The Checklist Brawl at Brigham and Women’s
I haven’t read the book called When Doctors Don’t Listen but it was just reviewed in the Boston Globe. Brigham and Women’s Hospital emergency room physicians Dr. Leana Wen and Dr. Joshua Kosowsky state that docs “often tune out a patient’s story when seeking a diagnosis and simply clue in on specific symptoms, which may lead them to over-test and over-treat.” Yeah, yeah, I have heard that before. We also don’t let patients speak long enough before interrupting and make a diagnosis before walking into the room. Guilty. Is it bad? Yes, it’s horrible! The issue is that we are now herding cattle in a system likened to Industrialized Medicine. The new quality indicators and P4P modules are only making it worse.
Here are some points made in the article:
- Today’s doctors have failed to practice the art of listening to gain a context in which to place a patient’s symptoms.
- Wen, who’s completing her residency training, admitted that she, at first, stuck to this form of cookbook medicine — ticking off a checklist of symptoms in her head as a patient spoke — in an effort to become an efficient doctor. “Without realizing it, this became my practice too,” she wrote in the book.
- Kosowsky, who’s vice chair and clinical director of Brigham’s emergency medical department, called it a “failure in the way doctors are being trained to think,” a result of too much reliance on high-tech imaging tests and blood tests to measure biomarkers that weren’t around a generation ago.
- “It’s about finding a balance,” he said in an interview. “Neither Leana nor I would say to throw all guidelines out the window, and doctors are well intentioned when they follow these protocols,” Kosowsky said, “but they’ve taken on an oversized role.”
- In an era that’s ushering in medical checklists to help doctors and nurses avoid transmitting infections or leaving instruments in a patient during surgery, both Wen and Kosowsky told me that while such lists make be fine for improving safety, they shouldn’t be used when making a diagnosis.
So wait a minute, there is an art to medicine? Cookbook medicine, guidelines, protocols and checklists aren’t everything? Thinking is important? Sounds like AUTHENTIC MEDICINE to me.
On a side note, Dr. Atul Gawande wrote The Checklist Manifesto, which argues that we need more checklists that will “bring about striking improvements in a variety of fields, from medicine and disaster recovery to professions and businesses of all kinds“. He is at the same institution as these writers. Who’s right? Wonder if there may be a little schoolyard fight going on over at Brigham and Women’s?
I think people get so enamored with checklists and protocols that they fail to realize every intervention isn’t appropriate for every patient. Review boards get very excited when an intervention isn’t done; the obvious fact that it wouldn’t help and MIGHT HARM a particular PATIENT are apparently nonissues. Medicine stopped being an art to these people a long time ago.
That is what I have been saying for years!
Checklists are a TOOL, and that is all. More important is HOW it is used, and the mindset of the user. Over the years in healthcare I have seen checklists ad nauseum and even designed quite a few. Some have been extremely helpful while others aren’t worth the paper they are written on. I use some checklists daily to ensure I get adequately detailed information, but recently completed a 27 page checklist my employer insisted be done immediately. I didn’t even have time to read it completely, so I’m sure that will be accurate. In my experience, checklists required as documentation are some of the least valuable, while those used informally and voluntarily are most useful. Of course, this assumes our goal is to assist clinicians in achieving good patient outcomes, and not regulatory satisfaction.
I recall years ago I went to the hospital for leg pain and they did a lot of tests for my circulation and found nothing wrong. No one asked about my environment but I figured out myself that since I drove delivery for a living, my drivers seat had worn down to almost nothing. Replaced the seat and my leg got better. Now I look for proximal causes anytime I have a medical problem to see if I am the one causing it. ps I quit smoking in ’94.
I think you just touched on the most pertinent factor in patient care. Active involvement by the patient or caregiver. Although physicians are given the overall responsibility for diagnosis and treatment, the greatest factor is still the patient. When they are honest and forthcoming during diagnosis, engaged during treatment planning, and responsible during treatment, outcomes are far better than than any checlist or system can accomplish. As in your case, you looked at your activity and environment, made changes that have resolved a current health issue, and (hopefully) prevented many more.
Hi! Doug, thank you for the excellent article, and everyone else, for your comments. I can see what you’re referring to as the “checklist brawl”, but actually, we are on the same page.
Let me explain. I totally agree with Dr. Gawande regarding checklist for treatment. If I am going through a surgery, or have a complicated chemotherapy regiment, I want to make sure a checklist is followed. That’s safe, and better, care.
However, what I disagree with is checklist for DIAGNOSIS. Studies have shown that 80% of diagnoses can be made based on the history–based on listening. Checklists of questions “do you have chest pain, shortness of breath, nausea, vomiting, etc?” miss the story, and result in misdiagnosis. When doctors stop listening, they miss the story, to the detriment of patients.
Is this common sense? Absolutely! As Doug points out, this is in fact authentic medicine that we are advocating for. This is hardly in competition to Dr. Gawande’s concepts, which are all very valid–for TREATMENT. The problem is that the first, most critical part, is often ignored: the DIAGNOSIS.
Hope this helps. Please do read our book if interested!
http://www.amazon.com/When-Doctors-Dont-Listen-Misdiagnoses/dp/0312594917/ref=sr_1_1?ie=UTF8&qid=1340904977&sr=8-1&keywords=When+Doctors+Don%27t+Listen%3A+How+to+Avoid+Misdiagnoses+and+Unnecessary+Tests
Thanks,
Leana Wen
I will Leana and thank you so much for the response. As I pointed out to my friend on this blog, Dr. Olstein, it is a balance of both. This blog fights against the pendulum going too far the other way (away from Authentic Medicine and towards Industrialized Medicine).
These complaints are very old and not very useful, as if doctors in the past were better than today. How much time are we supposed to spend with each patient? The more time, the less number of patients, and more people are sent to the ER. Also, what to do with the all-too-common patient with the laundry list of complaints? What about late patients? Old confused people on 30 meds who are dizzy? Truth is the majority of physicians today are excellent and doing their best in a very stressful profession. Teaching people to be “better listeners” will solve little.
Gawande is right. His checklists have to do with procedural and safety issues, not diagnosis and treatment. He advocates that we use in medicine what works in aviation. Checklists for history and physical are anathema.
The answer, in my opinion, is that we need BOTH. The problem is that the gov’t, insurers, and the administrators only care about the numbers (checklists) which swings the pendulum too far in one direction.
At one level, there is a belief that if we have enough checklists, there will be no errors (look at how many people reportedly die of medical error vs the number of people dying on commerical airliners….the two should be the same, no ?).
In the world of my hospital, the heparins by checklist are supposed to held if the person’s platelet count is less than 100K. In MY world (cancer care) I routinely over-ride that check box since the risk of my patients forming a clot is too high. There is no perfect line. A patient who is uremic needs more platelets, a patient with widely metastatic pancreatic cancer needs more anti-coagulation.
Time outs in the OR prior to an operation are an appropriate use of check lists. All the never events that I have reviewed (operation wrong site or wrong patient) usually had, for some reason, failed to do the time out.
I have a HUGE beef with evidenced based medicine, some times. In my world, the majority of the clinical trials are sponsored by drug companies who are doing the darndest to get drugs approved. I get that. It’s business. However, when I am asked to use “evidence” that would have precluded my patient because she is on warfarin, has had a stroke but seems a reasonable candidate for treatment…..there is no evidence for THAT patient. We are asked to extrapolate, but that extrapolation will always be imperfect.
Just some musings that go nowhere on a Sunday morning. Yes…clicks and guidelines can never be the be-all end all. The world of meaningful use and EMR’s would like to suggest differently, but it really isn’t so.
Great response!