Starting With Curious

I am rarely mistaken for George Clooney, and my job seldom resembles the TV show “ER.”  The vast majority of what we do is, at least after a number of years, pretty routine.  But every once in a while, life resembles art.  A couple of months ago, on an otherwise steady but undramatic day, the nurse walked a 2 week old baby back from triage and asked for immediate help.  The baby was blue, not breathing, and had no pulse.  A team of folks – nurses, other doctors – swiftly descended on the room and began working.  I directed one person to do CPR, others to try to get an IV and to give medications.  After a minute or so we were able to get a pulse, but the initial signs weren’t great.  The parents, who were in the room with us, asked if they should baptize the little girl, and they did.  After almost an hour, we had stabilized her and sent her to the neonatal ICU.  I went up and checked on her and her parents after my shift.  While things were improved, it was all still quite tenuous.

This past weekend, the triage nurse came back and told me and one of the nurses that there was a family in the waiting room that wanted to talk with us.  We went out to find the family of that little girl.  They wanted to thank us for what we had done, bringing a delicious lunch for the whole staff.  It was a touching gesture, as were the drawings from the girls siblings that said “Thank you for saving our sister’s life.”  But the best thing was seeing the baby herself.  She had spent a month in the ICU, but did well and went home.  The last time we had seen her she was literally on death’s door; now she was a pink, chubby-cheeked, smiling 3 month old.  As we exchanged thanks and hugs, all of us were a bit teary.

I happened to have a college senior interested in medical school shadowing me that day.  As we were sitting down to enjoy the pizza and ravioli, I told him that this sort of thing doesn’t happen every day, or even every year.  But, I said “This is what it’s all about.  Don’t forget that.”  It’s all about purpose – acting in the service of children and their families.

I also thought of our emphasis on “being here now.”  When the team swung into action that day a few months earlier, each of us was there, fully present, doing what we needed to do.  We were also there for the family, explaining what we were doing and what it meant even as we feverishly worked to save their baby.  And when that family returned, intact, to bring us a meal, it reminded me that it could have been very different.  Life is short, unpredictable, and very precious.

In our efforts to promote value, the need to reduce unnecessary variation and follow best practices in the form of clinical guidelines is clear.  As we think about moving toward more evidence-based practice, it may be worth considering some of the alternatives:

1.  Eminence-based practice.  This is where we do what we are told by people who, rightly or wrongly, are well-known in their field.  Although in many cases this may be reasonable and congruent with available evidence, assuming something is correct based solely on the celebrity of a source can be problematic. (See, for example, Tom Cruise and Scientology.)

2.   Precedence-based practice.  This falls under the category of “we’ve always done it that way.”  It is particularly prevalent at certain ivy-clad East Coast institutions, and is the reason we continued to use theophylline for acute asthma well into my fellowship years.  (The cutting edge doesn’t work when it is stuck in cement.)

3.  Elegance-based practice.  This is perpetuated by pharmaceutical and other manufacturers, who promote questionable products with eloquent testimonials and attractive advertising.  The poster child for this is Xopenex.

4.  Arrogance-based practice.  When one is willing to substitute one’s own thin anecdotal experience for the accumulated wisdom of the published literature.  Often expressed in the form of “my patients are different.”

5.  “Are you dense?”-based practice.  Also known as “execrance-based practice,”  this is an extreme form of variant #4 above, whereby not only does one assume one’s own practice is superior to the published evidence, but that all other practices are idiotic.

One of my favorite questions to ask fellowship applicants is what skills they think are important to be a good pediatric emergency physician.  Almost all of them respond with something along the lines of being able to multitask, building and leading a team, and maybe procedural skills.  When I point out the importance of those skills for almost any specialty, and ask for those skills somewhat unique to our field, many draw a blank.  To my mind, one of the unique skills of an emergency physician – indeed, one of the defining features of the specialty – is the ability to make decisions with incomplete information.

Of course, no one ever has truly complete information, but the limitations due to time and resource constraints in the setting of the ED are much greater.  Physicians have to determine and commit to a plan of action despite the fact that the patient’s history may be limited by the absence of a caregiver, or a prior relationship with the patient and family; some tests may not be available in off hours, and results of tests that are performed may not be available until after the decision has to be made; and competing demands more significantly limit the amount of time we can spend with a patient than in a scheduled setting.

Comfort with making decisions in the face of incomplete information, and being able to do so with an appropriate level of confidence, is a critical skill for the emergency provider, but is useful in a variety of contexts.  For example, business leaders must often make strategic decisions vis a vis their competitors without good intelligence on what the competitors’ plans are.  In a rapidly evolving healthcare environment, hospital and other leaders face a number of key decisions that will have impacts for years, when we don’t have a good deal of information about what the environment will look like even months from now.

