Friday, May 30, 2008

Spice of Life

Last week’s post brought some interesting responses. I had suggested that a large hotel’s elevator system was a good model for managing health care queues. A couple of people commented that, in principle, it might be advantageous to have a system that automatically assigns patients to the shortest wait list. However, they wanted to have a choice of which physician they saw.

They point out that personalities and skills vary among physicians, and some people will choose to wait longer so they can see someone they have confidence in.

I agree that it’s important to let patients choose their physician – recognizing that their choice may result in a longer wait. Our recently implemented "default" referral system recognizes this. As of May, all new referrals to our practice are considered "pooled" and go to the urologist with the shortest wait time. If the patient requires subspecialty attention, we set up the appointment with the appropriate urologist. However, the patient or referring physician can request ("No substitute") a specific urologist, with the understanding that there may be a longer wait.

Returning to the elevator analogy, some people may prefer the "services" of a specific elevator. Most of the elevators were glass-walled and faced out over a 40-storey atrium. Anyone with a fear of heights would be very uncomfortable with that ride and would prefer to wait for one of the enclosed elevators.

So, choice is important. But, it's not the only solution to this problem. And perhaps not the most desirable one, either.

The commenters' concern is about variation – in skill, attitude or personality. If we eliminate variation among physicians... problem solved! (OK, let's just say drastically reduce variation.) Some variation is desirable, if it brings value to the patient. Say, a subspecialty expertise, for example. But most of the time, variation in medical practice is just muda.

I know some of you are thinking You can't take a bunch of intelligent, highly-trained, technically-capable and highly independent professionals and expect them to practice the same way.

Really? Are you planning to fly sometime soon? As you board the plane, take a peek into the cockpit. The pilots are reviewing checklists and following standard procedures. They're certainly independent professionals, yet they're not allowed to "cowboy" that Airbus through the jetstream. When was the last time you heard of someone refuse to get on a plane because they weren't comfortable with the pilot's abilities? The aviation industry has standardized training and procedures so that we can travel safely and confidently.

This has been done in high-stake enterprises like commercial aviation and nuclear power, and it can be done in health care. While doctors scorn "cookbook medicine," most of us practise it to some degree, whether we realize it or not. Protocols for intravenous feeding, checklists for postoperative orders, and practice guidelines for cancer follow-up are a few examples that I used today alone.

(It’s ironic that "cookbook medicine" is used derisively. After all, chefs use cookbooks/ recipes in order to deliver consistent, high-quality results.)

As part of our Advanced Access project, we implemented a hematuria checklist for referring physicians. This standardized request for pre-consultation testing reduces confusion among referring physicians. They don't need to remember 9 different testing schemes when they refer their patient with hematuria. It (theoretically) increases the likelihood that we'll receive the necessary information in time for the patient’s appointment.

Developing, and agreeing to use, best practice models will reduce waste and improve consumer confidence in healthcare. As for physicians who cling to dysfunctional professional autonomy, here's a quote from a colleague, mocking docs who dismiss "cookbook medicine":
"I treat my patients individually, not by a cookbook. I reserve the right to screw up their care in a unique and tailored fashion."
He’s a little cynical.

Variety may be the spice of life, but it's the bane of quality.

1 comment:

  1. Originally posted 05/30/08 1:30 PM

    Standing ovation to Dr. Visvanathan for such a sensible approach to providing quality, accessible care. As a nurse and an educator I have wondered for years what was wrong with using a "cookbook" approach when it was best practice and would avoid confusion, uncertainty and mistakes.