August 2004

Talk to the Hand

By Michael J. Katin, MD

A long time ago, in a galaxy far, far, away, the primary concern of a physician was the care of the patient, both by addressing immediate problems and trying to contribute to the body of knowledge that would allow improved treatment in the future. In that era there was often not very much that could, in fact, be done for the patient except to express concern and occasionally to apply leeches.

Times have changed, although the leeches are still with us. I think we would all agree that the practice of medicine has become highly technical, with the physician sometimes seeming to serve as nothing more than a conduit for entering the patient into the appropriate diagnostic procedures and treatment. It then becomes necessary to function as a very effective conduit since there are a hostof interested parties watching for leaks. We are at the mercy of regulatory agencies monitoring every aspect of our practice from radioactive material handling to privacy. David Farber would conclude that we've wound up on the back of the pecking order and in danger of finding ourselves up the creek with our paddles leaking.

We all endorse doing as good a job as possible but the pressure will probably only increase. In July the Democratic Party nominated for Vice-President one of the most successful medical malpractice attorneys the world has ever known. It has been said that only Nixon could go to China or, for the IT and engineering staff, only Kirk could negotiate with the Klingons. Previous efforts at reforming liability laws have not been productive. Is it possible that Vice-President Edwards could overcome the obstacles to tort reform? How could one think otherwise?

In the unlikely event that Vice-President Edwards doesn't come through, however, the medical professional will need to continue to use extreme caution in avoiding errors or even the appearance of errors.  Fortunately, there has now been established a precedent for standard of practice that may relieve some of this intensity.

The principle is that, like the unobserved tree of academic legend falling in a forest and not making a sound,  errors cannot occur unless there is an audience.

Last month an article in the Annals of Internal Medicine (Pittet et al., 141:1-8, 2004) described that in Geneva, Switzerland, possibly the world's ultimate destination for cleanliness, that review of 163 physicians at the University of Geneva Hospital documented that adherence to hand-washing guidelines was higher (61% vs. 44%) when they knew they were being observed. This difference in compliance has therefore occurred 150 years after the germ theory had allegedly supplanted the miasma theory and blood generation theory of disease.  This also generated an editorial by Robert Weinstein reviewing the need to address this problem, distinguished by his allusion to, or possibly even invention of, the charming concept of the "fecal patina"

This article raises two other interesting questions.  First, why is it that in Switzerland, far more civilized than we are and ranked in the best 5% of all countries for life expectancy and low child mortality, that even with observation only 61% of the physicians followed standard handwashing protocol?  The second question is, with legions of epidemiologists available, wouldn't infection patterns be scrupulously tracked down and traced to these noncompliant physicians?  Maybe Switzerland's neutrality extends to an understanding with the bacterial world as well.  

This, of course, is not to endorse that we can excuse any errors we make only if nobody finds out about them.  It's a moot point anyway, since we have record and verify systems that probably should be marketed to handwashing stations in Switzerland and exceed the standards for nearly any monitoring authority on earth except for the Guinness Book of World Records.   We can try to do things right even if we don't know that anybody's washing, er, watching us.  We want to do everything we can to help our patients, but even if we're going to be viewed as conduits, we can be very good conduits.  Let's hand it to our specialty:  I know we con duit.  

email: mkatin@radiotherapy.com