Judgment and Experience
Good judgment, it is said, comes from experience. And experience, in turn, comes from bad judgment.
In a true sense, this principle is how we trained our surgical residents for nearly a century. They were primarily responsible for the patient’s care, including their surgical procedures. Experienced attending surgeons were available to assist or guide the resident when the need arose. But mostly, senior residents taught and supervised junior residents, and junior residents taught and supervised interns. Because of their responsibilities, surgical residents had to make decisions they could justify, and they were accountable for any poor decisions they made.
This all changed between the 1980s and the 1990s when Medicare refused to pay attending surgeons who weren’t physically present during operations. This produced a paradigm shift in medicine, providing significant cost savings for the Medicare program. Yet, it crippled the educational value of surgical residencies. By making the attending physician be physically present for every operation, the resident is no longer in a position to make independent decisions. In most cases, the attending calls all the shots, leaving the resident as an assistant or even an observer. Surgical decision-making and judgment are no longer being learned to the same degree.
Consequently, many surgical residents finish their training feeling unqualified to practice on their own. Some opt for fellowships in order to gain more experience in a supervised environment. Once they have completed their training and enter practice, however, they often state that it took them 5 to 7 years of practice – which is, coincidentally, the range of time spent in most residencies – before they felt entirely comfortable as an independent operator. It’s really too bad they couldn’t get that training during their residency, where they had actual supervision and support.
It’s true that we’re talking about patient care. And in previous eras, we let incompletely trained and experienced physicians manage those patients more independently. But how should these young physicians gain their experience? How else can they acquire the ability to exercise good judgment under pressure? Should this happen when they are out on their own, trying to build a practice and recruit patients when they have no structured supervision? Or should it be during their residency program where those financial pressures do not exist and attending physicians are built-in as available resources to supervise and guide them?
Spray Painting Them Pink
The paradigm shift in medicine is to fix the underlying problem, not its manifestation.
When the heart stops, oxygen supply to the tissues is cut so drastically that cells have to try to survive without oxygen, a process known as anaerobic metabolism. One of the consequences of this is an accumulation of hydrogen ions from the hydrolysis of ATP exceeding the rate of ATP production, producing a metabolic acidosis. This can be demonstrated on an arterial blood gas sample as a low pH (i.e., less than 7.40) and a negative base excess, otherwise known as a base deficit. It has been demonstrated that the lower the pH and the more severe the base deficit, the worse the patient will do, with death being the likely consequence for those with the most abnormal values.
We were first able to detect this clinically after the invention and development of blood gas analyzers in the late 1950s by John Severinghaus. Physicians began to note this acidosis in the early 1960s when cardiopulmonary resuscitation (CPR) was introduced. It was also noted that if sodium bicarbonate, a base, was administered, the acidosis could be reversed. For decades, it became standard practice to administer “bicarb” as a routine during CPR. The justification was that acidosis could impair cardiac performance and its response to catecholamines such as epinephrine (adrenaline). Because of this, clinicians were instructed to correct acidosis with sodium bicarbonate before giving epinephrine during CPR.
Of course, this was all theoretical because we weren’t directly measuring cardiac performance or catecholamine responsiveness. That was all below our radar. In fact, there are a number of studies and reviews spanning back several years that attest to the fact that such bicarbonate is, at best, of little use or actually harmful because of the severe acidosis it can produce inside the cells (which is definitely beneath our radar).
The simplistic approach was to fix a number that was actually the result of a problem rather than the problem itself. Correcting acidosis by giving bicarb is as effective as treating a suffocating cyanotic (blue) patient by spray painting them pink.
Quality Improvement and Lawsuits
There is a disturbing dynamic in the interplay between quality improvement and our parasitic medicolegal system.
Medical malpractice plaintiff’s attorneys consistently claim that they seek to get rid of bad doctors or bad hospitals, thereby justifying their frequently unfounded attacks on healthcare practitioners and facilities. If these claims are sincere, it suggests that they are providing a quality management service to healthcare. Unfortunately, the reality is quite the opposite.
Is “getting rid” of poor performers the right approach? Do we seek to “get rid” of anyone convicted of criminal behavior by executing all felons, or do we seek to rehabilitate them? What kind of rehabilitation or reeducation is offered to “bad” practitioners? How do we know the “bad doctors” are consistently poor performers? Does the legal process allow any metrics upon which to base these assessments, or is the determination made simply because a legal case can be built against the presumed incompetent and juries’ proclivity to reward sympathetic plaintiffs? What about those situations where an individual makes an unfortunate decision despite a stellar career of providing excellent care?
Rather than improving the quality of healthcare, the medicolegal system seeks to destroy it. The heavy penalties and resultingly high malpractice insurance means there is less money that can be spent on actual healthcare. Do we do this in any other industry? When a school system is failing to educate its students, do we sue them to get rid of the bad teachers and the bad schools? Or do we actually throw more money at them to help them improve? Did we destroy our national intelligence systems after 9/11, or did we throw more money at the problem and create whole new agencies and operational structures? In fact, it seems that in every other sector of our economy, any failings are treated with financial subsidies, especially with the current administration in Washington. It is only healthcare that is consistently expected to do more and more with less and less. We have been penalized with frivolous and ridiculous lawsuits for decades, fronted by specious claims that quality is being sought. And now, with the advent of Obamacare, the overwhelming expectation is that the healthcare industry will receive a financial penalty of 20%.
The paradigm shift in medicine will be to change the medicolegal system so that it is no longer a parasitic and destructive force.
Medicine out of the Box 