Close to Perfect

If you are looking for a theme to this blog, I have one.  The theme is not simply writing about what happens to be on my mind.  It is true, that I like to write about a variety of topics and my inspiration, like most people who enjoy writing, is based on what I know.  However, the overarching theme is really to write about topics that touch upon our shared humanity.  We have much more in common with each other despite efforts of the world around us that try to emphasize our differences.  I hope that in some way, my various posts will emphasize this point and encourage all of us to see what links us to others around us and throughout the world. 

As I mentioned in my last post, I am a urologist.  For those of you who are unfamiliar with this medical specialty, you may want to stop now and remain blissfully unaware.  I tell my patients, urologists are the plumbers of the medical world.  Unlike a nephrologist who focuses on the filtering function of the kidney, a urologists deals with parts of the genital and urinary tract that have gone bad or are obstructed (blocked) in some way.  It is a broad field that combines medical and surgical care, benign and malignant disease, and spans diagnosis, treatment and surveillance for many conditions. 

I have a heavy emphasis on surgery in my practice.  Like many surgeons, days in the operating room can be both exhilarating, stressful, and tedious all at the same time.  Not to delve into details but most of my practices relates to care of patients with urologic cancers and a major focus of my practice is robotic-assisted and minimally invasive surgery.  Last week, I had a long day planned with three minimally invasive surgeries.  How long a particular surgery takes is dependent on a long list of variables that include patient factors (prior surgery), disease factors (complexity of the problem the patient needs surgery for), and process/system related factors.  For the most part, I know what to expect for the first two variables.  I have been in practice for a while and knowing how a patients’ medical and surgical history will impact my surgery have come through trial and experience.  I also know how long in general it will take me to address a particular surgical problem-  an organ that needs to be removed completely or partially for cancer or other disease.  What I have less control over is the system/process level issues that I will face in any given day. 

Surgery takes a team.  Some surgeons practice in an environment where they have a consistent team that they work with all the time.  That is not true for me in an academic medical center and may not be true in other settings for other surgeons.  With a very fluid operative load at many academic medical centers, those who are managing operations in the OR need the flexibility to assign anesthesia teams, circulating nurses, and scrub techs/surgical assistants based on which surgeons are operating on a given day, how many surgical cases there are, what types of surgeries are running that day, how many hours of standard staffing the surgical team has, and a number of other variables.  This could mean that I start off with one team at the beginning of the day that changes over the course of the day as staff get pulled to other rooms based on their expertise, shift changes, or a number of other reasons.  This is for the most part done in the name of efficiently managing patient care and the needs of the staff, surgeons, and anesthesiologists.  This also doesn’t take into consideration the members of the team that are not directly involved in the surgical care: pre- and post-op nursing, techs that turn over the room, people who clean instruments to name a few.  A wrinkle in a normally scheduled day can occur if any of these people become scarce or unavailable. 

That is why my day last week was close to perfect.  I had a surgical day that started on time and ended two hours earlier than I would normally anticipate based on the uncertainty of staffing and surgical complexity.  The reason for this was not because I operated fast or cut corners.  The primary reason for this great day in the operating room was because I got to work with the same team from start to finish.  What was even better was that I worked with a group of highly skilled people that had experience with the type of surgeries I perform.   

This “perfect day” generated some thoughts and points I hope to discuss here.  My initial reaction was one of gratitude toward all the people I worked with that day.  The mantra amongst many physicians (especially those who tweet, blog, or communicate through social media) is that the practice of medicine is getting worse and many physicians are leaving medicine because of the hurdles placed in front of them to care for patients.  Here was a counterpoint to this argument-  I spent the whole day doing what I was supposed to do thanks to the great team that I got to work with that day.  At the end of that day I thanked my team individually and sent each one a note telling them how they made a difference in caring for patients that day.  In addition, I sent an email to all of their supervises expressing my appreciation but I also emphasized several important points. 

My first point (that is going to sound like a broken record) was that individually, none of us could have accomplished this feat of excellent surgical care and efficiency but putting the right team together allowed us to do this.  I don’t need to go over the data- we all know that putting consistent teams together improves performance. When people work together over time, it allows everyone to learn how each person communicates, their strengths and weaknesses, and most importantly to establish processes.  Throughout the day, the circulating nurse and scrub tech not only made sure the right equipment and supplies were available but also edited my surgical preference card to reflect what we needed to do the surgery accurately. 