This skill requires some humility: the less information you have when you make a decision, the more likely it is to turn out to be a bad one.  It also requires a thick skin, as the next-morning quarterbacks are all too happy to wonder aloud about what those people in the ED were thinking.  I have long contended that, although some people may never be comfortable with making decisions in the face of incomplete information, most of us are capable of doing so, and that it is a skill that can be developed through practice.  Recently, I read a fascinating book about decision making by the Nobel Prize-winning economist Daniel Kahneman that provides some support to this.  Thinking, Fast and Slow – about which I will comment more on in future posts – describes the two systems in our mind that are involved in decision making.  System 1 (in Kahneman’s terminology) is the one that allows us to form immediate impressions, take automated actions.  It is responsible for snap judgments.  As such it performs an important function (our forebears would have had a hard time if they had to do a thorough risk analysis every time they were chased by a large carnivore) and usually does pretty well, though it is subject to a variety of biases.  System 2 involved the slower, more conscious and overtly analytical processes that provide a check and oversight over System 1.  One could surmise that making decisions without complete information might involve suppressing System 2, allowing us to go with our gut impressions.  But in fact, it turns out that, again in Kahneman’s words, system 2 is “lazy”.  The challenge is not to suppress it, but to invoke it.  I suspect most of us realize that our gut impressions are subject to bias.  It’s why we have sayings like “don’t judge a book by its cover,” and why we abhor racial profiling.  As a result, I believe that we are suspicious of our System 1 judgments, and overcompensate by insisting on a thorough System 2 review before committing to anything.  Being able to rapidly do a System 2 check of System 1’s snap judgment, and recognizing the strengths and limitations of both, is key to successful decision making with incomplete information.

It can be a challenge to efficiently bring our System 2 to bear on decisions that seem time sensitive, especially when there are many such decisions to be made in a brief period.  Interruptions and distractions, things that keep us from focusing attention, will tend to degrade the quality of decisions.  The ED is rife with those distractions.  It requires a certain amount of mindfulness, of “being here now,” to use our System 2 most effectively.  It is that mindfulness that we can exercise as a way to make better decisions when we do not yet have all the facts.

Getting ready to leave the Medical College of Wisconsin and move to Children’s Hospital of Wisconsin has made me a bit nostalgic.  I recalled recently when I was interviewing for my first job after fellowship, I was asked by my soon-to-be boss how I would design the ideal academic position.  I described what was the predominant model at academic children’s hospitals for my specialty of emergency medicine: approximately 60% clinical time, with the rest devoted to scholarly activity (education and research).  To my chagrin, he replied that model was becoming extinct.  People would have to choose to be 80-90% clinical or 80-90% academic (and get the external funding to support that).  I ended up in the 80% academic track.

Here it is 20 years later, and in many places, including ours, that is still the model.  But Brian Strom was correct.  The death of that model occurred earlier in Philadelphia and some other places than here, and perhaps in adult medicine ahead of pediatrics, but the trends are clear.  For a long time we have heard that the “triple threat” (i.e., the superhero physician who is clinician, educator, and researcher all rolled into one) was no longer possible because only those with a singular focus on research could compete successfully for extramural funding.  But many academic physicians do research that is internally funded with excess clinical revenue. The idea that the margin generated by spending 60% of one’s time in clinical work can support the other 40% is simply no longer tenable.

This was underscored by a set of articles about the future of academic health centers that appeared recently in JAMA and NEJM.  The articles talk about a variety of challenges and potential responses.  But a common theme is the unsustainability of cross-subsidization of the academic missions by the margin generated by clinical activity.  That margin is being eroded by downward pressure on reimbursements, at the same time alternative sources of funding for research and education are drying up.  The relative size of the clinical and academic activities is going to have to change.

For children’s hospitals, especially, where the paradigm of the triple threat has tended to hang on, we will have to rethink what it means to be an academic physician.  Rather than every faculty member participating in all activities, we will need to specialize.  The majority of faculty will be excellent clinicians who may do some bedside teaching, and provide access to patient material for clinical and translational researchers, but who will not themselves be expected to generate traditional “scholarly products” such as peer-reviewed articles, abstracts, book chapters, etc.  Their efforts, however, will generate sufficient margin to allow a smaller cadre of colleagues to engage in research and core educational activities.

This would represent a significant cultural change for us, leading to some serious soul-searching.  How do we continue to provide adequate intellectual stimulation to people who are “only” clinicians?  Would the pay scale be similar for clinicians and academics?   How do we ensure that prestige and career advancement are equally available to those doing the clinical work, when the traditional path to promotion and success has been via grant funding and publication?  What is it exactly that makes someplace an “academic health center?”

Fortunately, we are not the first to face these questions.  An article about the experience of Brigham and Women’s Hospital, for example, provides some encouragement.  But I wonder if someone who trained at the Brigham 20 years ago would recognize the place anymore.  Nostalgia may be fun, but we can’t reminisce our way forward.