Accountability in the Medical Profession: A GIM Perspective

1. 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

2. Disclosures 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

3. Objectives Define accountability Provide a statement of the problem Describe what is known Outline future steps

4. A Definition The responsibility of an individual provider for the care that he/she does or does not provide for an individual patient

5. The Topic • Why? • Patient Safety in Surgery, Eds. P Stahel, Mauffrey • Procedural vs. cognitive specialties • Provider-patient relationships • Personal accountability vs. institutional

6. The Problem http://www.examiner.com/article/new-survey-income-and-job-satisfaction-of-physicians-part-2-of-2 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

7. The Public http://www.citizen.org/doctordiscipline

8. A Case 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.

9. A Case His girlfriend called an ambulance to take him to the emergency room in his local rural hospital, which lacked a CT or MRI scanner.

10. A Case 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.

11. A Case 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.

12. A Case 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.

13. A Case 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’.

14. A Case 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.

15. A Case 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.

16. Pitfalls for Accountability Time Stress Perfectionism Peer pressure Competing priorities And so on…

17. A Little History Sir John Gregory – Scotland/England 1700s Hopkins Circle Flexner

18. Guilds • Medieval to Gregory’s time • Tradeprofession • Service • Skill

19. ProfessionProfessionalism Leverage science for patients’ well-being Sympathy Conflict of interest Shared decision-making Medical Ethics

20. Medical Ethics Beneficence Nonmaleficence Justice Autonomy

21. Accountability Models Economic Political Professional

22. Aviation as a guide Learning from mistakes Making science of crashes objective Flattening flight crew hierarchy Targeted zero errors

23. The Example of Handwashing 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

24. Error Reporting Blamefree systems (i.e. PSN) Accountability Reprimand “Just culture”

25. Efforts in Academic/Training Settings • Surgical residency programs • Abstraction from “Professionalism” literature (Papadakis et al.) • Leveraging error tracking systems • CPHP/CPEP

26. What GIM Providers Can Do 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

27. A Conceptual Model Health Care Facility Community Patient Physician/Provider Accreditation/ Government Insurer/Administrative Party

28. Summary 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

29. Acknowledgements • Phil Stahel • LEADS faculty (Cathy Battaglia, Christine Gilroy, Rita Lee) • Holly Batal

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