Can We Do Without Heroism in Health Care?

Two icons of patient safety, Peter Pronovost (Time magazine’s Top 100, 2008) and Ara Darzi (British House of Lords) have recently penned a manifesto. It calls for a systems approach to safety assurance and less reliance on heroism to make up for weak systems.[1] The document is well written, persuasive and wrong. Well, not wrong, just not right!

Let’s start with the systems point. The argument put forward by Pronovost and Darzi echoes a constant refrain from safety pundits that goes something like this:

Health care is beset by safety problems; Adverse events (AEs) are more likely when weak systems leave gaping holes that link up to cause adverse events, as per Reason’s “Swiss Cheese” model; Systems approaches have massively reduced AEs in other industries; But two decades of trying to replicate these achievements have yielded little progress in health care; By Jupiter, we must try harder to improve the system!

However, it would seem more reasonable to conclude that health care is not like other industries – as argued in a previous post, only about one quarter of AEs arise from archetypal system problems in the sense that their root cause lies in the host organisation. The remainder follow diagnostic errors (broadly defined) and procedure-related errors. These both lie in the province of front-line doctors failing to exhibit sufficient skill. Of course manifest skill can be influenced by local conditions, for instance if the doctor has to care for more patients than she can cope with. And they emanate from a broader system concerned with selection, training and so on (see ‘Bring Back the Ward Round’ below). But it is hard for a hospital to indemnify itself against a surge in demand, and recruiting and training doctors plays out over decades.

Things that can be systemised are being addressed to good effect. Hospital-acquired infections are massively down; severe pressure ulcers down; medication error heading south; and wrong site surgery is right down.

The patient safety ‘industry’ needs to move on from its preoccupation with infection, falls, medication errors, pressure ulcers, and rare egregious errors. And to be fair, Pronovost has campaigned elsewhere for more emphasis on diagnosis,[2] while Darzi is a world leader in surgical training.[3]

And that is where we need to turn to this issue of heroism. Here the story goes something like this:

It took heroes, such as Charles Lindbergh, to establish aviation; But a modern airline pilot with a barn-storming attitudeis a “bloody nuisance”; Medicine also needed adventurous doctors like Christiaan Barnard in its heroic phase; But now we need bland team players who can follow guidelines

Now I am not arguing for the return of Sir Lancelot Spratt and fully understand that it is patients, not doctors, who put their lives on the line. But treating health care workers like office clerks is wrong – again and again clinicians have to go above and beyond, doing hard cognitive, physical and emotional work – a good doctor, has to ‘give of herself’.

A good doctor who has done a hard night in A&E has not just spent the evening following guidelines; she has made sound judgements under uncertainty, maintained her composure under abuse, coped with a stream of patients arriving faster than they can be seen, and she has kept a cheerful demeanour throughout. She may have helped hit the government’s four hour target. Doctors in many parts of the world feel demoralised, but medicine cannot go back to the hands-off approach of yesteryear – scrutiny and regulations are here to stay for very good reason. But don’t let the pendulum swing too far – recognise that the work is hard, that it cannot be completely codified, and that it is deeply personal, and leave space for just a little heroism.

— Richard Lilford, CLAHRC WM Director

References:

  1. Pronovost PJ, Ravitz AD, Stoll RA, Kennedy SB. Transforming Patient Safety: A Sector-wide Systems Approach. Doha, Qatar: World Innovation Summit for Health. 2015.
  2. Newman-Toker DE, & Pronovost PJ. Diagnostic Errors – The Next Frontier for Patient Safety. JAMA. 2009; 301(10): 1060-2.
  3. Singh P, & Darzi A. Surgical training. Br J Surg. 2013; 100: 307-9.

 

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4 thoughts on “Can We Do Without Heroism in Health Care?”

  1. Charles Lindbergh did not have a ‘barn-storming’ attitude. It’s a bit simplistic to equate him with mavericks. So where does Captain Sullenberger fit in as he is undoubtedly a methodical pilot but also falls under the term hero (he would not think so)? I understand what the intention is with this article and it is true that aviation has been successful in reducing accidents by understanding how humans behave in demanding situations. This has meant that planning, proven procedures and team work will give safe outcomes. However, there is still the need for pilots who can deal with major emergencies, something that appears to have been missing in the AF447 accident. Medicine can learn a lot from aviation if it is allowed to, but the level of litigation against doctors and nurses will only mean you will need ‘bland team players who follow guidelines’, to avoid litigation. Is that the main purpose of medicine? Aviation is not subject to the kind of litigation that blights medicine and this is a key reason why it is so safe to fly. Also, modern aircraft are extremely reliable and well designed and this aspect along with aviation medicine makes flying routine. The main variable for pilots is the weather but can be dealt with by learnt procedure and weather forecasts. The variable for the medical profession is the human body and the huge variety of medical conditions that arrive with short notice or no warning. In addition, the level of scrutiny and management applied to medicine is probably creating more challenges and distractions for medical staff, thus leading to unsafe conditions.

  2. OK. I should have read the whole article. But, the level of scrutiny has to be proportionate and relevant. It is the case in aviation although there are Black Boxes and Voice Recorders which do not directly interfere or impede pilots. Also, pilots are in charge of flying with no other layer of management involved in the flying.

    A quote from Edward Deming ‘The New Economics’
    “Unnecessary paperwork is a serious loss. A lot of it originates in management’s supposition that the cure for repetition of a mistake or fraud is more audit, more inspection. A letter to the London Times, 7 July 1990, displayed the fact that 23 % of the cost of running a hospital in the United States goes for administration, against only 5% in the UK. Ask any nurse in a hospital in the United States what duty diminishes the effectiveness of her education and aims – paperwork”.

    What is the proportion of hospital management costs in the UK in 2017?

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