NEWS 05.06.2010

Keynote speakers at DHSA research symposium address need for change in culture of health-care delivery

Safe air travel and antiquated medical practices like bloodletting may seem to have little in common, but the keynote speakers at the 2010 Delaware Health Sciences Alliance Conference used these arenas to argue for cultural and scientific change in America's health-care system.

John Nance spoke of the need to transform the human component of health-care delivery through collegiality, cooperation, and collaboration, and Michael Lauer advocated the use of comparative effectiveness research to guide decision-making in administering tests and therapies.

Nance is an author and aviator, and Lauer is a physician and director of the Division of Cardiovascular Sciences at the National Heart, Lung, and Blood Institute.

Lessons from Aviation

Nance's 18th book, Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care, won the American College of Healthcare Executives' 2009 Book of the Year Award. In it, Nance tells the story of fictitious St. Michael's Hospital, which undergoes a revolutionary cultural change based on a foundation of collegiality, cooperation, and collaboration-in that order.

Nance entertained the conference audience by incorporating anecdotes and video clips into a talk that had a serious message: "This is the way we've always done it" is not a valid argument for maintaining a dysfunctional system.

He emphasized that the pipeline between discovery and delivery has to include not only hard science but also sociology, psychology, and anthropology. "We have a lot to do in the area of people dealing with people," he said.

According to Nance, it's a myth that human perfection in medicine is achievable. However, he said, we can come much closer to creating an error-free medical system if health-care professionals work in teams where everyone's opinion is sought and valued and where no member of the team is afraid to speak up when something appears to be wrong.

Collegiality is a critical component of this approach, he said, because it promotes communication without barriers. "When you care about someone," he said," it's hard to put barriers between you. And in the end, we have to ask ourselves, 'What are we here for?' The answer is 'We're here for the patient.' We're not here to mark our territory or to argue about who's right."

The primary lessons that medicine can take from aviation, Nance said, are teamwork and the use of best practices. As an example he cited U.S. Airways Flight 1549, which experienced an emergency landing on the Hudson River and turned pilot Sully Sullenberger into an overnight hero for saving the lives of all 155 people on board.

"There was no miracle on the Hudson," Nance said. "Surviving the landing was not a miracle-landing on the water is a procedure you can read in a manual. Aviation is not smarter than medicine, but we got bloodied enough times to realize the importance of using best practices and understanding the difference between leadership and commandership."

According to Nance, part of the problem in the field of medicine is that doctors have been trained to work "out on the prairie," called to a patient's bedside at 2:00 in the morning with black bag in hand.

"The issue now is that we need to train them to work in teams in these marvelous modern institutions like Christiana Care," he said. "We can't do it the way we've always done it-we have to move on if we want to build a unified system. What we have now is a non-system with wonderful parts."

Lessons from Bloodletting

After experiencing good health for most of his life, America's first president died at the age of 67, when two of the three doctors attending him decided that the best treatment for his throat infection was bloodletting to eliminate the "bad humors" from his body. George Washington lost eight pints of blood in as many hours and almost immediately succumbed to shock and dehydration.

Despite his death-and many others-bloodletting was a common therapy for a wide range of ills well into the nineteenth century, and, according to Lauer, it remains a symbol for a paradigm within the medical system where treatments whose usefulness is questionable continue to be administered by doctors and requested by patients.

With health-care costs skyrocketing, the American Reinvestment and Recovery Act of 2009, also known as the stimulus bill, includes funds for the National Institutes of Health to support comparative effectiveness research. CER is aimed at containing costs and improving health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision-makers.

Much of the current focus is on tests. "With the tremendous proliferation of imaging techniques," said Lauer, "the issue of whether they're adding value or just adding cost is under close scrutiny. Just because a test can predict an outcome doesn't mean its use will prevent the outcome."

CER is aimed at determining whether screenings are actually life saving and whether there is solid evidence to support their use.

Lauer cited an example from his own field, cardiovascular medicine, where a study initiated in the late 1990s focused on the wisdom of discharging patients who have been successfully treated for an acute event but still have occluded arteries. The treatment of choice has traditionally been percutaneous coronary intervention, or PCI, a term referring to one of several procedures such as balloon angioplasty that are used to open blocked arteries.

"Many doctors were so convinced of the value of PCI," Lauer said, "that they actually thought it would be unethical to assign any patients to the control group, which was slated to receive all of the best medicines but no artery reopening procedure."

It took millions of research dollars and more than a decade to reach the conclusion that PCI of a totally occluded artery is not recommended after a heart attack if the patient shows no sign of ischemia, or limited blood flow.

"This moved a little faster than bloodletting," Lauer said, "but even so, one could argue that 11 years is too long."

Debate about evidence-based medicine is fierce for a variety of reasons, including patients' desire to have the most technologically advanced tests and therapies available, doctors' fear of malpractice, and insurers' efforts to contain costs.

As for bloodletting? In 1809, a surgeon named Alexander Hamilton (no relation to the statesman) actually conducted an early version of a randomized controlled trial that demonstrated just how deadly the practice was. Hamilton and two other Army surgeons rotated treatment of 366 injured soldiers at a hospital in Portugal during the Peninsular Wars. He and one of his colleagues lost only four and two cases, respectively, while the surgeon who "employed the lancet" lost 35 patients.

Despite the evidence, it took more than a century for the practice to be abandoned, and as Lauer asserted, it lives on as an icon of the medical profession's reluctance to give up commonly accepted tests and therapies.

Article by Diane Kukich