Risk Averse Cultures and Health Care

Risk Averse Cultures and Health Care

by

Howard Adelman

Introduction

Yesterday afternoon I was asked how I choose my topics each morning since they must require some prior thinking and preparation. They do. I explained that I collect material and slot items into files. But that does not explain my choices. I am not sure what determines them, except I seem to write about what is bothering me most, For example, last evening I went to dinner at a neighbour’s. They are a lovely and very interesting couple and the meal was phenomenal. They receive and the wife, at least, admits to occasionally reading my blog. Like many others, she finds the blogs are far too voluminous for her to become a constant reader.

There were two other very fascinating couples invited as guests as well. They knew nothing about me. As is usual on such occasions in which we gain a small amount of knowledge by acquaintance, I learned only a minimal about them. Nancy was not there because she excused herself since she is still sick with pneumonia. I thought of writing about the advantages of anonymity this morning but, since I rather enjoyed the experience, I found the subject hard to write about. Further, I had focused too much on trying to instill in my poor memory what happened to be able to give Nancy a full report, an activity I never usually have to perform, so I had not been sufficiently reflective to write abut anonymity.

Until the evening, I had thought I would write about the middle east peace process since Emmanuel Adler gave a wonderful and very comprehensive overview on the subject in a talk yesterday afternoon arguing that there was no peace process — only an instrumental process about pieces. I wanted to challenge his thesis in some detail and presumed that would be my topic this morning. But last evening left me very introspective and a little detached from world political issues.

So in answer to the two questions I received yesterday about how I choose my topics for my blog, I do not know. Upon only a little reflection, I think the answer is “the itch”. Whatever is bothering me more is possibly the main determinant. Last Thursday I missed writing my blog. Friday morning’s blog was very brief and was a response only to an intellectual and not a psychological itch. I had been in the hospital and was bothered by the experience on several levels. I decided to write about the experience as a way of explaining my absence – if anyone noticed – and my reflections on the experience.

The Instigation for my Hospital Incarceration

En route to my cardiac rehab program this past Tuesday, when I came up from the university subway stop at Dundas St. to catch the streetcar going west to the Western Hospital at Bathurst and Dundas, I suddenly felt faint and leaned against the wall of the office building. Within three seconds the woozy feeling evaporated. I boarded the next streetcar. However, just after I got off, I again felt woozy and leaned against a wall for a few seconds. I made a mental note of the two times: 8:31 a.m. for the second and I estimated 8:25 a.m. for the first.

During the exercise program I had four other similar episodes, usually after completing a particular exercise and rising up. However, when I was going to a previously arranged appointment with the doctor in the cardiac rehab program just after finishing my exercise program, when getting on the elevator from the 7th to the 8th floor, I had another incident. As it turned out, the doctor I was to see was married to my first cousin’s son, Peter, but I did not recognize her in the hospital setting; she recognized me. After she asked if I was still agreeable to her examining me since we were relatives, I told her about the 7 incidents that morning and noted that I had previous episodes but they came only about once every three days not seven within a two hour period. She advised me to see my cardiologist as soon as possible.

I made an appointment and was fitted into a cancellation at 1:30 the next afternoon. I first had an ECG, the first of four I would have that day. My cardiologist gave me a thorough examination, found nothing significantly untoward, but noted poor R wave progression. That could be an indicator of many possibilities and simply be a result of my old conditions. It just meant that instead of the normal progression in increase of the R wave when your heart beat grows from small to larger and larger until you get a large upward spike and then a downward one of a slightly larger size, you get a series of almost even waves, virtually no spike upwards and a larger downward thrust in the waves produced, The pattern could be a result of a previous condition or a sign of a new blockage or a variety of other possibilities.

My cardiologist wanted to fit me with a 48 hour haltor monitor, but suggested that a more rapid method of finding out whether the reason for my feeling faint was some dysfunction or anemia or perhaps even diabetes or something else was first to eliminate the possibility that it was related to heart function at the same time as blood tests were conducted. Since my pacemaker not only kept my blood pressure from falling below 63 beats per minute but also, as a secondary feature, kept a record of everything that happened in my heart, if I could get a record from my pacemaker’s memory right away, that would be invaluable. I phoned down to Mount Sinai Hospital and told the pacemaker clinic what was happening and they agreed to fit me in if I could get to the hospital within 45 minutes.

