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Accountability in the Medical Profession: A GIM Perspective Jeremy Long, MD, MPH Assistant Professor of Medicine Track Director, LEADS, U of C SOM April.

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Presentation on theme: "Accountability in the Medical Profession: A GIM Perspective Jeremy Long, MD, MPH Assistant Professor of Medicine Track Director, LEADS, U of C SOM April."— Presentation transcript:

1 Accountability in the Medical Profession: A GIM Perspective Jeremy Long, MD, MPH Assistant Professor of Medicine Track Director, LEADS, U of C SOM April 2, 2013

2 © 2012 Denver Health Disclosures I receive grant funding from the Colorado Health Foundation for LEADS (Leadership, Education, Advocacy, Development, Scholarship) Views are mine and do not represent TCHF, DH, or UC SOM 2

3 © 2012 Denver Health Objectives Define accountability Provide a statement of the problem Describe what is known Outline future steps 3

4 © 2012 Denver Health A Definition The responsibility of an individual provider for the care that he/she does or does not provide for an individual patient 4

5 © 2012 Denver Health The Topic Why? – Patient Safety in Surgery, Eds. P Stahel, Mauffrey – Procedural vs. cognitive specialties – Provider-patient relationships – Personal accountability vs. institutional 5

6 © 2012 Denver Health The Problem 54% job satisfaction for primary care physicians As many as 100,000 deaths annually attributed to medical errors Expanding statute/regulation/documentation Technology Malpractice & defensive medicine 6

7 © 2012 Denver Health The Public 7

8 © 2012 Denver Health A Case Scott Torrence, a 36-year-old insurance broker, was struck in the head while going up for a rebound during his weekend basketball game. Over the next few hours, a mild headache escalated into a thunderclap, and he became lethargic and vertiginous. 8

9 © 2012 Denver Health A Case His girlfriend called an ambulance to take him to the emergency room in his local rural hospital, which lacked a CT or MRI scanner. 9

10 © 2012 Denver Health A Case The emergency room physician, Dr Jane Benamy, worried about brain bleeding, called neurologist Dr Roy Jones at the regional referral hospital (a few hundred miles away) requesting that Torrence be transferred. Jones refused, reassuring Benamy that the case sounded like ‘benign positional vertigo’. Benamy was worried, but had no recourse. She sent Torrence home with medications for vertigo and headache. 10

11 © 2012 Denver Health A Case The next morning, Benamy re-evaluated Torrence, and he was markedly worse, with more headache, more vertigo, and now vomiting and photophobia (bright lights hurt his eyes). She called neurologist Jones again, who again refused the request for transfer. Completely frustrated, she hospitalised Torrence for intravenous pain medications and close observation. 11

12 © 2012 Denver Health A Case The next day, the patient was even worse. Literally begging, Benamy found another physician (an internist named Soloway) at Regional Medical Center to accept the transfer, and Torrence was sent there by air ambulance. The CAT scan at Regional was read as unrevealing (in retrospect, a subtle but crucial abnormality was overlooked), and Soloway managed Torrence’s symptoms with more pain medicines and sedation. 12

13 © 2012 Denver Health A Case Overnight, however, the patient deteriorated even further—‘awake, moaning, yelling’, according to the nursing notes—and needed to be physically restrained. Soloway called the neurologist, Dr Jones, at home, who told him that he ‘was familiar with the case and… the non-focal neurological exam and the normal CT scan made urgent clinical problems unlikely’. He went on to say that he would ‘evaluate the patient the next morning’. 13

14 © 2012 Denver Health A Case But by the next morning, Torrence was dead. An autopsy revealed that the head trauma had torn a small cerebellar artery, which led to a cerebellar stroke (an area of the brain poorly imaged by CT scan). Ultimately, the stroke caused enough swelling to trigger brainstem herniation—extrusion of the brain through one of the holes in the base of the skull, like toothpaste squeezing through a tube. 14

15 © 2012 Denver Health This cascade of falling dominoes could have been stopped at any stage, but that would have required the expert neurologist to see the patient, recognise the signs of the cerebellar artery dissection, take a closer look at the CT scan, and order an MRI. 15 A Case

16 © 2012 Denver Health Pitfalls for Accountability Time Stress Perfectionism Peer pressure Competing priorities And so on… 16

17 © 2012 Denver Health A Little History Sir John Gregory – Scotland/England 1700s Hopkins Circle Flexner 17

18 © 2012 Denver Health Guilds Medieval to Gregory’s time – Trade  profession Service Skill 18

19 © 2012 Denver Health Profession  Professionalism Leverage science for patients’ well-being Sympathy Conflict of interest Shared decision-making Medical Ethics 19

20 © 2012 Denver Health Medical Ethics Beneficence Nonmaleficence Justice Autonomy 20

21 © 2012 Denver Health Accountability Models Economic Political Professional 21

22 © 2012 Denver Health Aviation as a guide Learning from mistakes Making science of crashes objective Flattening flight crew hierarchy Targeted zero errors 22

