Hubris, and the need for less in all discussions…

My brother sent me this link recently just to tweak me.  But the story is really scary. 

There have been lots of comparisons to quality assurance in medicine
and quality assurance in the airline industry.  For instance, a
commonly quoted (but unverifiable by me) point is that if we accepted a
level of significance in the airline industry that we do in medical
research (an alpha of 0.05, basically a 1 in 20 chance of being wrong),
then there may be up to 33 airliner crashes per day.  We require pilots
to check and recheck all their data, using lists and verification by
others, yet if someone dares question a physician’s knowledge or
certainty about something, it’s regarded as heresy or insubordination
(or both, given the god-like status we like to assume).  There are
people who don’t fly because they are scared of the chances of dying in
a plane crash, but there are many (often the same people) who readily
present for admission to a hospital, where the error rate is far more
likely, and more deadly.
Two examples I have been thinking about a lot recently:
In my outpatient practice, there are a few physicians who would rather
not put their own orders in our admittedly clunky EMR – it takes time,
requires too many clicks, etc.  Despite having to write the notes
themselves, they require the nurses do place the orders.  While it may
not be their intent, this does set up a situation where the blame for
improper orders can be easily deflected by the physician.  This is why
so many hospitals are switching to CPOE (computerized physician order
entry).  At least if the process steps are minimized, the error (and
hopefully not the blame) trail is easier to follow.   In addition, it
gives clever system designers a chance to slide in some helpful
decision support.
The other example is in the realm of diagnosis.  Isabel
is a differential diagnosis database – a computer program where doctors
can enter a list of symptoms or clinical signs, and the program will
list a long set of diagnoses that are compatible with the patient’s
presentation.  There’s a touching story
attached to the development of this software, and I have met one of the
people responsible for the software, and they truly are invested in
improving medicine.  But a recent anecdote sticks in my head…nothing
dramatic, just a compliment delivered to one of my colleagues for being
"one of the best diagnosticians in the city."  I do not know what
situation led to this compliment, but it is usually given to primary
care physicians for thinking of the bizzarro diagnosis that no one else
thought of.  It’s usually NOT given for the vast majority of diagnoses
reached in primary care that are correct and based on the most likely
things to cause disease in the population.  In other words, we get
kudos for having the best memories.  But our memories are one of the
most fallible parts of our brains, and begin to atrophy over time.  So,
a decision support tool like Isabel would seem like the perfect tool,
yet it feels like an admission of weakness…I can never get the "best
diagnostician in the city" prize if I rely on a software program, now
can I?
There is so much that has to change in health care to achieve the level
of transformation that would make the system truly safe, patient
focused, and team-centered.  It seems too daunting sometimes.