Medical Care Is a System—It Should Be Subject to System Design and Analysis

The famous pilot, Captain Sullenburger, recently lectured some hospital administrators on safety. He compared the changes that had to occur in the airline industry to the changes that need to be made in medical care.

“Thirty plus years ago, before CRM (cockpit resource management), captains could be alternately Gods or cowboys, ruling their cockpits by preference or whim with insufficient consideration of best practices or procedural standardization…And first officers trying to do the right thing would never quite know what to expect. Some captains did not bother with check lists (and it was unclear who was responsible for what).”

“We worked to build a culture of safety that allows us to face an unanticipated dire emergency, suddenly, one for which we had never specifically trained, and saved every life on board…”

He then put the sorry state of medical care into an airline industry context.

“But medical mishaps, on the other hand, happen one by one. But as everyone in this room knows, all too well, the mortality in America’s hospitals from accidents and hospital acquired infections is nearly 200,000 people per year in the U.S., or 548 lives a day, the equivalent of two large passenger jets crashing daily with no survivors….(if that happened in aviation) the airline industry would come to a screeching halt; airplanes would be grounded and airports shut down. There would be Congressional inquiries and companies would go out of business.”

He then points out that most medical errors are the result of system failures. Just as in the aviation industry, safety requires the development of a culture where all participants were viewed as members of a team. A comparison is implied between the cowboy pilots of yesteryear and the doctors of today who choose not to bother with checklists. He goes on to decry the current medical situation where it is assumed that when something goes wrong it is the result of an individual’s error.

“Conventional wisdom often has it that if a nurse makes a mistake, he or she should be terminated, but the vast majority of harmful events are due to system failures not practitioner error. The (health care) leaders are responsible for the maintenance of these support systems, not the caregivers. And the current punitive culture only drives problems underground where they can never be examined or solved.”

Atul Gawande presented the commencement address to last year’s graduating class from the Stanford School of Medicine. He conveyed essentially the same message as Sullenberger, but he expressed it from the perspective of a surgeon.

“The truth is that the volume and complexity of the knowledge that we need to master has grown exponentially beyond our capacity as individuals. Worse, the fear is that the knowledge has grown beyond our capacity as a society. When we talk about the uncontrollable explosion in the costs of health care in America, for instance—about the reality that we in medicine are gradually bankrupting the country—we’re not talking about a problem rooted in economics. We’re talking about a problem rooted in scientific complexity.”

“Half a century ago, medicine was neither costly nor effective. Since then, however, science has combatted our ignorance. It has enumerated and identified, according to the international disease-classification system, more than 13,600 diagnoses—13,600 different ways our bodies can fail. And for each one we’ve discovered beneficial remedies—remedies that can reduce suffering, extend lives, and sometimes stop a disease altogether. But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we’re struggling. There is no industry in the world with 13,600 different service lines to deliver.”

This leads to the need for a systems-based approach to medical care.

“Diagnosis and treatment of most conditions require complex steps and considerations, and often multiple people and technologies. The result is that more than forty per cent of patients with common conditions like coronary artery disease, stroke, or asthma receive incomplete or inappropriate care in our communities.”

“Like politics, all medicine is local. Medicine requires the successful function of systems—of people and of technologies. Among our most profound difficulties is making them work together. If I want to give my patients the best care possible, not only must I do a good job, but a whole collection of diverse components must somehow mesh effectively.”

“Having great components is not enough. We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists—but we’ve paid little attention to how to make them fit together well.”

He then, ever so effectively, puts this issue into context.

“Earlier this year, I received a letter from a patient named Duane Smith. He was a thirty-four-year-old assistant grocery-store manager when he had a terrible head-on car collision that left him with a broken leg, a broken pelvis, and a broken arm, two collapsed lungs, and uncontrolled internal bleeding. The members of his hospital’s trauma team went swiftly into action. They stabilized his fractured leg and pelvis. They put tubes in both sides of his chest to reëxpand his lungs. They gave him blood and got him to an operating room fast enough to remove the ruptured spleen that was the source of his bleeding. He required intensive care and three weeks of hospital recovery to get through all this. The clinicians did almost every single thing right. Smith told me that to this day he remains deeply grateful to the people who saved him.”

“But they missed one small step. They forgot to give him the vaccines that every patient who has his spleen removed requires, vaccines against three bacteria that the spleen usually fights off. Maybe the surgeons thought the critical-care doctors were going to give the vaccines, and maybe the critical-care doctors thought the primary-care physician was going to give them, and maybe the primary-care physician thought the surgeons already had. Or maybe they all forgot. Whatever the case, two years later, Duane Smith was on a beach vacation when he picked up an ordinary strep infection. Because he hadn’t had those vaccines, the infection spread rapidly throughout his body. He survived—but it cost him all his fingers and all his toes. It was, as he summed it up in his note, the worst vacation ever.”

“When Duane Smith’s car crashed, he was cared for by good, hardworking people. They had every technology available, but they did not have an actual system of care. And the most damning thing is that no one learned a thing from Duane Smith. For we have since had the exact same story occur in Boston, with an even worse outcome. Indeed, I would bet you that, across this country, we miss the basic, unglamorous step of vaccination in probably half of emergency splenectomy patients.”

Finally, he makes the same point that Sullenberger made.

“Why does anyone receive suboptimal care? After all, society could not have given us people with more talent, more dedication, and more training than the people in medical science have—than you have. I think the answer is that we have not grappled with the fact that the complexity of science has changed medicine fundamentally. This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked for ever better performance in providing aid and comfort to human beings.”

Hopefully, more pervasive use of electronic information technology, combined with a change in attitude similar to what occurred in the airline industry, will provide better and more efficient medical care. Electronic information technology would have caught the vaccination issue with Duane Smith. Let us applaud the Obama administration for emphasizing its need.