During the medical school admissions process, the last step before signing on the dotted line and committing to a specific school for medical training is an event called Second Look. This is an opportunity for prospective medical students to revisit the campus, meet with faculty and current students, ask any questions, and look at the surrounding area for extracurricular opportunities including recreation and housing. Medical school applications are now a decade in the past, and I certainly do not remember much of the Second Look experience at the respective schools, however, one line from one professor was notable a decade ago, changed where I decided to go to medical school, and has stuck with me since.
As we were sitting around a table, prospective students nodding and smiling as faculty members shared about the benefits and future plans of this particular medical school, one of the older professors who had trained several generations of physicians in the past began talking about the hospital and the system in which the medical school was situated. To the best of my memory, his statement went as follows:
“If you take a good physician and place them in a bad system you get bad results. If you take a bad physician and place them in a good system you get good results.”
Surely this could not be true. With curricula that stressed individual achievement and excellence, surely a good physician could do everything to create good outcomes despite the system. Right? And then I began to reflect on this statement more.
Inherent in this statement was the belief that a good physician in a good system would yield good results and a bad physician in a bad system would yield bad results. The determining factor, therefore, was not the physician, but the system in which they were operating. A decade ago I took that lesson to heart. As I was considering this statement I realized in that moment that this particular medical school where I was enjoying Second Look and was planning on attending, was a bad system and that by staying in that system I was likely to yield worse results than if I were in a better system. Certainly, I still would have ended up with the degrees as well as the experience necessary to practice medicine as a physician-scientist, but the system itself was not engineered to be frictionless towards attaining favorable outcomes. Notably, that program has significantly turned around in the past decade, and is now a better system which has been reflected in the renewal of NIH grants that had previously been lost primarily related to systemic problems at the institution. As the professor noted the importance of systems in success, I realized that the other medical school that I was considering boasted a significantly better overall system, especially for training physician-scientists, and had been doing so for longer than any other program in the country. This school which was previously my first choice dropped out of contention, and the medical school which had at first appeared to be an unlikely choice became the place where I would train for the next seven years.
Beyond altering where I attended medical school, this lesson has continued to stick with me to this day. The validity of this lesson has been, and continues to be, repeatedly demonstrated over the years. Making good medical care easy, the default, makes achieving good medical care more likely. When patients are admitted to the hospital there is a general order set that must be filled out which differs between hospitals and institutions. Things like monitoring parameters, laboratory studies, medications to avoid blood clots, and code status discussion are common aspects of such an order set. There are also many combined order sets. For example, for the order set for high potassium in the blood, many common medications for high potassium may be brought up at their likely doses such as furosemide, insulin, bicarbonate, calcium, and albuterol, as well as relevant additional testing including an EKG, orders for continuous telemetry, and repeat blood work. The order set does not force or automatically order everything but prompts the physician with orders and dosages that may be appropriate. In these cases, the order set functions as a schema to organize possible approaches to diagnosis and management as well as reduces the friction, or the barriers, to implementing appropriate medical care. Within the order set may be clinical guideline or recommendation statements with citations of relevant studies, or parameters or cautions to be aware of for a particular condition or medication. Without such order sets, the door is opened for wider variability in practice patterns between practitioners, some of which may be evidence-based while others are less evidence-based. As well it relies on significantly more thoughtfulness and prepared schemas by each practitioner in order to deliver excellent care. Making good medical easy leads to good medical care.
During a given shift a physician makes decisions and clicks through orders hundreds to thousands of times. These clicks often are a critical component to delivering medical care for individual patients. The first step to making good medical care easy is reducing or eliminating unnecessary clicks, that is redundant or pointless prompts and making the electronic system easy to navigate. However, the system extends far beyond the electronic medical record. Making good communication possible is essential. Having a way for nurses, physicians, medical assistants, respiratory therapists, and other providers to communicate is essential for patient care. Doing so in a way that does not interfere with medical care but enhances care is the point of many studies. For example ease of reaching someone at any time is likely not the solution. For example during a code I have been called regarding non-essential aspects of care for other patients such as routine labs, nutrition orders, or clarification on an imaging order. This can be dangerous as there is no mechanism to filter out essential calls from nonessential calls without redirecting one’s attention from a critical situation to whatever phone call or page is ringing. In these cases, there should be a mechanism to have text messages or pages that can be read later and addressed at a better time to enhance clinical care. Beyond communication, the system is also defined by the ability to accomplish what may seem like mundane tasks but which are critically important including restocking supplies, providing patients palatable food, ensuring that medications are delivered on time, and working out the details of transitioning care back home. The best physician, no matter how well trained and well-intentioned, cannot touch on many of these critical aspects of the system on a daily basis, instead, the system in which they find themselves often beget their own results whether good or bad.
Yet this principle is not limited to medicine alone. Making it easy for people to make the “good” decision whether that be exercising, eating healthy, going to the physician for regular checkups, or taking care of their car, makes it more likely that the right behavior will be performed ending in a better result. In addition to working to improve oneself, the choice of the system is critical to achieving good results. The people, organization, and parts are critical to success. Picking the right system and then working to improve that system is essential for forward progress and achieving excellent results.
Choose a good system. Build a great system.
JR.Stanley 