Transcript J Long 4 2 13 DGIM - University of Colorado Denver

Accountability in the
Medical Profession:
A GIM Perspective
Jeremy Long, MD, MPH
Assistant Professor of Medicine
Track Director, LEADS, U of C SOM
April 2, 2013
Disclosures
© 2012 Denver Health
• I receive grant funding from the Colorado Health
Foundation for LEADS (Leadership, Education,
Advocacy, Development, Scholarship)
• Views are mine and do not represent TCHF, DH, or
UC SOM
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Objectives
© 2012 Denver Health
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Define accountability
Provide a statement of the problem
Describe what is known
Outline future steps
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A Definition
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• The responsibility of an individual
provider for the care that he/she does
or does not provide for an individual
patient
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The Topic
© 2012 Denver Health
• Why?
– Patient Safety in Surgery, Eds. P Stahel,
Mauffrey
– Procedural vs. cognitive specialties
– Provider-patient relationships
– Personal accountability vs. institutional
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The Problem
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• 54% job satisfaction for primary care physicians
• As many as 100,000 deaths annually attributed
to medical errors
• Expanding statute/regulation/documentation
• Technology
• Malpractice & defensive medicine
http://www.examiner.com/article/new-survey-income-and-job-satisfaction-of-physicians-part-2-of-2
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The Public
© 2012 Denver Health
http://www.citizen.org/doctordiscipline
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A Case
© 2012 Denver Health
Scott Torrence, a 36-year-old insurance
broker, was struck in the head while
going up for a rebound during his
weekend basketball game. Over the next
few hours, a mild headache escalated
into a thunderclap, and he became lethargic
and vertiginous.
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A Case
© 2012 Denver Health
His girlfriend called an ambulance to take him
to the emergency room in his local rural
hospital, which lacked a CT or MRI scanner.
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A Case
© 2012 Denver Health
The emergency room physician, Dr Jane
Benamy, worried about brain bleeding, called
neurologist Dr Roy Jones at the regional
referral hospital (a few hundred miles away)
requesting that Torrence be transferred.
Jones refused, reassuring Benamy that the
case sounded like ‘benign positional vertigo’.
Benamy was worried, but had no recourse.
She sent Torrence home with medications for
vertigo and headache.
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A Case
© 2012 Denver Health
The next morning, Benamy re-evaluated
Torrence, and he was markedly worse, with
more headache, more vertigo, and now
vomiting and photophobia (bright lights hurt
his eyes). She called neurologist Jones
again, who again refused the request for
transfer. Completely frustrated, she
hospitalised Torrence for intravenous pain
medications and close observation.
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A Case
© 2012 Denver Health
The next day, the patient was even worse.
Literally begging, Benamy found another
physician (an internist named Soloway) at
Regional Medical Center to accept the
transfer, and Torrence was sent there by air
ambulance. The CAT scan at Regional was
read as unrevealing (in retrospect, a subtle
but crucial abnormality was overlooked), and
Soloway managed Torrence’s symptoms with
more pain medicines and sedation.
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A Case
© 2012 Denver Health
Overnight, however, the patient deteriorated
even further—‘awake, moaning, yelling’,
according to the nursing notes—and needed to
be physically restrained. Soloway called the
neurologist, Dr Jones, at home, who told him
that he ‘was familiar with the case and… the
non-focal neurological exam and the normal CT
scan made urgent clinical problems unlikely’.
He went on to say that he would ‘evaluate the
patient the next morning’.
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A Case
© 2012 Denver Health
But by the next morning, Torrence was dead.
An autopsy revealed that the head trauma had
torn a small cerebellar artery, which led to a
cerebellar stroke (an area of the brain poorly
imaged by CT scan). Ultimately, the stroke
caused enough swelling to trigger brainstem
herniation—extrusion of the brain through
one of the holes in the base of the skull, like
toothpaste squeezing through a tube.
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A Case
© 2012 Denver Health
This cascade of falling dominoes could have been
stopped at any stage, but that would have
required the expert neurologist to see the
patient, recognise the signs of the cerebellar
artery dissection, take a closer look at the CT
scan, and order an MRI.
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Pitfalls for Accountability
© 2012 Denver Health
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Time
Stress
Perfectionism
Peer pressure
Competing priorities
And so on…
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A Little History
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• Sir John Gregory – Scotland/England 1700s
• Hopkins Circle
• Flexner
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Guilds
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• Medieval to Gregory’s time
– Tradeprofession
• Service
• Skill
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ProfessionProfessionalism
© 2012 Denver Health
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Leverage science for patients’ well-being
Sympathy
Conflict of interest
Shared decision-making
Medical Ethics
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Medical Ethics
© 2012 Denver Health
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Beneficence
Nonmaleficence
Justice
Autonomy
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Accountability Models
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• Economic
• Political
• Professional
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Aviation as a guide
© 2012 Denver Health
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Learning from mistakes
Making science of crashes objective
Flattening flight crew hierarchy
Targeted zero errors
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The Example of Handwashing
© 2012 Denver Health
• Infections acquired in healthcare settings
lead to >100000 deaths per year – many
(most?) are preventable with better
infection control (including hand hygiene)
• Passive vs. active efforts to improve
compliance
• AwarenessEducationTraining
EnforcementPunishment
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Error Reporting
© 2012 Denver Health
• Blamefree systems (i.e. PSN)
• Accountability
• Reprimand
• “Just culture”
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Efforts in Academic/Training Settings
© 2012 Denver Health
• Surgical residency programs
• Abstraction from “Professionalism” literature
(Papadakis et al.)
• Leveraging error tracking systems
• CPHP/CPEP
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What GIM Providers Can Do
© 2012 Denver Health
• Collaborate on ways to promote
accountability
• Use it as a tool with trainees to enhance
ACGME core competencies
(professionalism, systems-based practice)
• Discuss with care teams in clinical settings
• Discuss with patients
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A Conceptual Model
© 2012 Denver Health
Health Care Facility
Community
Patient
Physician/Provider
Accreditation/
Government
Insurer/Administrative Party
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Summary
© 2012 Denver Health
• Accountability is simply defined but more
complex when approached scientifically
• Medical practice involves a human element
which must be acknowledged but also
aided to seek best practice
• Errors must be framed in a way that
learning and improvement can occur
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Acknowledgements
© 2012 Denver Health
• Phil Stahel
• LEADS faculty (Cathy Battaglia, Christine
Gilroy, Rita Lee)
• Holly Batal
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References
© 2012 Denver Health
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