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Doctor Arrogance and Hospital Acquired Infections
Nearly everyone has encountered an arrogant doctor: one who simply will not listen or knows all the answers. Peter Pronovost is a doctor and so has had more opportunity than most to see arrogant doctors in action. In a recent commentary in JAMA, Pronovost discusses physician arrogance and the ways it can harm patients.
To Pronovost, the epitome of doctor arrogance causing harm is the high the rate of hospital acquired infections.
Each year, an estimated 100,000 patients die of health care-associated infections. About 31,000 of these deaths come from infections caused by a catheter in a patient's vein. Catheters are tubes that can carry fluid or drug into veins or remove blood from them.
The best way to reduce the number of these infections, sometimes called central line infections or CLABSI is well-known. And it's not exactly rocket science. But it's not happening.
Following five simple recommendations cuts the incidence of central line infections markedly:
A study begun in 2004 of over 100 Michigan intensive care units found that using a checklist of these five factors, along with making a few changes in hospital culture, cut the rate of central line infections by 66%, a decrease that has persisted for over three years. And the median infection rate in these hundred ICUs has been zero for over three years.
Other studies have shown similar results. Yet not all hospitals use the checklist.
Along with the checklist, the Michigan intervention included two other components. One was continued measurement of the number of infections occurring, since the first step in solving a problem is identifying that it exists. The second included tools to improve teamwork among doctors, nurses and hospital administrators. And this is where Pronovost finds resistance from physicians.
All medical procedures involve teamwork. But not all team members are created equal. The U.S. healthcare culture does not accept the questioning of physician behavior. When nurses are asked if they would speak up when seeing a senior physician inserting a catheter in a patient, but not complying with the checklist, their answer is generally "no." At least if the nurse wants to keep his or her job. This is a definite barrier to curbing infections.
Doctors know how to properly insert a catheter so that the chance of infection will be minimized. Yet, because lack of sleep, the need to rush to the next patient or simple American institutional inertia, shortcuts are sometimes taken. And in the curious world of American medicine, this is accepted as inevitable.
Hospitals and physicians are rarely held accountable for the outcomes of medical procedures on patients. Pronovost wonders if eliminating largely preventable, sometimes lethal, central line infections is not a priority of doctors and hospitals, what is? And he also asks: "what other industry would accept a routine safety violation that is associated with the deaths of tens of thousands of patients and not be held accountable?"
That hospital infections can be lowered is fact, not supposition. To Pronovost, the reason this isn't happening is largely due to physician arrogance. Yet the role of the hospitals and their administration can't be overlooked either. It can't be easy working in today's overcrowded, understaffed hospitals. If your doctor also works in a hospital, you might ask his or her opinion on why hospital infection rates are so high. It may not agree with Pronovost's, but it's likely to be every bit as pointed.
Pronovost's commentary was published by the Journal of the American Medical Association (JAMA) on July 14, 2010
An article on the reduction of central line infections in Michigan intensive care units was published online by the British Medical Journal (BMJ) on February 4, 2010 and is freely available.
Peter J. Pronovost, MD PhD FCCM, is a professor in the Departments of Anesthesiology/Critical Care Medicine and Surgery at The Johns Hopkins University School of Medicine. Pronovost's many other affiliations include serving as director of the Center for Innovation in Quality Patient Care and as an advisor to the World Health Organization.
July 22, 2010
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