From the stage, Dr. Atul Gawande sits in an armchair in comfortable repose and reads aloud to the mostly silent crowd. With his slight frame and soft-spoken demeanor, he makes no show of authority or presence. He commands the attention of the room with his reputation alone as he retells a story from his days as a young resident on an internal medicine rotation.
Dr. Gawande is a surgeon at Brigham and Women’s Hospital in Boston, but he’s better known as a popular author with a list of bestselling books. One of his favorite recurring topics is what the practice of medicine can teach us as about competence and performance. As he reads aloud from his current selection, he relates how the experience and conscientiousness of a senior resident allowed him to make a difficult diagnosis that would have been otherwise missed.
Closing the book, the doctor takes a deep breath and after a thoughtful moment observes, “In medicine, failure is easy. Failure ... is almost effortless.” Then he pauses while those words hang in the air, and the audience lets the observation sink in.
Failure is almost effortless.
The pain of poor care
Mulling over his words, my mind wandered to the noisy cabin of an H3 Sikorsky helicopter and a trauma patient enroute to the hospital, being cared for by an elite mountain rescue squad. I had been invited aboard to write a story about the team’s unique operation, and everything about them had impressed me greatly — except for that moment when the patient was secured to the treatment area. For all of their technical rescue skills, the team’s medical care was abysmal.
I thought about a paramedic friend of mine who had recently spent time riding along and photographing medical crews in the Middle East. He had been looking forward to seeing the street medicine of the highly trained and nationally recognized service. His opinion was succinct. “Nice guys, but their medicine sucks.”
One doesn’t need to travel overseas or fly in helicopters to track down poor medical care in the prehospital setting. It’s everywhere. None of this is news to ER staff, who witness daily the vast difference in care from one service to the next, and even among individual providers within the same organizations. EMS has its share of dirty little secrets, and this one is certainly up at the top of the list. Much of the care that we provide is simply substandard, even when our standards are low.
No easy solution for a hard problem
Solutions to this problem are predictable and often overly simplistic. The fix-it crowd clamors for higher educational standards, more clinical hours, stronger professional representation and rigorous quality assurance measures. None of these would hurt, but all of them overlook Dr. Gawande’s essential observation. The practice of medicine is hard. And failing to provide good care is far easier than rising to meet the challenge. Failure, as it turns out, is effortless.
I was thinking this over recently while teaching a class on sepsis in my home state of Colorado. A student asked about the physiologic mechanism behind hyperglycemia in septic shock. It was a great question, and I didn’t have a rock-solid answer.
Instead of dismissing the question as beyond the scope of our discussion and discreetly guiding the topic toward more comfortable waters, I dove in and asked if anyone could track down more definitive information. Several students started tapping away on their smartphones and keyboards and, in minutes, we had multiple sources with information about temporary insulin resistance in the presence of sepsis.
Question resolved.
In our modern world, at the height of the information age, no information is out of reach. No learning opportunity is denied us. Nothing prevents us from expanding our knowledge and our skills. The keys to the knowledge kingdom are not locked away. The road to improvement is open and available to all of us, but the road remains hard. The only real barrier is us.
Fixing our issues with medical incompetence doesn’t begin with a college degree program, or a new quality assurance system. It doesn’t begin with our education or our clinical rotations. It begins with us changing our own expectations of ourselves. It begins with the recognition that what we do each day is hard.
Difficult challenges, challenging solutions
We ask young, barely trained EMTs and paramedics in uncontrolled and sometimes hostile environments to make decisions that often challenge experienced physicians. We ask our personnel to perform physical assessments, complete medical histories, gather demographic data, implement interventions and reassess their results — all while moving toward the appropriate hospital. It is a job often completed inside the hospital in twice the time with triple the resources. And we do this with some of the least trained personnel in our industry.
None of this is said with the motivation to let us off the proverbial hook. Instead, I bring it up as a reminder that our job is difficult. Failure will always be the most tempting option, especially when it is so common and apparently acceptable.
We could simply take the hard-nosed approach. We could raise the bar of competence high and demand the heads of all those who fail to meet our exacting standards. But I fear that we would be left with a lot of empty ambulances and unanswered calls for help.
Raising the bar will be an important part of our solution. But another critical and less comfortable component will be the recognition of how frequently we stand in our own way. It is often our nature to choose the path of least resistance. We don’t consciously choose the path of failure. The most tempting thing about it is that it requires no thought at all. We simply wake up, put on our uniform and go to work.
It is effortless.
