Do we need mathematicians to take care of our hospitals?

Eratosthenes was a Greek scholar of the third century BC. He was a mathematician among other things. But what I find amazing about him was that he was able to calculate the cicurmference of the earth without leaving his home Egypt. It did not require computer based mathematical calculations nor the advanced technology that became available centuries later. These technologies largely confirmed his finding that was based on observations of the differences in sun's position in Alexandria and the town of syene further south. While we ourselves are unable to make such intelligent inferences from our daily observations of nature, we almost always use simple logic and rudimentary math to get through this complex world. But unfortunately such simple approaches don't seem to work for professionals especially medical professionals and that too with regard to assessing their own competence. They prefer to search for inferences that do not question their competence.

It was diwali of 2005 and I was not expecting a call from Eratosthenes. However that morning, I got a call from Dr. Jaggy (name changed) whom I had met some months ago in a conference in south India. He wanted to know more about one of the latest incubator models in the market. As we got deeper into the discussion, he told me that results from the IVF treatment cycles were not as good as expected and concluded that a better incubator would solve his problems. Sensing that there was an underlying issue that may have triggered the call, I was tempted to ask for details. This doctor like most others was in no mood to admit the need for help. And on the other hand I did not want to sound like I was looking for more work. I decided to remain in listening mode. This was not easy for me but I did not want to make it any more difficult for him. I decided not to ask for figures but I needed to decipher the numbers. There was no way I thought I could understand the problem without objective information. Erastosthenes came to mind and I decided to 'decompose' the problem. First I needed to know what the recent past meant. As my thought machine went to work, I expressed my wish that his diwali call should have brought better news than the 'lower than expected' results. The quick reply was indeed revealing as he opens up that he was hoping for the same since last Diwali. And at that moment, I felt like Eras who had just recorded the elevation of the sun in Alexandria. It was clear he had been struggling with this problem for more than a year. . A long standing problem that needed a solution also meant an opportunity for me. While I began calculating the money from a potential consulting opportunity presenting itself before me , I wanted to know what the embryologist on his team had to say about the problem. His reply was probably as illuminating as the sunshine over Syene. He said' "They all say that there is nothing wrong but the results don't improve." The word 'they' seemed to be louder and clearer than everything else. I couldn't control my curiousity any longer and I asked him ," what do you mean 'they'? I thought you had only one embryologist". His answer seemed to cover the entire circumference of the problem. I did not need to understand the science of deductive analysis to understand why changing members of his team did not solve his problem. In IVF the performance of a clinic is dependent on the competence of its doctors and embryologists and of course properly functioning equipment. A new clinic with new equipment that is deemed as functioning well by the continuously replaced embryologist is usually indicative of a problem with the third variable. But for a doctor who runs the show, it is easier to find an alibi in the incubator. This is a common problem with under performers especially professionals. Acknowledging their inability to perform a task within reasonable limits of acceptability is not easy. But when it comes to patient care, it is the obligation of hospital leadership to take remedial action when unnecessary suffering is observed.

A few days after that call that would bring me money, I was at the receiving end of under-performance. My wife underwent a caesarian in a hospital that had differentiated itself in the region for its higher standards of care. Prior to the caesarian, we expressed our preference for spinal anesthesia. But we did have question about the risks for which we were given very comforting answers. Unfortunately, my wife ended up in bed for several days suffering from severe spinal headache. For a complication that was usually rare, we were resigned to the fact that theory of probability did not work in our favor. However in the weeks that followed, I made some inquiries internally during my regular visit to the hospital as a consultant. I learnt that the spinal headache complication levels were alarmingly high and a couple of months later complaints from obstetricians led to the management instructing the anesthetists to reduce the use of this technique during caesarians. I found it quite strange that in a hospital doing about hundred caesarians a month, they could not zero down on the poor performer using simple math. I had to assume that an acknowledgement of incompetence and knowledge of basic mathematics is after all a rare combination in clinical care. Unfortunately patients are at the receiving end of this avoidable mix of poor self perception and selective ignorance.

Standard operating procedures for bed time stories

The school organized 'Storytime Saturday' for the children in junior kindergarten. Parents would need to accompany their wards and together experience a story telling session. So last saturday I took my younger daughter Noora to listen to the story about the toad princess. At the end of the story, there was a lively discussion on the benefits of bedtime story reading. The teachers led the session and much was said about how it can improve parent-child bonding, imparting of good values, improvising language and lots more. I was so impressed with the school's initiative and thought that we should do this more frequently at home. That Saturday after a long day of shopping, we reached home tired and wanting to jump into bed as soon as possible. With the inspiring morning session still in my mind, I suggested we should have a story session if the kids were not too tired. What should have happened then was to have me read out a nice story, the kids listening attentively and they would gradually fall asleep. But what happened was nothing of the sort. I asked my elder daughter to get one of the books, sit in her bed and read out the story. My younger daughter and myself made ourselves comfortable on the bed. Within a few minutes I was asleep. Parent-child bonding, language training and everything else went up in dreams. The intent was good, the benefits were clear and environment amenable but it things did not turn out the way they should. A similar combination of circumstances and unintended outcomes occur unfortunately in patient care.

I am reminded of this today as I try to think of the effectiveness of training in clinical organizations The objective of training is always to impart the knowledge and experience of the trainer to the trainee and in clinical environments it mostly involves skills training. It is expected that at the end of training the trainee will eventually be able to duplicate what he or she has learnt and that too in a real environment. It can go wrong and even the most well intentioned trainee may fail to competently execute a newly learned skill. Once we have mastered the skill, we are more confident to undertake the task but we still can go wrong because of several reasons. One could be due to an error in judgment while executing a task. The kind we can make when we try to discern the type and location of pain of a patient reporting at the emergency room. Another reason could simply be the inability to make a decision when overwhelmed with complex circumstances. This is the kind when you are confronted with a young boy brought in with multiple injuries from a car accident. You did everything you could towards the injuries but you pump in the antibiotic that he is allergic to. The patient was accompanied by his father but no one on your team remembered to elicit this important piece of information from him. The second type of error is not due to lack of competence or absence of knowledge. It is simply the result of failing to execute an activity in a careful sequence.

I believe that such errors can be avoided or at least the probability of it happening can be reduced by having standard operating procedures or SOPS as it is commonly referred to. It could even be a defined clinical pathway where in a clearly charted out sequential course of action is meant to be followed. The problem with SOPs (and in this discussion I will include clinical pathways) is not just who should create and issue one but most importantly how it should be written up. I will try to summarize my opinion and I must say that the same rules would apply for SOPs on virtually anything even outside healthcare. In my view, SOPs must be detailed yet not too restrictive and it should leave room for professional judgement wherever possible. But being detailed does not mean intuition is ignored. We do not need to answer the 'does the pant zipper need to be downed before or after' type of questions. Yet we should also remember that SOPs will be used by newly trained or less experienced persons. Hence we should never leave out the essentials, must be clear, lucid and most importantly easily communicable.

Communicability reminds me of an afternoon at the school playground. It was probably in grade 4 or 5 and we all seated ourselves on the ground in a circle. The teacher whispered something in the ears of one of my classmates seated next to her. There were about twenty of us and each one would have to listen carefully and then whisper what he had heard into the next one's ear. The words would travel the circular route and when it reaches the last person he was supposed to reveal to all what he had been told. It turned out be a very amusing experience when an unspeakable something was announced to our curious bunch. It was a good laugh that afternoon in the playground but when I think of it now I realize that it is not an unusual occurrence even in the most sophisticated of technical environments.