Not everything broken can be fixed

February 5, 2015 8:26 PM

In memoriam: Dr. Michael Davidson, cardiac surgeon, killed while doing a job he loved. A reflection on bad outcomes versus mistakes and taking risks versus playing it safe.
posted by treehorn+bunny (18 comments total)

I think aviation-style checklists might actually be super-useful in today's healthcare milieu. I would not be surprised if what's holding it up is the question of whether such things are billable to insurance.
posted by infinitewindow at 8:36 PM on February 5, 2015 [2 favorites]

He sounds like he was a great man and a darn good doctor. I think at the level Dr. Davidson was working at, a lot of what he did was art as well as science. Again, a lot of what doctors must do is assess risk versus reward and let the patient or the family decide what is the course of action that they want to take having been told the options and the risks.

I have had 3 spinal surgeries and have had stents put in my heart twice. I was made well aware of the risks and the probabilities of success (or failure). I was given at least one other option each time. With my back, I chose to exhaust most of those options before surgery. With my heart, I chose stents over a bypass. I have had some issues with Plavix for my stents, mainly excessive bleeding, but I don't blame my cardiologist for prescribing it. There is really no one to blame. It is simply a risk of the medicine.

Sure, the health care system in the US has many issues, but to me, the critical issue is time. I want my doctor to have time to meet with me, to discuss treatment and alternatives and especially the time to think herself about what course of action is best.

Knowing only what I read in this article and in the paper, it sounds like this was a bad outcome not a mistake.

Thanks Dr. t+b for posting.
posted by 724A at 8:55 PM on February 5, 2015 [2 favorites]

*sigh*. I remember when this was reported on the news, "Doctor shot". There weren't a lot of details then. So sad to hear what a wonderful doctor and person we lost.

A dot for Dr. Davidson:

.

and a few more dots for the patients he would have treated:

. . . . . . . . . . . .
posted by benito.strauss at 9:10 PM on February 5, 2015 [9 favorites]

An interesting article, but I think the criticism of Chesley Sullenberger's efforts to reduce healthcare errors is unfair. Sullenberger is trying to get systemic and preventable errors, such as hospital-acquired infections, down to zero, by implementing practices adopted by the aviation industry, such as checklists and team communication (aka crew resource management). Given what we know, the death of Dr. Davidson's patient, which may or may not be due to side effects of the medication she was on, doesn't really fit the profile of the type of errors that Sullenberger is trying to fix, imo. Dr. Davidson probably knew about the side effects, but deemed the risk worth it.
posted by longdaysjourney at 9:26 PM on February 5, 2015 [10 favorites]

Yeah, Atul Gawande is another huge fan of checklists, and there is plenty of peer-reviewed evidence that they reduce death rates. Sully's criticism is perfectly valid -- when we have an air crash caused or partially caused by pilot error, we don't go with 'ah, well, whattayagonna do' or simply blame it on the inadequacy of the pilot and say the cure is to filter out bad pilots. We recognize that even a good pilot can be a bad pilot in some circumstances. We look at all contributing factors -- was the crew exhausted? was communication unclear? were they inadequately trained for the situation? Even social factors are examined, whether the cockpit culture was too authoritarian and thus the copilot wouldn't feel free to point out an obvious mistake.

And the entire checklist procedure was instituted because of recognition of human limits. If you have more than a few basic steps, the human mind can easily lose track of them, especially when there are distractions. Or they can execute the most familiar version, forgetting that they are in a different craft with different requirements. And so on. So getting away with the surgeon-as-god, doctor-as-god model, the same way they did from piloting, is an entirely valid goal, and if Sully can use his fame to encourage that, all power to him.
posted by tavella at 9:40 PM on February 5, 2015 [22 favorites]

There's an article in the New Yorker about the phenomenon of patients attacking physicians in China, if you're as curious about that line as I was.
posted by pmdboi at 10:07 PM on February 5, 2015 [4 favorites]

“Yet the analogy between airplanes and hospitals is seriously flawed: people don't get on airplanes because they would otherwise die.”

But surgery and piloting are both complex skills with many complex steps that need to be done in order with no major omissions, where clear, effective communication among members of the team in critical moments is vital and where misunderstandings can be fatal… and so on. It is pure hubris to think that doctors can’t lean from any other profession just because other professions are not centred around curing the sick.

