TedMed talk- Functional Medicine

Some of you might want to check out this video of a talk given by Mark Hyman about a "systems" approach to health care.

"Our current approach to chronic disease is like using hacksaws to treat trauma"--Mark Hyman (in the video)

"Functional Medicine addresses the underlying causes of disease, using a systems-oriented approach and engaging both patient and practitioner in a therapeutic partnership" - The Institute for Functional Medicine

Whoops! Totally forgot to post this on Saturday

Professor Jennings’ promise that Atul Gawande’s book, Better: A Surgeons’ Notes on Performance would be an easy and enjoyable read definitely held true.  I even read parts of it leisurely in the park as suggested.  Gawande’s tone of voice throughout the book it casual, even friendly.  I found myself laughing at parts, especially during the chapter, “Naked,” which discusses the awkwardness and danger involved in a doctor’s attempt to perform as appropriately as possible when examining his patients in the buff.  (By the way, never say “boob” or comment on a patient’s tattoos or tan lines, for you future doctors).   This book touches upon many of the issues and factors that we have discussed in class, exemplifying the complexities of “the hospital” as a system with many dynamic parts that influence overall success. Seemingly simple standards, such as hand washing, are explained to be extremely difficult to implement.  Why is it much easier to enforce standards of hygiene in the operating room than in nonsurgical patient care? 

 These questions drive the goals of Deborah Yokoe and Susan Marino, women whose job it is to minimize the spread of infection within the hospital.  Maintaining hygiene is one of the many systematic intricacies involved in the smooth running of a hospital. He also discusses how efficiency in scheduling, staffing and stocking of materials are crucial.  I particularly enjoyed the chapter “The Mop Up,” which discusses the way medicine is administered in alternative circumstances. (The chapter about war also touches upon this). Gawande joins Dr. Pankaj in an effort to vaccinate 4.2 million children in Southern India, in only three days!  Doctors created a special marking system to distinguish between vaccinated and non-vaccinated children.  This chapter was particularly interesting to me because it mentions the possibility of patient mistrust or skepticism to medicine.  Some parents refused for their children to receive the vaccination, as a rumor spread that the Indian government was trying to sterilize Muslim children. I think that this is a difficult issue for doctors to face, not only on WHO expeditions, but also in the everyday hospital setting. What are you supposed to do when a patient refuses treatment?  In class, we began talking about some factors that influence consent, such as age and coherence.  I think the issue of consent is especially interesting when it involves children.   

To stray off topic a bit, last semester I conducted research on the now closed Willowbrook State School of Staten Island, New York, where hundreds of mentally handicapped children were administered live hepatitis cultures in an attempt to devise a vaccine.  The parents of these patients consented to the experimentation, but there was severe controversy surrounding these experiments (conducted by NYU’s Dr. Saul Krugman in the 1950s) since it was thought that parents were coerced to consent for their children’s participation in order to grant their children admission to the facility at Willowbrook. This is just one of many cases in which incentives were used to induce patient participation in experimentation, another includes the Tuskegee syphilis experiment performed on impoverished black men in the South.  Medical ethics are always sticky, anything that involved the endangerment of one’s health/life leads to vexed debate.

Is it Worth the Risk?

Gawande's article "The Checklist" addresses the issue of doctors being required to use a checklist when dealing with patients or in the transition period between patients.  The argument is whether or not doctors should be required to use such checklists or whether doing so would be a waste of time and resources in an industry that is already understaffed and low on time.  My assertion would be whether or not it is worth the risk to not require doctors to use such a checklist in the hospital.  While most doctors would point to their years of training and experience as justification for not needing a checklist, I believe that looking at other professions in which great risk is involved that employ the use of checklists will help add validity to their use in the hospital.  What comes to mind immediately for me is astronauts.  Astronauts train for almost a decade to do one mission.  They know exactly what they are going to do and when they are going to do it.  And yet the countdown procedure before take off lasts close to two hours as they check to make sure absolutely everything is in order, even if they know beyond a shadow of a doubt that it is.  In this case, the idea of a checklist is being used for the safety of the astronauts and probably also has to do with the monetary investment that has gone into the expedition.

To take the most seemingly harmless example from the article about the checklist, handwashing is something that a lot of doctors and nurses complain that they don't have time for, so having a checklist require them do it would be a waste of time.  My assertion is whether or not the risk of infection of a patient is worth that extra few minutes a doctor needs to make sure they are sterile before interacting with a patient, and I for one would say that it is not worth that risk. 

Checklist

Gawande does an incredible job on describing how there are thousands of steps to complete in the intensive care unit. These steps are not only the ones needed to save the patient but also to keep them stable for the time that they are held in ICU.

As Gawande says most actions taken in the ICU consist of brushing the patients teeth to prevent bacterial buildup, turning them in bed so that pressure ulcers don't form and many more daily routines that will not even come to mind when thought of. Along with the huge responsibility of being a doctor, a nurse, a surgeon how can people go by doing all of these steps without skipping one or making a tiny mistake? That is where the checklist steps in.

