What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Saturday, April 22, 2006

The Pursuit of Excellence.

At last an article in the Herald that points out something good about the U.S. Health System. In the Editorial “A Healthy Dose of Safety”, it is revealed that there are 50% fewer deaths from preventable medical causes in the U.S. compared to Canada. The credit was given to the impact of malpractice prevalence. The article goes on to describe how frequent medical errors are in hospitals compared to airlines, and then adds the caveat that “it is an apples and oranges comparison.
I must say, the article precipitated considerable consternation on my part that a comparison could even be presumed. Patients entering a hospital are ill, people entering airplanes generally are quite well. Every aspect of a patient in the hospital must be considered; medications, illness and its impact, the hospital facility, etc. Virtually hundreds of decisions and possibilities need to be made and considered, on each patient, each day, while the patient is in hospital. Patients are in the hospitals for days, people are in airplanes for hours. The airline’s main concern is how to get a person from point “A” to point “B” in reasonable comfort and safety. The hospitals main concern is to rescue people from severe illness and manage their recovery. More like comparing apples to elephants, if you ask me!
On the other hand, I have been aware of an increasing “blasé” attitude in Canada pertaining to “good” health care over the years. As practitioners, we are chastised for practicing medicine from a “malpractice” perspective, and even though, as pointed out in the article, significant medical errors in the U.S. are half of what they are in Canada, this type of medical practice is considered to be “not cost effective”.
The U.S. has been using “health care extenders” for many years as a way of reducing cost. The problem with our system using these non-professional extenders is we continually push for increased productivity in a system where there is chronic undersupply of health care providers. To put this in perspective, let us take a scenario where two hockey players are asked to shoot sixty pucks at the open net from the blue line in one minute flat. One of the hockey players is an average guy who has played hockey a lot, but is not a professional. The other hockey player is Wayne Gretzky. Who do you think will miss the net most often? If the average hockey player could take his own time, he would have far fewer misses. In theory, many health extender personnel are quite competent to do the job for which they were trained; but when under stress and asked to continually to speed up their production, accuracy suffers.
For that matter, the same principles apply to professionals. Some ten or so years ago complaints were registered with the College of Physicians and Surgeons of Alberta regarding physicians restricting their practices. It was felt that physicians had a societal obligation to see patients. To me, at the time, this was absurdity, although the College did deliberate on this issue. In my letter to the College, I advised them that their primary concern was for the public, and as such they should more rightfully be assessing those physicians that did not restrict their practices, and should be reviewing physicians who were overextending themselves (to my knowledge, they never have). There is clear evidence that physicians are often so overworked that they are functioning at a level of alcohol impairment. Now compare this scenario to the situation of airline pilots, stewardesses, and air traffic controllers. This group, rather than being pushed to work longer and faster, is rigidly controlled as to consecutive hours they are allowed to work.
When I was part of the administration of the Rockyview Hospital, I put together a program to more effectively track medical errors. At the time, medical records personnel had to go through nurse’s notes and doctor’s notes (after patient discharge) to glean out any problems that may have arisen during the hospital stay. Of course physicians were to make references as well, to “complications” in their discharge summaries. Unfortunately these summaries were often done from memory and often weeks after the patient had left the hospital. I proposed that one specific sheet on each chart should be dedicated to patient complications while in hospital. This could be done as a “formed” work sheet that both doctors and nurses could chart any adverse events. The page would indicate specifically the nature of the adverse event, e.g. secondary to hospital, medication, surgery, disease, idiopathic, etc. The care giver would simply tick off the appropriate box and make a short comment (slipping and breaking a leg in the hallway would be checked under “hospital” and the comment may be “wet floor”). Health records could easily assimilate all adverse events and they could be analyzed and addressed appropriately.
This suggestion was rejected. The reason given was that “charts were already too thick” and the benefits weren’t evident. My conclusion was “if we aren’t aware of what is going on, we don’t need to address it”. More recently, there has, rightfully, been more attention given to errors in our hospitals. But I doubt that there is still a good “tracking system” in place. It would be a “blemish” on the face of our beloved health care system.

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