Sunday, January 3, 2010

Seven-year Itch

My partners and I had under our care a man with a life-threatening problem. His urinary bleeding was severe enough that he required blood transfusions every few days. Surgery seemed the only option that would help him. The complicating factor was that he had suffered a heart attack a week earlier. Giving him an anaesthetic would put him in danger of a second, more serious heart attack.

If we put off the surgery, his condition would gradually deteriorate. At that point, if surgery was performed, he would be weaker and more susceptible to the stress of the operation. Both courses – continuing observation and blood transfusions, or performing surgery – were risky.

Surgeons have a predilection toward intervention over observation. Maybe it’s because physicians with that temperament choose surgery as a specialty. Or, maybe surgeons develop that trait because the medical system triages patients who will benefit from intervention, and streams them into our hands. Whatever the reason, we recommended surgery to our patient. We prepared him as best we could and then took him to the operating room. The bleeding was stopped and he went home 2 days later.

That was a very gratifying and immediate result.


Over the last 3 years, coincident with our urology group’s Advanced Access project, I’ve become involved in other quality improvement efforts, both in the Saskatoon Health Region and also on a provincial scale. As does our office project, these other initiatives address significant deficiencies in health care. I continue to work on all these projects because I strongly believe that, when implemented, they will transform the way patients experience care in Saskatoon and Saskatchewan.

“When implemented”, that is, because it is taking a long time to see results!

In all these projects, the first phase was very exciting: Working with excited and motivated colleagues, and imagining possibilities. But initial planning has given way to the long slog. We meet regularly, but I’m getting discouraged at the lack of progress that I perceive.

I don’t mean that there isn’t action on these projects. Policies and protocols are being written, and subcommittees are formed. But I want to see changes that improve patient care. Pronto. Or I want to focus my efforts on something that will make a difference.

Maybe I’ve been spoiled by Advanced Access. After all, our office project is on a smaller scale, in an environment where I have a fair bit of direct influence, and involves a group of motivated people who directly provide patient care. (I include the docs and our staff in that group.) We’ve had quick payoffs from changes like pooled referrals, better communication with referring docs, and optimizing our patient recall practices. It’s very gratifying to see prompt results from implementation of these changes.

Perhaps physicians’ temperaments (selected by medical schools, or nurtured in medical schools – your choice) are more suited to the satisfaction of immediate results: Surgery for appendicitis, or penicillin for strep throat, for example.

I’m griping partly out of frustration, but I also want to explore my discouragement in order to understand how to maintain other physicians’ engagement in change initiatives. If enthusiasts/early adopters become disenchanted with the slow pace of change, then it’s going to be exponentially more difficult to keep the next echelon of physician champions engaged.

If you’re an administrator, you may be reading this and thinking “Well, what’s so special about Kishore’s time and effort? I sit on the same committees and share the same frustration.” Yes, I’m sure you do. But, there is a significant difference between us. I have another job – my clinical work – and in that job, I get to see the results of my actions regularly and promptly. Almost every consultation requires coming up with a management plan, and then putting the plan promptly into action. Even when the outcomes aren’t the desired ones, there’s still a satisfaction in working through a problem and executing a plan on your patient’s behalf.

So, if I (and other physicians) don’t find satisfaction in tangible results from quality improvement efforts, I can devote all my time to clinical work.

I’m an action junkie. Give me my fix.

1 comment:

  1. You wrote about physicians needing tangible results from quality improvement efforts, so they do not revert to 100% clinical work.

    That thought is sobering to me as a facilitator of QI. How do I ensure my customer-clinicians, can see success of their improvment efforts? (Introspective question. You need not answer.)