Not Everything that Counts Can Be Counted
Author: Alastair Ireland
14/11/19
Not everything that counts can be counted. Not everything that can be counted counts.
Two tweets stopped me in my tracks last week. The first referred to a letter in the Lancet (1) from a group of experts in sepsis about what they referred to as ‘hysteria’ around sepsis care. The second announced the untimely death of a young Emergency Physician from Canada and contained a link to her observations about being a patient (2). Both challenge assumptions and were a timely reminder for me about two of the oldest most fundamental principles of medicine: primum non nocere – first do no harm and ‘Cure sometimes, treat often but comfort always’. Credit to Hippocrates. He knew what he was talking about over 2000 years ago, and though drilled into me as a student, I asked myself whether in our high pressure world I could pay more attention to this wisdom.
The letter in the Lancet raises an important issue about overtreatment and unintended harms. Regardless of your views on the drive to identify ‘sepsis’ (or as we used to say ‘infection’) quickly and the debate around the evidence about the importance of giving antibiotics in the first hour after diagnosis, we need to take stock. The letter was written partly in response to a politician’s statement that every one of the 52,000 annual deaths due to sepsis was a ‘preventable tragedy’. The letter pointed out the fact that that nearly 80% of the deaths occurred in patients older than 75 and the high incidence of frailty and co-morbidities with increasing age mean that the actual cause of death may not be that clear. And even with treatment, not necessarily preventable.
But in our guideline dependent, protocol driven service we are measured on our performance against well-intentioned targets. Time between arrival to hospital and giving antibiotics is measurable. We can count it. Others can assess our compliance. Timely antibiotics are important – in those that need them – but they need to be effectively targeted to avoid toxicity and resistance developing. But does this sometimes mean that we give the wrong treatment very quickly to people who won’t benefit, in our rush to meet a target.
“When it comes to processes, adherence to the process frequently becomes the objective, as opposed to achieving the objective that the process was put in place to achieve”
This graph shows us that for any treatment the rate of harms or side-effects are fairly constant. For those who have a clear indication for treatment, if it is effective, benefits outweigh potential harms. With greater resource we offer the treatment to more people. Indications may be weaker and the treatment may have less effect … but rates of harm remain constant. At some point, all we are doing is exposing patients to harm with no added benefit. As a simple example, angulated unstable fractures usually need internal fixation despite the risk of wound infection. Undisplaced stable fractures, if internally fixed have the same rate of infection.
We are encouraged to ‘personalise care’ (3). But where there is a drive to meet targets or a focus on compliance with guidelines, it becomes a difficult and a ‘brave decision’ to deviate from the protocol, even though it may be the right thing to do. We fear criticism from colleagues and peers if we get it wrong and there is rarely acclaim for choosing NOT to intervene with a test or treatment. Is it any wonder CT scanning rates are skyrocketing? There’s a famous phrase: ‘Good surgeons know how to operate, better ones when to operate, and the best when not to operate’. This could be applied to every test or therapy.
Unfortunately all too often and increasingly we tend to err on the side of investigation and intervention, believing that we should treat everything that can be treated, until we have exhausted all available options. Rather like dogs chasing sticks, we seem to be programmed this way.
But in amongst all the protocols and targets, we mustn’t lose sight of that essential personal connection we have with our patients or, worse still, fail to to understand their needs. As Atul Gawande pointed out in his book Being Mortal “Our most cruel failure in how we treat the sick and aged is the failure to recognise that they have priorities beyond merely being safe and living longer’.
Simone de Beauvoir put it even more strongly in her 1964 book Une Mort Très Douce, describing her mother in hospital:
““One is caught up in the wheels and dragged along powerless in the face of specialists’ diagnoses, their forecasts, their decisions. The patient becomes their property. (My mother) reduced by her capitulation to being a body and nothing more, hardly differed at all from a corpse. A poor defenceless carcass turned and manipulated by professional hands”. ”
It takes some experience to know, in talking to patients and relatives, how to present the options honestly, but this is the key to ensuring that the right decisions are made. Good communication with colleagues responsible for ongoing care and documentation of these discussions is essential. In many places these decisions are written in specially designed ‘Treatment Escalation Plans’ in the clinical record. But whether a form is available or not, it is most important to ensure that carefully considered care plans are not ignored to the detriment of patients.
Comfort, dignity and compassion are paramount. Always. They are difficult to measure. But they count.
Which brings me back to the second tweet and the words of Barbara Tatham, an emergency physician from Canada who died last month from cancer. If you can, click the link and listen to her words directly. Only 4 minutes but challenging and profoundly important ...
https://content.blubrry.com/emc/Barb_Tatham-Physician_Compassion.mp3
After describing her treatment, complications and deterioration from a disseminated skull tumour, she went on to say:
““What I want to leave with you today is the power of connection. And the power of education. And the power of presence. The patient-physician relationship is far more than you realise. It has an impact that lingers. I’ve spent more nights in the Emergency Department as a patient than I ever want to again. And those moments. Those little moments matter so much more than you realise. For the patient that’s going through a lot, even though they don’t look like they’re going through a lot and they look healthy like me, it’s a journey. Not one that anyone really wants to be on. Those little moments that you have can change somebody’s life. The moments where my physicians have had heart – and I can feel their heart in my care – makes all the difference. And the moments when their heart’s not there also make a difference. A good friend of mine reminded me of one of my favourite quotes today by Maya Angelou. It says ‘people don’t remember what you say and people don’t remember what you do; but they do remember how you make them feel’. So today, thank you for making me feel heard.””
So perhaps at times we need to rethink our priorities. Clearly for people who need it, the right intervention at the right time is vital though we must be careful to avoid harm. But more important than we often realise, are the small moments and the signs that we really care ... and the essential truth that, at the core of medicine, is a human relationship.
References:
1. Singer M, Inada-Kim M, Shankar-Hari M
Sepsis Hysteria: excess hype and unrealistic expectations
Lancet. 2019; 394:1513-1514
2. https://twitter.com/EMCases/status/1184647259612422145
3. Personalising Realistic Medicine: Chief Medical officer for Scotland’s annual Report 2017-2018. Scottish Government Publication. 25 April 2019