The first principle of health care is to “first do no harm”. In the complex system that we live we seem to have forgotten to whom we are responsible. The duty of care and the equitable distribution of such has taken a back seat. The comfort of the staff is vital but their competence is far more important to our patients. Many seem to believe that our staff members being “nice” is the key to care. ThIs misguided notion is taking us into the weeds and missing the real problem in many institutions. Our real problem is competence and consistency. If the goal of our system is to provide consistent and dependable care we must first stand up for equity. The equity I mean is equity of care standard.
The care delivered varies wildly and the reason for such disparity is as varied. Fortunately many institutions have noticed the problem but their solutions seem worse than the problem. The government has stepped in because we have not consistent applied the care we know to be best. The government has used the same consumerist benchmark of satisfaction that is used in retail sales as a proxy for care delivered. This approach is sub-optimal at best. It is not likely to be the best measure. However, our opposition to these measures will not improve patient care. What we need to recognize is that patient satisfaction can be a good proxy if we work in a system where competence is priority number one.
Patient satisfaction is a complex fickle beast. We cannot practice from the point of providing a ‘satisfying’ experience. Our care should be directed at proving the best outcome to all. The only way to provide such care is if our systems are focused on designing best in class care systems and staffing such systems with competent staff. In recent years our systems has fallen into the sad and despairing state were we have lost focus on care and the competence of our staff. The misguided first basis focus on the social behaviour of the staff is driving the best out of the system and putting out patients at the mercy of the less competent, but ” nice”. If our purpose is best in class care and superior outcomes there is only one matrix that matters. We must provide our patients with the best trained staff. Our efforts must be evidence bases and physician driven.
There is a curse that inhabits the American work place. We have become slaves to profitability and not to best outcomes. The primacy of profits has led us to misunderstand the nature of work and the importance of worker satisfaction. Making ever-increasing profits is the goal but how we get there makes a difference. Some employers have lost their focus. Sustained profitability is about worker satisfaction. In many fields lip service is paid to the worker, while they are trapped under inhumane work conditions. Fortunately work conditions in the developed world are better than they were. However, we still have a way to go before we can claim victory over poor working conditions. The severity of the impact of poor conditions is dependent on your industry. In health care the impact can be life threatening.
Our culture for too long as valued hard work over smart work. We seem to believe that the worker that workers longer hours is more noble and deserving of praise. This misplaced praise has led to continued poor choices and has led to the misery and burn out of the American middle class. The depth of the problem continues to go unnoticed and unacknowledged. Poor outcomes continue to be placed at the feet of poor training and individuals are blamed. I too have a tendency to blame the individual. The truth is that sometimes the individual is to be blamed, but we too often neglect to evaluated the conditions under which mistakes are made. The systems under which most of us work are archaic, inefficient and are undermining our ability to be the best we can be.
I will be attacked for my stand but the truth needs be told. I love my work because it gives me the opportunity to help my fellow humans at a time when they are most in need. From my limited experience that help is best delivered when I am well rested. Some may consider me weak for insisting that adequate rest is required for best productivity and patient safety. I, however, would rather follow the evidence that suggests that efficiency and safety are best attained with a well rested and optimally trained work force. The conditions of many operating rooms where staff can work full daytime shift and take overnight call then work a full day shift is putting our patients at risk.
The unfortunate problem is that when a staff member makes a mistake that harms a patient she alone is blamed. The idea that she needs to take personal responsibility for her mistake is commendable , but essentially is a cop-out. Her bosses are just as culpable, because they have put in place a system that does not allow her to work at her best. The continued scapegoating of individuals is a sickness in our system that needs to be driven into the grave. Our success is dependent on the balance and efficiency of the systems we construct. Spending money on technology is commendable and necessary but alone will not improve patient outcomes.
Better pay is a great place to start, but is a poor quality band-aid when one works under mentally oppressive conditions. Improving the system starts by focusing on the best assets of the system. Our human capital is our best asset and must be treated as such. We are not robots, we are better. We may not be able to work as long hours and we get bored easily; but until robots can think intuitively and problem solve on the fly we will continue to be the best part of the workflow equation. Functioning at maximum efficiency must be out foremost goal. For humans to be focused and efficient we must have adequate rest and distraction. If we would focus on those areas many of our problems would be resolved without the need for expensive investments in equipment.
Let us invest in our best and most productive assets, our people.
Life expectancy in the USA as of the most recent data is 78.61 years. Along with longer life span we have a every increasing number of surgery. With out-patient surgery rapidly growing year over year. The population over 65 years are living a more active life still and are requiring more surgical intervention. Our peri operative technologies have improved to allow us to provide safer care to those at the extremes expectancy range. WIth this improvement and comes many additional questions. The question of post op delirium continues to be a problem and will increase as the populations ages and more surgical procedures are available.
