Feature Article

In Uncertain Times, Clinicians Can Still Make a Difference
2009;14(3):1A, 4

Clinicians can provide quality caregiving by remembering to pay attention to the details at patients’ bedsides and by adhering to performance measures.

NASHVILLE—Similarly to the worldwide economy, health care in America has reached the point of crisis: 43 million uninsured patients often wait longer than they should before seeking medical attention. Many times they present with more severe illness and have worse outcomes than insured patients. The number of hospital beds is shrinking and the percentage of critical care beds is growing, as is the need for critical care staff. “In essence, the need for the critical care team is becoming dire,” said Mitchell M. Levy, MD, at the 38th Congress of the Society of Critical Care Medicine (SCCM). “So it’s appropriate at a time like this, when we’re balanced on a razor’s edge of uncertainty, that we ask ourselves as clinicians in general and as ICU caregivers in particular, ‘Can we make a difference?’”

Dr. Levy answers this question in the affirmative. Health care professionals can make a difference in patients’ lives “through a commitment to caring and remembering the small things we do at the bedside of our patients. The recognition that keeping track is important represents the evolution of accountability and the benefits of performance measures,” he said. Dr. Levy is Professor of Medicine at Brown University in Providence, Rhode Island, Director of the Medical ICU at Rhode Island Hospital, and the current SCCM President.

Modern Times
While it can be challenging for any clinician to take time to make a difference in patients’ lives, ICU staff face particular obstacles, Dr. Levy stressed. In addition to integrating data from the current literature into a cohesive therapeutic plan based on collaborative decision making, ICU workers on a regular basis must also help patients’ families cope with the prospect of losing a loved one.

“This challenge to balance intellect and compassion in an intense environment is for many of us the force that drove us into critical care,” Dr. Levy remarked, yet it is also the factor that leads many to burnout and exhaustion. Along with the advancements in medical technology that have been developed over the past 70 years has come greater pressures to “cure” rather then comfort and care for patients, he contended. In addition, the ICU environment is frenetic and ensuring clear communication is often a struggle. “In many ways, I think that genuine caregiving has become a luxury,” Dr. Levy lamented.

However, there are ways to provide care in such a “fast-paced, task- and technology-driven environment,” Dr. Levy explained, including taking the extra time to meet with families or reassure an anxious patient, and refusing to settle for an easy diagnosis and instead reviewing diagnostic test results one more time. Often, if one member of the ICU team does not take these extra measures, it is the collaborative environment inherent in the ICU that prompts another member of the team to remind him or her. “Collaboration might provide the best weapon to combat the distractions common in the ICU,” Dr. Levy said.

Common Problems Among Physicians
Across specialties, there are pitfalls that compromise quality care, Dr. Levy observed. For example, in a study of 7,000 outpatients living in 12 metropolitan areas in the United States who were surveyed about quality of care indicators, only 54.9% reported receiving recommended preventive care, 53.5% reported receiving recommended acute care, and 56.1% reported receiving recommended care for chronic conditions. The results of another study—this time of more than 3,600 physicians who provided usual care to 24,581 Medicare beneficiaries—showed that well-established preventive health care services (eg, influenza vaccinations, colon cancer screening) were performed on average about 50% of the time.

Even clinical experience may not be a panacea. “Although we would love to believe that as we get older we get wiser and that our collective clinical experience alone will make us better clinicians, this might not necessarily be the case,” Dr. Levy warned. He cited a systematic review of 59 studies published in 2005 relating medical knowledge and health care quality to years in practice and physician age. Most studies reported decreasing outcomes with increasing years of practice across all outcome measures, he said.

“Some of this may be the gap between what we think is happening and what is actually happening,” Dr. Levy speculated. He cited a study showing that while 92% of ICU physicians surveyed reported frequently or always using a lung protective mechanical ventilation strategy to treat acute lung injury, an audit showed that only 4% of patients actually received such treatment.

Being Accountable
Perhaps the biggest pitfall is the clinician’s desire to maintain autonomy. “Surely we must be willing to yield some decision-making power in the interest of improving patient outcomes,” Dr. Levy asserted. “The data certainly suggests that when we surrender this autonomy and standardize care, patients do better.” He emphasized that consistency helps improve patient outcomes as well as accountability. The next step, he added, “should include refining the process of evidence-based medicine by ranking data, identifying clinical practices that lead to better outcomes, and identifying our understanding of tools that facilitate the change in clinical practice behavior.

“Being accountable to our patients and their outcomes is the right message for them and for all of us. This is being a good caregiver. We can advocate for accountability. If not us, then who?”

—Adriene Marshall

Suggested Reading
Bauer M, Brunkhorst F, Welte T, et al. Sepsis: update on pathophysiology, diagnostics and therapy [in German]. Anaesthesist. 2006;55(8):835-845.

McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-2645.

Pham HH, Schrag D, Hargraves JL, Bach PB. Delivery of preventive services to older adults by primary care physicians. JAMA. 2005;294(4):473-481.

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