Over the last seven months, the state of medicine, as we have known it in the United States, has been found out. Disjointed, disheartened, and failing. For every ounce of energy we have put into patient safety, quality improvement, and preventing medical errors over the past 20 years, we have simultaneously drained the soul from medicine by turning our work into a commodity, with a price attached to every action or inaction. In aspiring to cut costs, we destroyed the foundation of modern medicine. Public health, preventative care, and those on the front line of medicine, primary care, were shunned for shiny technology, life-saving and preserving interventions, and proceduralists. Those physicians who were left behind were leaving medicine because of lack of respect, poor pay, and unobtainable goals, while physicians in high tempo flashy jobs like mine were leaving because we could not keep up with the pace, the appetite for more and more instead of better and better and the constant moral injury at the bedside of an unconscious and unfixable patient.
COVID did not create these problems. As with most things, all COVID did was highlight and exacerbate them, but the answer cannot be to look backward. Back then, it was worse in a way that is hard to recognize in the state of horror we are in right now, but back is not the way forward. In order for medicine to come out of COVID a better and changed pillar of society, we will have to pivot away from the medicine we imagined it to be and use innovation to propel medicine into the realm of a just culture: “… what kind of accountability promotes justice and safety: backward-looking and retributive, or forward-looking and change-oriented.” As the third “wave” or more accurately, the third deadly crest of one giant wave moves across the world and the U.S. specifically, we will need to apply the concept of a just culture to our disaster surge plans in order to achieve optimal patient safety: “Health care organizations need to develop a culture that harnesses the ideas and ingenuity of health care professional by employing a commitment-based management philosophy rather than strangling them by overregulating their behaviors using a control-based philosophy.” The foundation of medicine that we seem to pine for was built on fear, hierarchy, and tradition. Depending on those attributes led to the unmitigated disaster of our initial response. Waiting for peer-reviewed literature, refusing to listen to those who were screaming at us from across an ocean and then insisting that our bottom dollar was more important than the preservation of the life of our most precious resource, our people, beckoned us to the edge of chaos. What carried us through was grit, integrity, commitment, advocacy, and listening to those on the ground.
And now, here we are. Back to ground zero. But this time, the wave is on top of us. Yet again, listening to those at the top and waiting for marching orders has led us astray. We put our guard down. Went back to life as it used to be. Convinced that maybe we could harken back to those golden days of normalcy. Back to elective surgeries, standard surgical masks, standard intubations, doing invasive procedures when they weren’t necessary because the patient “likely” didn’t have COVID. We even had the Joint Commission back telling us to put our food and drinks away. But what we didn’t see or hear was the truth, “A concern, however, is while many health care leaders declare patient safety as an organizational priority and are, convinced they see evidence of safety, front line staff continues to report concerns about actual safety practices and priorities.”
What makes it even more insidious is when some of the front line staff are the very people who make a hospital or health care organization the money they need to function. In the current health care landscape, that is those who do surgeries and those who do procedures. We cannot ignore the fact that when elective surgeries stopped, people were laid off, fired, or had their salaries froze or decreased. This begs the questions then, why would we not do everything we can to maintain elective procedures at all costs in order to maintain the livelihood of others? And the answer lies in the fact that doing everything also meant doing everything safely. And safely means slowly. And slowly means loss of profit, which means the answer is to do what is expected of you from a hierarchical standpoint and push the pace at the expense of safety. Safety to the patient. Safety to the physicians, nurses, and techs in the operating room. Safety to the next patient. What we lost was our integrity and advocacy. What we gained was failure and death.
True leadership would recognize that those on the front line who do not make the institution a profit are terrified to speak up, and often stuck between putting food on the table for their family and doing what is morally right. “Minimizing a culture of blame, in which leaders accept accountability for safe systems, and creating an environment in which staff feels free to report errors and systems vulnerabilities openly must start with leadership acknowledgment that barriers exist.” Now is the time for health care systems, hospital administration, leadership in general at the local, state, and national levels to advocate for those who they are entrusted with leading. Without the safety and protection of their health care workforce, loss of patient safety will be the first byproduct of our clinging to a past that got us here. To now, to 2020. We may stand on the shoulders of giants in medicine, but those giants stood on the shoulders of the vulnerable. A just culture recognizes the contributions and concerns of those who were previously merely pawns in an ivory tower of greatness. The safety of patients in the time of COVID is dependent on our commitment to a just and change-oriented mindset. Forward, not back.
Nicole M. King is an anesthesiologist.
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