How the older patient is cared for in the peri operative time frame is and will continue to be of special concern to themselves, families and increasingly to payors. The process of getting from diagnosis to the surgical suite is basically divide in 2 routes, either via he emergency room or the physician office. The peri operative preparation is as import as the intra operative care and involves many, however as an Anesthesiologist i will present the process from my vantage point.
The care of any patient starts with the basics, taking a good history. For all patients under the care of an anesthesia provider taking a focused and directed history is vital to the safe delivery of appropriate care. For the older patient extra attentions should be placed on history of delirium in the post operative period which i would suggest should be considered to include the first 24 hours post PACU discharge. Other vital components to evaluate include vision impairment and hearing loss. For the visually impair consider how soon after arrival in PACU to return glasses. For the hearing impaired do they use hearing aids, can they be left in for the procedure. Does the patient lip read. Even for those that do on lip read, looking directly at them, speaking clearly with proper enunciation without shouting works very well to transmitted data.
Carefully look over medications for hints to treatment for early dementia. Ask about early dementia. What happened after last surgery. Who will be present in the post operative period?
There is no clear evidence that anesthesia specifically is the cause of post operative delirium. The choice of anesthesia should be based on what intervention will provide for the safest working conditions and facilitate a rapid low pain recovery. For those with dementia the suggestion that regional alone maybe advantageous is not as clear to me as it maybe to others. From my experience regional as the sole anesthetic in a demented even for very minor procedures will be a challenge because of the lack of circumstantial awareness from the patient. The lack of awareness can and often leads to lost of cooperation and increased risk of morbidity to the patient. The primary anesthetic must provide the appropriate working conditions firstly. The demented patient like all patient must first be in optimal surgical condition. General anesthesia is often the most optimal choice. General anesthesia is not one thing but many varied combination of drugs and this is where the judgement of the anesthesia provider can be very helpful. From my vantage point the goal is to provide the most advantageous conditions using the lowest dose of the fewest drugs required. A monitor that was dependable in the judgement of anesthetic depth would be of great utility in the older patient. The BIS monitor is claimed by some to be such a monitor, but many others find it inconsistent and unreliable. I have not seen any evidence that convinces me that it provides and advantage. It may provide some advantage but that advantage is not clear to me. The traditional monitoring of anesthetic depth includes observation of changes in vitals and direct observation of the patient may be insufficient to guarantee adequate depth but is still the best we have. A vigilant provider is still the best monitor. I hope that one day soon we will have an even better monitor. Without that monitor the provider needs to be conscious to balance depth with risks of post operative delirium. The drugs that we use to maintain anesthesia are important potential risk point and one area that is especially concerning are the anticholinesterases. These drugs are used as apart of the cocktail for reversal of paralysis and can cause delirium and should be used with caution. The optimal situation would be to not need them, meaning if necessary we should avoid paralysis. However, if paralysis is needed full reversal should be used because incomplete reversal could make the post operative situation worse. Additionally making sure all our anesthetic if below therapeutic levels before going to the PACU is beneficial.
Once the optimal condition for surgery have been meet and the anesthetic is optimized to decrease the risk of post operative delirium the patient needs to be cared for in a PACU that continues to optimize recovery. The environment needs to the at an appropriate temperature with appropriate lighting and quiet. Use the minimum required monitors to get the job done. The nurse in the PACU is a vital partner, she needs to orient the patient to date time and location. Orient, orient and orient again. Assurance of adequate hydration, pain control, empty bladder, treatment of nausea if present, prevent hypoxia are all vital. If delirium occurs, low dose benzodiazepine and family at bedside should be considered. The use of regional anesthesia is a great tool to assist the post operative period. I find the most utility of regional in the patient with dementia or at risk of delirium is in its ability to provide significant long-lasting pain control that decreases the amount of opioids needed in the recovery period.
Special attention to the needs of the older patient at risk for post operative delirium is a worthy goal. However, we must not be lead from first principles. We must provide a safe environment for the procedure. With careful planning and attention to detail we may be able to decrease the risks, but we should not lose site of the facts. Fundamentally, there is no good evidence that the type of anesthetic correlates with risk of post operative delirium. The only consistent fact is that the patient has had surgery. Teasing out the specific component of the peri operative environment that increases risk is still some way off. What anesthesia providers need to provide safe conditions that decrease risks based on the evidence we have.
