Sunday, October 2, 2011

Fly "Hospital" Airlines.......

The aviation industry is extolled in the patient safety literature as a pre-eminent example of highly reliable organizations. They are used to provide a model to be emulated in order to enhance safety within medical practice.

This paper from the BMJ discusses the results of anonymous survey's and attitudes related to errors,perceived stress, and teamwork between aircrews and various medical teams (surgical and ICU).
( http://www.bmj.com/content/320/7237/745.full.pdf )

Not surprising, the aircrews are more sensitive to their own stresses and more willing to admit the effects of fatigue on their decision making and eye hand coordination, etc. While there may be valuable insights derived from this comparative study, the essential differences between the work environments of the aircrew member and the physician member of a health care team are profound and underestimated in these comparative surveys.

However, my intention today is not to critique the patient safety movement, but rather to comment on the more profound issue of the effects of the focus on industrial reliability and its unintended effects on therapeutic effectiveness.

I am now working most of the time as a hospitalist in a local hospital. I was discharging a patient who I had episodically followed for some days, but who was originally admitted by my colleague, the medical director of the local hospitalist organization. The patient asked if he was going to see my colleague, and he confessed he was confused as too who I was in the delivery of his care. The patient had a life threatening episode of pulmonary embolism for which my boss did a bang up good job of penetrating to the threat and promptly began thrombolysis of his clot. The patient knew perfectly well that his life had been completely dependent on this excellent practitioners excellent care. However, he was a patient on a hospitalist service and therefore the doctor safeguarding his life literally changed every 12 hours and often times every day he was cared for by another physician, many times, especially during the nocturnalist covering his care, his identity totally unknown to the patient.

He was perplexed, initially to understand that he was in database lingo in a 1:many relationship when his previous understanding and experience of medical practice was that he was in a 1:1 relationship to his primary care physician.

It occurred to me at this time, as it has any other number of occasions that hospitals would prefer if our relationships to patients was identical in character to that of the Captain of an aircraft to the passengers within that aircraft. Essentially anonymous, assumed to be competent, but indifferent to the actual natures and characters or characteristics of the passengers and vice versa.

In this model of the hospital, the hospital provides the nurses/stewardesses and pilots/physicians and controls the interactions within the hospital and just as on the airways a commercial interaction rather than a human interaction occurs.

However, the human in pain, disease, and fear is not the equivalent to the excited pleasure or the bored business traveler with respect to customer relationship management. The patient deserves, desires, and requires the ministrations of a real person with therapeutic intent and therapeutic will.

Among my strongest held beliefs are that in the field of medicine, there are some, too few perhaps, who are gifted with a therapeutic personality. That the practice of good medicine taps the depths of the souls of those who serve the patients best interest. That shamanistic power exists in many and perhaps most successful practitioners, and those without this ability to tap the pre-technological wellsprings of healing are ineffective in transforming their patient's into healed and whole human beings.

These dimensions of medicine, the cultural and mystical/spiritual dimensions are increasingly ignored, marginalized, and minimized in the 'practice' of medicine to the detriment of the patient and the practitioner.

In my discussions with the young patient who I was helping too process through his trip to the healthcare factory, I was deprived of the true sense of gratification and sense of personal healing power that comes from being on the spears point, and invoking the skills I spent a lifetime in acquiring, renewing, and enhancing by being their for his personal crisis and leading him out of the valley of death. That joy belonged to my partner. However, for him that gratifying experience was transformed into a technical exercise of correct decision making, bereft of the truest reward in medicine, the sincere thanks of the saved patient. And the patient was left thanking my partner only in the third person as I was to relate his deep gratitude to my colleague.

In the maturity of my practice, my field once so exciting and rewarding, one in which I was sure I was immune to 'burnout' now has transformed to the point that I am virtually as anonymous to patient's as the highly qualified, highly talented, highly skilled aviators who take off and land our planes.

I wished ultimately to grow old with my patient's and too drink of the well of shared experiences, now my draught is bitter, cold, and unappealing... the dregs of a warmed, heady, vaguely sweet grog now gone cold, bland, and nauseating in its uniformity.

Intensity Is A Four-Letter Word or In The World of the Bland, The Half-hearted Rule....

In the summer of life,
I exhausted myself in the struggle,
heroic, in my eyes,
life and death, dependent upon
my own
strength as well as the patient's will to live,
and clinical wisdom and the joy of selflessness
came effortlessly as my just reward.