I just made it. After Robin put the reader on my chest just on top of the pacemaker and read the behaviour of my heart from the day before, when she looked at the print out she almost shouted “Eureka!”. The ventricular arrhythmia precisely correlated with the times of my fainting feelings the day before. However, there was no record of one I thought I had had at 2:30 p.m. at the time of my phone call to the pacemaker clinic that day. Nevertheless, the almost exact correlation between symptoms and irregular heart rhythm re yesterday was exciting science, but it also turned out to be distressing news.

My Admission to the Hospital

As Doctor Wald said, ventricular arrhythmia is an indicator of high risk of a heart attack. I had experienced tachychardia rather than fibrillation, the condition for which I had been previously treated. He wanted to admit me to the hospital right away and monitor me directly overnight. This was both the safer option, especially since they did not have a portable haltor monitor available.

I had no idea how upset I was by the news until I phoned my son and tried to tell him what was happening so he could be with Nancy when I phoned her. In the past year I have handled each piece of news about another negative turn of events with regard to my heart with cool aplomb. Not this time. I thought I had been finished with one heart correction after another – stents, ablations, angioplasties, pacemakers. I hated that my daily schedule was being more and more governed by the dysfunctions of my body. I hated physical exercise, but agreed to participate in the cardiac rehab program as my part of the bargain given the hard work and devotion of all the health professionals. I disliked the activity but was very conscientious in doing my exercises as I was instructed.

But I had a sense of limits. And I feared the latest news had crossed the line of my limits. I was totally surprised at my reaction, particularly since I had upset and worried my son. He immediately said he was coming down and would bring an overnight bag with him. As it turned out, I had plenty of time to think about my reaction as I sat on the sixteenth floor in the waiting area of the pacemaker clinic as there had been a CODE RED announced over the loudspeakers and the elevators were not then operating until they announced the All Clear. Code Red was obviously an emergency evacuation procedure. I have never learned once why they are called, and this was not my first experience of a CODE RED. Further, in all my experiences in hospitals, I had never seen any effort to begin to evacuate the hospital. I interpreted the announcement of CODE RED, or whatever colour, to be just ways of communicating to everyone how super-alert the hospital was to patient safety even though I knew better and recognized the code system had a direct utility function.

When I was being examined and just before the discovery of the correlation between my irregular heart waves and my symptoms of feeling faint, there had been an earlier CODE BLUE with an announcement of where the medical emergency team was to report. I assumed the emergency was a cardiac arrest or something equivalent, but perhaps it was an emergency in the delivery room. You cannot escape the sense that hospitals are high risk places from the constant instructions to sanitize your hands to limit the spread of hospital-based infectious agents and the repeated questions by each health professional who sees you and asks what your name is and where you live.  I am sure that routine use of two patient identifiers has significantly reduced those incidents where the wrong patient was treated by a health practitioner. But the by-product is a very heightened awareness and corresponding sense of tension that a patient is now in an institution that is inherently dealing with high risk issues and has numerous practices in place to minimize those risks.

Surrender

When my son arrived and we met on the first floor after I had gone to admissions, I had recovered my equanimity and my proneness to resort to a bad and morbid sense of humour in the face of possibly scary news. As we sat in the hospital room in the cardiac ward on the sixteenth floor waiting for the next steps, I tried to bargain for my son to go out and get me a pastrami sandwich as my just compensation for having to endure a new setback.

When my wife Nancy arrived – AND SHE GOT OUT OF BED IN SPITE OF HOW SICK SHE WAS, though needless to say she was past the infectious period — she put her foot down and insisted I keep my contract with my dietitian at Western hospital to develop new eating habits. That second set back of denial was just another in a series in which I surrendered the determinations of choice and options to others over the next 24 hours. The third step was that they were to transfer me to the CCU unit so they could more thoroughly monitor me. Instead of a room, it was really a booth with glass doors that opened onto a central nursing station from which they would constantly monitor the oxygen in my blood, my heart rhythm, my pressure, my heart rate, etc.

