Dacey, Ralph G. Jr MD
I would like to discuss some of the challenges I see that result from the unintended consequences of health system reform. As neurosurgeons, we have a duty to the individual patients under our care—and a collective duty to existing and future patients—to define the optimal practice of neurosurgery. Our patients are among the sickest of any specialty. The operative procedures they require are expensive, technologically complex, and sometimes associated with the risk of serious complications. For these reasons, health policy makers will continue to have our specialty directly in their crosshairs as they attempt to simultaneously reduce healthcare expenditures and improve patient safety.
I believe that we must, as a specialty, improve our stewardship of the healthcare resources we control and we should do everything possible to systematically improve the safety of neurosurgical procedures for our patients.
PATTERN OF UNINTENDED CONSEQUENCES
However, in the background for most of us as we work on cost control and patient safety initiatives is the disturbing feeling that we must justify our work to a group of nonsurgeon health policy activists who are advocating for changes that often seem to be at odds with the best interests of our patients.
These policy makers compose a “health policy establishment” made up predominantly of physicians who have left the active practice of medicine. I think that there 2 kinds of people in America today. Group 1 is made up of businessmen, entrepreneurs, farmers, artists, warriors, physicians, and surgeons. These are the people in our society whose responsibility it is to do real things and accomplish tangible objectives. The other group, group 2, is made of politicians, most lawyers, the press, and government regulators. The responsibility of group 2 is to criticize, regulate, and litigate against those in group 1. For most of these group 2 people, the regulatory process is an end in itself; they are not concerned with the unintended consequences of their proposals.
These unintended consequences are very important, and I have noticed a disturbing and recurring pattern as policy makers seek to change the way we care for our patients and train tomorrow’s surgeons.
This pattern starts with the identification of a perceived problem in healthcare delivery. A solution to the problem is proposed. Often, the proposed solution leads to an improvement in processes and outcomes. However, not infrequently, the solution results in unintended consequences that are worse than the problem the solution was meant to correct.
There is a historic example of this pattern of unintended consequences that occurred on the Chicago River. As we all know, the sinking of the Titanic in 1914 was a tragedy of epic proportions. Many of the passengers on that ship died of immersion hypothermia because the ship was underequipped with enough lifeboats. After the sinking, critics and reformers stridently called for solutions. As a result, the Seaman’s Act was written, approved by Congress, and signed by President Wilson in 1915. Among other things, this legislation mandated that ships must carry enough lifeboats to accommodate every passenger and crew member. Existing ships were therefore retrofitted to carry additional lifeboats. As a result, The SS Eastland, a passenger ship that plied the Great Lakes, was equipped with many additional lifeboats. On July 24, 1915, the Eastland was to transport 2000 factory workers and their families from the Western Electric plant in Chicago to a picnic in Michigan City, Indiana. While the ship was boarding about 2000 passengers, it abruptly rolled over and capsized at the dock. A total of 844 people, many of them children, were killed, with most of them drowning while trapped below decks.1 What was the cause of this tragedy? It was later concluded that the installation of the additional lifeboats in compliance with the Seaman’s Act made the already top-heavy ship more unstable and more prone to capsizing. So the pattern is this: A problem with a process or system is identified. Activists and reformers propose a solution. The solution often works, and the process is improved. But sometimes, an unintended adverse consequence ends up being worse than the problem intended to be remedied.
Recently, this pattern has been played out in 3 areas relevant to neurosurgery: further proposed restrictions on duty hours, government policy on hospital readmissions, and the exclusion of neurosurgeons from the intensive care unit (ICU).
DUTY HOURS RESTRICTIONS: ATTENDINGS
During the past 10 years, while working on the American Board of Neurological Surgery and the Residency Review Committee, I have spent a great deal of time on the resident duty hours problem. Recently, however, an even more disturbing proposal surfaced from the same group of health policy activists who drove the resident hour restrictions.2,3 These sleep scientists have demanded that elective surgical procedures be canceled if the attending surgeon has performed surgery during the previous night. The Sleep Research Society has endorsed model legislation in this area.
Our experience with the resident duty hours informs us about what is likely to occur in this new regulatory area. We will be presented with a complex web of interacting rules that will make it harder for us to be there for our patients when they need us. The regulators will insist that every facet of sleep science—ranging from hours in bed to accumulated sleep debt to circadian influences—will have its own rule. What are the likely consequences of this policy? In the United Kingdom and Ireland, the imposition of work hours restrictions for consultant surgeons has led to tremendous scheduling difficulties and staff shortages.4 In many surgical practices in the United States, there is not an adequate number of neurosurgeons to permit cross-coverage of such elective cases. Patients will be subjected to emotionally disruptive cancellation of surgery related to an arbitrary set of complex scheduling rules that would mirror the duty hours restrictions for residents. This development has the potential to tie us up in knots worried about regulatory compliance when we should be concentrating on our patients’ complex problems.