23 © 2012 Denver Health The Example of Handwashing Infections acquired in healthcare settings lead to >100000 deaths per year – many (most?) are preventable with better infection control (including hand hygiene) Passive vs. active efforts to improve compliance Awareness  Education  Training  Enforcement  Punishment 23

24 © 2012 Denver Health Error Reporting Blamefree systems (i.e. PSN) Accountability Reprimand “Just culture” 24

25 © 2012 Denver Health Surgical residency programs Abstraction from “Professionalism” literature (Papadakis et al.) Leveraging error tracking systems CPHP/CPEP 25 Efforts in Academic/Training Settings

26 © 2012 Denver Health What GIM Providers Can Do Collaborate on ways to promote accountability Use it as a tool with trainees to enhance ACGME core competencies (professionalism, systems-based practice) Discuss with care teams in clinical settings Discuss with patients 26

27 © 2012 Denver Health A Conceptual Model 27 Physician/Provider Community Health Care Facility Patient Insurer/Administrative Party Accreditation/ Government

28 © 2012 Denver Health Summary Accountability is simply defined but more complex when approached scientifically Medical practice involves a human element which must be acknowledged but also aided to seek best practice Errors must be framed in a way that learning and improvement can occur 28

29 © 2012 Denver Health Phil Stahel LEADS faculty (Cathy Battaglia, Christine Gilroy, Rita Lee) Holly Batal 29 Acknowledgements

30 © 2012 Denver Health References 1.McCullough LB. John Gregory and the invention of professional medical ethics and the profession of medicine. Dordrecht, Boston: Kluwer Academic; 1998. 347 p. 2.Beauchamp T, Childress J. Principles of Biomedical Ethics. 5th ed. New York: Oxford University Press; 2001. 3.Page K. The four principles: can they be measured and do they predict ethical decision making? BMC Medical Ethics. 2012;13:10. PubMed PMID: 22606995. 4.Laube DW. Physician accountability and taking responsibility for ourselves: washing the dirty white coat, one at a time. Obstet Gynecol. 2010 Aug;116(2 Pt 1):248-53. PubMed PMID: 20664382. English. 5.Tsai TC, Lin CH, Harasym PH, Violato C. Students' perception on medical professionalism: the psychometric perspective. Medical Teacher.29(2-3):128-34. PubMed PMID: 17701622. 6.Murray RB, Larkins S, Russell H, Ewen S, Prideaux D. Medical schools as agents of change: socially accountable medical education. Med J Aust. 2012 Jun 4;196(10):653. PubMed PMID: 22676883. English. 7.McCullough LB. Holding the present and future accountable to the past: history and the maturation of clinical ethics as a field of the humanities. J Med Philos. 2000 Feb;25(1):5-11. PubMed PMID: 10732872. Pubmed Central PMCID: Source: KIE. 65253. English. 8.Hall DE. The guild of surgeons as a tradition of moral enquiry. J Med Philos. 2011;36(2):114-32. PubMed PMID: 21576372. 9.Duffy TP. The Flexner Report--100 years later. Yale Journal of Biology & Medicine. 2011;84(3):269-76. PubMed PMID: 21966046. 10.Lynch J. Clinical responsibility. United Kingdom: Radcliffe Publishing Ltd; 2009. 11.Smith SD, Smith S. Physician autonomy in the age of accountability. Minnesota Medicine. 2007;90(10):20-2. PubMed PMID: 18038738. 30

31 © 2012 Denver Health References 12.Morath JM, Turnbull JE. To do no harm: ensuring patient safety in health care organizations. San Francisco: John Wiley & Sons, Inc.; 2005. 13.To err is human: building a safer health system. Washington, DC: Committee on Quality of Health Care in America, 1999. 14.Donaldson LJ. Professional accountability in a changing world. Postgraduate Medical Journal. 2001;77(904):65-7. PubMed PMID: 11161069. 15.Goldmann D. System failure versus personal accountability--the case for clean hands. N Engl J Med. 2006 Jul 13;355(2):121-3. PubMed PMID: 16837675. English. 16.Wachter RM, Pronovost PJ. Balancing "no blame" with accountability in patient safety. N Engl J Med. 2009;361(14):1401-6. PubMed PMID: 19797289. 17.Wachter RM. Personal accountability in healthcare: searching for the right balance. BMJ Quality & Safety. 2013 Feb;22(2):176-80. PubMed PMID: 22942398. English. 18.Emanuel EJ, Emanuel LL. What is accountability in health care? Ann Intern Med. 1996 Jan 15;124(2):229-39. PubMed PMID: 8533999. Pubmed Central PMCID: Source: KIE. 49315. English. 19.Hochberg MS, Berman RS, Kalet AL, Zabar SR, Gillespie C, Pachter HL, et al. The professionalism curriculum as a cultural change agent in surgical residency education. American Journal of Surgery. 2012;203(1):14-20. PubMed PMID: 21983000. 20.Boelen C. Building a socially accountable health professions school: towards unity for health. Educ Health. 2004 Jul;17(2):223-31. PubMed PMID: 15763765. English. 21.Whittemore AD. The competent surgeon: individual accountability in the era of "systems" failure. Annals of Surgery. 2009;250(3):357-62. PubMed PMID: 19730172. 31

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