Friday, December 7, 2007

Friday Night Relaxing

I recently acquired Sirius satellite radio and I must say: how did I use to deal with drives to and from hospitals before? Imagine being able to control your listening environment completely as you navigate traffic lights, jams and off ramps. Here's my top 5 settings:
1. Channel 32, Grateful Dead radio
2. Channel 26 Left of Center
3. Channel 35 Chill
4. Channel 72 Jazz
5. Channel 17 Jam Bands

I also listen to Jim Rome as a guilty pleasure. In general, though, listening to regular radio is barely tolerable anymore. We've entered the era of optional commercials. You don't even have to watch your favorite TV show with commercials anymore; just watch it the next day on the internet, or wait for the entire season to come out on DVD.

Anyway, there's a terrific article in the New Yorker this week by Atul Gawande. Dr Gawande is a surgeon from Harvard who is also a rather prolific writer. His books "Complications" and "Better" were best sellers. He also writes regularly for the New Yorker as a medical correspondent. Now I have to admit, a few years ago I wasn't the biggest Atul Gawande fan. I suppose I was just jealous of the dude. He is a scientist, a compassionate physician commited to excellence, and a decent man who had endured some personal tragedies. But I focused on his occasional over-earnestness and tendency toward sententiousness in his writing. He was Dr Harvard and the quintessential "academic surgeon" and I was just sick of hearing about him. But I've come around. He's genuinely an intellectually curious guy. His prose is lucid and coherent. I like his stuff.

The article this week is entitled "The Checklist" and it's mainly about the efforts of a intensivist from Washington DC named Peter Pronovost to standardize protocols of care for ICU patients. There's plenty of science to show that unsterile technique leads to higher central line infection rates. That maintaining patients on prophylactic heparin/lovenox will reduce DVT rates. That early enteral nutritional support reduces morbidity in the critically ill. What Provonost found was that most American ICU's weren't consistently following these relatively simple guidelines. His radical idea was to standardize intensivist practice via the use of clinical checklists. Each central line placed had to be done according to protocol; mask, gown, gloves, sterile drapes, chlorhexidine scrub. Nurses made sure residents and attendings followed each step. Ultimately, infection rates were reduced 66%, saving millions of dollars and countless lives. Such a simple idea; but more effective than the billions of dollars pharmaceutical companies spend each year on the development of drugs that provide marginal and sometimes dubious benefit.

The point is that medicine has become too complicated for a single person to remember all the details that ensure its safe and efficacious delivery. The idea of a checklist eliminates the possibility (hopefully) of a crucial forgotten step. All well and good. But I always get wary of medical practice than relies too much on algorithmic thinking. You have to be careful not to try and implement formulas in all areas of medical care, especially surgery. It certainly works in trauma care and the safe placement of central lines. But you don't want to lose the element of flexibility. Sometimes a particular patient won't fit into the paradigm. You could standardize the laparoscopic cholecystectomy if you wanted; mandate that each resident trainee learns the steps in an organized, checklist-type fashion such that by the time he/she graduates, the procedure proceeds without even thinking, one step naturally leading to the next in a robotic, automatic fashion. But I don't operate that way. Each case is always just a little different. Anatomy, body habitus, little quirks always seem to arise that require a bit of improvisation. Sometimes I'll put the subxiphoid port in first, other cases require the subcostal ports to be first. Sometimes you have to take the gallbladder out of the liver bed first, in order to see. I do cholangiograms most cases, but not always. I leave drains in when I feel it's warranted. Sometimes I keep the patient on Zosyn post-operatively, sometimes one dose of antibiotic is all they get. Certainly the overall goal and concept is unchanged, but the route of accomplishing it varies. Algorithmic medicine relegates patients to the status of "object"; a thing upon which to execute a process. Never forget that that body sleeping under the sterile drapes is an individual; with subtleties and variations that just may not fit into your "scheme".


The Happy Hospitalist said...

You can't put a square peg into a round hole. While some stuff can be standardized, so much of medicine can't be.

Standarazing sterile technique? Yes.

Standardizing a patient?

Anonymous said...

I sure wish I knew your name so I could have you as my general surgeon.