A far better way of managing this issue is to educate surgeons about the balance of their professional responsibilities so that each surgeon can make a reasonable determination of the potential impact of fatigue on his or her performance in a specific instance. Instead of being compelled to comply with a whole new array of regulations, we should redouble our efforts to strengthen our culture of accountability and professionalism. We should study and understand the effects of fatigue on surgeon performance. We should cooperate with our partners and colleagues in developing sustainable working schedules that will ensure that we show up rested and prepared to work. We should develop strategic approaches to the unpredictable surges in volume and intensity that characterize surgical practice. It is a matter of surgical professionalism.
A few weeks ago, I had an experience with how fatigue could potentially affect my performance. I was scheduled to resect a right frontal glioma on a Monday morning. We planned to perform the procedure in the intraoperative magnetic resonance imaging suite, so it would not be easy to reschedule the case for another day or time. At midnight on Sunday night, the night before the scheduled glioma resection, I had to go in to evacuate an intracerebral hematoma in a patient with a ruptured middle cerebral artery aneurysm. I was awake from midnight to 5:30 AM. What should I have done? If I rescheduled the case, the patient and family would have been disappointed and the tumor may have grown, possibly affecting the extent of resection. If I went ahead, would fatigue affect the outcome? As it turns out, I recognized that I was tired and called one of my colleagues. I briefed him on the specifics of the case and introduced him to the patient and family. He was able to do the surgery, and it went well. As I reflected on this experience, I am sure that it is better for us to rely on our own professional standards as opposed to an externally applied, regulatory straightjacket.
Officials at Centers for Medicare & Medicaid Services and health policy experts in academia have been searching for ways to squeeze more cost out of our healthcare system. They have noted that many patients, especially those with congestive heart failure and chronic obstructive pulmonary disease, need to be readmitted within 30 days with an estimated yearly cost to Medicare of $17.4 billion. Readmission rates vary between 10% and 20%, and hospitals with a more disadvantaged socioeconomic status appear to have significantly higher rates. The payers have settled on the tactic of not paying for hospital readmissions and penalizing hospitals for readmission rates that are higher than expected as part of the Accountable Care Act.5 It has seemed odd to some observers that a federal program with the responsibility to fund care for elderly patients penalizes hospitals for providing needed care. But the reformers have concluded that almost all readmissions are indicators of poor quality of care. Even if one accepts the premise that readmissions are indicators of care failure for congestive heart failure and chronic obstructive pulmonary disorder, does it make sense that this concept should be extended to all readmissions, including readmissions for a neurosurgical service?
We examined our experience with readmissions at Washington University in St. Louis in an effort to answer this question. A database of readmissions within 30 days of discharge over about 1 year was retrospectively reviewed.6
Of 3552 primary admissions, 348 patients were readmitted, for a readmission rate of 11.5%. The readmissions were then assigned by 2 independent neurosurgeons to 1 of 3 categories. There were 113 readmissions for electively scheduled operative cases (27.8%). Thirty patients (7.37%) were readmitted as a result of unrelated causes from primary admission. There were 264 adverse events requiring readmission. We had a low threshold for attributing a readmission to an adverse event. However, the majority of these adverse events either were not preventable or were related to the natural history of the disease. We concluded that a significant proportion—63%—of readmissions to a large neurosurgical service at a major teaching hospital were not avoidable.
When a neurosurgical patient develops symptoms after an operative procedure, careful practice usually includes a neurologic assessment and maybe some imaging or a period of observation in the hospital. A policy that punishes the surgeon for readmitting a patient runs the risk of incenting sloppy and potentially unsafe care.
Do we want neurosurgeons second-guessing themselves when they make the decision to readmit a postoperative patient? The simple fact is that in some cases, additional care, whether it is an operation or an additional admission, may be completely appropriate and necessary. When the Medicare program or other payers prevent us from providing this care, they are getting between us and our professional responsibilities to our patients.
Since the days of Harvey Cushing, it has been recognized that patients with surgical diseases of the nervous system must be managed by neurosurgeons who are committed to taking care of their patients across the spectrum of care from diagnosis to outpatient visits. In the ICU, neurosurgeons pioneered the use of intracranial pressure monitoring, cerebral blood flow determination, and modulation of cerebral metabolism in critically ill and injured patients.
Recently, however, our ability to care for our patients in the ICU has been challenged. Pronovost and colleagues7 have advocated for a reorganization of ICUs with a requirement that the units be staffed with intensivists and “closed” on the basis of the premise that the immediate availability of an intensivist will allow better treatment and prevention of problems and the more efficient use of resources. After this initial publication, the Leapfrog Group, an advocacy organization of major employers and healthcare purchasing organizations, issued an ICU physician staffing “standard” that was rapidly and uncritically adopted by most US hospitals because of Leapfrog’s market clout. Credentialing and ICU organizational models at many US hospitals were overhauled.
