The FAA responded to a number of high profile aviation accidents by making a series of important changes in the cockpit. Their studies revealed that some mistakes happened because subordinates were too afraid to question the captain. After these changes, the captain was still left firmly in command but a new environment was created where subordinates felt (more) comfortable to voice any questions or concerns.
A similar thing needs to happen in medicine. Doctors walk around like gods in the hospital but they are still human and make mistakes. The problem is that everyone is too afraid to correct the doctors when they make obvious mistakes. Don't get me wrong---the doctors must remain in charge, but they will still goof up so people need to feel free to offer advice and criticism.
And it'd be nice if they treated their patients with some respect and as if they had a functioning brain instead of as objects. Obviously this does not apply to all doctors but this happens with alarming regularity.
How often has this been said to programmers/tech startups? The answer is typically shield the nerds from customer support by introducing extroverts. And doctors who are often nerds are forced by design to deal with people constantly. No easy solution here.
I've always found my doctors to respond to my inquires with any amount of detail or sophistication I require. Both in Canada (my home) and the United States (where my girlfriend is from).
This was touched on (in the context of surgery rooms) in The Checklist Manifesto - as I recall, having everyone introduce themselves helps make people more willing to communicate and correct.
> Doctors walk around like gods in the hospital [...] The problem is that everyone is too afraid to correct the doctors when they make obvious mistakes.
This is a blanket statement that is untrue in my first-hand experience as a medical student. If you see a mistake is being made and can back up your opinion, you are treated with respect.
The problem is that medicine is very complicated and there are often not single 'correct' solutions. Given competing reasonable interpretations, the physician liable for the patient will (and should) make the final choice.
There is an alarming amount of anti-physician bias here. Physicians walk around like Gods? No, they walk around like people who generally have a very good clue and years of experience about what they are doing and are constantly attacked for issues outside of their control or completely outside of their patients' understanding, despite their best intentions and efforts.
> If you see a mistake is being made and can back up your opinion, you are treated with respect.
Are you treated with misrepect if you feel a mistake is being made, but you can't back it up ?
I believe students and young doctors should be pushed towards raising their concerns even if they can't back it up. From an external viewpoint I also believe progress can be made in that direction (I never worked in a hospital).
You have implicitly answered the question...and demonstrated the attitude that is the wrong answer.
When experienced people see something that doesn't fit, they often don't immediately know what subconscious cue let them know that something was wrong, and it is often someone else who can supply the critical piece of information. If you want good outcomes, you DO NOT push them to suppress their thought process. Instead you encourage them to speak up, everyone tries to figure it out, and then the final result helps train people's intuition of, "This is OK" and "This wasn't, you were right to wonder what about this situation reminded you of that case we saw last year where someone died."
If you are serious about finding problems, you need to not prematurely shut off feedback. Requiring people who think something doesn't look right to have backed that opinion up before they speak up is a problem.
Say I'm a medical student and during an operation I notice unusual numbers on the screen. I don't even know what the numbers mean (hey I'm a student!) but they look freaking unusual. Should I tell Dr. God about these numbers ? Last time he told me to shut up because I could not support my concern.
There are hundreds of situations where you believe something is a mistake but can't give clear supportive arguments. I hope blaming young medical professionals for raising their concerns in these situations is not the norm.
Point taken, but I am not sure about this scenario. You can always ask "What do these numbers mean?" You might look stupid, but I'm pretty used to that by now.
The original parent referred to "obvious mistakes" made by physicians, which I don't think your scenario encompasses.
Our subconscious mind recognizes something and predicts a bad outcome, which gives us a feeling of something being wrong.
That's what expertise is essentially. Being able to offload things that took conscious effort before into the unconscious. So a bad feeling from an expert (subordinates are experts as well) should be voiced, and investigated.
It's a very good point you make and many have already made great comments in reply. But as a physician who strives to prevent errors, I will throw in my two cents:
The culture is changing. The youngest physicians are working more reasonable hours and spending more time learning about errors in medicine and being collaborative in preventing them. I can personally say that I have seen techs, nurses, medical students and even other physicians prevent a potential error by simply asking a question. Of course, ego can still get in the way... but that's when your tact can help. Something as simple as, "what if we did this instead?" or "did you mean to order this?" can make it easy for a person to admit their mistake and move on.
I encourage you to read one of Atul Gawande's books for a very approachable treatment of the topic. This is the emerging culture in Medicine.
I believe Malcolm Gladwell has written about this. Others have as well. Typically this is less of a problem for US pilots, and more so in other cultures. For example, some of the studies showed that this type of thing was actually more prevalent in cultures that tended to be hierarchical, and where elders/authority figures should not be challenged (The usual example is Asian pilots.) I believe that the high profile accidents were Korean? (I could be wrong)
There are ways to measure this type of hierarchical control (better terminology escapes me at the moment), such as the Power Distance Index [0][1]. I've always enjoyed thinking about this as basically, how likely is an underling likely to tell his boss that's he wrong and he can go shove it? In this case, you can see why it's one aspect of the psychology/geography of where and why entrepreneurial activity occurs.
