The scary part of the adaptive unconscious is that it is inaccessible to the conscious mind because it is unconscious. But there is a way to modify the adaptive unconscious: reflection. I am not advocating candles, incense, and Kenny G. But reflection on physician behavior has to occur, and it must be much more than just focusing upon the adverse events (which, by virtue of being adverse, are fully in the conscious mind). Reflection that meaningfully changes unconscious behavior has to be focused upon what seemingly didn’t happen. It is a step-by-step analysis of a physician’s performance in ordinary time.
Put another way, every quarterback in the NFL leaves the football game thinking about the interceptions thrown (the dramatic mistakes), but only by virtue of reviewing the game film does he become aware of the interceptions he almost threw. Unlike the NFL quarterback, the hospitalist does not have the luxury of reviewing game film, but the need for reflection on the “near miss” events is no less important.
This takes time, and it likely takes an element of external discipline that the ordinary physician cannot provide for himself. Time is addressed in the next threat, but see the summary of this discussion as simply this: In the face of the prevailing culture of peer review and RCAs, there has to be equal attention paid to finding time and structure to reviewing a physician’s performance in the absence of adverse events. Perhaps this is structured alone time; perhaps its structured time with other hospitalists as a group discussion—I don’t know. But some element of reflection in the absence of “what went wrong” has to occur, lest we find ourselves in 2020 repetitively responding to adverse events, wondering why in 10 years’ time, the number of adverse events has not appreciably diminished.
Threat 7: Failure to Optimize Efficiency
Our story began in 1999 with a focus on hospitalists improving efficiency. The second chapter of our story, of course, has been on improving quality and patient safety. Interesting, isn’t it, that we find ourselves where we began? For Chapter 3 begins again with a focus on improving efficiency, not for financial ends, but for the meaningful enactment of quality and patient safety. Two points make the case.
If I were reading the discussion above, and not writing it, I am sure I would have your same response: “Great, more things (reflection time) to do with a fixed amount of time, and no additional money. Thanks for another unfunded mandate.” The reality is that until we get to an ultimately inspired healthcare system, there is unlikely to be financial support, or a discounting of RVU expectations, to support reflection. So with a fixed amount of time, and increasing activities to fit into that time, there is only one answer: We must become more efficient.
Taiichi Ohno, Toyota’s chief engineer, described what are essentially the bones of “LEAN” in optimizing efficiency. The challenge before us, despite what we have already done, is to further eliminate the “Muda”: activity that does not add value. Not only will this save money, but it will also create the additional time necessary for reflection, which is in turn requisite for a meaningful culture of patient safety and quality.
But there is another reason, one that makes improved efficiency essential in advancing patient safety. In the early part of the century, Yerkes and Dodson published the performance vs. stress curve.2 Like preload to the heart, the authors postulated that performance (on the Y axis) was related to stress (on the X axis) in a rainbow curve. With very little stress, there was very little performance. As stress increased, so did performance, at least to the inflection point on the rainbow curve, after which too much stress led to decreased performance. If you have ever stared blankly at a computer screen trying to formulate a response to the simplest of e-mails, you have experienced both tails of the Yerkes-Dodson curve.