None of us would question the value of having a specialist in neurointensive care collaborate in taking care of our sickest patients. But a problem arises when neurosurgeons are prevented from caring for their patients in the ICU. In the neurosurgical ICU, the critical maneuvers of urgent decompression of the brain or spinal cord play a central role in determining the neurologic outcome for many of the diseases we treat. Leapfrog is a serious and influential group, but it has no infrastructure or expertise in initial certification, maintenance of certification, and training program accreditation or in deciding who should care for which patients. These areas of expertise as they affect neurosurgical patients rest almost exclusively with the American Board of Neurological Surgery, the Society of Neurological Surgeons, and the Residency Review Committee for Neurosurgery.
Neurosurgical leaders must continue to make the case for the principle of neurosurgeons being able to care for their patients though the entire episode of care, including in the ICU. We cannot let a misdirected policy proposed by people who do not understand what we do separate us from our patients at the most critical junctures.
The common denominator in each of these examples I have cited—attending duty hours restrictions, punitive policies on readmissions, and the exclusion of neurosurgeons from our ICUs—is the unintended consequences of well-meaning but ill-conceived healthcare policies that result in neurosurgeons being unable to live up to the professional standards of our specialty of commitment to our patients and ownership of the outcomes of our treatments. In each case, a new policy initiative is getting between us and our patients. I believe that the accumulation of these experiences is discouraging and demoralizing for members of our intense specialty and, if unchecked, will lead to a cynical and counterproductive sense of detachment among neurosurgeons and other hardworking specialists.
What are the special attributes of neurosurgical professionalism that are put in jeopardy by these policies?
I believe that neurosurgical professionalism is characterized by a meticulous attention to detail in diagnosis and technical surgical treatment tempered by a balanced, common-sense approach to the patient. The best neurosurgeons are honest and humble in light of their awesome responsibilities, and when a neurosurgeon embarks on a course of treatment for a patient, he or she owns that responsibility to a degree greater than seen in other specialties. It is perhaps this last aspect of neurosurgical professionalism that is most challenged by the policy changes I have described.
I believe that we have serious responsibilities when it comes to living up to our professional standards. There is an example in history that is instructive here that is described in General H.R. McMaster’s excellent book, Dereliction of Duty.8 In 1960, when Robert McNamara came from Ford Motor Co to become President Kennedy’s Secretary of Defense, the uniformed, career military leaders were told that things would now be different and that a new businesslike approach would be practiced in the Pentagon. There was great pressure to conform, get with the program, and support the civilian leader’s policies, especially with regard to the conduct of the escalating and unconventional conflict in Vietnam. General McMaster, who earned a PhD in history from the University of North Carolina, describes in his detailed, well-referenced book how these experienced and high-ranking officers failed to advise the president and secretary on the basis of their true beliefs and standards of military professionalism. McMaster attributes a great amount of blame for our nation’s tortured experience in Vietnam to the senior military leadership for not using their best professional judgment in telling their superiors that what they were proposing would not work.
RESPONSE TO THE CHALLENGE?
General McMaster’s lesson for us as neurosurgeons is that clearly, in the near future, we will be buffeted by many changes as the imperatives of healthcare reform and cost containment are confronted, and as leaders in our healthcare system, we have an important set of responsibilities. First, and in general, we should embrace the positive changes that are developing. We must make our hospitals, ICUs, and operating rooms as safe as they possibly can be. We must be judicious stewards of the expensive resources that we control. We should enthusiastically participate in the NeuroPoint Alliance and National Neurosurgery Quality and Outcomes Database and demonstrate superior outcomes for our patients. We must vigorously support our leaders in the American Association of Neurological Surgeons, Congress of Neurological Surgeons, and Washington Committee as they advocate for us on a national level. And we must take advantage of our positions as local community leaders and become more active politically.
When newly proposed policies are contrary to our patients’ interests or they make it difficult or impossible for us to fulfill our professional responsibilities to our patients, we should firmly push back. There is a tendency for health reform advocates to perceive anything less than complete support for new initiatives as obstructionist. Neurosurgeons who do not immediately conform are described as “just not getting it.” Just because we do not agree with a certain proposed change does not mean that we do not believe in the importance of patient safety or cost-effective health care.
Fundamentally, we need to rely on our sense of what is right for our patients based on our knowledge of neurosurgery and our professionalism. We should work diligently to improve patient safety and to improve healthcare value. But we should be alert to the unintended consequences of proposals for healthcare reform. We should not go along with ill-conceived proposals for change just because they are politically correct in our hospitals. Future generations of patients depend on us to maintain our standards of professional commitment. Our great specialty will continue to thrive only if we speak loudly and firmly to demand policies that ultimately serve the best interests of our patients.
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The author has no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.