> The problem is that everyone is too afraid to correct the doctors when they make obvious mistakes.
Why do you think that is the core of the issue? Sorry to be that guy, but massive citation needed.
Not only that, but it appears (based on the wiki article below) CRM procedures you are mentioning have already been widely adopted by the healthcare industry.
Sorry to disagree, but they are certainly not widely adopted, although there is a fair degree of buzzword compliance without meaningful implementation.
I'm an ER physician in the US, and have worked in 5 hospitals in the last six years during residency and afterwards. Some of them occasionally would have some kind of 'patient safety' didactic lecture, but none had the specific small group training between doctors, nurses and other staff that CRM requires. If a hospital were serious about such things, they would pay staff to attend such training, and measure the behaviors, and make a portion of pay dependent upon adhering to the principles: I have never heard of a hospital doing this.
I think there is good evidence that CRM works (http://www.ncbi.nlm.nih.gov/pubmed/12546286) but the hospitals won't do it unless forced to by a regulator or accrediting organization such as jcaho, in my opinion. I'm curious to know whether the airlines took on the concept by choice, or we're forced to by the FAA...Of course, it's a lot harder to 'hide' a plane crash than a failure to correctly treat a sick patient. There's also some perverse incentives: if a hospital does the wrong thing, and makes someone sicker, that often means that the hospital can bill more for a higher level of care, for a longer period of time: you can always blame the underlying illness...
> Sorry to disagree, but they are certainly not widely adopted, although there is a fair degree of buzzword compliance without meaningful implementation.
That may be true, but OP implied that nurses being too afraid to correct doctors was the main cause of avoidable patient death, which is a massive stretch. Especially when the article itself is so prone to the obvious bias of life-threatening surgeries not taking place when doctors aren't working.
> I'm curious to know whether the airlines took on the concept by choice, or we're forced to by the FAA
The linked article glosses over the distinction between teaching hospitals, which did show a difference, and nonteaching hospitals, which did not see a significant difference. At teaching hospitals, there are research cardiologists and administrative types (division chair, officers of national organizations, journal editors) in addition to plain old clinicians. Everybody has to do time "on-service" directing the care of hospitalized patients. Naturally, the chiefs and the lab rats have to attend the big meetings, so their on-service time is in other months of the year. During the meetings the clinical cardiologists are mostly left in charge, and their clinical skills are better maintained, leading to better outcomes. Note that these outcomes had to do with acute high-risk cases, not elective interventions, etc.
It seems that having most of the cardio guys away at the conferences means there are less invasive procedures.
I would guess that what is scewing the result though is that the invasive procedures carry short term risk for a long term health benefit. The study only sees the decrease in short term risk (less invasive procedures) but is blind to the long term consequences of not doing the procedure.
Your post brings to mind an article by (I think) Ben Goldacre in which he recounts that inserting a stent to "solve" narrowing of the arteries has never been shown to be a net benefit to the average patient (except for emergency cases).
Nevertheless, cardiologists have continued to carry out operations to insert "new! improved!" stents which successively claim to eliminate the problems of previous designs over what is now something like three decades of medical practice. None of them have worked.
I'll try and find the article, but a quick web search hasn't turned it up.
This was originally unknown and non-obvious (massively narrowed coronary arteries are ok?) but now known and modern clinical guidelines (which are written by physicians) have changed to reflect this reality. This was confirmed by well controlled multi-center trials. It's not cardiologists inserting "new! improved!" stents for the thrill of it.
This doesn't reflect the case of the example patient who has angina upon exercise with significant stenosis, but is not undergoing an active MI. That patient may still be stented and have their lifestyle improved drastically, despite there not being an urgent requirement.
It's not that it was unknown and non-obvious - it's that as each successive stent was shown not be an effective treatment, cardiologists continued to operate for decades, confident that the next "new! improved!" version would work, even though none of the previous ones had.
The reasons for this are a combination of the difficulty of publishing neutral or negative results & surgeons' entirely natural inclination to do something rather than nothing, even if nothing is actually the right thing to do, because operating is what they've trained their entire lives to do.
The same thing happened with extreme chemotherapy followed by bone marrow transplant as treatment for many cancers in the 80s: something like a $billion was wasted on treatments that didn't work. The reasons why it took so long to demonstrate that that particular treatment was ineffective were not entirely the same - read "The Emperor of All Maladies" for the details - but shared the optimism of doctors & patients combined with a plausible theory, which is what ultimately makes for a potentially toxic combination.