And of course in the past they have learnt from others: the whole process of laying out tools in order, calling for them by name, having them placed in the surgeon’s hand with the name of the tool being repeated back was not invented by doctors themselves, it came from the time and motion expert Frank Gilbreth.
posted by Quinbus Flestrin at 11:13 PM on February 5, 2015 [4 favorites]

"data from the Bureau of Labor Statistics suggest that the incidence of homicides at general medical and surgical hospitals is similar to that in lawyers' offices and lower than the rates in hotels, real estate offices, and government workplaces."

The problem, then, is not that there is a breakdown in trust between doctors and patients, or a cultural shift.

The problem is that you have lots of guns: getting rid of the guns will make doctors safer from the occasional violent patient.

This is a recurring theme in US criminology, I think...
posted by alasdair at 1:37 AM on February 6, 2015 [13 favorites]

Alasdair--no need to "I think"--I am very confident you are right. The media and many of us are always looking for "the motive"--dissatisfied employee/spouse/parent/child, marginalized/alienated/loner. mentally ill/Asperger"s/addicted, racism/cop/power. But the common element is always he presence of a firearm--often a handgun/assault rifle.
posted by rmhsinc at 2:07 AM on February 6, 2015 [4 favorites]

I think also this is a result of a sick/healthy binary that dominates Western culture, wuth a very strong focus on the healthy part. I'm not a doctor but my mum was a medical receptionist so I grew around a lot of them, and have many doctor friends and a sadly sickly constitition, and I have seen in medical contexts a real ignorance and fear of sickness. People still view hospitals I think as a place you go to get "fixed", not a place you go to when you are sick. Death is viewed as abnormal, as a failure, rather than an inevitability, and health is viewed as a state rather than a continuum.

On this context I do think doctors take on an almost culturally shamanistic role, they fulfil a social function not just a medical function. And it a very hard role to play right, I think. It carries a heavy burden.

I can't help feeling that of we paid more attention, as a society, not just to our mortality but to the very corporeality of our bodies and the minds they house, we would have a better and more even discourse for medical interventions in our lives. A sense of power rather than impotence.
posted by smoke at 3:07 AM on February 6, 2015 [5 favorites]

It's not that there are too many guns, it's that the people who should be armed aren't.

How much you want to wager that a significant number of Dr. D's colleagues and coworkers haven't gone to New Hampshire and armed themselves?

I'm shocked that the NRA isn't using him as an example to loosen Massachusetts' restrictive firearms laws.
posted by Renoroc at 4:37 AM on February 6, 2015

I would wonder if Atul Gawande would weigh in, especially considering that Brigham is his hospital.
posted by dr_dank at 5:01 AM on February 6, 2015

.
posted by Dashy at 5:13 AM on February 6, 2015

A relative of mine had surgery (hand, not heart) at Brigham and Women's Hospital less than a week after the shooting. There was a large memorial almost completely covered with notes about Dr. Davidson. On the positive side (silver lining, perhaps), it seems that other than mourning, the doctors are not allowing this to change things at the hospital.
posted by Hactar at 6:32 AM on February 6, 2015 [3 favorites]

"It's ok--let them fall."
(The tears) Oof.

.
posted by Sreiny at 7:24 AM on February 6, 2015

A lot to unpack in that article. The part that matters most to me is the part about healthcare quality and mistakes, though, since every one of us is eventually going to be touched by this issue in some direct way.

There isn't an industry where standardization doesn't lead to a fewer mistakes and better quality, yet it just hasn't happened in healthcare yet. For all the advances we make in the *science* of medicine, ten times more human lives would be saved by focusing on the *process* of medicine.

Problem is, nobody pays for quality in healthcare in this country. Nobody can quantify it particularly well, and reimbursements (for the most part) aren't based on outcomes. There's some movement here and there, particularly on the government payment side, but few initiatives have worked out in the long run. Measuring quality is just crazy hard.

If I'm Big Medical Center (perhaps I am), I'm paid significantly more by Big Insurance Company if I'm A) well regarded by their customers because of my strong brand, B) large enough to get a lot of market share, C) have super advanced skills. Notice how there's no: "D) I don't kill people as often as the next guy."