I have loved health care for as long as I can remember. I cannot imagine doing anything but providing care . What I have learned in the trenches is that the love of providing care is not enough. Over time i have realized that a fundamental problem with health care is not in the expensive of it but in the nature of the people in it. We want to provide care, but we bring into the system our biases. Those biases allow for less attention to be paid to some patients because of their language or skin color. We may say that we provide the same care to all patients, but as a black physician I see otherwise. My experience of the system at institutions where I am not known by members of staff is vastly different. The consequence of this uneven care is a system where those that can afford care and are the correction completion receive care that is more compassionate and timely.
How do we overcome the inherent bias in the system? The answer is not more training nor necessarily more diversity. The answer will be in the wide-spread use of evidence based payment structures. Our medical systems are complicated and expensive but are systems in name only. We have a complex string of components. All the parts are mostly well-trained and competent. However the results we obtain are not commensurate with the level of training nor the level of expense. The incongruity of expense and quality of results continues because those attempting to improve the system have not acknowledged or do not recognize the biases of the system. The gap in quality of outcome is most obvious in communities of color. The often given excuses are truly just that. Recognizing that there is a problem is the first step to a solution.
Paying for quality work is the only avenue to improved results. The question as to how we get better care for all patients is simple and complicated, but we have a great example in the aviation sector. My brother is an airline pilot and his training is extremity rigorous, but he starts his day with a checklist. He does not feel that his autonomy is being challenged, but that he is making sure that he does not kill himself. We in health care do not have any real skin in the game. Until the decision makers have some skin in the game we will not embrace what is necessary to make our constellation of components into a functioning system. Let us start delivering quality care by implementing checklists. Checklists are reminders of the quality in our options. The checklist is not for you it is for your parents and friends. That checklist is not for you, it is for that provider that is on her sixth surgery of the day. It is a nudge because she is tired. A checklist is for every one of us. It helps us by removing silly mistakes from our systems. For me the checklist is my hope that I will be treated like a patient deserving of care on the off-chance that I am a patient in a strange place where all that can be seen is the color of my skin.
The current rise in measles cases is a direct result of poor vaccination coverage. The current and pass trend in not vaccinating children is dishearten and threatens public health. How did we get from measles being almost completely eradicated to the highest numbers in decades? I want to suggest that this is emblematic of the poor scientific education of American society. We have allowed the principles and fundamental laws of nature to be undermined in the public discussion of societal problems.
The pervasive acceptance of the creation myth and the almost complete rejection of the pursuit of scientific knowledge is at the root of the resurgence. The lack of understanding and rejection of the scientific method has led to a population that questions everything without the requisite background information. Questions are healthy only when the questioner has a grasp of the context of the questions. We have lost our ability to objectively analyse the facts. The is not because the population is less intelligent that prior generations, but because we have had a 30 year campaign to undermine the foundations of scientific thinking. Scientific facts and precepts are attacked for economic reasons. The concerted and coordinated attacks have led to a wide-spread loss of societal scientific identity. We have lost our understanding of our place in the earth’s ecology. Instead of seeing our species as apart of the larger ecological system we have deluded ourselves into the belief that we are superior.
Many are under the miss-guided idea that creationism is an equal theory to evolution. This as lead to loss of understanding of the biology of life. Without a grasp of the facts of evolution an understanding of biologic life is not to be expected. The current concepts of biologic life are based on evolution and its essential component natural selection. Without a working understanding the general population is susceptible to the quacks that propagate the anti-science garbage that masquerade as alternative “scientific” theories. These vessels of idiocy need to be marginalized. They are the most dangerous threat to our society. Humanity will not be killed by global war or a rock from space. Humanity will be destroyed if we do not accept scientific facts and methods in our approach to the ecological system. Science is the only route to understanding the physical world. We are a small part of a larger ecosystem. We are not essential to this system. If we do not understand that fact we will join the many other dead ends of evolution on our home planet.
Our ability to educate our people will determine over survival as a species. Let us drive the anti-science crowd from the places of power and consign them to the waste-bin of history.
The curious nature of the American electorate once again fascinates me. The ongoing discussion of health care coverage and delivery is schizophrenic at best. The most recent pools show a population in need of health care coverage but the same group most highly skeptical of the most recent attempt to improve their ability to access coverage. Furthermore those who are most in need, and treated the most poorly by the current system are still willing to hold onto the failed system. It is unfortunate but the same the tactics developed and used by the cigarette industry to convince us that cigarettes are safe are being used to undermine the ACA. Many are against the ACA without investigating the potential benefits.
The cable talking heads have succeeded beyond their wildest dreams. They have so muddled the facts that it seems no one has a grasp of the services that will be improved. The problem with that assumption is that it is far from being a fact. The data are there if we as consumers would only look beyond the imbeciles on cable T.V. The problem is that our attention is firmly planted on the imperfections and not the goals. We are not being true to the fundamentals of American cultural strength, the belief that we can do it if we want to. I can only suggest that the opponents do not want Americans to succeed. The success of American Corporates is not the same as the success of Americans.
