Abstract
C
I discussed this case with several faculty members at my local academic medical center. One of the geriatric professors said that due to the reduction in resident work hours, the faculty is relying more on the use of checklists. The standard checklist includes a yearly screening mammogram for a 60-year-old female. The resident was simply “checking the box.” The professor also explained that health care reimbursement is now being tied to health outcomes and one way to measure outcomes is by monitoring the number of mammograms (or colonoscopies, pap smears, flu shots, etc.) ordered, boxes checked, regardless of the appropriateness of the test. Quality outcome measures are also used in both regulatory review of health care businesses and marketing campaigns.
Atul Gawande, a well-known author and surgeon, wrote a book, The Checklist Manifesto—How to Get Things Right. He describes how checklists were first adopted by airline pilots when planes became too complicated to be left to the memory of any one person, no matter however expert. He points out that much of the work of various fields: financial managers, fire fighters, police, lawyers, and most health care providers, has become too complex for them to carry out reliably from memory alone. 1
The upcoming geriatric tsunami will likely further stress our teetering health care system and I predict that there will be more reliance on checklists. Checklists have been shown to improve patient safety, save time, and increase efficiency, and can be a great tool but not as a “one-size fits all” approach. They can save mental bandwidth, but herein lies the problem. Providers stop thinking about patients as individuals when the goal becomes checking off all the boxes rather than providing the best care for that particular individual.
Did any of the health care providers involved in Ms. Smith's care actually look at her as a person sitting in their offices? She was a very frail hospice patient with a life expectancy of six months or less. Why was an asymptomatic breast cancer even diagnosed much less treated? The primary care physician got to check off the mammogram on a checklist that will earn credit for health outcomes scores. The hospital system and specialists will benefit financially from the biopsy and radiation treatment. As many of us know, the overutilization of health care resources is one of many problems with our current health care crisis. Will checkbox medicine encourage these types of situations to continue and how can we improve upon the current system for the benefit of patients, their families, and the health care system?
The many Ms. Smiths that I see in my practice have frustrated me. However, I was encouraged to see an article in Chest about an expert panel review of the American College of Chest Physicians (ACCP) recommendations for lung cancer screening. The following bullet point caught my eye, “We recommended against low-radiation dose CT screening in cohorts at low risk of developing lung cancer and in individuals with comorbidities that adversely influence their ability to tolerate the evaluation of screen-detected findings, tolerate treatment of an early stage screen-detected lung cancer, or that substantially limit their life expectancy.” 2
The authors of the Chest expert panel report added the following statement to the ACCP recommendations. “At very severe stages of a comorbid condition it can be clear that low-dose CT screening is not indicated (e.g., advanced liver disease, COPD with hypoventilation and hypoxia, NYHA class IV heart failure) because competing mortality limits the potential benefit, and harms are magnified. At less severe stages it can be difficult to determine if an individual's comorbidities are significant enough that they should not receive low-dose CT screening. Further research is required to assist clinicians with this decision.” 3
Some people might say that Ms. Smith was the one to “blame” for her utilization of health care services. When I learned of the situation and went to her home to see her, she told me that she got the mammogram and subsequent treatment because she was “doing what her doctor told her to do.” As providers in the field of hospice and palliative medicine, I think we are in an optimal position to work with our colleagues, health system administrators, government and regulatory agencies, and patient community to model our approach of customizing care plans to fit the individual.
I spoke with a retired pilot who told me that pilots use checklists to ensure that they think about each item and make a judgment. They are not “graded” on the number of boxes checked nor is their compensation tied to the number of boxes checked. They view a completed checklist as assurance that they have thought through all the angles and can safely fly. They do not use a checklist as a substitute for judgment but rather as a tool to organize their judgment.
Looking at each person as an individual and considering whether the general recommendations are right for that person at that time in their life is something that comes naturally to us in the field of palliative medicine. We need to find a way to reward the general medical community, regulatory and reimbursement agencies for following our mission.