I bet you would find 'similar' results in very different domains.
Like fewer work accidents on construction sites when the foreman is absent, less casualties among soldiers while the commander is sleeping, etcetera.
When cardiologists are away, I'd imagine no non-emergency procedures/surgeries are performed (no heart transplants, quintuple bypasses, etc), which has to be a significant factor here.
Aside: Cardiologists actually do not perform heart transplants or bypasses surgeries themselves, instead those are done by cardiothoracic surgeons. This is a pretty common misconception.
I don't really know. This study looked at the ACA and AHA national conferences. I doubt there are many surgeons at the American Cardiology Association meeting; cardiology is highly specialized. There are probably some at the American Heart Association meeting.
It might depend on how risky the surgery is in each discipline.
I'd expect heart and brain surgery to be among the riskiest, whereas other types of surgery might be significantly less risky. I wouldn't expect most cancer patients to die from their surgeries, for example.
Would depend on, among other things, how easy it is to "schedule" complicated cases. For some specialties this is straightforward, for others, it's not.
Well, it might be interesting to see whether there's a difference between cardiologists attending conferences (making patients feel like their cardiologist must be strongly committed to his/her specialty) vs. cardiologists who are away on vacation.
It's because many fewer interventional procedures are done when there aren't any doctors to do them. This isn't even really very new. For example, during the Canadian physicians' strike, mortality also went down dramatically.
Any mortality differences would be temporary. The next study will show that mortality increases after cardiologists return from the conferences as they do all of the procedures that they put off, and then levels out again. Simple.
Really not very impressed with this headline, but any opportunity to rag on doctors is typically taken in the mainstream media.
>>> High risk patients admitted with heart failure during meetings had a 30-day mortality rate of 17.5%, compared to 24.8% when more cardiologists were there. Cardiac arrest 30-day mortality was 59% during meetings and 69.4% at other times. Not surprisingly, the rates of percutaneous coronary intervention were lower during meetings, too (20.8% versus 28.2%).
In my view, they could have done with one or two fewer significant digits based on the size of the error bars in the graph. My interpretation: Need to collect more data and see if this is reproducible.
Signifacant figure abuse is surprisingly widespread in science. At least 23.432361% (+-10%) of papers I have read have managed to get their significant figures wrong.
Among other things, more focus is put on the possible interpretations of this (and it explicitly cites the source of those possibilities as the research paper), and has a better explanation of the source of the data for the analysis.
There's nothing wrong with the original at all, it should stay.
In fact the original is far superior to the Ars "summary" because it provides a more neural headline, also provides link to the paper up front, provides the abstract, provides the key graph with error bars and information about comparison to other disciplines. It ends with a reasonable evaluation that this hasn't proven anything either way and calls for more investigation.
Furthermore it was also written December 23rd by a site specialising on these matters rather than by Ars, a pretty low brow generalist site, on December 27th. While the Ars author has a PhD in biology, the guy who got the scoop four days earlier is eminently qualified in this area.[1]
The original link is a better article, published earlier, by a more appropriate author on what appears to be (although that isn't hard) a better site. The HN mods shouldn't be changing the links except in extreme cases anyway.
[1]"Aaron E. Carroll, MD, MS is a Professor of Pediatrics and Assistant Dean for Research Mentoring at Indiana University School of Medicine. He is also the director of the Center for Health Policy and Professionalism Research. He earned a BA in chemistry from Amherst College, an MD from the University of Pennsylvania School of Medicine, and an MS in health services from the University of Washington, where he was also a Robert Wood Johnson Clinical Scholar.
Aaron’s research focuses on the study of information technology to improve pediatric care and areas of health policy including physician malpractice, the pharmaceutical industry/physician relationship, and health care financing reform."
There is the anecdotal correlation to the contrary w/ May being the first or second most popular suicide month and also the month when the American Psychiatric Association has its annual meeting. I think that was mentioned in Infinite Jest or some other novel, but it is true as far as correlations go.
See this is why I love science. Somebody does a study, and we learn something absolutely new that we wouldn't have known.
More follow up research needs to be done, but this potentially means that the doctors can change how they treat patients and significantly improve patient mortality.
They need to add the individual doctors as factors in their regression.
Otherwise this could just be "inexperienced or checked-out doctors are more likely to go to the conferences.". It's no surprise that there are differences in survival that depend on which doctor you get.
Certain patients (those classified as 'high risk') do better when cardiologists in certain hospitals (teaching hospitals) are away at academic meetings.
A similar thing needs to happen in medicine. Doctors walk around like gods in the hospital but they are still human and make mistakes. The problem is that everyone is too afraid to correct the doctors when they make obvious mistakes. Don't get me wrong---the doctors must remain in charge, but they will still goof up so people need to feel free to offer advice and criticism.