I spent two days this week at an Australian Institute of Company Directors course, most of which we spent talking about Risk – legal, financial, moral, cultural.
Risk these days is part of everything we do, it cannot be constrained by regulation or policy. The best companies embrace risk, encourage innovation and support the individuals within it to manage risk through a culture of competence and trust.
Lets turn this to a conversation about how health systems manage risk. In particular how risk is managed in rural and remote areas.
I am a rural generalist with advanced skills in obstetrics and anesthetics. What does this mean if the system manager says that risk can only be managed by transferring the patients to a tertiary center?
What if one of my patients has a complication after the birth of a baby, such as a third degree perineum tear, that requires repair. I am trained to repair these, I just don’t do it often.
Risk mitigation would say that the patient should go to the best “Perineal Repair Service” and if you follow the logic the best service may not even be in Australia.
What say I have someone present with Ventricular Tachycardia a serious rythm disturbance of the Heart. Its OK to Defibrillate (Shock) them if they’re unstable, but not OK as an elective procedure, where in my system they should be sent hundreds of kilometers away to a Cardiologist.
This says much about trust in rural clinicians to be prepared, competent, capable clinicians and more of the lack of knowledge displayed by senior health administrators of the challenges of dislocating ill people from care.
Dr Atul Gwande highlights the move to specialism through a story on hernia repairs at Shouldice Hospital in Toronto. Shouldice Hospital is a conveyor belt when it comes to hernia repair. Precision, like making a Breitling Watch, comes through automation and standardization of the procedure, to the point that the clinicians performing the operation are mostly not surgeons at all.
The New Yorker in an article called No Mistake expands on this proposing that super-specialization and removing the human element is the only way to get better outcomes, to reduce Risk.
Is this what the country needs? – More super-specialization in smaller and smaller aspects of care, where the person becomes a series of components to be replaced, upgraded or removed.
Risk tolerance is a matter of attitude, approach and perhaps a bit of self deception. As a long term rural doctor, my risk tolerance and perhaps my acceptance of uncertainty is much greater that that or my junior and urban peers.
Does that make me a poorer clinician than my city colleagues with the technology at their fingertips?
Where is the patient in this conversation, are rural people more or less accepting of risk?
Farming for example is all about risk, whether it will rain tomorrow, should I plant that crop. Mining is a dangerous occupation and safety management becomes integral to ensuring workers come home at the end of the day.
I haven’t an answer myself, but I think we have to have the conversation.
Every patient I see is an opportunity to have a discussion about risk because their appetite will be different. I don’t think we do this well. Often people choose to stay closer to home, to accept that their doctors and nurses, while not experts in their field, have trained for and are competent in safe practice.
There is no better example of shared decision making than “birthing on country” where the context of risk is framed within cultural and community decision making.
Can health systems embrace an integrated culture of learning and training, coupled to trust and competencies?
As a long term rural doctor I have learned to cope with the vicissitudes of rural practice. I supervise and educate many younger clinicians as they embark on rural careers.
Most of what I do isn’t teaching, more empowering the doctors to use the learning and the skills they have spent many years training in.
Generalist medicine is about knowing when to say “I don’t know”, while embracing the rewards of delivering quality care to grateful people in resource poor environments.
Generalist medicine is about understanding risk and uncertainty and having that conversation with the people you care for. Risk cannot be designed out of healthcare, it must be embraced.
The rise of the generalist health professional is challenging the march to specialism. Enabling well trained competent clinicians to deliver expert care within a defined scope of practice to the whole person in a community context is a key solution to containing costs, and improving quality.
The challenge is that, by and large, the health system has failed to embrace these professionals, preferring metro-centric specialist led systems. These constructs are more expensive, less responsive and disruptive to rural families.
We desperately need our health system to be less prescriptive, less policy driven and more trusting of health professionals to get on with the business of delivering quality care.
There will always be “Bad Apples” and “Adverse Outcomes” but stifling shared decision making with our patients isn’t the answer.
The best thing a clinician can do is “know their limitations”; we cannot do that if we are never given the opportunity to find them in a protected and embracing learning environment.