Should your hospital be your ride?

I recently had the opportunity to attend an event by my institution’s human-centered design group.  With escalating penalties for 30-day re-admissions on the horizon, they’d been charged with finding a way to bring our rates down. Like any set of Lean-trained professionals, they began delving into the chain of causes leading to patients bouncing back into the ER (i.e. the “5 Whys”).  Their thought process was: We’re having too many 30 day re-admissions (why?). Because patients are missing their follow-up appointments (why?). Because they can’t arrange transportation (why?).  At this point, two different threads emerged. On the one hand, public transport wasn’t sufficiently robust to deliver the patients to their appointments and take them home in a timely manner; on the other hand, patients had trouble arranging rides home because clinic appointments tended to run late and they never knew when they needed to be picked up.  The latter is a process-centered, Lean-friendly kind of problem (and can be addressed as such). But what about the former? The logic was that “Either through re-admission penalties or taxi vouchers or some other way, we’re paying for these patients inability to find adequate transportation. So why not do it directly?” So the presenters began a pilot program providing transportation to patients who couldn’t find a ride.

Note that we only got “3 Whys” deep before we lost the distinction between the responsibilities of the healthcare system and the responsibilities of society at large. Since many hospitals are public institutions, I don’t believe this is necessarily wrong.  However, we need to acknowledge the uncomfortable position this puts us in.  The medical-industrial complex already plays a large role in our lives. By expanding the explicit responsibilities of healthcare organizations, we also expand their responsibility for the (generally unspoken) social determinants of health.  Doing so creates redundancies and conflicts between different healthcare organizations and between healthcare organizations and the social support systems they try to supplement. Competition drives innovation, but economics of scale drives efficiency.  The question is: how de we find a balance between the two?

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Are doctors obligated to seek knowledge that has no medical benefit?

The New York Times published an article titled “A Life-Death Predictor Adds to a Cancer’s Strain” or, alternatively, “Genetic Test Changes Game in Cancer Prognosis.”  The piece is interesting on several levels, but, to me, serves to highlight an increasingly common ethical conundrum: are physicians obligated to seek knowledge that is available but has no possible medical benefit?

Most of us are familiar with the Schrödinger’s cat thought experiment (the basic setup: a cat is placed in a box, along with a device that has a 50/50 chance of killing it within the hour).  Suppose Schrödinger decided to actually carry out this experiment and you happen to be the veterinarian for the poor soul whose cat he borrowed.  Having been rushed to the scene by a distraught owner, you are faced with a choice: open the box and reveal the cat’s present state of health or wait and let the cat reveal itself by its eventual demands to be let free (or lack thereof).

Where my story runs parallel to real life: at the point of decision, Schrödinger’s veterinarian and the physician have no power over the patient’s outcome.  Their professional capacity as healer has been exhausted. The cat is either dead or alive.  The patient has Class 1 or Class 2 ocular melanoma (and its attendant mortality).  Until the proverbial box has been opened, however, neither state of affairs has quite come to pass.  The patient is neither doomed nor saved.  The physician stands as the portal of knowledge, holding the key that could dispel fear but also kill hope.

Typically, patients just want the good news.  In a perfect world, only patients with the treatable Class 1 melanoma would have the test performed.  Their Class 2 counterparts, on the other hand, would avoid it and preserve their hope until the end.  Unfortunately, this perfect world requires physicians with prescience (or an ethics “flexible” enough to perform the test without the patient’s knowledge).

What, then, of our imperfect world?  Is the possibility of relief worth the risk of a death sentence?  Further, what is the physician’s role in answering this question?  It is my belief that the option must be presented. The decision to know or not know is deeply personal.  Once he has stepped outside of his role as healer, the physician has no expert knowledge to justify any form of paternalism.  While he can serve as counselor, interpreter and friend, the physician has no right to decide if the possibility of finding a dead cat is worse than waiting next to a terrifyingly silent box.

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A Rare Episode of Political Outrage

Have we, as a nation, tired of trying to do good? Through long years in Iraq and Afghanistan, through all the bumbling and corruption, through all the billions of dollars spent and thousands upon thousands of lives lost, this was our last defense: “Despite our shortcomings, we are trying to do good.”

