Chapter 11 of 27
Patient X was a 70 year old woman who had had a large ruptured aneurysm in her brain. This is usually a catastrophic event. She was transferred to a teaching university hospital setting and her aneurysm was successfully clipped. Unfortunately, she developed hydrocephalus or high pressure in her brain with dilated (enlarged) ventricles.
She had a shunt procedure that helps to drain the cerebro-spinal fluid (CSF) from the ventricles into the peritoneal area (the abdomen). The shunt procedure had to be repeated because blood blocked the drain. The doctors did not realize for 3 months that the shunt was not placed properly. During these 3 months, the patient went downhill. When it was realized that the shunt was not placed properly, it was replaced and then because of further complications it was removed.
This case demonstrated Murphy's Law. The result was a relationship between the family and the chief neuro-surgeon that could be described as strained. There was no trust. The case could not proceed because the family and the surgeon could not reach any decisions.
Patients want to avoid confusion, contradictory opinions and complexity by believing in the doctor as the hero or God-like figure and as the sole maker of the decisions. However, contradictory opinions have proven very important in helping to resolve complex "real world" healthcare problems. Unfortunately, many doctors enjoy their God-like role and are arrogant and angry when challenged or confronted with contradictory viewpoints.
A second opinion was historically felt to be enough. However, this approach is simplistic and does not result in good decisions being made about complex problems. Often the second opinion will concur with the primary decision maker to avoid rocking the boat and upsetting the authority figure.
RCM's "Deep Dive" process challenges all assumptions and involves sourcing opinions from many experts at different centers of excellence. Since each center will likely have a different approach, this results in competing hypotheses. Many patients are fearful of this process because they anticipate upsetting their doctors and ending with paralysis through analysis. Just the opposite happens.
Debate is good for your health.
When forced to interpret the facts through a different, perhaps uncomfortable lens, assumptions are challenged. This moves the decision making away from the limited processing of the rational mind and into the more sophisticated decision making processes involving the emotional brain. Emotions, when invited into the decision making process, can be very effective in helping to resolve difficult and complex issues and problems. Emotional decision making takes the decision to a deeper level and often to a better quality decision.
A large NASA study of pilot error in the 1970's concluded that the God-like certainty of the pilot in command was a major source of error. If other crew members had been consulted, or if the pilot had considered other alternatives, then some of the bad decisions might have been avoided. As a result, the goal was to create an environment in which a diversity of viewpoints was shared by all the crew members. This has resulted in a dramatic reduction in accidents from pilot error.
The same process was adopted at the Nebraska Medical Center which began training its surgical teams in 2005 in the same methods used by the pilots. All members of the surgical team are encouraged to express their concerns to the attending surgeon. In addition, team members engage in post-operation debriefings at which everyone shares his or her views.
The results at the Nebraska Medical Center were impressive. A 2007 analysis found that after fewer than six months, there was an increase from 29% to 86% in the feeling of being free to question decisions of those with more authority. This led to a dramatic decrease in medical mistakes. Before this process was introduced, only 21% of cardiac surgeries were classed as uneventful. After this process was introduced, the number of uneventful cases rose to 62%. The medical teams started to think together which deters certainty and stimulates debate. This is the ideal scenario for good decision-making, in which a diversity of opinions are openly contributed and shared.
It is important to challenge all the assumptions and to introduce competing viewpoints when confronting decisions about complex healthcare problems. RCM's "Deep Dive" process introduces multiple viewpoints. This forces the decision making process to become stronger by inviting powerful emotions to help to process the decision.
New tactics are being introduced in healthcare to encourage teams of doctors to share their opinions without upsetting the clinical lead. This has resulted in fewer medical mistakes.
When it all comes together!
How We Decide, Jonah Lehrer, Houghton Mifflin Harcourt, pages 251-255.