7 70
PATIENT-CARE APPRAISAL AS CONTINUING MEDICAL EDUCATION* ROBERT J. CULLEN, PH.D. Associate Director Health Care Review Center Seattle, Wash.
I N medicine, continuing education and discovery are not forms of self-indulgence aimed at furthering man's pleasures, but rather necessities to ease man's suffering. They are as essential to a doctor's career as keeping abreast of changing statutes is to an attorney. It was to identify the educational needs of physicians in the state of Washington that the patient-care appraisal (PCA) system was conceived and developed. In its brief existence it is fulfilling this original purpose and doing considerably more-as I shall illustrate in a moment -but, first, what is PCA? Briefly, it is a program in which practicing physicians identify their needs for continuing education through a process of self-assessment. It is essentially a professional activity of practicing physicians. This setting of criteria in itself constitutes an educational program. The criteria are utilized to identify educational needs by comparing them with summaries of what is actually happening in the hospital. Where current practice falls short of the physician-constructed criteria, educational programs are initiated. Now, let us take a quick glance at how the PCA system-and the Health Care Review Center as it is related to PCA-came into existence. Five years ago the Washington State Medical Association decided to take an active role in continuing medical education and began laying the groundwork for what was to evolve into the concept of PCA. From the beginning the association realized that this program would require not only adequate funding, but also the cooperation of its own members and other medical-related institutions, such as hospitals, the University of Washington School of Medicine, and the Washington/ *Presented as part of a Symposium on Continuing Medical Education held by the Committee on Medical Education of the New York Academy of Medicine October 10, 1974.
Bull. N. Y. Acad. Med.
PATIENT-CARE APPRAISAL
PATIENT-CARE
77I
77'
Alaska Regional Medical Program. Over the next few years comprehensive studies were undertaken and polls conducted throughout the state. The association endorsed the concept and terminology of PCA in place of medical audit. The following premises of continuing medical education formed the basis of the PCA program: I) Continuing education is the professional responsibility of every physician. 2) Continuing medical education (CME) should be designed to meet the practical needs of physicians. 3) An evaluation of the care of patients would be the most valid means of identifying educational needs. 4) Since CME is a collective professional obligation, it should be centered in the smallest practical collective units-the community hospitals-where individual physicians have the best available opportunity for expressing their personal educational needs. Concurrent with the development of PCA, the Committee on Continuing Medical Education of the Washington State Medical Association recognized the growing pressures for recertification of physicians. The committee went on the offensive in CME to weaken any move by legislators or others which would require that physicians attend CME courses as a prerequisite for practicing medicine in the state. It was believed that by objectively showing the attention paid to CME by members of the medical profession, outside interference would be weakened or deemed unnecessary. Criticism from outside the medical profession was taken seriously; the committee believed that a program of PCA which identified and corrected the educational deficiencies of physicians would be more beneficial to them than required attendance at educational programs. Two regional workshops on PCA were then held to demonstrate and disseminate a working knowledge of the concept of PCA, and the program was nearly launched. The final step was to set up the Health Care Review Center for the operation of the PCA program. This was developed by Dr. Robert H. Barnes, an internist from Seattle, and myself. The statewide program has been endorsed and supported by doctors, hospitals, and other medically allied organizations. It is the official CME policy of the Washington State Medical Association. Vol. 51, No. 6, June 1975
7772 72
R. J. CULLEN
The PCA system of CME is still in its infancy. It is a remarkably healthy and promising youngster, already demonstrating its efficiency and worth, perhaps even more than expected. However, it is not without problems and some resistance. The reactions to PCA have ranged from enthusiastic to grudging acceptance. Over all, however, it has been well accepted. When the concept was first taken from the womb of theory, stood on its own two feet in the daylight of reality, and was actually tried in the hospitals, barriers were encountered. Some physicians looked upon the PCA program as a medical policeman trying to tell them how to practice medicine; in fact, the opposite is true. The PCA program meets the requriements of the Joint Commission on the Accreditation of Hospitals (JCAH) for medical auditing and is part of a larger program which enables medical staffs to meet the requirements of the state's Professional Standards Review Organization (PSRO). Rather than acting as a policeman, PCA helps physicians to meet the standards of the metaphorical medical police. Another obstacle to immediate acceptance of the program was what might be called the "keeper syndrome." Although physicians continually maintain interest and accept responsibility for their own patients, they are generally not inclined to accept responsibility for patterns of care delivered to all patients of all other doctors. Physicians may be brothers in the art of healing, but they do not see themselves as their brothers' keepers. They do not want to be their brothers' peepers. Still other barriers to acceptance of PCA were the fears of "cookbook medicine," the comfort and familiarity of existing educational approaches such as clinical pathological conferences and ward rounds, the discomfort physicians felt with interdisciplinary groups, the lack of cooperation among hospitals on credentials and privileges, the physician's lack of allegiance to individual hospitals (most doctors would rather switch than fight) and, finally, the fact that everybody is already too busy. PCA programs are looked upon as just another burden added to existing work. The purpose of the Health Care Review Center is to assist hospital and medical staffs to overcome these barriers and to successfully implement PCA programs. A successful PCA program must have these key elements: i) A physician in charge Bull. N. Y. Acad. Med.