Which brings me to my second point.  Doctors fleeing medicine will not solve the challenges that all clinicians face in caring for patients.  I could have stopped at thanking my team but I emailed everyone’s supervisor to emphasize how good our care can be when the system works in an ideal state.  “Defending in place” to steal a critical incident term and trying to improve the system from within has a better chance of solving the problems we face than leaving the system all together.  We are all replaceable and as more physicians leave practice out of frustration, Health Systems will develop alternative strategies.  The risk is that these strategies will not meet the standards of care that we expect for our patients.  If our motivation is to deliver care to people who need it, doctors need to be part of the solution and not merely vocal victims outside the system.  People have developed various mechanisms to fight back- large single specialty groups, concierge care just to name a few but underlying these are financial motivations.  Financial needs of physicians who have expended a huge opportunity cost to become doctors is an important consideration but we must marry this with the obligation of a physician to help our fellow human beings be healthier and alleviate suffering.  I think it is hard for physicians to do this in these alternative models because, by nature, they are adversarial to the established systems.  While these models can be change agents, they need to take into consideration the broader issues of health and wellbeing (beyond financial remuneration) to have a seat at the table for making clinical practice for all clinicians better.

My third point again might seem stale but it is important to call this out in the hierarchical system of medicine and particular surgery.   Surgery, especially high risk surgery, has historically been a cult of personality.  The expert surgeon is both revered and feared.  This has created environments in the past where surgeons who mistreated their team in the OR were given a pass because of what they were able to do.  I find this totally unacceptable as someone who cares about patient care.  Often, surgeons who function in this way wind up working with people who are considered “survivors” because they keep their mouth shut and do what they are told.  While on the surface, this might seem effective, in emergency circumstances or cases where that surgeon is not performing at optimal level, the fear and culture created in that environment prevents the rest of the team from speaking up.  Unfortunately, we see this all too often.  Our surgeons are aging and the medical community continues to grapple with how to value experience of a senior physician but understand the limitations of all of us as we get older.  In addition, age often has nothing to do with it.  If certain people had not spoken up, how long would the neurosurgeon, “Dr. Death” been allowed to maim and kill people who trusted him with their care?  Surgery is a team sport and while the surgeon is often the captain of the team, valuing the experience, expertise, and opinion of all of the members of the team in the OR suite can be the difference between life and death.  I believe that while our education and credentials provide us the skills and expertise to perform certain functions, it does not entitle us to view ourselves as better than someone else.  If you asked an experienced surgeon to act as a scrub or circulator, they would realize quickly that they were not trained to perform these vital roles and everyone in the room must be respected for what they contribute. 

I’m going to make one more point.  This revolves around the tension in any administrative role responsible for staffing balancing expertise and coverage.  Having held administrative roles, I appreciate both sides of the argument.  As I alluded to above, administrators are not intentionally trying to pull valuable people out of the room.  Their primary responsibility is ensuring that there are enough people to get the days work done.  They have to contend with all sorts of issues- staff calling in sick, staff preferences, unexpected emergencies, surgeries that take longer than planned and numerous other tiny variables that pop up during the day.  While systems are in place to proactively manage this, the “best laid plans of mice and men”….often are foiled by the circumstances we would least expect.  The tension for those on the receiving end to emphasize my point above is that we are not simply widgets.  Putting person A or B into a surgical case can result in vastly different outcomes. 

There is a compromise that to some might seem uncomfortable.  Especially in academic institutions, we labor under the belief that we are “All Above Average” to borrow a potentially tarnished term from stories about Lake Wobegon.  But the truth is, the average needs to be set internally and not externally.  When we do this, we end up with the typical bell-shaped curve where, yes, some of us are above average but others are at or below average.  Inherent to the idea of staffing effectively is the concept of avoiding overtime and attempting to create as much consistency in a schedule as possible.  The administrative solution is to move us around like widgets but this hurts the busiest and most efficient surgeons the most.  The surgeons that operate a few times/month should not be treated the same as those who operate 3-4 times/week.  Running an experiment where key surgeons who set a good team culture in the OR, are busy, and provide consistent outcomes to their patients by ensuring a consistent team (within reason) and evaluating the effect through a PDCA cycle with the metric of surgeon/staff satisfaction, cost per unit of service (which would take into consideration efficiency and time), and patient outcomes (length of stay, readmission) and comparing this to standard staffing would give leadership of a health system data to understand how thoughtful teams impact not only the OR but downstream hospital days and patient outcomes. 

I called this post “Close to Perfect” for a reason.  In healthcare and other industries, we try to achieve perfection but it is an endpoint we will never reach.  We can only try being better every day.  We can’t get better if we leave medicine altogether, fail to value our teams, or are unwilling to consider alternative strategies.  I viewed my day in the OR as a lucky circumstance but luck should have nothing to do with this.  I have had other good days in the OR before and since but it creates a huge strain on me when I am working with the less than optimal team.  Next time you are working with your team, don’t forget to thank them, value them for what they contribute, and strive to be a little better together the next day. 

If you made it here, thanks for reading my post and I appreciate any insights and comments you may have. 

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