While nobody died, the procedure could have gone smoother. The patient, a corpulent man in his late 40s had been on dialysis for half of his life. Two transplanted kidneys failed, and multiple access procedures and his native arteries and veins were beyond salvage. Multiple stents were plastered within his chest, making his upper extremities impenetrable. The superior vena cava was blocked. The left iliac vein had been his lifeline for the past year and now was surrounded with pus. He came in septic. The dialysis catheter in the left groin was removed. He still needed dialysis. Somehow.
An occluded stent lay within the left external iliac vein. The veteran radiologist knew that the stent was not that old and might contain a soft “core.” Ploughing through the fat and musculature above the inguinal ligament, he skillfully aimed a needle at the center of the stent. It gave and he gently maneuvered a variety of wires into the vena cava and met with success! Several inexperienced techs worked with him as he barked orders, colorfully buttressed with a slew of profanity. The tension was high. Several times the wires came close to being pulled out but were saved at the last minute. The poor technician’s hands were uncontrollably shaking. Observing the procedure, I reassured her stating: “He doesn’t bite, just take it one step at a time.”
While the patient would not have immediately died, establishing dialysis access was critical and lifesaving. Working with an inexperienced team did little to bolster the radiologist’s confidence. Although the radiologist was one of the best in his field, he was not immune to the pressure. Extreme tension dissolves even the most placid individual’s restraint. His assistants’ inexperience increased his frustration.
Second base
Using a baseball analogy: it’s the bottom of the ninth, your team is up by one, and the opposing team is at bat. There is one out. The bases are loaded, and a ground ball is hit to the shortstop, who fields the ball cleanly and throws to second for the double play. The second baseman has failed to cover, and the ball lands in right field. Two runners score and the team has lost because of the error.
Who is covering second? That question is central to the frustration and isolation that the radiologist felt in a critical moment when he lacked confidence in his assistants. Success is exclusively up to him, and no help is on the way. What happened to those seasoned techs who had worked with him for years? Those veterans who knew what each wire, catheter and balloon did, and where they could be immediately retrieved: experienced techs could have made the job much easier and certainly less stressful. Some moved on to higher paying jobs during the pandemic when the hospital refused to meet their salary demands. Some retired, some were demoted for discourteous behavior, and some were fired.
Human resource failure
Staffed as they are with non-clinical human resource (HR) employees—who know little to nothing about the positions they fill—they accept candidates who correctly check a number of boxes. Positions are staffed with employees who have agreed to work at a pre-set salary determined by financial officers who know nothing about the demands of highly complex surgical or radiologic procedures. HR personnel, abstracted as they are from real dramas of medical care, are unable to separate the wheat from the chaff. Nor do they manifest a desire to learn.
During the pandemic, HR and administrators complained that they could not retain doctors, nurses and technicians because of outlandish salaries offered by temporary staffing companies. Yet they were happy to pay $120 per hour to a “temp” instead of giving another $10 per hour to excellent, loyal employees with recognized value to the system. As such, many of these core employees left and have not returned. Even worse, HR made no attempt to recognize key employees, nor acknowledge their fundamental contribution to the system.
Regretfully, hospitals’ current culture has been replaced by externally imposed standards of behavior that fail to portray human experience. Emotional temperance has replaced expertise; inexperienced personnel have been given responsibilities far in excess of their capabilities. This is particularly destabilizing in healthcare, and potentially dangerous for the patient. Medical error rates have increased but only the most egregious cases are reported. Moreover, lack of trained staff, while more obvious in the operating room (OR) and radiology suites, is reflected in other ways by increased length of hospital stays, longer OR turnover times, utilization of equipment, limitless diagnostic tests, and, ultimately, outrageous costs. Retention of key individuals is paramount to achieve excellent outcomes.
HR departments have to accept the lion’s share of the blame. While adopting the DEI (diversity, equity and inclusion) philosophy is beneficial and desirable, it only works with meritocracy. Partially trained individuals eventually realize that they lack expertise and retreat from accepting responsibility, only to become resentful when confronted with a crisis. If they have the will and the stamina, they ultimately acquire the experience and enjoy the satisfaction that accompanies achievement. Unfortunately, promotions are not based on expertise, an attribute administrators fail to appreciate. Even an occasional—but rare—word of praise will suffice.
Creating effective groups
HR departments and most hospitals have yet to acknowledge the importance of creating “effective groups,” a concept that is vitally important in healthcare. From heart transplant groups to interventional radiology to nursing floors, teams are the cornerstone of excellent outcomes.
It also helps if HR and hospital administrators appreciated that physicians are highly educated, motivated people with the lofty goals of curing people and succeeding professionally. They come laden with idealism and critical thinking skills. They look for the
opportunity to solve problems and refine processes to enhance care. When denied the chance to fulfill their expectations, they become disillusioned and filled with moral outrage. Then they leave.
Some years ago, at the inception of robotic surgery, a small hospital in upstate New York was matched against an Ivy League competitor in Manhattan. The researchers went back five years later to look at the results and found the smaller hospital enjoyed better outcomes than their prominent competitor. The smaller hospital was able to train and retain the same team of surgeons and nurses while the larger, world-renowned hospital suffered numerous defections. The smaller hospital experienced cultural growth, and a sense of pride and shared identity. Their leadership was respected and inspired the team members to achieve superlative results.
That was, of course, before the pandemic, an event to which many hospital systems lay blame for their failures. While partially true, valuable team members who could have been retained were allowed to leave for wont of small increases in salary and lack of recognition of their contribution.
Instead, these professionals were never acknowledged as integral and criticized for their lack of loyalty. HR departments now complain that Gen Z and millennials lack commitment. But also true is that when hiring new physicians and key team members, existing doctors’ recommendations are often ignored. Since administrators have little appreciation of what transpires when dealing with critical medical challenges, their hiring decisions are based on irrelevant factors—often social perception. They, their institutions and the patients would be better served if they spent more time on the front line of medicine to gain an understanding of what is really essential.
Transactive memory
Loyalty to an institution and accomplishing highly complex tasks are accomplished by developing what is known as “transactive memory,” through which collective intelligence is achieved and shared.
Returning to the baseball analogy, the second baseman would instinctively know to cover the “bag,” as the scrub tech instinctively knows to hand over a Crafoord clamp when blood is gushing from the aorta. But creating a staff capable of achieving those goals requires an investment of time, money and patience.
Regretfully, our capitalistic, fragmented, patient-unfriendly, expensive healthcare system seems loathe to make that commitment. Patients are not ignorant; they will respond to and seek excellent care. Ultimately, a healthcare system espousing these virtues will be both medically and financially rewarded. And their employees much happier.
Arthur E. Palamara, MD, is a vascular surgeon practicing in Hollywood, Florida, for 44 years. He is active in county, state and national medical organizations.