PATIENT-CARE APPRAISAL
PATIENT-CARE
APPRAISAL
773
2) A nonphysician who is trained as a program coordinator to do the administrative work 3) The capability to retrieve data 4) The evaluation of medical care is done only by physicians 5) Problem-solving ability 6) Continuing medical education 7) A direct line of accountability As a demonstration of how the PCA program can work, I shall present several examples from the evolution of PCA in hospitals throughout the state of Washington. A study of the use of blood at one hospital indicated that the employment of whole blood was high compared to the use of packed cells; this resulted in an unnecessary use of blood components. Educational programs were developed and, after their implementation, a follow-up study showed a reversal of what had been an unsatisfactory and costly habit. A separate study and follow-up on acute blood loss at another hospital showed a change of from 20% to 70% in the use of Ringer's lactate in the stat treatment of blood loss after appropriate corrective action was instituted. Not all problems in hospitals lead to educational programs. Solutions can come when false impressions are identified. For instance, one hospital found that its surgical staff did not have a method for evaluating care other than one based on impressions. The-staff wanted to initiate a system whereby they could collect data to evaluate problems and effect appropriate corrective action, either through administrative or educational approaches. The operations nurse was asked to keep a record of the percentage of patients on whom the history and physical examination were documented prior to operations. It was found to be between 5o and 75%. Obviously, this contradicts recommended procedures and has some legal implications, Corrective action, based upon departmental consensus, was taken by the chief of surgery, who simply ordered that no patient could leave the ward without a history and physicial examination recorded on the chart, except in emergencies. At first this created some discontent, but in less than two weeks the program was working quite smoothly. The patient-history and physical-examination records which were completed prior to operation climbed from as little as so% to almost ioo%. Another example of false impression concerns an individual physiVol. 51, No. 6, June 1975
774
774
R. J. CULLEN R. J. CULLEN
cian. Concerning gall-bladder surgery and length of hospital stay, this physician believed that the care he provided was at least as good as that of others and probably better in terms of shorter lengths of stay. When he had his own charts reviewed, he found that his stays were, in fact, no shorter than the average; one chart with an i8-day stay was identified. A careful analysis of this chart showed that the stay was justified as the patient had problems in four other systems, including diabetic and cardiovascular conditions, but these had not been listed on the face sheet. The physician concluded that his impressions about his care were not always correct and that his documentation was not always precise. For further illustration, I shall describe in greater detail a report from a PCA subcommittee. This report on pulmonary embolism not only demonstrates significant improvements, but changes of attitude as well. Thirty charts on pulmonary embolism were reviewed, using criteria established by a PCA subcommittee. When the findings were summarized at a conference, it was found that difficult breathing was not mentioned in 43 % of the cases. In the words of the subcommittee chairman: "We were all surprised to find that fever was present in almost half the cases. More surprising was that venous disease was not mentioned in 93 per cent of the cases." The report went on to state that medications given patients were not mentioned in 76% of the cases. "In the laboratory work," the report continues, "it is felt that lung scans were probably under-utilized and that arterial blood gases also were under-utilized." The list of shortcomings was much longer, but the point here is the outcome of these findings. Several programs evolved because of the findings in history, physical, and laboratory work. For example, in the diagnosis of pulmonary embolism the symptomatology, physical findings, a lung scan, and a study of blood gases were all discussed. Following this discussion, the use of arterial blood gases in this suspected condition rose considerably. A follow-up study was conducted; it showed a significant improvement in specific history and physical-examination items. The use of the lung scan went up from 37 to 57 % and the use of blood gases went from 37 to 73%. Admittedly, this is only a thumbnail sketch of the evolution of PCA and the Health Care Review Center in the state of Washington. Although it was developed purely for educational purposes, it has, as I Bull. N. Y. Acad. Med.