For the fourth time in as many hours, the nurse took my pulse, my pressure, weighed me and asked my height. As is routine, before she began, she confirmed my name and my home address. I had my third ECG and application of a pressure cuff, and I was taught how to detach the electronic hook up measuring my cardiac rhythm and another device that electronically monitored the oxygen in my blood. Another nurse came in to take blood samples and still another came in to push a catheter feed into my arm.

Protest

That’s when I finally protested. Why did I need a  catheter? I was not being fed intravenously. Nor were drugs being introduced intravenously. I was here to be electronically monitored. The nurse responded to my protests to say she would check with her superiors. She returned ten minutes later and told me her orders required her to hook me up to an intravenous lead presumably in case something took place where health professionals might need direct access to my blood system. But I insisted there was almost little chance that I would need a peripherally inserted catheter for chemotherapy, antibiotic therapy or nutrition. The nurse could not justify the procedure but simply insisted that she was required to carry out the procedure.

I knew that I did not have to agree and could have refused. I was not sure what the consequences would be for me. I had clearly upset the nurse who was not used to such recalcitrance on the part of patients or demands for justification. I do not know whether I agreed to comply either out of compassion for the nurse or because it was ten at night and I was by now very tired. I permitted her to proceed, but my resistance must have made her nervous and the consequences of my resistance ended up with what is normally a relatively painless procedure being very painful.

Transparency and Accountability

The pain persisted, though not as acutely, over the next 24 hours until the catheter was removed. More importantly, the psychological pain was even greater as I felt I had been coerced into agreeing to one of the many routine procedures of hospitals to minimize risk even when making such procedures universally routine may not be indicated by any rational assessment of risk management. More personally, I could not overcome the feeling that the real function of a hospital was to reduce the patient to a passive and compliant obedient subject rather than a responsible agent because the cost of informing and getting active cooperation was expensive in time and effort in spite of hospital health workers being advised to solicit patients buying into procedures by being transparent about risks and rationales. Transparency practice and procedures for obtaining patient buy-ins are both hard to implement and even more difficult to overcome the culture of the professionals knowing best what is good for you. 

Now do not get me wrong. Since I lived in the same Mount Sinai Hospital when I was a medical student over a half century ago – in the building just south of the current one that is now a convalescent hospital – there has been a tremendous improvement in greater transparency and accountability in dealing with patients as well as tremendous strides in reducing operational deaths, greater management of anaesthesia, drug dispensing and a whole host of procedures to make hospitals both safer and more open to patient participation in their own health management. And I should be the last to complain since I have been such a great failure in my own health management. Though I know the health professionals are totally committed to reducing my risks for my benefit, I still respond almost like a spoiled child and resent being reduced to a passive agent who simply follows orders when there is no apparent reasonable justification on offer for a procedure.

A Risk Averse Culture

It is true that hospitals are very high risk environments and most of the risks are not self-evident to either patients or even most health practitioners. Further, my own studies of Canadian culture have indicated that we live in a highly risk averse culture, both in exaggerating the risks we perceive and in our choices of risk preferences. Cognitively we tend to have a great focus on risk assessment. Emotionally our risk attitude has a very low threshold of tolerance, especially in our institutions. I recall when I worked in radiology when I was a medical student to learn that we x-rayed anyone who had any head injury even if, as in the vast majority of cases, there was no indication that an x-ray was needed at all. “Better safe than sorry” was a byword even though the counter-effects of overuse of x-rays were not factored into the equation let alone the costs where the monies saved could be used for other more rationally determined preventive procedures.