The checklist has proven to reduce the errors made in medicine. But as most of you have highlighted this is sometimes a matter of ego and self-confidence for doctors. Having been going through the same processes for years and years can make some doctors reluctant in wanting to use the checklist. But I think that no matter how good a doctor is or how many years he has trained, they have the chance to make mistakes every once in a while. So, to minimize the damage that might be done to the patient, the checklist should be used.

Ego

(After multiple technical errors and a faulty wireless connection…many attempts later)

As some people have mentioned already in their posts, it seems absurd that doctors would ignore results and refuse to use simple devices like checklists to save patients’ lives. 

This part of the article reminded me of Gawande’s section in Better about handwashing. He tells the story of the Viennese obstetrician Ignac Semmelweis who in 1847 figured out a way to reduce the leading cause of death from childbirth, childbed fever (puerperal fever). In hospitals, the maternal death rate was 20%, whereas for home births it was only 1%. With proper handwashing procedures, he got the rate in his ward to fall to 1%. However, colleagues were offended by the claim that they were the cause of these deaths and he in turn "took calls for proof as a personal insult" (16). On both sides, there seems to be an overly large problem of ego. His colleagues were offended by his theory and he was offended by their disbelief; a fairly absurd reason to endanger the lives of patients.

In Gawande’s account of the modern-day implementation of proper handwashing protocols, some similar problems arise. However, the solution of "finding solutions from insiders" (25) and looking for instances of "positive deviance" (25) seemed to be one possible solution to the problem of ego. When the hospital implemented this program, "it was the first time those people had been heard, the first time they had a chance to innovate for themselves" (26). This idea of innovating for themselves and change from within seems to help avoid the problem of ego to some extent. Having to worry about whether doctors will be personally offended and noncompliant when trying to save patients’ lives is seems to imply a much larger problem amongst those who pursue the medical profession today.

Also, for more interesting thoughts from Gawande: http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html

Are Doctors “Too Good” for a checklist?

   

          Gawande does a wonderful job describing the ways in which hospitals can remarkably reduce error via checklists. Despite the stunning evidence and substantial difference a simple checklist can make, I am baffled as to why hospitals across the nation have yet to adopt such system. Although Gawande touches upon such reasons, I wonder if physicians are not taking these checklists seriously because of egotistical reasons. They are undoubtedly effective and empirically proven so why not? It is possible that doctors’ reluctance steams from overconfidence. Going through decades of education and training and then having to use a checklist to tell them the things they already know may fell demeaning. Below is an excerpt from the article that led to my assumptions:

It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The body is too intricate and individual for that: good medicine will not be able to dispense with expert audacity.

          Although understandable, I think this is a foolish reason not to use an empirically proven device that significantly reduces error. It is not a question that many doctors are competent experts, however, they also are human and make mistakes. Adhering to checklists does not indicate incompetence, in my opinion, it is indicative of responsibility and conciseness and is the epitome of competence. Furthermore, as an aspiring physician, I would feel so much better if I can turn to a checklist or have a nurse point out something that I forgot to do. To achieve good medicine, there is no room for pride and I believe so much more can be accomplished via a team effort without the added pressures of making simple mistakes. 

The Human Body: Modern or Moronic

Atul Gawande's "The Checklist" portrays a very frustrating push- pull relationship about the lengths and limits of human beings. On the one hand, you have doctors who have the luxury of saying survival in hospitals is a commonplace thanks to the technical achievements made by human intelligence and creativity. On the other hand, it sounds like these technical achievements are making survival too robotic. The first example in the article describes the surreal incident of doctors being able to go to extraordinary lengths in order to save a girl's life who ordinarily would have been pronounced dead upon arrival to the hospital. The chance of her being able to not only survive, but regain the quality of her life was turned around 180 degrees in a matter of two weeks thanks to both modern machinery and the doctors' knowledge about it. This story spoke highly of doctors acting as real life superheroes, but they were only allowed to have such a success story because of the machinery available throughout the hospital. In fact, when the girl's story of recovery was being shared, it sounded more like someone was building a Frankenstein robot rather than saving a human's life. In one way it sounds like less of a triumph because the doctors forced recovery upon a body which could not heal, with the help of doctors, on its own. In another way it says that people should be proud that technology allows doctors and patients to have more control over the safety and progress of their recovery because patients deserve to live as long as they can. In no way do I think that a person's life should be cut short when there are so many modern options that could go so far as bring someone back from practically the dead, but I question if people want to prevent death and disease so much, they will recreate their bodies with pumps and tubes and metal in order to add years on. Why not take advantage of all the medical choices we have waiting to help us; I just question the quality of a person's life being improved when part of them was built in a laboratory.