October 13, 2015

NASHVILLE, Tennessee — Patient outcomes depend just as much on well-coordinated teams as they do on technically skilled clinicians, said Atul Gawande, MD, a health policy professor at the Harvard T.H. Chan School of Public Health in Boston and a staff writer at The New Yorker.

To illustrate, he described the case of Duane Smith, who was involved in a car accident and was left with broken limbs, a fractured pelvis, collapsed lungs, and a ruptured, hemorrhaging spleen, which had to be removed.

Smith pulled through after a 3-week stay in an intensive care unit, but did not receive the three vaccines that would guard against streptococcus and other bacteria that the spleen normally clears.

Two years later, during a beach vacation with his wife and daughter, Smith came down with an ordinary strep infection that his body was powerless to combat, and developed sepsis.

"He survived, but he lost all of his fingers, all of his toes, and his nose," Dr Gawande told more than 3000 people here at the Medical Group Management Association 2015 Annual Conference. Many groaned when they heard what happened.

"It's not clear where the breakdown was," he explained. "Some people thought the outpatient physicians would take care of it. Some people thought maybe the ICU would take care of it. The ICU thought maybe the surgeons would take care of it. But it didn't happen."

It's hard to believe. But hospitals weren't all pulling in the same direction to begin with.

"We have trained, hired, and rewarded physicians for being cowboys, but it's pit crews that we need for our patients," he explained. "Teams of clinicians deliver far better results than autonomous specialists, each doing their own thing."

In his 2009 bestselling book — The Checklist Manifesto: How to Get Things Right — Dr Gawande points out that surgical checklists are one way to build clinical teams that keep patients like Smith from falling through the cracks.

In the operating room, such checklists, adopted from the aviation industry, prod clinicians to periodically stop and review surgical goals and safety risks — before the induction of anesthesia, before the first incision, and before the patient leaves the operating room. In the process, every team member introduces themselves and describes their role.

This approach is in sharp contrast to the traditional culture of the operating room, in which everyone concentrates on their own specialized tasks, but not necessarily the big picture, Dr Gawande said. "The most common places where things break down are the spaces between these folks."

Hospitals implementing surgical checklists have achieved dramatic improvements. "The average reduction in complications was 35%, and the average reduction in death was 47%," he reported.

"There isn't a drug or device that can do anything like this, and it's free. It's hard to believe. But hospitals weren't all pulling in the same direction to begin with," Dr Gawande explained.

More to Life Than Living Longer

During his presentation, Dr Gawande advocated for a new checklist: seven end-of-life questions for terminally ill patients. This reflects his professional and personal interest in the problems of aging, which he addresses in his latest book, Being Mortal: Medicine and What Matters in the End.

In that book, published last year, Dr Gawande explains that medicalizing mortality — merely keeping people alive, whether in a hospital ICU or a nursing home — tends to increase human suffering, and wastes money in the process. He also describes how it is possible to help people die on their own terms, but truly live until that time comes.

"We assume their goal is survival," he told the audience. However, "people have things to live for besides living longer."

Dr Gawande described one seriously ill patient who said he wanted to continue to receive medical treatment as long as he could eat chocolate ice cream and watch football games on television.

But every person is different. In Being Mortal, Dr Gawande chronicles his father's death from spinal cancer, and says that his father believed that life was worth fighting for if he could sit at the dinner table with his family and friends.

The checklist for terminally ill patients that Dr Gawande helped develop can be used to uncover a person's wishes.

Seven End-of-Life Questions for Terminally Ill Patients
What is your understanding now of where you are with your illness?
How much information about what is likely to be ahead with your illness would you like from me?
If your health situation worsens, what are your most important goals?
What are your biggest fears and worries about the future with your health?
What abilities are so critical to your life that you can't imagine living without them?
If you become sicker, how much are you willing to go through for the possibility of gaining more time?
How much does your family know about your wishes and priorities?


Dr Gawande said he has occasionally pushed the questions too hard with terminally ill patients, or soft-pedaled them. But getting the questions right has been "one of the most gratifying experiences that I've had, and our team has had," he said.

"And that's weird, because I'm a surgeon," he pointed out. "I want to go and fix things."

Medical Group Management Association (MGMA) 2015 Annual Conference. Presented October 12, 2015.


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