Listen to a Canadian emergency physician’s perspective on healthcare from Pat Croskerry on this episode of the Perspectives on Healthcare Podcast with Rob Oliver. Dr. Pat Croskerry is an emergency physician and professor of emergency medicine in Halifax, Nova Scotia, Canada. In addition to his MD, he also has a PhD in experimental psychology. An internationally recognized expert in patient safety, he is conducting research on clinical decision-making and medical education reform. In 2016 he was nominated to the Canadian Association of Emergency Physicians Top 10 List of the most impactful Canadian medical educators. Dr. Croskerry is a member of the baby boomer generation.
Here are three things that stood out as Dr. Pat Croskerry gave us a Canadian emergency physician’s perspective on healthcare:
· Medical errors rank as the #3 cause of death
· A lack of medical knowledge does not generally cause medical errors
· Medical professionals can play the role of facilitators of good decision-making in their patients
You can find out more about Dr. Pat Croskerry by googling his name. You can also find out about his book through the link below:
https://www.amazon.com/Cognitive-Autopsy-Analysis-Medical-Decision/dp/0190088745/
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Here is the transcript of “Pat Croskerry: A Canadian Emergency Physician’s Perspective on Healthcare”
Rob Oliver: Welcome. And I am excited to share with you today that we have officially gone international, and my guest today is from the wonderful country of Canada, our friendly friends just north of the border. His name is Pat Croskerry, and he is located in Nova Scotia. He is a member of the baby Boomer generation. He has practiced emergency medicine. He has written a number of books. His accolades. I will put a full list of his accolades in the show notes because they’re too numerous to mention right now. But he has been an important figure in Canadian medicine. So let me just say, Pat, welcome to the show.
Pat Croskerry: Thank you. I’m happy to be here.
Rob Oliver: Absolutely. So tell me a little bit about yourself and your role in health care, please.
Pat Croskerry: Thank you. I come from emergency medicine. I’ve been an emergency physician for the last 35 years or so, and I was a Department head for ten years. So that gives you a particular perspective on what’s going on behind the scenes in emergency medicine. My own interest predominant interest in medicine, aside from an emergency, was I was very interested in patient safety since I was a medical student, and in fact, myself and some emergency colleagues set up the Canadian National Symposium on Patient Safety, which ran for about ten years. We focused on all aspects of patient safety, and it’s a complicated business. But I eventually became increasingly interested in the errors which occur from physician thinking. That is to say, clinical decision making, because these appear to be the most consequential for patients and just to complete the story. I had earlier trained as a psychologist, and I was quite comfortable with the language and the concepts of cognitive science, both through. I didn’t train specifically as a cognitive psychologist, but throughout my undergrad and graduate training, I spent a lot of time in cognitive psychology, so I got to be familiar with the language and to appreciate the importance of cognitive science is to the decisions that we make in everyday life, not just in medicine, but in everything we do.
Rob Oliver: Okay, talk to me a little bit about patient safety and what you were working on there. I’m assuming it’s more than just putting a risk band on someone that says that they are a fault risk. What were you looking at with patient safety in particular?
Pat Croskerry: Well, to begin with, we looked across the spectrum because patient safety was a fairly new concept at the turn of the century. It really didn’t sort of kick off until the Institute of Medicine report appeared to worry human. So at that time, we were interested in all aspects of it in the way the system works in the way that the individual works. And eventually we came to focus on the medical error and the adverse events that come from that. And now your listeners may be aware that medical error is ranked about a third or so behind heart disease and cancer as a leading course of death, which is absolutely astounding, as I say, all aspects of patient safety, how the system fails from the local Department or clinic that you’re working in all the way through to how it fails on a national level. And our findings particularly started to focus in on how doctors think. And around about 2006, we were helped considerably by Jerry Grootman’s book, How Doctors Think People’s focus tended to be if your doctor failed you or the health care system failed you. People often said that the doctor didn’t know enough or that they don’t know what they’re doing, and that to us. When we looked into that little more deeply, we realized that medical knowledge is really not a major contributor to medical error. It mostly comes about to how doctors think. And that’s really where most of our emphasis lay. We were interested in how doctors and caregivers thought their way through the problems that they were presented with. So I think that was the main issue around quality care and all the other sort of parameters of care, quality and safety. They seem to flow from how people make decisions.
Rob Oliver: What were you finding were the influencers that were detrimental to decision making? Was it external circumstances? What were the factors that were contributing to poor decision making?
Pat Croskerry Yeah. Well, number of studies have been done on this, and it sort of breaks down into contributions from the environment in which you work our actual workplace, and that we referred to as the system and the other contributor is the individual and how the individual thinks. So some of the classic earlier studies had looked at that looked at the origin of medical errors and found that they overlap significant extent. But in general, you could say that the system that the patient is in fails about a quarter of the time and the individual caregiver, the physician, the nurse practitioner, the physician’s assistant, whoever’s the final conduit for the diagnosis, they fail about 75% of the time in terms of the contribution to patient safety and error. I’m not saying that physicians fail 75% of the time. They don’t. They succeed about 85% of the time. So the thing that we were interested in particular, in how diagnoses get made, it became apparent that physicians were failing there about 10% to 15% of the time.
Rob Oliver: Got it. What does quality health care mean to you?