PATIENT-CARE APPRAISAL
PATIENT-cARE
APPRAISAL
77 5
775
pointed out earlier, met many other requirements. To name just a few: PCA helps a hospital fulfill its legal responsibilities; helps fulfill the requirements of the JCAH and the PSRO; promotes the team concept in the care of patients, and employs hospital staff without the use of outside theorists and bureaucrats. The goal of PCA and physicians is the same-quality care of patients-but PCA is a physician-controlled and physician-oriented program. There is one more vital role of a PCA system that is especially significant in view of the new requirements of the PSRO. The physicians of the state of Washington believe that only licensed physicians have the ability and the right to practice medicine. Therefore, the state's PSRO must not be in a position to tell physicians how to practice medicine. Hospital-based PCA programs maintain the review of care by physicians at a local level. Thus, the PSRO can provide a support system for hospitals so that they can effectively review the care they are providing and correct their own problems. Further, the PSRO should provide training programs and technical assistance to assure that hospitals can meet the requirements of the law. I shall close with a thought from the director of the Health Care Review Center, Dr. Robert H. Barnes: * True art is never the offspring of formula, prescription, or recipe, but the spontaneous expression of vital and individual feeling. The creative spirit can neither be legislated nor predicted. In the practice of medicine, we must consciously separate the art from basic science and skills. A Patient Care Appraisal program must never destroy spontaneity, individuality, inventiveness, or dissatisfaction with the status quo. A professional sense of claustrophobia brought on by an over-whelming and enveloping prescription on how to practice medicine will destroy the soul and spirit of a great profession. On the other hand, the profession must never impose a slovenly product upon the patient in the name of freedom or individual prerogative. Through PCA, I envision the combined wisdom of many physicians being brought to bear on the needs of patients, while the one-to-one physician-patient relation is respected and strengthened. *Barnes, R. H. and Cullen, R.: Patient
Washington State Med. Ass., 1973.
Vol. 51, No. 6, June 1975
Care
Appraisal. Why and How. Seattle,
PATIENT-CARE APPRAISAL AS CONTINUING MEDICAL EDUCATION* ROBERT J. CULLEN, PH.D. Associate Director Health Care Review Center Seattle, Wash.
I N medicine, continuing education and discovery are not forms of self-indulgence aimed at furthering man's pleasures, but rather necessities to ease man's suffering. They are as essential to a doctor's career as keeping abreast of changing statutes is to an attorney. It was to identify the educational needs of physicians in the state of Washington that the patient-care appraisal (PCA) system was conceived and developed. In its brief existence it is fulfilling this original purpose and doing considerably more-as I shall illustrate in a moment -but, first, what is PCA? Briefly, it is a program in which practicing physicians identify their needs for continuing education through a process of self-assessment. It is essentially a professional activity of practicing physicians. This setting of criteria in itself constitutes an educational program. The criteria are utilized to identify educational needs by comparing them with summaries of what is actually happening in the hospital. Where current practice falls short of the physician-constructed criteria, educational programs are initiated. Now, let us take a quick glance at how the PCA system-and the Health Care Review Center as it is related to PCA-came into existence. Five years ago the Washington State Medical Association decided to take an active role in continuing medical education and began laying the groundwork for what was to evolve into the concept of PCA. From the beginning the association realized that this program would require not only adequate funding, but also the cooperation of its own members and other medical-related institutions, such as hospitals, the University of Washington School of Medicine, and the Washington/ *Presented as part of a Symposium on Continuing Medical Education held by the Committee on Medical Education of the New York Academy of Medicine October 10, 1974.
Bull. N. Y. Acad. Med.
