Owen's Letters to The (Healthcare) Hackers
Colleagues were discussing the relationship between pharmacists and medical doctors.
Colleagues were discussing the relationship between pharmacists and medical doctors. Here is a thing I had to say…with slight edits for completeness and grammar. I didn't go to town on sentence structure like I would more regularly do for the purpose of readability, because I want the audience reading this to have a sense of the reading level of the audience as part of the exercise. I usually write shorter sentences for general audiences and longer sentences are lazy, but an indication of the expected reading level of a specific audience. Now, onward…
As a strong agree with a great and nuanced perspective, I want to highlight that the interactions between expert pharmacists and expert clinicians and physicians works well when those experts are able to actively and in real time— or some very interactive asynchronous back-and-forth— be allowed to do so. The ability to leverage the expertise of pharmacists is not gained by their replacement of physicians in the care of patients, but by our active engagement with reciprocal expertise.
I think it's similar to the role of bedside nursing and it's denigration in the service of promoting advanced practice nurse is as Physician replacements.
Health is complex. The back-and-forth between health professionals and health benefits professionals on this very listserv is a remarkable testament to that fact.
Pharmacists and doctors and nurses going back-and-forth with each other on a team leads to better outcomes. Asynchronously second-guessing each other— or creating one as a proxy for the other— is not as good as serious teamwork in the service of the health of the patient.
Pharmacists can do some things with patients directly. I don't entirely know what those could or should be because I'm not a pharmacist. I don't understand their training anywhere nearly as well as I understand the training of doctors. Because of course I don't.
Bedside nurses understand the care of patients in hospitals dramatically better on a minute to minute and hour to hour basis than any physician is likely to, also.
My world, as a physician and outpatient mental health care, was improved immeasurably when a bedside nurse was added to the team.
These are different professions, not replacements for each other. We learn from each other. We understand different things and can share them with each other in real time. Or, in asynchronous systems that are designed to capture the value of that collaboration, not try to replace one thing for another thing that's cheaper.
We need to solve two problems at once, one of the problems, to cite
is a weak link problem: we are only as safe as the failure points in medical care. This is a domain in which nursing excels and frankly doctors don't necessarily. Pharmacy is also excellent at the weak link problem of prescribing errors, etc.Don't do the thing that could kill you, error error error error.
The other problem we need a is the Strong Link solution, where we are only as good as the best solution.
The Problem of getting the best possible answer for any given persons medical problem is different than avoiding danger.
One great answer that is the right diagnosis or the right treatment matters a lot.
My argument is it's actually different problems we are solving with highly expert physicians and highly expert nurses and pharmacists.
Some of these protocol driven approaches can protect us from bad outcomes, which is really important and a weak link problem. But the genius of a great correct diagnosis in a complex situation is a strong link issue. We are only as healthy as the most comprehensive Lee correct understanding of our problem. We are also only as healthy as the amount of harm we’re able to avoid by carefully controlling for known dangerous risks that we can mitigate.
We routinely confused these issues. The FDA, for example, is a weak link Solve. It is here to protect us from things that would be dangerous if they failed. Medical care is not something that's FDA approved. Treatments deployed by medical professionals are FDA regulated. But the very fact that doctors are allowed to prescribe “off label” tells us that the actual practice of medicine is about getting the right answer, not just avoiding the wrong answer.
And we don't wanna confuse the two. FDA approval or clearance doesn't mean it's the right treatment for you. It means that in people for whom it is the right treatment, under rigorously controlled conditions, it's acceptably dangerous. The level of danger is some thing that the regulatory agency is willing to sign off on given all the things associated with the underlying condition. It doesn't mean it's good. It doesn't mean it's good. It doesn't mean it will help you. it means that the rigorousness of the assessment of its dangerousness is within acceptable limits.
That's why we have teams. Somebody's gotta keep an eye on the risks, and somebody else has to keep an eye on the best possible outcomes and benefits, and those two people might be best working together. never has the word “two” been an underestimate more robustly than in that prior sentence.
As my mentor in medical school, Ralph Josefowicz, put it: “you're not here to learn to follow protocol. Doctors are not great at following protocol anyway. If you wanted protocol followed perfectly, you would've asked the nurse because they'll be better at it. We're training you to understand underlying pathology and mechanisms so you know when to break protocol”.
Knowing when to break protocol is a strong link problem. And it requires more than just physicians, it requires teams.
A special thank you to
for being the registered nurse who taught me everything about how important that role is.Hat tip,
and and all my hacker friends.—Owen Scott Muir, M.D.
Well explained and I totally agree.
Cool kids club indeed. Thanks for all your contributions. Owen.