My observations were that the risk averse culture of Canadians and of institutions like Canadian hospitals have only grown more extreme even as the improvements in dealing with minimizing risk have also soared ahead yielding great improvements. I also believe that greater vigilance towards risk has also been accompanied by a greater sense of risk and a corresponding greater distrust of institutions like hospitals even as they have made enormous strides forward in reducing risk by enhanced awareness, enhanced sharing of information, processes to increase the motivations of the workers in hospitals to become keen about risk reduction, introduction of routine risk-mitigation procedures, better feedback mechanisms, and better articulation of standards, universal protocols and training in procedures. Further, these approaches to attitudes, training and institutionalization of procedures have pervaded all areas of the hospitals both with respect to physical and mental health as well as the development of early warning and acute alert systems. But there has been a corresponding negative effect on a patient’s sense of empowerment rather than an increase that should be expected to correspond with enhanced transparency and communication.

Another instance of taking control away from me took place that first evening. I had sent my son home to drive back to the hospital with my regular pills, only to learn that I could not take those pills but only the same medicines but ones provided by hospital staff. I went along with the requirement and took the pills they supplied since they did not look too dissimilar to the ones I usually take. But this became just another instance of hospital safety procedures having the indirect effect of enhancing a patient’s sense of impotence.

Underemployment of Foreign Professionals

The rest of the hospital visit was the usual – being woken at 5:45 for the routine round of blood pressure tests though the other readings could be made from the desk. My temperature was again taken and again I was asked my name and address. Luckily, they fitted me in for my echo exam early and by just after nine that was completed. As it happened, the technician operating the echocardiogram machine had been trained as a cardiologist herself in an eastern European country. She had passed her exams here – which she thought were relatively easy – but like the vast majority of immigrant doctors had been unable to find a residency to complete the qualifications. If I understood her correctly, there were two other eastern Europeans in the same position in the cardiac unit.

Since she was trained a s a cardiologist, she could have interpreted the results for me. But she declined to do so. She knew the rules and I was being unfair in pressing her to tell me the results. More importantly, she was far more accepting of her reduction in power than I was as a patient. As she said, she knew what she was getting into when she chose to immigrate to Canada.  I resented the position in which she had been placed far more than she did. As she said, at least I am not diving a taxi.

NOT Pastrami

I returned to my room to eat the best meal of the hospital day – a plastic cup of orange juice, a small bowl of cheerios and 1% milk, and a thin slice of decent banana bread. At lunch, the soup was bland and tasteless and the main course of rice and chicken was inedible. Tapioca chocolate pudding was definitely not on the diet included in items I could eat by the dietitian at the Western Hospital. I wondered why the provision of fresh vegetables and fruit failed to conform to the Canada food guide. 

Results

I had the usual visit of students with the resident during rounds but I behaved myself. The visits of cardiologist resident were also uneventful. They seemed to visit merely to reassure me that the electrical cardiologist would be by relatively shortly.

I waited all day for the results. By 3:30, growing impatient, I went to look for the electrical cardiologist to tell me the results, greatly distressing the nurses who thought I had just unhooked myself to go to the washroom. The doctor finally came, long after I had returned, and finally gave me the results. The arrhythmia was probably the result of the dead heart muscle interference from the old silent heart attack I had once had in the past. I had been put on beta blockers to prevent precisely such spikes, but my old cardiologist had taken me off them because the beta blockers were presumably only supposed to be used for three months after the surgical procedure. The specialists now put me back on the beta blocker. The electrical cardiologist did not think insertion of a defibrillator, similar to the procedure in inserting my pacemaker, to prevent high spikes and the corresponding risk of other more invasive procedures would be necessary. There was no new source of blockage. The news was all positive and I was visibly relieved.

On Friday I was fitted with a 48-hour portable haltor monitor and its readings would be supplied to my regular electrician – my electrical cardiologist – when he returned on Monday and I could then see him for a final determination. I had missed John Fraser’s party at Massey College on Thursday evening. I had to cancel my trip with my wife to New York on Sunday – she was, in fact, still too sick to go – to see the art show Frieze and visit my daughter. I was advised not to fly until I received the all clear. But I had been given an enormous new reprieve.

I phoned my wife and all my children with the good news, but was still left with the after-effects of both a feeling of powerlessness and a determination to be better prepared, not for a healthier life, but for better preparation to be in charge as my body continues to deteriorate. Risk management is not the only issue. Who manages is the prior question. 

Perhaps that’s why I write this blog. I gain a facsimile of power.

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