Ebola and the tension between bureaucracy and medical judgment

If another case of Ebola emanates from the unfortunate Texas Health Presbyterian Hospital, the root cause analysts might mount their horses, the Six Sigma black belts will skydive and the safety champions will tunnel their way clandestinely to rendezvous at the sentinel place.

What might be their unique insights? What will be their prescriptions?

One never knows what pearls one will encounter from after-the-fact risk managers. I can imagine Caesar consulting a Sybil as he was being stabbed by Brutus. “Obviously Jules you should have shared Cleo with Brutus.” Thanks Sybil. Perhaps you should have told him that last night.

Nevertheless, permit me to conjecture.

First, they might say that the hospital lacks a culture of safety which resonates with the values and aspirations of the American people.

That’s always a safe analysis when the Ebola virus has just been mistaken for a coronavirus. It’s sufficiently nebulous to never be wrong. The premise supports the conclusion. How do we know the hospital lacks culture of safety? “Cos, they is missing Ebola, innit,” as Ali G might not have said.

They would be careful in blaming the electronic health record (EHR), because it represents one of the citadels of Toyotafication of health care. But they would remind us of the obvious: “EHRs don’t go to medical school, doctors do.” A truism which shares the phenotype with the favorite of the pro-gun lobby “guns don’t kill, people kill.”

These come under the “logically true, but I think you’ve missed the point” genre.

What would they say about the epidemic of documentation to prove that physicians are not following their natural inclination of being robber barons, of checklists hemorrhaging from every pore, of the stanzas of prose to express the patient has no serious ailment?

They’d tell us not to throw the baby out with the bathwater, even though the baby is being asphyxiated by the excessive bathwater.

“The problem is not too many checklists, it’s too many wrong checklists. If only the hospital staff used the right checklist, the checklist for Ebola, this problem would not have occurred.”

This sort of speech brings a standing ovation at a medical meeting: “The problem is not too many regulations, but too few regulations that work,” or “The problem is not that big data sucks is that we suck with big data,” or “Don’t underutilize but appropriately utilize diagnostic tests.”

Encore.

The trouble is if you’re a simpleton like me, and simply don’t get things the first time, you might be inclined to wonder just how does the ‘right’ checklist appear. Does it drop like manna from heaven? And what are we supposed to do with the other 9,999 “right checklists,” including the one for bird flu, circa 2009?

Checklists don’t go to medical school, doctors do.

The problem solvers might identify an atmosphere of suspicion and lack of collegiality where nurses don’t tell doctors for fear of being condescended and doctors don’t ask because of their unshakeable superiority complex.

They might tell us that Thomas Duncan was let down by a system which was practicing with twenty first century tools but a nineteenth century approach to communication, which had strong horizontal but lacked vertical integration. Thomas was a victim of medical silos.

(I have no idea what horizontal and vertical integration means. I heard it somewhere and it sounded clever.)

The problem solvers might offer five prescriptions:

  1. Sensitivity training for all physicians.
  2. Mandatory courses on Coursera on quality and safety.
  3. A must watch video for all health care workers on the importance of communication, with real patients who have been harmed by lack of communication.
  4. Six Sigma liaison person in the hospital and an identifiable safety champion for each clinical section.
  5. An app for Ebola.

The CEO of the hospital will pledge $1, 000, 000 on quality and safety including a safety awareness month where workers will be encouraged to tell their safety story.

Life will go on.

Allow me to make a more modest proposal. Find three physicians and three nurses, professionally orthodox, yes I do mean old school, and liberally endowed in common sense, who are illiterate in modern managerial speak. I know a few from the Twitterverse, but I warn you, they are not that easy to find.

Let them observe physicians and nurses for a few days and see if they are doing the basic steps properly and if not, why not. How much time do they spend doctoring and nursing, and how much time do they spend documenting their doctoring and nursing?

I suspect they will tell us that when everyone is responsible for everything no one is responsible for anything.

That when nurses try to be doctors (and accountants for CMS) and doctors try to be managers (and accountants for CMS) there will be a de facto shortage of doctors and nurses.

That if we design doctors for EHRs, rather than EHRs for doctors, we will get neither useful doctors nor useful EHRs.

That if we make making simple diagnosis difficult we will make difficult diagnosis appear simple and wrong (this piece makes this point far better).

That when we fret over every eventuality we become more fragile (to borrow Nassim Taleb’s lexicon) to the real risks. I mean the real risks, the catastrophic ones, like Ebola. One cannot be permanently vigilant of everything. One will simply tune out.

They might say that Thomas Duncan suffered a profession increasingly tuned out by irrelevancy that is no longer exploited for what it does best.

Is there a middle ground between managerialism and judgment? May be an app for common sense, or guidelines and protocols for judgment.

No, of course not. I was just being facetious. The two are fundamentally oppositional. But only physicians can beat the decline in judgment induced by the epidemic of noisy irrelevancy.  If we fail, managerialism will fill its space, leading to further decline, then even more managerialism, a vicious cycle.

Be afraid. Very afraid. Not of Ebola, but of the fragility and costs of medicine if this happens.

Saurabh Jha is a radiologist and can be reached on Twitter @RogueRad.  This article originally appeared in the Health Care Blog. 

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