The hospitalist thus finds herself stuck between the proverbial rock and a hard place: Discharge early (i.e. before you are ready to do so safely) but ensure that patients don’t come back. There is no easy answer to this potential dilemma, except to say that the solution rests with people who do have a systemwide perspective. To this end, it will be the hospitalist “on the ground,” familiar with the need to prevent readmissions but sensitive to the need to discharge early, who will have the unique insight to design solutions, for all elements of the hospital system, that ensure meeting both ends.
Threat 6: Ignoring the Adaptive Unconscious
Think about whether this has ever happened to you: You finish a busy day at work, with many thoughts still on your mind as you begin your car drive home. Thirty minutes later, you find yourself sitting in your car in your driveway, wondering, “Wow, how did I get home? I don’t remember that drive at all.” Such is the benefit of what Timothy Wilson in his book Strangers to Ourselves calls the “adaptive unconscious.” See it as the mind’s ability to go on “autopilot” to accomplish repetitive tasks without requiring conscious thought, freeing up the mind to devote mental energy to something else. It’s adaptive, of course, because without it, it would be impossible to do any physical activity (i.e. collecting your wallet and keys as you leave the house) while simultaneously doing another activity (i.e. talking on the cell phone as you leave the house). The danger, however, is that tasks that are performed by the adaptive unconscious autopilot are quite inaccessible to the conscious mind for inspection and improvement.
Now consider this example. Have you ever seen a patient in the ED, sat down at the nurses’ station with the chart (contemplating all that needs to happen for the patient’s care), only to look down a few minutes later to see a fully completed set of admission orders? And you say, “Wow, how did these orders get done? I don’t remember writing these at all. Well, thanks for that.”
The focus of the quality- and patient-safety movements has been on changing the physician’s “conscious mind” decisions. But the reality is that the vast majority of what we do in our daily lives is performed without conscious thought. You can’t begrudge it, because again, without it, you would be paralyzed. But it has profound implications for the goal of advancing quality and patient safety in our practice of medicine.
There are two points to make in the context of this discussion. First, the adaptive unconscious is not a magical gift; it develops as a product of our repetitive tasks. You can make that drive home, or write those admission orders, without conscious thought only because you have done it hundreds of times before. And here’s the implication: Much of the behavior that is not conducive to optimal patient safety is a product of what we have done for the past five years. And what we do now in changing physician behavior has implications not only for today, but also for what we will do five years from now.
With this in mind, the bad decisions that result in adverse events do not concern me as much as the bad decisions that do not result in adverse events. The adverse outcome has enough drama to immediately bring the decision into the realm of the conscious, making it accessible for the physician to change behavior. But a bad decision (call it a “near miss”) that does not result in an adverse outcome remains inaccessible to the conscious mind. And should the bad decision be repeated again and again, it would insidiously become integrated into the adaptive unconscious, forever coloring the physician’s delivery of care.