In theory, none of us SHOULD need to do medical collaboration. In an ideal world, each healthcare provider has perfect knowledge of every disease and impeccably up-to-date information on their patient, at all times.

The reality? Each healthcare provider has a rich, powerful, and incomplete perspective. That means that the super-specialist and the aide both have a crucial role to play. And that the more we communicate with each other about our patients, the more fully we can help them.

It’s not often you have precise confirmation of this reality. But a recent article in JAMA put a spotlight on it for me.

One of the more routine things we do as doctors is recommend cancer screenings. It’s not the most sophisticated analysis; it’s not the most intense moment. But it is important and absolutely does save lives.

As routine as this may be, however, it is still powerfully impacted by the real limitations we have as busy, human people who are acting within a context of too-short visits and too-hectic care contexts. In fact, this recent study by the University of Pennsylvania, and published by JAMA, shows that "As the overall clinic day progresses, clinicians may face decision fatigue, defined as the depletion of self-control and active initiative that results from the cumulative burden of decision making"' and that "Relative to 8 am, the adjusted odds ratios (OR) of clinician ordering and patient completion of breast cancer screening was significantly lower for each hour from 10 am to 5 pm."

In other words, even the most fundamental aspects of the care we provide are impacted by our own energy levels and the context in which we see the patient. 

This isn't shocking; it is completely natural and human. But — it’s our responsibility to support ourselves so that every patient we see gets the same standard of care. Just as it is our responsibility to wash our hands, it is our responsibility to get the collaboration and support we need from colleagues through telemedicine-based medical collaboration. We can't fix the healthcare system. But we can make sure that we have the tools we need to work effectively within it — every hour of the day. 

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In a recent New York Times article, Dr. Peskin tells the story of one of her patients — Shirley.

The first time that Dr. Peskin saw Shirley, she had been taking shots on a daily basis to deal with her diagnosis of Multiple Sclerosis.

5 months later, Dr. Peskin saw her again because she had now suffered anaphylaxis from the shots. In the process of treating the anaphylaxis, another doctor ended up reviewing Shirley’s history and concluded that she didn’t have MS at all — indicating that the decades-long course of daily shots were actually unnecessary.

In other words, Shirley’s first doctor made an incorrect diagnosis; that diagnosis was confirmed by a second doctor; and a it wasn’t until a third doctor was involved that the mistake was revealed.

This story certainly isn’t unique. In fact, mistakes are often revealed at the junction point between two doctors — whether it’s during a handoff or because care has been taken up with a new doctor for a different reason.

To me, there are three important findings that relate to this story:

• Mistakes must be part of our medical experience.
  The entire structure of our medical system and practice treats mistakes as an unpardonable, inexcusable part of care. That means that, as Dr. Peskin explains, doctors are left to deal with the intellectual and emotional aftermath of making a mistake on their own. And, I think, learnings from mistakes are limited. Far better would be to incorporate a thoughtful exploration of our mistakes into our practice — in a way that doesn’t necessarily make anyone “wrong” for having made the mistake in the first place. This is one crucial reason that all ClickCare cases are automatically archived and searchable for teaching and reflection.
• The more we collaborate, the better we do.
  If you collaborate, you don’t need to wait until a mistake is found “after the fact” — another set of eyes (or two or six) can help us make better decisions and diagnoses in the moment.
• Handoffs are not collaboration.
  It’s important to note that Shirley would likely have received more thoughtful, appropriate care if her three doctors had been able to work together, sharing perspectives. This type of collaboration creates far better, more sophisticated care than simply bouncing the patient between providers. It’s possible that her original doctor had important insights about her that informed the diagnosis of MS — and rather than reversing the original diagnosis, perhaps the final doctor would effect the change by integration or interpolation, while engaging together about the care.

Shirley's case didn't end badly, and all of her doctors had been working hard to provide the best care possible. But we believe that a better way is possible, easy, and doable -- if doctors have the right tools and the right mental framework. Doctors don't have to "go it alone" and be infallible -- they can collaborate and they can learn from their mistakes. 

Medical mistakes are the 3rd leading cause of deaths in the US.

Only heart disease and cancer kill more people every year than medical mistakes ranging from "surgical complications that go unrecognized to mix-ups with the doses or types of medications patients receive." 

And a new study from the ECRI Institute looks at a subset of these mistakes -- patient identification mix-ups -- finding that the magnitude of the problem is huge, and that the EMRs are not helping.

It's not that we shouldn't ever make a mistake, as healthcare providers.

In fact, I am proud that in the medical field, we have an ethos of looking at and learning from our own mistakes. Medicine is not an exact science, and we are still learning and evolving our practice. For instance, anesthesia was only invented about 150 years ago, so it's not shocking that we're still experiencing avoidable surgical complications. Some even say that we are "practicing medicine." 

That said, the ECRI Institute looked at 7,613 wrong-patient errors at 181 health care organizations -- and many of these mistakes are surely avoidable.

The study cites examples like: 

• A patient in cardiac arrest who wasn't resuscitated because the care team thought he was a different patient who had a do-not-resuscitate order.
• A patient who was not supposed to eat or drink but was provided with a meal and choked.
• An infant who received breast milk meant for another infant, leading to the child being infected with hepatitis.

Medicine is limited and I certainly don't expect that we won't make any mistakes. But when mistakes are made because we're not making the most of every member of the medical team, or because we're not communicating well -- that is unacceptable. In looking at the study, my response was embarrassment and anger. We have to be doing more, as a medical profession, to advance the healthcare collaboration and care coordination that would prevent these kinds of mistakes. 

We see 3 key reasons for these heartbreaking mistakes:

• We're sidelining key people on the medical team.
  Whether it's the orderly delivering a meal or a piece of equipment, medical support staff, the nurse giving a medication, or the specialist stopping by on the weekend -- we all have different types of information available to us and we all need to be informed and informing each other. I see a certain kind of arrogance reflected in these numbers. And it is the arrogance of not understanding that every person on the medical team -- regardless of where they are on the continuum of care -- must be part of the team.
• We're too rushed.
  Perhaps it is no one's fault, or perhaps it is the fault of all of us. But we are in such a hurry, and so overloaded by administrative duties, that we are not taking time to do healthcare collaboration and care coordination. We are rushing through the simple things, and it is creating complex problems that are devastating in their long-term consequences. 
• Care coordination simply isn't happening.
  Care coordination isn't that complicated, but it has been shown to have dramatically positive effects when it comes to this kind of mistake. If the nurse and the specialist were both filled in on what happened in the last 12 hours, and had a simple way to ask and answer questions... if the nurse on the first shift and the nurse on the second shift could check in with each other asynchronously... these mistakes could be avoided... if they simply coordinated. There are simple and cheap solutions to making care coordination happen, so our excuses are fewer than ever. 

So why is this situation -- in which basics like care coordination are overlooked and our mistakes are the 3rd leading cause of death for our patients -- allowed to persist?  Well, as Dr. Makary shared in discussion about that Johns Hopkins study, "You have this over-appreciation and overestimate of things like cardiovascular disease, and a vast under-recognition of the place of medical care as the cause of death. That informs all our national health priorities and our research grants." That's exactly why, in the telemedicine field, it's trendy for money to go towards flashy health monitoring, and not the more foundational work of supporting dynamic healthcare collaboration. Our short-term thinking is literally killing our patients. It's time for us to think as a team, and do the important, transformative, and ultimately deeply satisfying work of care coordination -- that will save both healthcare and the patient in front of us. 

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