As far as I can tell, there is little disagreements over the facts: who was killed, what weapons were used, who gave the order. This is not “solid intelligence.” This is children dead in the streets. And yet, we hesitate. “We are tired of war.” we say, as if armed conflict is like hunger, a desire to be sated but not overindulged, instead of a travesty to be avoided except when absolutely necessary.

But, sometimes, it is necessary. We are at a turning point. Previously, chemicals weapons were of limited use to the isolated dictator, since the common wisdom was deploying them would bring down the wrath of the international community. Turning a blind eye to Assad now will send every tyrant in the world scrambling to add to their arsenal.

For many, many reasons, Syria is not Iraq. We cannot having done wrong in the past prevent us from doing what is right now. We cannot mistake laziness for caution or political expediency for wisdom. We cannot mistake being tired with having learned something.

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Do We Only Care When the Privileged Die?

I have no doubt that Lewis Blackman was a wonderful young man.  He beams out of all the pictures included in The Faces of Medical Errors, a charismatic, good-looking teenager.  Despite our tendency to deify the dead, I have no trouble believing all of testaments to his intelligence, character and joy.  Based entirely on the courage and poise of his mother, I’m sure all of the praise heaped upon him in the opening minutes of the video cannot begin to touch the reality of his potential as a human being.

And yet, as these accolades rolled on, I felt a growing annoyance pulsing in the back of my skull.  The purpose of the film was to viscerally connect us to the consequences of medical errors, to strip away the comforting veneer of facelessness from patient safety lapses and give us a regrettable casualty we could fixate on. As I gazed at the pictures of Lewis floating by, I couldn’t help but wonder if the video was unintentionally striving to sell us on the “regrettable” part of the formula. Lewis could have been my little brother.  He was athletic, talented Caucasian male born to educated parents who entered the hospital for an elective procedure.  Despite our best efforts, race and class are difficult to eradicate from our visceral reactions.  Even as I was moved nearly to tears by the Lewis’s story, a dissenting voice was growing in strength

What if Lewis had been a poor African-American boy, in the hospital for a sickle crisis?  Or a homeless person, in the hospital for an OD? Or an undocumented immigrant, in the hospital giving birth? Or a teenage drug dealer, in the hospital for a gunshot wound?  Especially in light of recent events in Florida, it is difficult to argue that, as a culture, our assignment of blame is unbiased. Rationally, I believe that the death or injury of any patient due to a preventable error is inexcusable.  Each is equally a tragedy.  But I cannot with perfect honesty claim that any of the stories above would impact me the way Lewis’s did (I am interested if any of my colleagues here at Telluride with more diverse backgrounds feel differently.  Do I only care so asymmetrically about Lewis because, to paraphrase President Obama, “ten years ago, Lewis Blackman was me”? Please let me know your thoughts on this.).  The realization made me equally sad and angry.  I was angry that the film was pulling strings whose very existence filled me with shame.

This is not, however, meant to be an analysis of class relations.  I’m writing about this internal struggle because of the revelation that followed on its heels.  Lewis was, by most estimations, a child of privilege.  While this does not make his death any more tragic, it does make it more problematic.  Lewis entered the hospital with powerful advocates who, while not medically trained, were educated and assertive.  If Lewis, backed by a mother who understood what his vital signs meant and was unafraid to speak up for her son, could fall victim to a harmful medical error, what chance do the indigent, the elderly and the handicapped have in our medical system?   What a call to action this is!  Our methods of healthcare delivery are capricious to the point of transgressing  our normal social constructs.  This realization allowed me to harness the emotional power of Lewis’s story to remind myself that Lewis, compared to hundreds of other patients in the hospital that day, had an excellent chances of walking out unscathed. Scores of more vulnerable patients are exposed to the same systems that caused his tragic.   If we truly hope to do no harm, Lewis’s story should serve as a constant reminder of how far we have to go to protect all of our patients, regardless of the situation into which they were born.

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