When Doctors and Nurses Work Together

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Dr. Christian Pettker, left, and Cheryl Raab, a nurse, work together in New Haven.Credit Jessica Hill for The New York Times
Doctor and Patient
Doctor and Patient

Dr. Pauline Chen on medical care.

Not long ago, I heard a respected senior colleague recount to a group of medical students and trainees the story of a patient who had died under his care some 15 years earlier. Afterward, he had spent hours talking with the family, trying, he said, “to be as kind to them as I possibly could.” The family had been grateful for all his efforts, but my colleague still struggled even to tell the story.

“Were you afraid of getting sued?” one of the students suddenly asked.

My colleague’s eyes widened, and he answered slowly, the tone of his voice shifting from grieving to professorial. “In medicine, malpractice isn’t something we just think about when a patient dies. Malpractice is always in the back of your mind.”

The handful of senior doctors in the room nodded in grim agreement. Every one of us either had been named in or knew of a colleague embroiled in litigation. That evening we all urged the aspiring clinicians to be the best and most compassionate doctors they could be. We knew all too well how much easier it is simply to order more tests and procedures than necessary and to overtreat in hopes of avoiding a lawsuit.

But a study published earlier this year in the American Journal of Obstetrics and Gynecology has revealed that a group of doctors at Yale-New Haven Hospital has been quietly working to change the culture of “defensive medicine” that so many have come to accept as inevitable.

Beginning in 2003, the hospital’s department of obstetrics and gynecology, in collaboration with their malpractice insurance carrier, initiated a series of reforms to improve care. Those in charge had no illusions. Obstetrics was, and remains, one of the most legally embattled specialties, accounting for the highest proportion of malpractice payouts over $1 million. Their goal was only to make a small dent in adverse patient outcomes.

They first asked outside experts to review their work. With those recommendations in hand, they instituted guidelines and certification requirements to standardize practices like the interpretation of fetal monitoring or the administration of oxytocin, a drug used to help with labor.

Taking a cue from the airline and defense industries, the leaders of the safety initiative trained their physician and nursing colleagues to communicate better, resolve conflict and work in teams. They created a computerized system for individuals to report anonymously events that might have caused harm to a patient or a visitor like a medication error, a fall or the spread of infection, and a patient safety committee to track and review those cases. They established the “Two-Challenge Rule,” which allows colleagues to question why a particular test or procedure has been ordered if they are not sure it’s right, and then to halt the action or order if, after two tries, the clinician in charge can offer no reasonable explanation. And they mandated that a fully trained obstetrician be at the hospital 24 hours a day, in person and not just by telephone, to supervise inpatient care and doctors-in-training.

To foster greater interdisciplinary understanding, they required obstetricians beginning their training to shadow nurses for a day or two to learn about their work challenges.

Most important, they hired a nurse to lead the safety program. Her responsibilities included overseeing the training sessions, meeting regularly with providers for feedback, and working with the safety committee to evaluate patient outcomes.

The changes resulted in a significant decrease in the number of adverse patient outcomes, like traumatic birth injuries, admissions to the intensive care unit and death.

But leaders of the initiative also discovered that their changes had had a dramatic effect on malpractice suits. The number of liability claims against obstetricians in the Yale department dropped more than 50 percent. And while the values of malpractice claims awarded or settled in Connecticut continued to rise, Yale’s obstetric liability payments fell by 95 percent, a saving of almost $50 million over a five-year period.

“People sue when something goes wrong with their care,” said Dr. Christian Pettker, chief of obstetrics at Yale. “You can’t turn that into a happy situation, but you can mitigate it by reducing the level of harm.”

The changes did not come without challenges. Start-up costs for the first year were over $200,000, and the program required an additional $150,000 annually to maintain.

There was also significant resistance to the reforms. Some clinicians chafed at the time and bureaucratic demands of undergoing training and then certification for skills they had been using for years. Others felt stifled and even threatened by the level of oversight implicit in the new array of clinical guidelines and protocols.

But because the department’s malpractice insurance carrier was a co-sponsor of the initiatives and had made them a requirement for coverage, clinicians had no choice but to accept them.

As the department’s patient outcomes began to improve, however, so did the clinicians’ attitudes. Dr. Pettker and his colleagues found that over time, the percentage of doctors and nurses who approved of the changes nearly doubled, with some of the most resistant doctors and nurses becoming champions of the teamwork and safety initiatives.

“Medicine can be scary because we have such power to do harm,” Dr. Pettker said. “But in a culture of teamwork, you feel like everyone has got your back.”

Dr. Pettker and his colleagues are now working with national obstetrics organizations to help other departments across the country incorporate similar changes. Their greatest challenge, however, lies at home. “A safety and teamwork culture is not something you can just implement, then walk away from and expect to continue,” Dr. Pettker said. “The really hard work is the daily work you need to do to keep it going.”

“But I think our results show that it pays to do the right thing, both for patients and for the system at large,” he added.