“Today, Jaded Julie, we’re going to talk about judgment.”
“You mean Judgment Day like in church with singin’, shoutin’, and wavin’ my arms?”
“No Julie, I mean personal and professional judgment, as in making important decisions. Consider a veterinarian who specializes in small animals. Her good judgment tells her not to go out to a farm to treat a sick draft horse.”
“How about some examples in human health care, Curmudge? I bet that’s where you were heading all along.”
“Let’s start with primary care and the ED. Most of the illnesses and injuries that patients come in with are low acuity. As they say in the ED, ‘treat and street.’ In these situations, mid-level providers like NPs or PAs are just what the patients need. I have a physician friend who is delighted with the NPs in her practice. She says they can do 90% of what a physician does.”
“That’s great, Curmudge, but where does judgment enter the story?”
“It’s the other 10%, Julie. It’s the NP’s judgment of when the patient needs to be seen by a physician. Of course she is limited by her license and state regulations, but I would favor good judgment any day.”
“Some people call NPs and PAs ‘physician extenders,’ but that sounds demeaning. ‘Advanced practice’ or ‘mid-level’ are more appropriate terms.”
“It isn’t just the NPs who need good judgment. The primary care physician needs to judge when a specialist must be consulted, and sometimes the specialist determines that the patient should see a subspecialist. In rare cases the patient must go to a world-class medical center for diagnosis and treatment. Excellent judgment by the providers and the patient is critical at each step along this pathway. If the patient has compelling concerns about her diagnosis and proposed treatment, she should seek a second opinion.”
“But Curmudge, doesn’t the patient stop when she reaches a physician whose credentials match her illness?”
“Ah, Jaded Julie, here is where judgment enters the picture big time. Credentialing cannot guarantee the best of all possible outcomes for every patient. I would personally have reservations about a provider who might be near the lower limit in relevant experience and would want to push the envelope of his proficiency. Examples of this have appeared in recent news articles about poor outcomes from robotic-assisted surgery, presumably performed by physicians with inadequate experience with the specific device.”
“So who makes the judgment about the best path forward for the patient?”
“The patient does, but not without help. She should go back to her primary care physician—hopefully in a medical home where she is well known—and review her diagnosis, proposed plan of care, and provider. Of course, she can use her computer to find evaluations of hospitals in CheckPoint and physicians in HealthGrades. In addition, she should get advice from people she trusts, including retired health care professionals and their spouses. It seems that every senior has a health care story to tell; Ms. Patient should listen. After careful consideration and the best judgment she can muster, she should make her decision and proceed with confidence and faith.”
Affinity’s Kaizen Curmudgeon
Friday, June 18, 2010
Thursday, June 10, 2010
The Guys in the Yellow Shirts
“Jaded Julie, you’d like those guys in the yellow shirts.”
“I already do, Curmudge. Most of them are young, big, good-looking, and they’re building things or otherwise doing something useful. They don’t have anything in common with you.”
“That’s not entirely true, Julie. I once helped our sons build pinewood derby race cars when they were Cub Scouts. But I must admit that the folks from The Boldt Company and the subcontractors doing construction around the hospital are vigorous. When they pass me on the stairway, they usually take the steps two at a time.”
“So why are we writing about the construction crew? They are probably courteous to you because you remind them of their grandfather.”
“To me, the unmistakable characteristic of the Boldt construction crew is that they are paragons of workplace safety. They recently received an award for that from the Wisconsin Safety Council.”
“I think what you are saying Curmudge, is that these guys are excellent examples of working safely, especially in their use of personal protective equipment (PPE). Each person wears a high-visibility (usually yellow) shirt or vest, a hard hat, work boots, and safety glasses. In addition, if he is working in a noisy environment he must wear hearing protection. If you had worn hearing protection during your early paper mill days, you might not need hearing aids now.”
“You are right as usual, Julie. And in addition to their being good examples, they are enforcers. Steve Kappell told them to enforce their safety culture on any Affinity people entering a construction area, and they do. When they were building the Heart, Lung, and Vascular Center, they even gave Betsey a pink hard hat.”
“Further, to keep us from inadvertently going into an unsafe area, there are signs and yellow barricades all over the place. They must have anticipated that you sometimes wander out of your office with your brain left behind in the computer.”
“Not only do the Boldt folks protect us from the hazards of their construction, they also minimize the impact of the construction on the hospital environment. They build wood and plastic containments around areas where they are working and put blue dust-catching mats where they walk from the work areas into the hospital. And every day a worker uses a wet mop to remove the day’s dust from the stairway.”
“Some days noise from the construction activities is unavoidable. I have occasionally felt that whatever device they were using was going to come right through the wall. Nevertheless they make every effort to lessen the disturbance. This includes adjusting their schedule so that the noise occurs during the off hours of our workday. So Curmudge, what is our take-home lesson from today’s discussion?”
“Safety doesn’t happen automatically. It must be infused from the top down throughout an organization until it becomes a culture. The Boldt Co. has obviously achieved that. They deserve our appreciation for working safely on our site, for keeping us safe around their construction, for making the extra effort to reduce their impact on our environment, and for serving as excellent examples.”
Affinity’s Kaizen Curmudgeon.
“I already do, Curmudge. Most of them are young, big, good-looking, and they’re building things or otherwise doing something useful. They don’t have anything in common with you.”
“That’s not entirely true, Julie. I once helped our sons build pinewood derby race cars when they were Cub Scouts. But I must admit that the folks from The Boldt Company and the subcontractors doing construction around the hospital are vigorous. When they pass me on the stairway, they usually take the steps two at a time.”
“So why are we writing about the construction crew? They are probably courteous to you because you remind them of their grandfather.”
“To me, the unmistakable characteristic of the Boldt construction crew is that they are paragons of workplace safety. They recently received an award for that from the Wisconsin Safety Council.”
“I think what you are saying Curmudge, is that these guys are excellent examples of working safely, especially in their use of personal protective equipment (PPE). Each person wears a high-visibility (usually yellow) shirt or vest, a hard hat, work boots, and safety glasses. In addition, if he is working in a noisy environment he must wear hearing protection. If you had worn hearing protection during your early paper mill days, you might not need hearing aids now.”
“You are right as usual, Julie. And in addition to their being good examples, they are enforcers. Steve Kappell told them to enforce their safety culture on any Affinity people entering a construction area, and they do. When they were building the Heart, Lung, and Vascular Center, they even gave Betsey a pink hard hat.”
“Further, to keep us from inadvertently going into an unsafe area, there are signs and yellow barricades all over the place. They must have anticipated that you sometimes wander out of your office with your brain left behind in the computer.”
“Not only do the Boldt folks protect us from the hazards of their construction, they also minimize the impact of the construction on the hospital environment. They build wood and plastic containments around areas where they are working and put blue dust-catching mats where they walk from the work areas into the hospital. And every day a worker uses a wet mop to remove the day’s dust from the stairway.”
“Some days noise from the construction activities is unavoidable. I have occasionally felt that whatever device they were using was going to come right through the wall. Nevertheless they make every effort to lessen the disturbance. This includes adjusting their schedule so that the noise occurs during the off hours of our workday. So Curmudge, what is our take-home lesson from today’s discussion?”
“Safety doesn’t happen automatically. It must be infused from the top down throughout an organization until it becomes a culture. The Boldt Co. has obviously achieved that. They deserve our appreciation for working safely on our site, for keeping us safe around their construction, for making the extra effort to reduce their impact on our environment, and for serving as excellent examples.”
Affinity’s Kaizen Curmudgeon.
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