If you don't have time to do it right, when will you have time to do it over?John Wooden
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Patient-centered shared decision-making is one of the toughest tasks in clinical medicine. It involves a collaborative effort to collect and assess evidence, leavened with clinician experience, and framed within the context and values of the individual patient.
The world of medicine is quite properly focused on finding and applying the best available evidence to processes of care. Unfortunately, too often this results in the use of inappropriate hard targets and mis-applied guidelines. National quality groups, payors, government agencies, professional societies and medical care organizations (including my own) are eagerly looking for ways to improve care by standardizing care around evidence-based best practices. While I celebrate the replacement of eminence with evidence, I wish I saw more humility. The evidence is imperfect and provisional, and the resulting targets and guidelines should be understood as a place to start discussing appropriate care, not a way to end discussion of what is appropriate for a given patient in a given setting. I call this Practicing Safe Guidelines.
The deluge of clinical information I face every day is littered with clinical junk mail.
I did my family practice residency in a Catholic hospital in the mid west. The strong presence of nuns in leadership and the quiet influence of the attached order and Catholic school lent an unmistakably religious atmosphere to the hospital. Mostly, as residents, we were too busy and too tired to either notice or care, but occasionally the interface between the hospital’s spiritual context and the world of patient care was uncomfortable. Even jarring.
Throughout our medical training we are told again and again that the most important task is an accurate diagnosis. And we hear it at CME lectures and read it in journals. An accurate diagnosis is certainly essential if one wants to offer successful and safe treatment. But it is not enough to ask and answer: “What is the diagnosis?”
She called in tears. Beyond tears, actually. She was so upset that it was impossible to get a coherent history and the triage nurse was only able to ascertain that her psychiatrist was no longer willing to prescribe her long-term clonazepam, she couldn’t function, and that she couldn’t afford the urine drug test. She insisted she wasn’t suicidal and didn’t need to go to the ED Crisis Unit, but begged me to prescribe the clonazepam that her psychiatrist had discontinued. With considerable misgivings, I found a way to see her for an extended appointment later that week.
Alone we go faster, but together we go further. Alone things are simpler, but together things are better. Alone we control the process and perhaps the product, but it is together that we learn and grow.
Let’s do it together.
Sidney Dekker is a world recognized researcher, successful author, speaker and consultant on safety, error, and complex systems. He is currently at Griffith University and most recently was Professor of Community Health Science at the University of Manitoba. He founded the Leonardo DaVinci Laboratory for Complexity and Systems at Lund University. HHis framework for understanding errors, safety and why things go wrong in complex systems is very applicable to managing for excellence (quality and safety) in the health care environment.
My institution is striving to become more patient-centered, and is making good progress, but has an odd way of showing it sometimes.
The primary care providers (PCPs) I work with all love what we do. Partnering with patients to improve their lives is challenging but rewarding work, and I almost never hear regrets about going into primary care. But we do complain. And one of the things we like to complain about is that we often feel abused by our better paid limited-specialty colleagues. It doesn’t happen often, but when it happens, the bad feelings may linger for a long time.
George Bernard Shaw said: “The single biggest problem in communication is the illusion that it has taken place.”
Science is not a linear or predictable path to truth.
A recent commentary in the New York Times eloquently addressed the phenomenon of psychiatric diagnoses biasing clinicians and resulting in poor care. One concern that arose in the comments was that this might increase the likelihood that patients would withhold crucial diagnostic and therapeutic information, to their detriment.
Simplicity and transparency are key ingredients to organizational health.
I made an extra trip to the nursing home to visit him on his hundredth birthday.
Trust but verify (Doveryai no Proveryai) is a Russian proverb that underlies an important principle in medicine. We need to trust our patients, our tests and our knowledge - but must also always remember to check and verify.