Monday, August 23, 2010

Air, space, and primary care checklists

There is a mesmerizing - some would say hypnotic - air traffic control display at the National Air and Space Museum in Washington, DC that shows the flight paths of every airplane over the United States during a 24-hour period in 2006. At any given moment, up to 6,000 planes were in the air, and the total number of flights numbered in the many tens of thousands. Immediately after the 9/11 terrorist attacks, air traffic controllers were instructed to land every one of them at once. And miraculously, they were able to do so without a single runway collision or plane running out of fuel.

After reading Harvard surgeon Atul Gawande's bestselling book The Checklist Manifesto several months ago, I learned that a feat that seemed miraculous to an outsider really wasn't. Since the early days of aviation, when planes became too complex for even the most experienced pilots to control without making an occasional devastating error of judgment or omission, pilots have depended upon checklists to manage both routine tasks and once-in-a-lifetime emergencies, such as last year's "Miracle on the Hudson" landing of a crippled US Airways jet in the Hudson River in which every passenger was rescued. Gawande's book goes on to describe how checklists have revolutionized industries as far apart as skyscraper construction and his own studies of safety in surgery.

Since reading Gawande's book, I've thought about how checklists might be applied to improve the performance and efficiency of primary care. On one hand, we already have many checklist-type procedures in family medicine: obtaining vital signs (which can include smoking status and body mass index in addition to height, weight, temperature, and blood pressure), paper or electronic applications that help family physicians to remember recommended immunizations, screening tests, checklists for diabetes care, and so forth. And through trial and error while developing the patient-centered medical home, we've found that regular practice meetings called "huddles" can serve much the same purpose as a surgical team organizing itself for a major operation.

On the other hand, primary care is, by nature, inherently less predictable than surgery or construction or piloting a commercial airliner. Beyond patients scheduled for health maintenance visits or chronic care checkups, we are trained to expect the unexpected, never knowing who is going to walk into the door on any given day with a limp, fracture, shortness of breath, chest pain, or other undifferentiated symptom, each with its own particular diagnostic approach. How can we possibly design a checklist for these? Does it even make sense to do so? I'd love to hear your ideas.

1 comment:

  1. I have one checklist for my patients. What is their expressed need? What is their real need? And how can I facilitate these? The checklist begins with me clearing my slate when I knock at the door.

    Clearing the slate is also need for primary care workforce. What is predictable is 400 million Americans in the middle portion of this century in need of about 440,000 to 500,000 primary care physicians divided by about 33 years to reach this level. This results in about 15,000 annual graduates (if 100% remained active and in primary care) or about 18000 to 20000 with a family practice level of 85% active and 85% remaining in primary care at top volume.

    Pediatric primary care is limited to its current 60,000 (limited by age and location).

    The remaining flexible IM, NP, and PA sources can be counted on at the current time for 20 - 30% remaining in primary care (steady deteriorations in the past 12 years). Correcting for lower volume, lower activity in the US workforce, and fewer years in a career results in even more graduates needed to reach sufficient primary care.

    Given a break by doubling the primary care percentage back up to 50% remaining in primary care as in the 1990s, the requirement for sufficient US primary care would be well over 60,000 annual graduates for a combination of all three to attempt primary care recovery - IM, NP, and PA. Note that IM is at 7200 annual graduates, NP is at 8200, and PA is about 5500 to 6000. Why would a nation expand primary care sources for primary care recovery when the current outcomes are 3 to 4 graduates to get one in primary care?

    These three flexible sources dominant primary care with 80% of the 27,000 annual graduates, but will deliver only 40% of the primary care of the nation. Family medicine with 3000 and PD with 3000 are only 20% of graduates but will deliver 60% of the primary care.

    What is predictable is that generic expansions of IM, NP, and PA no longer work to resolve primary care deficits. There is simply not enough primary care delivery per graduate for these sources. The cost is too high for the primary care yield and the number of graduates required to maintain workforce, much less recover primary care.

    Family medicine with 5 to 10 times more primary care delivery per graduate is a primary care and basic health access recovery vehicle.

    Others claim primary care graduates. Family medicine claims primary care delivery and primary care delivery where most needed - elderly, rural, underserved, lower income, middle income, CHC, poor, near poor (Ferrer, Rosenblatt, Mold, Bowman)

    All sources of primary care that will remain in primary care will be important, but treatment campaigns that distract from real solutions are the worst possible treatments of all.

    Robert C. Bowman, M.D.