Two very different cultures in medicine

Was the surgeon a princess, complaining about a pea under her mattress? Or am I a sheeple, accepting a woefully inadequate system? What do you think?

I received a call from a surgeon in another community, updating me about a patient I had referred. During her discussion of the patient, she commented rather parenthetically and without any details that there had been a problem during surgery. When I asked what the issue had been, she told me that the patient had done fine, but that there had been two problems during the procedure leading her to file a ‘ticket.’ Two standard items (gauze and a specific type of retractor) were not immediately available on the OR tray during surgery. The retractor turned out to be present but not in its usual place, requiring a pause while she and the scrub nurse searched and ultimately found it. Only half of the usual supply of sterile lap pads had been included, the remaining obtained from the supplies in the OR during the case.  Listening to her talk about how disruptive this was, and how she and the team responded, several things struck me:

  • Surgery has a culture where it is accepted that everything possible must be done to ensure that surgeon has all the equipment and all the information necessary before the procedure starts. There is a viewing facility for films. The chart and operative packs are checked for completeness before anesthesia begins. The operative site is marked with indelible ink. The equipment packs are designed to contain everything necessary for the procedure.
  • Even small things that are easy to resolve are considered disruptive and therefore potentially dangerous; they extend surgical time, interrupt concentration and flow, and increase the risk of error and harm.
  • The team is not expected to ‘make do’ in the face of missing or non-functioning information or equipment.
  • Inefficient and unreliable systems are known to make OR turnover slower, decreasing revenue
  • There are systems and extra people ready to immediately identify and fix issues.
  • In this instance, the OR managers made sure it was resolved by end of day and would not be repeated the next day.  Specifically, she noted that the process started by deciding whether this was an individual problem (a person who did not use the proper system or did not use the system properly) or a systems problem (where the system itself was the issue).

This is nothing like the outpatient world of the PCP using an EHR with a patient during an office visit:

  • In our world, clinicians are expected to figure out how to do safe and high-quality care despite chronically missing information and user-hostile systems. There is rarely discussion of re-engineering either the work-flow or the EHR to make them smooth, reliable, and intuitive so the clinician can focus on the two things that can never be standardized: the patient and the illness. The EHR is optimized for audit and billing, not clinical work or user efficiency. We routinely see patients without access to the full range of information pertinent to their visit, often without even knowing that there is information missing. (The unknown unknown.)
  • Small issues are ignored, and medium to large issues are not addressed with anything resembling urgency - if they are addressed at all. EHR forms routinely include broken functionalities, navigation is complex and distracting, interfaces are busy and poorly designed and hide important clinical information. Information is not automatically presented in the correct context, and worse, there is no search function to find it. Decision support is not consistently integrated into the EHR but often requires opening separate programs or navigating to separate web sites and then manually entering patient-specific information. The printer is located far from the clinician and the patient who need the printed material. The limited guidelines and standards that are present in the EHR are frequently incorrect and out of date. Equipment is routinely stored in locked closets in a different room.
  • Making do is not merely acceptable, it is the standard. We are routinely told that ‘we know the EHR is hard to use, but there is nothing we can do about it.’
  • Our culture and systems ignore the fact that, in addition to impairing safety and quality, poorly engineered systems that make the clinician think about multiple things other than the patient also impairs productivity. (It costs the institution money.)
  • In the primary care office, there is no system designed or specific staff on hand (or even remotely available) devoted to ensuring that the clinician has all the needed equipment and information before beginning a visit. 
  • Glitches and problems are hard to report, and often addressed as a specific problem rather than an instance of a systems failure. (A result that didn’t ‘flow’ into the data base will be manually entered, but the reason for the problem not investigated and resolved.)

When I told her she was being picky, she responded that I had it backwards. She was not wrong to demand a system that allowed her to focus laser-like on the patient and the procedure.  I was derelict in not demanding a similarly reliable and efficient system that would allow me to be focused on the patient and our interaction.


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