The intellectual dishonesty of the talking heads and those in charge of the news media is disheartening. They have no regard for the uninsured. The consequence is that the people who need help the most have been convinced that there is no help to be had. The truth is not deceptive nor is it hidden. The ACA is good for Americans. The ACA aka Obama Care is good for American business and will be a success. Success will not be achieved overnight, but will be a long hard fight. The fight is against those who do not believe that government has any part to play in the delivery of services and those who do. The battle is against the deceitful. The battle is against the business lobby. The battle is primarily against the ignorance that parades in fine suits on 24 hour cable T.V.
Those of us objectively looking on need to not only look but need to shout down the liars and the dishonest. How do we inform those that need the information the most? I would suggest a grassroots election style campaign. We need to start by informing ourselves. Each of us needs to study the benefits and pitfalls of the law. Without in dept knowledge we cannot be effective advocates. Go advocate, it is our moral duty.
I am impatient and stubborn and I am working on it. Well, not really. I like being stubborn more that I like being impatient. In spite of that, I like being both. Both traits may seem to be negatives, but they are only negative if the full breath of human endeavor is not evaluated. My primary impatience is with how little respect many of us have for other people’s time. I hate waiting so I stopped using bank tellers in the late 90’s. Internet banking then was slow but still better than standing in a line.
I always opt to do it myself. It has to be done right the first time so no time is lost. I am not a master of all. I know when to call for help.
The people who work closely with me know I have an opinion on most topics and that I am sure that my way is correct. Truth is I am not always correct, but I am willing to do the work to ensure I am correct. I am accepting the stubbornness label because I have been labeled as such. I don’t really think that I am stubborn. I just know that I am right and I will defend my stance even if I am the only person that holds that position. I have done the work, have you. That’s my view, take it or leave.
One of the weaknesses of these two traits is that I don’t delegate well. I chose to become an Anesthesiologist so I would not have to delegate. I am a doer. The general direction of medicine makes delegation a larger and larger part of the practice. I am not sure what are the benefits, except for potential financial rewards. I would love to think it provides improved quality of care. However, that is questionable. Superior quality of care is provided by better trained providers. I am going to keep on being impatient and stubborn because it’s the only way to deliver a high level of care. Do you have a different answer?
The current consternation in our country about the provision of health insurance for the entire population is somewhat baffling. The selfishness that says that ones lack of insurance is always your fault is truly inhumane. Maybe I am the selfish one because I want to get paid for my services. The dilemma we have is that most of us don’t understand the care delivery system and more problematic is that we don’t understand the concept of insurance. Neither is easy to explain in our 30-second 24-hour news cycle. The paradox of not wanting to spend hundreds of dollars to save hundreds of thousands is lost on the general population. More precisely, ‘a penny of prevention is worth a pound of cure’. It seems that the few that understand either gain from the broken system or are powerless to change it.
The conditions that lead to lack of insurance are varied and are sometimes self-inflicted. In spite of this, it is our responsibility to care for each other. After my last weekend on call I have come to the conclusion that access to health care including insurance is a basic human right. Some may disagree, but I say you are 100 percent wrong. My other conclusion is that I am not the selfish one. Sadly, that leaves you. Yes, I know I have no right, but I have seen too much to disregard the obvious and pervasive selfishness and disregard shown to the weakest among us. We claim equality for all but are quick to disregard the suffering of others so we can continue to consume more than we need. The obesity epidemic is the prime example. We buy more, consume more and throw out more food than we need many times over. At the same time we claim concern for the hungry. We however are oblivious to our own part in their deprivation. We, and that includes me, don’t really care about the others. We want to be seen to care without putting in the work.
For those that are now labeling me ‘one of those liberals’. Yes I am a proud Liberal. Yes I am a proud Capitalist. Yes I am a proud Libertarian. Yes selfishness is good, but greed is not. The selfishness of Capitalism looks to preserve individual advantage and caring for the weak is a part of that process. The problem is that most people are not informed enough to even look out for their own advantage. The low information citizen is easily manipulated into thoughts and actions that are not in their interest. The sadness I feel is enough to make me not care, but the truth is that some of us are not capable of not caring. We are the ones attempting to keep society balanced. Sadly in spite of the obvious we are still convinced that the majority of the population is caring and empathetic. I beg respectfully to disagree. Few people are truly heroic and even fewer are willing to tell the truth when they are the only ones who believe it. This is where we are. Our selfishness is self-centered, poorly directed and lacking in insight. This lack of insight will be the death of us all as a species.
What will we leave behind when evolution no longer has any use for our poor survival instincts? Are you planning on making a change this year?