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Simplifying Complexity

By Dr. Sachin D. Shah

Recent advances in medicine have been impressive. Patients today live longer than they ever have, even those with chronic medical illnesses that previously would have dramatically cut short lives even ten years ago.  And the envelope is continually pushed forward.

As a result, the care of the average patient in a primary care clinic, especially those affiliated with academic medical centers that provide tertiary and quaternary care, has become more complex. A major focus of primary care has become preventing costly, avoidable hospitalizations in our patients with chronic diseases and to optimize the quality of life and outcomes for even our sickest patients.

Cost containment and quality improvement are high, inextricably linked priorities in medicine these days.  If we improve the quality of our care, we can often lessen the costs associated with providing the care.  One way to improve quality is by reducing errors in how we practice medicine.

In “The Checklist Manifesto,” Atul Gawande describes a dichotomy between errors of ignorance and errors of ineptitude.  Errors of ignorance occur because we simply don’t know enough.  Errors of ineptitude, on the other hand, occur because we fail to make proper use of what we know.  The latter type of error is avoidable and thus should be considered unacceptable.  Gawande eloquently explains how the use of checklists has had an enormous impact on safety in the airline industry and how indispensable such a simple tool has become in a variety of the most complex situations, from organizing disaster relief efforts to building skyscrapers.

Medicine is wrought with ever more complexity, but an extraordinary amount of knowledge is easily accessible to us.  As physicians, we’re constantly bombarded with information from the medical literature detailing data supporting innovative approaches, new medications, and the clinical practices that optimize outcomes.  Checklists have been implemented with astonishing success in ICUs and in operating rooms like Gawande’s.  But there’s a place for them in Primary Care as well.

Evidence-based guidelines exist for a large proportion of the most common chronic medical problems we see. However, given the avalanche of information we’re subjected to as generalists, we often simply cannot keep up. Sometimes we don’t know what the latest guidelines for chronic kidney disease say, or how to best manage atrial fibrillation. Maybe we’re still doing things the way we learned them in residency, even though the most updated data supports a different approach.

I started my job at a busy, established academic primary care practice about 16 months ago. I've inherited patients from a lot of different providers, and have noticed that everyone does things really differently (diplomatic phrasing).

But the stakes are high for our patients with conditions like diabetes, congestive heart failure, and COPD. Following the guidelines can have a dramatic effect on preserving their health and adding years to their lives.

Besides cost and quality, implementation of electronic health records (EHR) and ensuring their meaningful use is another high priority in medicine today.  A well-designed EHR should unify all of these principles.

The EHR offers an opportunity to improve the care our patients receive by helping cue physicians to remember the important aspects to cover for each problem, based on the evidence-based guidelines that exist for so many of the most common problems.

We cannot rely on our memories as physicians in the face of such complexity.  Checklists based on guidelines for each disease our patients have should prompt us: my diabetic patient needs a pneumonia vaccine; my patient with congestive heart failure should be on an ACE inhibitor; my healthy patient is overdue for colon cancer screening. 

Even experts need help. Despite the years of education and training we undergo as physicians, our hubris shouldn’t prevent us from conceding that our memory has limits. Checklists are no substitute for clinical reasoning and decision making. But they can play a critical role in reminding us of the simple steps that undeniably improve patient outcomes. Our patients deserve the best possible care period, not the best care that we can remember on a given day when we see them.

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