Sunday, November 26, 2006

Fly me away to the OR

In my last post, I brought up the issue of the current push to ensure that docs and hospitals should meet a whole series of quality improvement measures. Many in the business world (such as the Leapfrog Group) look upon medicine as a rag tag bunch of people who are trying to do the right thing, but need better management to reign in complications (really with an eye to reigning in costs). They, correctly, point to the success the airline industry has had in establishing an excellent safety record; we could learn a lot from these folks, IMHO (actually, there is a good review of airline safety applicability in the July, 2005 issue of the Journal of the ACS -- "The Aviation Paradigm and Surgical Education"; McGreevy JM, pages 110-117). But I do think it's a bit over simplistic to compare health care delivery to the delivery of people and goods via aircraft. Here's the best way I can describe the differences.

You buy a ticket to go from Dallas to Chicago. You check in, board the plane, and are flown with a surprising degree of ease to your destination by a pilot who will then shepherd the same plane on to Boston, and maybe points beyond. After a certain period of time, he will fly a similar plane on a similar set of routes. Cool. You don't think twice about all of the little things that go into a successful flight --- the mechanics, the safety checks, the fuel, weather issues, etc.

Now let's compare the pilot to, oh, I don't know, a general surgeon (what I lack in imagination is made up by a complete deficiency of imagination), and that surgeon will do four operations today. The first is a laparoscopic cholecystectomy on a healthy 50 year old; the second is an incisional hernia repair on an obese, diabetic, hypertensive 70 year old; the third is a colectomy for cancer on a reasonably healthy 65 year old, who had an MI last year; and the fourth is an urgent laparoscopic cholecystectomy --- but that patient is put at the end of the day, because she is on Coumadin and needs to have her anticoagulation reversed, carefully though because of her CHF. Please don't laugh --- I have these types of days not infrequently.

That, to my way of thinking, is sort of having the pilot above start out flying on a nice sunny day in a 737, switching to an aging 747 that's not in the best of shape for the next flight, flying as carefully and straight in a thunderstorm for the third flight, and then trying to safely land a Sopwith Camel with one wheel missing at the end of the fourth flight.

I'm not trying to say that what I do is in any way more stressful or difficult than what others do for a living; this comparison is itself overly simplistic. I am just trying to make the case that each doctor-patient interaction is not the same, and some are vastly more challenging than others --- and that coming up with an absolute set of parameters that must be met in each and every instance is difficult, if not impossible, and will not be applicable in a large number of cases.