Tuesday, October 24, 2006

I Agree --- In Spades

For those general surgeons out there who receive General Surgery News, I hope you took the time to read this article by Dr. David Cossman --- he redefines the term "rant," and in the process pokes a stick in the eye of the of those who push "quality improvement" initiatives upon us that have no proven quality nor any hope for improvement. Here are a few excerpts:

This time, the blood on my hands was my own. And it was from a self-inflicted wound. Unintentional, not wholly unexpected, but surprisingly painless for a cut down to bone from a 10 blade through a latex glove. For those of you who have watched me operate lately and suspect a demyelinating disease as the root cause of this vicious digital attack, you’ll have to wait a little longer before I hang up the needle holder. I’m neurologically intact, but apparently incapable of operating the new “safety sleeves” on our scalpels without what must have appeared to have been an earnest attempt at autoamputation.

After the tetanus shot, six stitches, Ancef and washing off the “yes” in magic marker on the bleeding finger, I did what every red-blooded injured American would do—I called the manufacturer of this stupid thing and threatened to sue.

Silly me; I missed the point again. It seems that this protective device had been added for everyone’s protection except the one using it. .... The safety sheath was not there to protect me or my patients. It was there to protect the manufacturer, the distributor and the hospital that handed me the knife against lawsuits charging malfeasance, negligence and disregard for the user’s safety. There it was, a bloodstained inch-and-a-half piece of half-penny plastic, the symbolic refinement of modern day risk management at its best.

.....Sound familiar? Is it still a surprise when laws, policies and programs not only don’t work but too often are 180 degrees off target? No, it’s not surprising, because too often these instruments of public policy are little more than an opportunity to articulate a point of view instead of well-thought-out solutions to problems. It’s not surprising that policies and laws that are nothing more than ornamental expressions of political correctness not only fail to achieve a stated goal but may, paradoxically, almost comically, produce exactly the wrong results. Part of the problem is that they frequently address problems that don’t exist or might not exist.

.....failed social policies long on good intentions but short on results enjoy near-immortality because to criticize them exposes one to a veritable thesaurus of epithets. It seems that society saves rigorous outcome analysis and expectations of perfection only for projects where profits are involved. If you’re spending money instead of making it, you get a free pass if the cause is right. That’s why the drug companies take such a beating, even though there isn’t a single reader of this column whose life won’t be prolonged because of their products.

.......The moral equivalent of the carpool lane hit our profession big time with the brilliant introduction of the 80-hour workweek. I have to chuckle each time I read a “study” that attempts to quantify the effect the 80-hour workweek has had on patients, residents and surgical outcomes, as if anything would convince the perpetrators of this foolishness to retract the policy if it wasn’t working.

....Of all that has been written about the 80-hour workweek there is only one irrefutable fact: It is here to stay but not because it contributes even an imaginary sliver to patient safety. It is here to stay because it is the public’s warning shot fired across the bow of the medical profession to warn us that we’re in the crosshairs of public scrutiny. It really is hard to imagine that the policy could serve any other purpose. After all, you have to admit it’s a stretch to believe that a “postcall” resident asleep on the end of a retractor somewhere in the right upper quadrant is a danger to anyone. Oh I forgot, they’re going to go home, get some rest, and then read, read, read Schwartz’s Textbook of Surgery so they’re going to be better and smarter doctors in the future. Or better yet, they’re going to read Proust and Voltaire so they’ll be better, more cultured and more humane doctors so they won’t wind up jaded and cynical and write columns like this.

...On the other hand, the purpose isn’t really to solve the problem, is it? No, what we’re witnessing here is as primitive (and futile) as an ancient animal sacrifice, hoping that the gods (media, lawyers, politicians and patient advocacy groups) will sate themselves with the scent of the entrails laid at their feet.

....Remember the law of unintended consequences. Even if you could squeeze surgical education into a shorter workweek, even if you could prove to the Resident Review Committee that your residents are actually doing as many cases as they used to, even if you can make up numbers to show that no one has died in a hospital since the enactment of this absurd offering to the gods, we would still have the unintended consequence of what punching a clock has done and will do to a surgical culture molded by a century’s obsession with tireless adherence to dedication, detail and discipline. To defend that culture against the ululations of the compliance jackals and the medical error junkies is to get tarred as the anachronistic defender of an outdated order.

....In the final analysis, I’m not far from lying in my hospital bed looking up at my surgeon who is fixing to rummage around in my chest, brain or abdomen. I don’t want to look up and see a time clock puncher in my hour of need. I don’t want someone who went weeping to the program director because some attending looked at him or her cross-eyed. I don’t want someone who was given six chances to pass the boards. I don’t want someone who had the time to wait 30 minutes in the Starbucks line to get a double decaf vente latte. I want someone whose training has steeled him or her to handle whatever it is he or she is about to find inside. I’ll take such a person, even when she’s tired. I know he or she will wake up and do the right thing when the time comes.

One day, I'll find a way to match the voices of frustration whispering inbetween my ears with the words I write the way Dr. Cossman does. And, I'd like to add, there is not one single word in this column I could even remotely disagree with.