PATIENT-CARE APPRAISAL
PATIENT-CARE
77I
77'
Alaska Regional Medical Program. Over the next few years comprehensive studies were undertaken and polls conducted throughout the state. The association endorsed the concept and terminology of PCA in place of medical audit. The following premises of continuing medical education formed the basis of the PCA program: I) Continuing education is the professional responsibility of every physician. 2) Continuing medical education (CME) should be designed to meet the practical needs of physicians. 3) An evaluation of the care of patients would be the most valid means of identifying educational needs. 4) Since CME is a collective professional obligation, it should be centered in the smallest practical collective units-the community hospitals-where individual physicians have the best available opportunity for expressing their personal educational needs. Concurrent with the development of PCA, the Committee on Continuing Medical Education of the Washington State Medical Association recognized the growing pressures for recertification of physicians. The committee went on the offensive in CME to weaken any move by legislators or others which would require that physicians attend CME courses as a prerequisite for practicing medicine in the state. It was believed that by objectively showing the attention paid to CME by members of the medical profession, outside interference would be weakened or deemed unnecessary. Criticism from outside the medical profession was taken seriously; the committee believed that a program of PCA which identified and corrected the educational deficiencies of physicians would be more beneficial to them than required attendance at educational programs. Two regional workshops on PCA were then held to demonstrate and disseminate a working knowledge of the concept of PCA, and the program was nearly launched. The final step was to set up the Health Care Review Center for the operation of the PCA program. This was developed by Dr. Robert H. Barnes, an internist from Seattle, and myself. The statewide program has been endorsed and supported by doctors, hospitals, and other medically allied organizations. It is the official CME policy of the Washington State Medical Association. Vol. 51, No. 6, June 1975
7772 72
R. J. CULLEN
The PCA system of CME is still in its infancy. It is a remarkably healthy and promising youngster, already demonstrating its efficiency and worth, perhaps even more than expected. However, it is not without problems and some resistance. The reactions to PCA have ranged from enthusiastic to grudging acceptance. Over all, however, it has been well accepted. When the concept was first taken from the womb of theory, stood on its own two feet in the daylight of reality, and was actually tried in the hospitals, barriers were encountered. Some physicians looked upon the PCA program as a medical policeman trying to tell them how to practice medicine; in fact, the opposite is true. The PCA program meets the requriements of the Joint Commission on the Accreditation of Hospitals (JCAH) for medical auditing and is part of a larger program which enables medical staffs to meet the requirements of the state's Professional Standards Review Organization (PSRO). Rather than acting as a policeman, PCA helps physicians to meet the standards of the metaphorical medical police. Another obstacle to immediate acceptance of the program was what might be called the "keeper syndrome." Although physicians continually maintain interest and accept responsibility for their own patients, they are generally not inclined to accept responsibility for patterns of care delivered to all patients of all other doctors. Physicians may be brothers in the art of healing, but they do not see themselves as their brothers' keepers. They do not want to be their brothers' peepers. Still other barriers to acceptance of PCA were the fears of "cookbook medicine," the comfort and familiarity of existing educational approaches such as clinical pathological conferences and ward rounds, the discomfort physicians felt with interdisciplinary groups, the lack of cooperation among hospitals on credentials and privileges, the physician's lack of allegiance to individual hospitals (most doctors would rather switch than fight) and, finally, the fact that everybody is already too busy. PCA programs are looked upon as just another burden added to existing work. The purpose of the Health Care Review Center is to assist hospital and medical staffs to overcome these barriers and to successfully implement PCA programs. A successful PCA program must have these key elements: i) A physician in charge Bull. N. Y. Acad. Med.
PATIENT-CARE APPRAISAL
PATIENT-CARE
APPRAISAL
773
2) A nonphysician who is trained as a program coordinator to do the administrative work 3) The capability to retrieve data 4) The evaluation of medical care is done only by physicians 5) Problem-solving ability 6) Continuing medical education 7) A direct line of accountability As a demonstration of how the PCA program can work, I shall present several examples from the evolution of PCA in hospitals throughout the state of Washington. A study of the use of blood at one hospital indicated that the employment of whole blood was high compared to the use of packed cells; this resulted in an unnecessary use of blood components. Educational programs were developed and, after their implementation, a follow-up study showed a reversal of what had been an unsatisfactory and costly habit. A separate study and follow-up on acute blood loss at another hospital showed a change of from 20% to 70% in the use of Ringer's lactate in the stat treatment of blood loss after appropriate corrective action was instituted. Not all problems in hospitals lead to educational programs. Solutions can come when false impressions are identified. For instance, one hospital found that its surgical staff did not have a method for evaluating care other than one based on