scientific method into the clinical setting. In contrast, M&M conferences are essentially anecdotal reviews of an incredibly small number of adverse events. I would not understate their importance as teaching tools (when they are conducted in a pedagogically appropriate manner), but they do not deal with systemic problems, with near misses, with the manner in which communication fails.
As Lucien Leape and others have stated, and as Dr. Gupta makes clear in a way he certainly did not intend, the medical profession needs to have dramatically improved training in the science of process improvement as part of the undergraduate and graduate medical education curricula.
Very, very much on target.
ReplyDeleteYou are so RIGHT!! He serves those in the insurance who want to keep charging but not spending --obviously, all will be available to the Haves who think like Gupta.
ReplyDeleteI had read that essay yesterday and had EXACTLY the same reaction as you.
ReplyDeleteNot only are M and M conferences everything you say, but many hospitals are dropping them, and most of the time they do not result in anything but recriminations rather than systemic change.
But beyond that, to have them be the only solution he offers to the MASSIVE dimensions of the problem was just plain bewildering.
The M&M (as it still is done in many places) is an old boys club that loves to finger point especially at other services or departments. I remember one case at my hospital where surgery at their M&M blamed anesthesia, anesthesia blamed internal medicine, and internal medicine blamed surgery at their M&M. The only group who saw it correctly was nursing who blamed all three services because each could have done better.
ReplyDeleteAnother aspect of Dr. Gupta's solution is that it largely only addresses errors of commission - that is, things done when they should not have been done. As has been shown by many investigators (including Kahneman and Tversky), we as humans value losses more than gains. Because of this we are more apt to see the harm arising from our actions and miss the harm from our inactions - be it beta blockers in AMI or handwashing. The dramatic, uncommon, possibly unpredictable events as articulated in M&Ms drain our attention and create a huge opportunity cost for recreating care delivery that would benefit many more people.
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ReplyDeleteAgreed. While Dr. Gupta brings light to an important issue, the solution he offers is severely lacking as seen by years of M&M conferences.
I'm wondering (and not snarkily) if the underlying issue here is that part of our medical culture, at least in the US (I don't know about elsewhere), is the unwitting assumption that medicine is not like other sciences - somehow above science - so that there's no need to look elsewhere for useful methods.
ReplyDeleteThat would be ironic because of course the same people talk about science and the scientific method, and disparage those who they believe aren't good at science.
Again, I don't mean that in an insulting way: I'm really looking for objective insights. I mean, you gotta be academically strong to become an MD - so what's the disconnect? It's gotta be a cultural malfunction, because nothing but culture resists change so firmly.
Patients are told to report medical device adverse events to the FDA which approves most implanted devices without clinical testing, no warranty, no post market national registry, no voting patient representation on advisory panels and no judicial patient protections to counteract federal judicial entitlements by the medical device industry. Surgeons seem tone-deaf to patient concerns or are defensive when it is clear that an implanted device fails(metal on metal hips, surgical mesh, ICD leads). The system is a failure.
ReplyDeleteI think that the main problem is that there's an assumption that we are perfect until we fail - and that failure is evidence that we will fail again.
ReplyDeletePracticing medicine requires trust - trust that your images are from the right patient, trust that the meds you're giving are correct, trust that the lab result is from your patient and not some other person. When that trust is compromised, most people lose faith in a person permanently. This extends to departments as well - it only takes one or two mistakes in lab results before providers become very suspicious of the lab (despite the fact that millions of tests are done correctly each year). Ironically, Dr. Gupta's article has the same "just trust me, we've got it handled" language that is used to instill trust in patients.
The change in thinking that needs to happen is in looking at mistakes as system problems. It's also important to recognize that anyone could make a mistake. An M&M that allowed for a real evaluation of an event and called for systems change would go a long way toward accomplishing this goal. But from what I'm hearing here, that's not what those are about.
I do agree that M&M is not the best venue to make system-wide safety changes, but it provides insight into complications, some of which result from the actions/inactions of individuals, and others due to a system problem.
ReplyDeleteSurgical M&M was historically to put trainees under the microscope, to underscore the type of responsibility involved when one operates on other people.
M&M can devolve into a less valuable experience as described above. But when done right, it is an important venue for continued learning and improving outcomes. Complications can be debated and dissected, and new protocols adopted to prevent similar future outcomes. With the current trends toward diluted residency experiences and more care provided by non-physicians, we should strive to maintain high-quality M&M conferences.