Pat Croskerry: Well, if you want to talk about quality in general, there are about half a dozen parameters that the patient safety movement has focused on. It should be health care that is safe, that you avoid harm to patients. It should be effective that you’re doing the right thing at the right time. It should be centered on the patient. It should be timely. You get to problems earlier rather than later. It should be efficient. And it should be equitable, which means that it shouldn’t involve personal characteristics such as gender, ethnicity, geographic location, socioeconomic status, things like that. So that’s the overall picture of quality. But at the danger of repeating myself. But I’m happy to repeat myself on this one. We found that if we focused on quality of decision making and this isn’t just sort of mission statement, this really is saying decision making is very important. If we have good decision making, then those are the parameters of quality will tend to follow. I think it’s important that we recognize that this is a special skill. It isn’t just a sort of general notion of what people should be doing. I think now that we have to start at an early age in teaching people how to make decisions. It is a science and it can be taught. And if you look at what the psychologists have discovered, children around the age of seven or eight or nine fairly early on can begin to understand concepts of critical thinking. And so we think it has to start way back there. But then eventually we hope it would mature into University courses and degrees and eventually sort of graduate work in decision making. So that’s the direction we’d like to see it go. And there are some encouraging sites that is beginning to happen now. But of course, in medical, in health care, we haven’t yet fully acknowledged that how people make decisions is one of the most important, if not the most important characteristic of their clinical behavior.
Rob Oliver: Got it. Can you give me an example of quality health care?
Pat Croskerry: Well, I think it’s essentially getting the right diagnosis to the right person at the right time. I think diagnosis is probably the most critical thing that we do. So if you’ve got the diagnosis right, a lot of other things will follow. So I would put an emphasis on an essential feature of health care. Quality is correct diagnosis at the right time.
Rob Oliver: Got it. What do you wish people understood about your role in health care?
Pat Croskerry: Well, I think that physicians have played different roles in health care over the years and at different times we’ve been seen as authoritarian figures. We’ve been seen as for some people, a high priced help. What I’d like to see evolve is a notion of physicians and health care providers as facilitators of good decision making by the patient so that the patient can make decisions and choices that are rational and will lead to healthier lives. I mean, I see the physician in that sort of role rather than I’m going to go to a doctor to get fixed, or I’m going to go to a clinic to get fixed. So we’d like to see our role, or I would I’d like to see our role as more teachers and coaches in how people navigate their choices in life. And if we do that, then we might be able to stop a lot of disease from developing in the first place instead of fixing it once it’s happened. So I just like to emphasize the patients. We’re not authority figures. There’s nothing special about us other than we are well trained to help people in making good decisions about how they should live and how they can internalize good decision making.
Rob Oliver: Yeah, in some ways, this is way oversimplification in an analogy. But people sometimes view the doctor as the fairy godmother whose magic wand is the prescription pad where you go to the doctor and they write the prescription for the thing that’s just going to magically fix you. And what you’re talking about is changing that paradigm to it becoming not even just a mutual process of decision making, but empowering the patient to make better decisions. Is that a proper understanding of what you said?
Pat Croskerry: I think you said it a bit clearer.
Rob Oliver: No problem. What excites you about the future of health care?
Pat Croskerry: Well, I actually got excited yesterday by saying a paper in the literature it was on medical decision making, and it’s one of the few things that does excite me about medicine is this. When I first started on this journey about 20 years ago, there was virtually no awareness or insight in medicine into these issues. If you go back historically and look at the medical literature, you can see references to clinical decision making and so on now and again. But nobody kind of took it explicitly or seriously. This general assumption seems to have been made through medical training that if you put medical students through these curriculum that we devise through a process of osmosis or something else, they will acquire some sort of diagnostic acumen and some sort of skills in clinical decision making. But we don’t teach people explicitly how to do this. And there is a whole curriculum that you can use to actually help students in training in understanding what goes on when they’re actually making a decision. This is a hard science. This is a very well defined science. Now I’m excited because from there being very little about 20 years ago, there are a number of papers emerging now which talk about I did a review of medicine, the medical literature about five years ago, and virtually every discipline, from Pediatrics to surgery to psychiatry dermatology, all of them. They’ve all be all begun to publish their own papers in the impact of cognitive biases on medical decision making and started to open up their own literatures about this. So I think this is an exciting development, and I think it’s going to shape the way that medical practice is going to be done down the road.
Rob Oliver: I understand. Thank you. What is one thing medical professionals can start doing today to improve the quality of healthcare?
Pat Croskerry: Well, I do think that the majority of physicians out there and probably the majority of listening to this podcast will not have had explicit training in decision making. I would say if I was embarking on a medical career, if I was at the beginning of it or whatever field I was in, I would start trying to get familiar with these concepts of how psychologists describe what we do when we’re thinking. And I’ve seen myself really as a sort of translator, as somebody who translates the psychological literature into the medical literature so that we can use the work that they’ve done. I think our capacity for becoming rational decision maker, a rational decision maker is probably the most important goal that we should have. And I don’t think all of us understand that. But there are now some very well written papers out there that are worth reading, as well as several books. And most importantly, if you’re in medical education, I think you have to make sure that this approach is covered in your curriculum. There is actually an ethical obligation to do this. And a number of schools have started going in that direction in the UK, in the States and in Canada. And just a few weeks ago, I was invited to do a talk in Brazil, a virtual talk in Brazil, and the name of the conference was the first Brazilian conference on clinical decision maker, and I was very gratified to see that. And they were very much influenced by the work that had been done in North America. But the field really is opening up. We all have an obligation to be familiar with the concepts that people are beginning to talk about.
Rob Oliver: Yeah. And if anyone who’s interested in learning more about this, I will put a link to your latest book in the show notes so that they can check that out. In the meantime, thank you so much for joining me. Pat Croskerry, I appreciate your perspective on healthcare.