I get a bonus here and there for quality, but it's not something I'm going to invest a huge amount in because healthcare is an increasingly cutthroat business. Margins are very tight (25% of hospitals operate in the red), so I'm going to invest in things that help that bottom line if I don't want to go broke. Of the hundred hospitals in my state, I know for a fact that almost all of them have been acquired, have acquired, are thinking about an acquisition/merger or are seeking ways to avoid acquisition.

So, I invest billions in facilities, machines, marketing, M&A, high-acuity skills (proton beams and the like), IT systems, etc. None of that has anything to do with process improvement. I spend a little money on Lean Healthcare and read Atul's books, but you'll NEVER hear that your local hospital is investing $100M in quality improvement. As a hospital, I don't see that as a direct investment in the bottom line, and man is that bottom line hurting right now.

Payments will eventually level out and unify across providers and we'll get a better handle on what "quality" means. That's what most people in the industry believe will happen. At that point, the best ROI comes from process improvement to lower costs and reduce fuckups.

Until then, sorry your hospitals are killing you, America. It's not that people in healthcare are evil, they just don't have the luxury of doing their jobs real well right now. Too worried about what the other guy is doing to fix our own shit.
posted by pjaust at 12:12 PM on February 6, 2015

Sully's criticism is perfectly valid -- when we have an air crash caused or partially caused by pilot error, we don't go with 'ah, well, whattayagonna do' or simply blame it on the inadequacy of the pilot and say the cure is to filter out bad pilots.

I think the answer is not so clear cut. The memorial piece didn't do the greatest job of elaborating on the issue, but the point is that not all deaths are avoidable. Not all medical problems can be solved or be attributed to errors. And the sicker a patient is, the less likely the problem can be solved. In the current age of measuring outcomes, physicians are disincentivized from taking risky cases, like the shooter's mother, because they are very sick and their odds are bad, and that means the surgeon's personal outcome statistics will suffer. Davidson was putting himself in jeopardy: for getting bad "quality" scores, for having bad outcomes, for having angry patients, by taking dangerous cases. Because many people do not understand the diffence between a bad outcome (a known risk of an intervention) and a mistake (potentially avoidable). The shooter clearly thought an error had been made, rather than appreciating the fact that Davidson was willing to take on a high risk case and give his mom a shot at better health. Of course, I don't know all the facts of the case, just speculating based on what we know about Davidson and the patient, obviously an elderly and sick woman who would have major risks when going to surgery. But similar stories play out across the country. No surgeon should take a futile case to the OR, and there are still many cases where surgery is done inappropriately on patients who should have been made "comfort care" or hospice. But I do think it's unfortunate that the malpractice environment and the quality measurement crusade make surgeons loathe to take cases in which there is a potential for a significant benefit, but the risk is high.

My feelings were also colored by the setup in the memorial essay - the example of a child dying of sepsis. When I was in training, I saw a child come in with sepsis, a case that still haunts me. She got so ill within just a few hours time with a fulminant MRSA infection that on arrival to the emergency department, we had to intubate her and put her on a ventilator, and despite getting maximal antibiotic treatment and supportive care very quickly and early on, within one day she was on total life support, and in 2 days, she was dead. And that's just one of many examples of a non preventable death. Not that we should ever be complacent about what we do - there are always things that can be improved upon.
posted by treehorn+bunny at 4:00 PM on February 6, 2015 [9 favorites]

Checklists and patient safety interventions are actually making pretty substantial inroads into medicine. I've been at a couple of hospitals now that have "ICU bundles" intended to reduce infections related to central intravenous lines, and I've also seen a rise in residency programs using checklists to make sure that handoffs between shifts of physicians cover all the information that the incoming shift needs (these handoffs have always occurred but with reductions in resident work hours they are happening more often and are now being done in a more structured way). Some processes are more amenable to structure and checklists than others.

But it's true, people who are elderly, frail, and sick have a substantial risk of bad outcomes no matter how good the care they get is. Dr. Davidson apparently specialized in treating people who were considered too frail for regular heart surgery, which is pretty sick indeed. People at that bleeding edge are, in fact, the ones figuring out who is too sick for a surgery, and who is horribly ill but might do well, and setting the standards of care for all the other interventional cardiologists/CT surgeons, so that they can say with confidence to patients that people with their constellation of oroblems will either benefit or not from a procedure.
posted by The Elusive Architeuthis at 6:38 PM on February 6, 2015 [3 favorites]