We need to think about Diagnosis as an orchestrated Relay Race not the 100M sprint we’ve created

This great TEDxBeaconStreet talk by ENT Surgeon Ayesha Khalid asks “Why We Can’t Fix Our Healthcare System?” before concluding by asking the audience if we’re even asking the right questions and suggesting a new approach for getting to a diagnosis:

…at the end of a busy day when I was an hour behind I looked at the clock and it was 430 and I walked in with my last patient who was Charlie and as soon I walked in I asked Charlie “Hi sir how are you doing?” Charlie bristled: “Do not call me sir. You’re the seventh doctor that I am seeing, I’ve had oodles of tests, multiple blood work, nobody knows what’s wrong with me and I tell you there is something that’s going on”. Puzzled I examine Charlie, I looked inside his sinuses and I tried to figure out what was happening, but nothing. I couldn’t find anything so I did what all of us sinus surgeon’s do when we don’t know the answer: I ordered a CAT scan. And then I looked at Charlie and said “While I’m excited to figure out this journey with you and figure out what’s happening I have to go. I’ll call you tomorrow with the results of this CAT scan and off I went to the hospital to see Patients… …so the next day I went to clinic and I immediately open Charlie’s CAT scans and tried to look through the images to find out what was wrong. Negative nothing on the results, nothing on the sinus scan. Essentially I was still curious so I scrolled the images myself I look through the brain images and the neck images. damages and suddenly and noted with growing horror that Charlie had a mass that was growing in his brain and eroding through the bone. I called him in and I let him and his wife see the scan. His wife started slowly weeping but Charlie looked relieved: “thank you doc for believing in me”, and long story short Charlie went on to get treatment and still is doing well today cherishing his beautiful family. But this is not a story about me as a Doctor or Charlie as a Patient, this is a story about the thousand Charlie’s in the world who are unable to get a health care diagnosis. Why is that? Why is it that we have so many talented physicians dedicated to helping Patients who are unable to help the Charlie’s of the world?

…we can’t solve the health care system because maybe we haven’t been asking the right questions… …as a Patient when you walk in to see your Doctor there’s a 15% chance that they’re either going to miss your diagnosis or have the wrong diagnosis by the end of the visit and that’s going to increase your chance of getting sicker or dying twice as likely. So where do we go from here? Well I think systems thinking asks us to structure the conversation completely differently to take a step back and really ask why is this happening? Perhaps because when Charlie went to the Doctor he stated his problem any received some tests, got a medication that didn’t help him and was sent home and the pattern repeated itself. We’re trying to engineer a relationship between the Doctor and the Patient that is efficient but not meaningful. Perhaps what we need to do is change the nature of the conversation and ask Physicians to take the time to step back and listen to Charlie’s story and in order to do that we have to ask ourselves the following question: Shouldn’t seeing your Doctor not be something that’s rushed? In fact I believe that seeing your doctor should be like getting together with a friend for a cup of coffee, but I know some other you’re still thinking about this 15% fifteen percent what if we don’t know the answer as the doctor what if we can’t find out what’s wrong with you where do we go from here and this is where the health care system and its competitive nature does not help us. So from the moment we get into medical school it’s a deep culture of competition we have to get the best grades to get into the specialties we want. Be the best surgeon with the fewest complications and work in the best hospitals. And I found that despite my training, despite doing research despite my training as a surgeon at Harvard Medical School all this enabled me to do is to continue to focus on the body parts that I operated on and not really have a holistic view and the bigger problem with that was that I was so focused on proving individual performance for which we as doctors are measured rewarded and now publicly displayed that I didn’t have the time to really collaborate with other doctors when patients were trying to get a diagnosis.

So this brings us to the third question: what if we don’t know the answer? What can we learn from failure? I have to be able to as a Doctor get permission from you the Patient to be able to look you in the eyes and tell Charlie I don’t know what’s wrong with you but I’m going to help you get that answer. We as doctors have a lot of anxiety when you come to see us. When we don’t know what’s wrong with you the stakes are high, maybe life-and-death. In that way when Patients come in and expect that we’re able to tell you what’s wrong it really stresses us out to not be able to do that and so we reach for more tests in order to quickly come up with the diagnosis but what we really need to be able to do is go on this journey together to partner with our patients in our quest… …what Charlie really needs is a better patient experience through this journey and in order to do that he needs to give me permission as a doctor to say “I don’t know what’s wrong with you but we can get there together”.

So that brings us to this systems thinking approach which is downright confusing when you look at it but if you think about it what we’ve talked about here today is really framing the conversation making the doctor our friend thinking about failure and what we can learn from it and perhaps changing the paradigm so that its okay with ourselves our colleagues and our Patients to not always know everything.

Perhaps Charlie’s manifesto or call to action today is really for you as Patients to be able to demand to tell your story and for us as Physicians to be able to go on this diagnostic journey with you and more importantly to be able to look you in the eye and tell you when we don’t know. Are we ready to accept this?

…getting to a diagnosis is not the 100 meter sprint that we’ve created. It should be a well orchestrated Relay Race with several runners in order for us to win…

I think this talk provides some very revealing insights into the cost of our failure to document care. A few thoughts I had on watching it:

> We can’t begin to apply system based thinking to the healthcare experience because the key events aren’t being efficiently recorded (or when they are they are filtered because we’re trying to make the most expensive and time constrained individual record them).

Let’s imagine for a moment how differently Charlie’s experience with Dr Khalid might have gone had we properly documented Charlie’s care and used the tools of our time to prepare both Charlie and Dr Khalid for the consultation:

at the end of a busy day when I was an hour behind I looked at the clock and it was 430 and I called up my last Patient and said “Poor Charlie, it says here I’ll be the 7th Doctor you’ve been referred to. You must be exhausted from all the journeys, tests and medications that you’re been given. I know it’s not going to help you but I’ve already put a note on the system so that our decision support aids pick this type of thing up and no other Patient will ever have to go through such a terrible experience.

Clearly no one has really worked out what’s wrong and I’m now going to be working with you on this journey until we get somewhere and you’re happier with things. First thing I’d like is for you to give me a time/date when you could come in for a scan and then I’ll immediately view the images and give you a call to arrange for you to come in here to have a coffee with me to discuss what we’re going to do next. How does that sound?

> Poorly thought out efforts to enable Patients to be able to email their Doctor 24×7 are typical outcomes when we focus on engineering Doctor/Patient relationships that are just super efficient extensions of the visit but fail to think about the need for them to be meaningful (or mindful of the fact that the 2000 year old model of healthcare is broken forever).

> I think we need to think of Documentation of Healthcare as the Baton they use in relays: The first runner at the finish line with the Baton is holding documentation that they have effectively connected with all the other members of their team.

Can you begin to imagine what we’d learn and how quickly the precision of the evidence base for medicine would evolve if every single Patient journey was properly documented?


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