Happy Independence Day and sincere gratitude to all who are serving in the armed forces to keep us independent, as well as to their loved ones.  My son, who is studying to become a naval aviator, is on a summer cruise off Cyprus, and it gives our family a different perspective on the 4th of July beyond fireworks and barbecues.

In 10 Powerful Ideas for Improving Patient Care, (ReinertsenJ, Schellekens W.  2005, 35-42), the authors discussed the paradox of physician autonomy, in which individual variability of physician orders becomes a breeding ground for complexity, error, and waste, which leads to suboptimal patient outcomes and subsequent increased healthcare oversight of medical decision-making by payers and government regulators.

Reinertsen and Schellkens noted that physicians talk about evidence in groups (eg. national meetings, grand rounds, and morbidity and mortality conferences), but implement it as individuals.  They cited experience from the New England Deaconess Hospital (NEDH) in which cardiac surgeons went over a year without patients experiencing postoperative mediastinitis once they all agreed that any PACU or ICU patient with a blood sugar over 110 mg/dl would be placed on an insulin drip to maintain blood sugar between 80-110 mg/dl.  Previously, the annual incidence of mediastinitis at NEDH had been 1.2%.

In a subsequent example on multidisciplinary rounding in the ICU and the adoption of patient-care bundles, they detailed the importance of physician champions and peer-group pressure, in which adopting physicians confronted resistant physicians with, “Are you so good that you are exempt from all the evidence in the literature?” and “So are you saying that you value your autonomy more highly than the patient’s outcome?”

Reinertsen and Schellkens noted that standardizing work gives physicians more time to:

• see more patients
• spend more time with individual patients
• spend more time with thier families

Clearly, if standardization were easy, we would all have done it already.  Standardization requires:

• courage to face resistant colleagues
• knowledge of the evidence and its limitations
• confidence in one’s own performance data
• willingness to trust processes over which one has influence but lacks control

In a related post, Overly High Healthcare Administrative Costs, Dr. Kenneth Fisher makes a case for Appropriate Care Committees to leverage the local impact of physician champions.  Acknowledging the controversy, he wrote:

“There will be oversight….The question is do we want oversight from bureaucrats… who are hundreds of miles away making crucial healthcare decisions… it’s a patient’s … worst nightmare.”

Moving from independence to greater interdependence is what gives many of us hope.  We have a noble tradition of co-mentoring  fellow physicians, acknowledging that we all have knowledge, insight, and experience that add value.  Effective collaboration allows healthcare professionals with diverse backgrounds to develop new approaches to improve care based on a shared vision rather than to play the role of a victim.  As such, collaboration can help healthcare professionals to reconnect with the values that attracted them to healthcare in the first place.

What do you think:

• Do you agree with Reinertsen and Schellkens that the medical orders that flow through nursing and hospital pharmacy resemble the languages spoken at the Tower of Babel
• How have physician champions improved care where you work
• Most healthcare professionals see little value in creating another committee to solve current problems; what do you think about the questions Dr. Fisher raises about professional oversight

As always, I welcome your input.

Kenneth H. Cohn