From the Editor

The white wall


 

My father was a general surgeon in a very small town in West Virginia. He was very successful and his patients loved him. He loved them, too, and chose to practice well into his 70s. In retrospect, he should not have.

Dr. Matt Kalaycio, editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute.

Dr. Matt Kalaycio

Perhaps brilliant in his day, he was less so at the end of his career. I realized his deficiencies when I was in residency. I wondered if, despite his undeniable experience, his age was compromising his clinical acumen.

There are data available that support my suspicions. Investigators from the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health reviewed a random sample of Medicare beneficiaries admitted to a hospital between 2011 and 2014. They hypothesized that physician age may affect outcomes such as 30-day mortality, readmissions, and cost of care. Among the more than 700,000 admissions by more than 18,000 hospitalists, the 30-day mortality rates were significantly higher for physicians aged 60 years and older, compared with younger physicians. Importantly though, there was no difference in mortality for older, but high-volume, physicians, compared with younger ones.

These results were published in the BMJ (2017 May 16;357:j1797. doi: 10.1136/bmj.j1797) by the same group that described a similar reduction in mortality among female versus male internists (JAMA Intern Med. 2017 Feb 1;177[2]:206-13). Both studies attracted widespread media attention.

The BMJ study analyzed outcomes among hospitalists who exclusively manage inpatients. Hematologists, in contrast, are largely based in the outpatient setting or in a lab. Yet, hematologists are often called upon to cover inpatient units of very sick patients. We care for patients with acute leukemia, thrombotic thrombocytopenic purpura, and graft versus host disease, among other debilitating diseases. In that sense, I believe data generated from hospitalists probably apply to inpatient hematology as well.

Having just been the attending on one of these services, I am uncomfortably certain that they apply. I proudly boast that I once attended for 6 months in a year. I was good at it and enjoyed it. With time, though, we hired additional staff and I acquired administrative duties that decreased my attending service time. I now attend for 2 weeks, twice a year.

During the last one of these service times, I began to suspect that I was not as sharp as I once was. I don’t think I missed anything, I just didn’t seem to catch changes in clinical status as quickly as I once did. I was less comfortable with the new medications I was prescribing. I was depending more on the clinical pharmacist and the hematology fellow to keep track of side effects and dose adjustments. I was worried – more than ever – that I would make a mistake. The last thing I want to be is dangerous.

As department chairman, though, it is part of my job to ensure that no one else is dangerous either. The Joint Commission mandates Ongoing Professional Practice Evaluation (OPPE), which is intended to help assess a practitioner’s clinical competence. Yet, the commission recognizes that “Cognitive specialties (internal medicine, family practice, psychiatry, med specialties ...) are very difficult” in terms of identifying meaningful data that can be evaluated.

We do not have adequate tools to assess clinical competency. As a result, we are generally aware that physicians do a poor job of policing our own, in no small part because of a reluctance to identify and confront less competent physicians. Where police departments are accused of hiding behind a blue wall of silence, are physicians guilty of maintaining a white wall of silence?

Of course we are. How many clinically shaky fellows do we graduate into our profession every year? How many of us are aware of colleagues who are unskilled, but are reluctant to speak up about them? Our sins are documented in books such as “Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans” by Rosemary Gibson and Janardan Prasad Singh and “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” by Marty Makary.

Concern for my own competence notwithstanding, medicine as a profession requires reflection on its role in allowing substandard patient care to continue.

Punishment doesn’t seem to be the best way to right wrongs. The punished may not learn the lesson and the unpunished will be less forthcoming with their own errors.

Taking a lesson from highly reliable industries such as airlines, the medical profession is addressing medical errors better. For example, my institution has mandated thorough checklists before any and all invasive procedures, including bone marrow biopsies. Through a morbidity and mortality review of a case of hepatitis, we developed an automatic method of ordering hepatitis panels in every patient treated with monoclonal antibodies. Making systemic changes to prevent error avoids having to punish those who make errors, while holding accountable those who skirt the built-in safeguards.

We are less successful at applying similar error mitigation techniques to individual physicians who may not be clinically excellent. Examples abound of physicians who provide substandard care, but are allowed to continue. The repercussions continue at Wake Forest Baptist Medical Center, where a pathologist misdiagnosed some cancer cases over at least a 2-year period of time. Physicians, as a group, are not as good at certifying competency as are nurses, advanced practice providers, and pharmacists.

With many academic hematologists having relatively small practices, getting older, and getting burned out, the potential for patient harm as a result of medical error increases. Further, these physicians may not realize their increased risk and may be indignant when confronted.

I am interested in best practices that address this difficult and contentious issue. I hope our readers will offer their policies and procedures so that we can learn from each other. Patients should not have to worry about their doctors’ competency and doctors should be able to hold each other accountable by removing the white wall of silence.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.

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