President’s Corner

Sheryl Beard, MD, FAAFP, Andover

KAFP President’s Letter

Reviewing 20 Years of Medicine Changes in 2020

This year I celebrated my 20th year since graduation from medical school. The standards of medical care in the U.S. have changed dramatically since my time in training 20 years ago (And swung back again ― think long acting insulins ― first it was NPH then insulin glargine and now it’s NPH again!)

For example, we used to do pap smears as soon as possible in sexually active women. Now some women can wait up to five years for their next exam. Sometimes I have patients tell me that they don’t want to wait that long. I accommodate. We used to strive to get LDLs to less than 70 and now we treat based on risk, and sometimes people look at me like I am crazy suggesting they might not need to be on medication. This is shared decision making. When medicine changes, I feel like we roll with the punches – incorporating changes with the patient’s best interest in mind.

I remember the year I graduated from the University of Kansas School of Medicine. It was 1999, the Institute of Medicine (IOM-now named the National Academy of Medicine) had just published “To err is human: building a safer health system” ― launching the modern patient safety movement. In the report, the IOM identified that medical errors led to more deaths than many other feared entities such as motor vehicle collisions and breast cancer. It was estimated at the time that as many as 98,000 people died each year due to medical errors. Others argued that medical errors were just the cost of doing business. The IOM made recommendations about what should be done to make healthcare a safer place:

  • Establishing a national focus to improve knowledge surrounding patient safety
  • Learning from errors by mandating a reporting system
  • Raising performance standards for institutions
  • Implementing safety practices at institutions

After the report, many hospitals were mandated to report complication rates in certain areas related to patient care. I was new to the hospital medical staff at the time and found it informative, yet a bit wasteful of manpower that every meeting consisted of reporting such rates.

The infection control team would report rates of central line associated bloodstream infections or CLABSIs. Hospitals identified that CLABSIs could be prevented by adopting a systematic approach to safety, just as aviation does. By promoting systematic steps from insertion of the line all the way to care of the line, hospitals were able to reduce these infections. CLABSIs were just one example. Identifying systematic approaches to ventilator associated pneumonias and catheter associated urinary tract infections also worked well to decrease the occurrences of these infections.

Hospitals not only wanted to reduce infection rates, they wanted to reduce medication errors. They started computerizing order entry for medications. This reduced the errors made by poor handwriting or mis-written orders. Hospitals barcoded armbands for patients and pharmacies barcoded medications. The efforts reduced medication errors, and overall these efforts have reduced harms. We have saved lives. But there is still much work to be done in the area of patient safety.

What does the next 20 years look like? The National Academy of Medicine (NAM) has now identified improving diagnosis in healthcare and improving ambulatory care as the next hurdles to overcome. The NAM states that diagnostic error is one piece of that improvement plan. I recently had a patient who sustained an injury and needed imaging. The report was normal, but I suspected something was still not right. I suggested the patient see a specialist. Then I received a new report showing a significant defect was noted on the image. Was this human error? Was this a transcription mistake? Was this an error in medical record keeping? Was it a missed diagnosis? Regardless of the problem, the patient needed good care and ultimately got what she needed. But the answer to diagnostic problems are complex and likely require patient and team member input. We need a culture that supports accurate and timely diagnoses. We need medical liability reform. We must be able to learn from our missed or delayed diagnoses. In addition, our payment structure is currently not set up to support making the most accurate diagnosis.

We have come a long way in improving patient safety. We have stopped those statins. We have removed those catheters. We have barcoded our patients. We have endured the EHR for patient safety. Let’s keep working. We need to improve our diagnoses, and not just human error. We need to improve our collaboration with other clinicians, policy makers, patients and their families and researchers. Here’s to 2020 and striving for better!

Sincerely,

Sheryl Beard, MD, FAAFP
President

References:
  1. Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. https://doi.org/10.17226/9728.
  2. https://psnet.ahrq.gov/issue/improving-diagnosis-health-care
  3. National Academies of Sciences, Engineering, and Medicine. 2015. Improving diagnosis in health care. Washington, DC: The National Academies Press