In 2017, Dr. Don Berwick wrote about “breaking the rules for better care.” He was discussing a more systematic way for organizations to ask clinicians, staff, and patients about the “habits and rules [that] appear to be harming care without commensurate benefits and, with prudence and circumspection, to change them.”
As I spent long hours on the wards recently doing all I could to care for my patients, I faced many ingrained norms and rules that often got in my way.
To be clear, I am a “systems guy,” who advocates for putting in place systems and standard procedures, and I clearly recognize the importance of this for our patients’ safety. However, I am also deep down somebody who grew up on punk rock and the grunge ethos of Rage Against the Machine. I had midnight blue hair when I was 16 – it basically looked dark and respectable when I was inside, but would shine blue out in the sunlight – to me, just the right amount of subversive for someone who was going every summer to the Warped Tour and blasting Rancid from my car, but was also quietly studying AP biology and aiming for straight “As.”
This is the type of rebelliousness I propose we hospitalists practice in the hospital. We’ll play within the system, but we are also going to find more subtle ways to rebel a bit for our patients. It keeps us human.
Dr. Reid, @medicalaxioms on Twitter, recently explained this in a tweet thread, though per usual, he took a more provocative and cynical stance than I generally would. He talked about how to avoid letting the system make you into “a mindless heartless sodium-correcting note writing indentured servant.”
I had an important conversation with a resident today. [thread]
— Medical Axioms (@medicalaxioms) August 1, 2019
Welp, in Dr. Reid’s mind, you have three options:
- “Abandon your human uniqueness. Accept your role as a nameless faceless provider. A biological kiosk dispensing medical advice and tablets in an efficient and cost-saving manner.”
- “Stand up and carry your flag into battle. Go full-on #Braveheart.”
- “Option 3 is not immediately intuitive. It is the most subversive. You do not fight the power. You do not call anything or anyone out. By most indications you do what is expected. Blend in. Go along. Get along… Underneath this guise you exercise your freedom. Do what’s right. Break rules if necessary. Conspire with patients and fellow practitioners to deliver care with feeling in a system that has none… You do this with your time which is yours to use as you please. And with honesty. And by building alliances with other people who understand the most important work is hidden from view.”
During a one-on-one afternoon visit, I recently sat and spoke to a terminally ill hospitalized patient, and she told me about how she had “chocolate” listed as an allergy in her hospital records and how this has followed her around throughout her hospitalizations. If she eats too much chocolate, she begins itching and having a rash. It was a real allergy, but one she said she knew how to manage throughout her life, and she just doesn’t overdo it. But here in the hospital, it limited what she was allowed to order. She had pleaded her case to the nurses and cafeteria but to no avail. I told her I was going to delete this allergy from her chart and let her order whatever she wanted. We both smiled and laughed. The next morning on team rounds, we shared a knowing glance with each other as I know she ordered some chocolate chip cookies the evening before. Not exactly raging against the machine, but still a little gesture that mattered.
In fact, diet orders are a great way to buck some norms and develop rapport with patients. They have you on a low-sodium, carb-controlled, renal diet? Good Lord, man. Let me help you out with that.
A resident and I recently described in Annals of Internal Medicine how we developed a bond with a patient over a shared love of punk rock and how we floated around many hospital accepted standard procedures to get her discharged for her birthday and to allow her to return to the oncology infusion clinic on Monday to receive her needed intrathecal chemotherapy.
I like to think this type of act was inspired at least a little bit by one of my favorite – and perhaps one of the most shocking – examples of hospital rule-breaking I have heard: Maureen Bisognano’s moving story about her brother Johnny, who was diagnosed with Hodgkin’s Disease in his late teens.
“A group of physicians doing rounds came into his hospital room, and they were talking over his head. When they left, one of the doctors came back into the room, and Johnny told him he wanted to go home. The doctor took my jacket, picked him up and carried him in the jacket out to my car, breaking all the rules.”
Maureen described how her brother spent the last few weeks of his life surrounded by his friends and family who cared for him. “I learned that breaking the rules is sometimes the right thing to do, and we have to face death in an entirely different way. I believe everyone should have the kind of death my brother had. And this all happened because of that physician and his courage,” Bisognano wrote.
“… Punk rock is about more than tattoos and music. It’s a way of living…” Liz Salmi (@TheLizArmy), recently tweeted. Her twitter bio describes her as “bringing punk rock to healthcare.” Yes, right on.
I absolutely LOVE this story!
Punk rock is about more than tattoos and music. It’s a way of living… and you, @EricTopol, are pretty punk rock for taking screenshots of journal articles and sharing with the world. ??
?@ChrisMoriates #punkrockhealth https://t.co/iEGmFlPogx
— Liz Salmi (@TheLizArmy) July 16, 2019
Perhaps we all need to be just a little more punk rock when it comes to caring for our patients. Just enough to do what’s right… and to maintain our own beating hearts.
However, unlike Dr. Reid’s particular rant, I do think there is also an important role for us to advocate for and lead systems-level changes. Please don’t be so cynical. We can do both. Just sometimes when the pace and obstacles of those systems changes get me down, and when I am tired of trying to “go full-on #Braveheart,” I am simply going to continue to quietly go sit and enjoy some chocolate with my patient.
What do you do to practice some hospitalist rebelliousness?
Agree break rules whenever common sense indicates if there is no harm but benefit for the patient and less expense
Shortly before my retirement, I finally realized that the more boxes you checked on the EMR, the better a doctor you were. Accordingly, I checked the ‘do not smoke’ box and, the ‘do not smoke around your baby’ box on a patient’s discharge instructions. Thus, having now added two more checked boxes to my ‘checked box count’, I was a much better doctor than I had not done that. The fact that the patient was 70 years of age, and did not have a baby, and never was a smoker had nothing to do with it.
I break every damn rule I feel like is in my way to deliver PROPER patient care. I don’t tell anyone anything. It’s always better to ask for forgiveness than permission.
The bureaucracy does not always know what is right and wrong. When I worked in a small country hospital I had a patient with inoperable esophageal cancer whom I would dilate weekly to allow him to swallow liquids (before SEMS). This actually worked for several months. At one of these sessions I just knew I had perforated his esophagus. He was not a surgical candidate and did not want any intervention. I admitted him. HIs one request was that he wanted his dog with him when he died. Of course no dogs allowed. The hospital was a one story with most rooms having windows to the outside. I lifted the dog through the window (an Irish Setter – pretty heavy) He died comfortably and with his dog.
Nice work!