impressions. The-staff wanted to initiate a system whereby they could collect data to evaluate problems and effect appropriate corrective action, either through administrative or educational approaches. The operations nurse was asked to keep a record of the percentage of patients on whom the history and physical examination were documented prior to operations. It was found to be between 5o and 75%. Obviously, this contradicts recommended procedures and has some legal implications, Corrective action, based upon departmental consensus, was taken by the chief of surgery, who simply ordered that no patient could leave the ward without a history and physicial examination recorded on the chart, except in emergencies. At first this created some discontent, but in less than two weeks the program was working quite smoothly. The patient-history and physical-examination records which were completed prior to operation climbed from as little as so% to almost ioo%. Another example of false impression concerns an individual physiVol. 51, No. 6, June 1975
774
774
R. J. CULLEN R. J. CULLEN
cian. Concerning gall-bladder surgery and length of hospital stay, this physician believed that the care he provided was at least as good as that of others and probably better in terms of shorter lengths of stay. When he had his own charts reviewed, he found that his stays were, in fact, no shorter than the average; one chart with an i8-day stay was identified. A careful analysis of this chart showed that the stay was justified as the patient had problems in four other systems, including diabetic and cardiovascular conditions, but these had not been listed on the face sheet. The physician concluded that his impressions about his care were not always correct and that his documentation was not always precise. For further illustration, I shall describe in greater detail a report from a PCA subcommittee. This report on pulmonary embolism not only demonstrates significant improvements, but changes of attitude as well. Thirty charts on pulmonary embolism were reviewed, using criteria established by a PCA subcommittee. When the findings were summarized at a conference, it was found that difficult breathing was not mentioned in 43 % of the cases. In the words of the subcommittee chairman: "We were all surprised to find that fever was present in almost half the cases. More surprising was that venous disease was not mentioned in 93 per cent of the cases." The report went on to state that medications given patients were not mentioned in 76% of the cases. "In the laboratory work," the report continues, "it is felt that lung scans were probably under-utilized and that arterial blood gases also were under-utilized." The list of shortcomings was much longer, but the point here is the outcome of these findings. Several programs evolved because of the findings in history, physical, and laboratory work. For example, in the diagnosis of pulmonary embolism the symptomatology, physical findings, a lung scan, and a study of blood gases were all discussed. Following this discussion, the use of arterial blood gases in this suspected condition rose considerably. A follow-up study was conducted; it showed a significant improvement in specific history and physical-examination items. The use of the lung scan went up from 37 to 57 % and the use of blood gases went from 37 to 73%. Admittedly, this is only a thumbnail sketch of the evolution of PCA and the Health Care Review Center in the state of Washington. Although it was developed purely for educational purposes, it has, as I Bull. N. Y. Acad. Med.
PATIENT-CARE APPRAISAL
PATIENT-cARE
APPRAISAL
77 5
775
pointed out earlier, met many other requirements. To name just a few: PCA helps a hospital fulfill its legal responsibilities; helps fulfill the requirements of the JCAH and the PSRO; promotes the team concept in the care of patients, and employs hospital staff without the use of outside theorists and bureaucrats. The goal of PCA and physicians is the same-quality care of patients-but PCA is a physician-controlled and physician-oriented program. There is one more vital role of a PCA system that is especially significant in view of the new requirements of the PSRO. The physicians of the state of Washington believe that only licensed physicians have the ability and the right to practice medicine. Therefore, the state's PSRO must not be in a position to tell physicians how to practice medicine. Hospital-based PCA programs maintain the review of care by physicians at a local level. Thus, the PSRO can provide a support system for hospitals so that they can effectively review the care they are providing and correct their own problems. Further, the PSRO should provide training programs and technical assistance to assure that hospitals can meet the requirements of the law. I shall close with a thought from the director of the Health Care Review Center, Dr. Robert H. Barnes: * True art is never the offspring of formula, prescription, or recipe, but the spontaneous expression of vital and individual feeling. The creative spirit can neither be legislated nor predicted. In the practice of medicine, we must consciously separate the art from basic science and skills. A Patient Care Appraisal program must never destroy spontaneity, individuality, inventiveness, or dissatisfaction with the status quo. A professional sense of claustrophobia brought on by an over-whelming and enveloping prescription on how to practice medicine will destroy the soul and spirit of a great profession. On the other hand, the profession must never impose a slovenly product upon the patient in the name of freedom or individual prerogative. Through PCA, I envision the combined wisdom of many physicians being brought to bear on the needs of patients, while the one-to-one physician-patient relation is respected and strengthened. *Barnes, R. H. and Cullen, R.: Patient
Washington State Med. Ass., 1973.
Vol. 51, No. 6, June 1975
Care
Appraisal. Why and How. Seattle,
