Transcending Quality In Pursuit of Clinical Excellence

This was initially published on the Arnold P. Gold Foundation Blog.

 

Quality and Excellence

 

In a time when there’s a growing emphasis in medicine on the idea of quality, you, as members of the Gold Humanism Honor Society, carry the task of preserving and propagating excellence.

 

If we’re going to talk about quality and excellence, we must first be very clear about what the two words mean.

 

The writer Seth Godin taught me that quality is a term coined by industrialists like Edwards Deming who pioneered the changes that made Toyotas the reliable cars we know today.

 

Through his pursuit of quality, Deming made sure that every car ran the same, felt the same, looked the same, and as a result, could be produced as efficiently, affordably, and error-free as possible.

 

In other words, quality means meeting a very clear, predetermined set of rules. Quality is reproducible and it is scalable, and we see it arising everywhere in medicine.

 

From quality-improvement projects that develop hospital-wide systems to get antibiotics to critically ill patients as fast as possible, to quality metrics that hold physicians accountable for making sure each and every diabetic patient has the right blood sugar levels.

 

And rightly so! If we can make healthcare more affordable, more efficient, and less error prone, we should do it.

 

But. If we chase only quality to a degree that we lose sight of excellence, we fail our patients.

 

Because excellence isn’t a measure, or a statistic, or a check box on a check list. Excellence is a feeling. Excellence is a moment.

 

It’s the quick wink we exchange with a patient when our team passes by on rounds.

 

It’s noticing the subtle sigh a patient lets out when we tell her we still don’t have the diagnosis, and making the effort to unpack the emotions brewing beneath her stoic surface.

 

It’s remembering that the physical exam embodies much more than uncovering diagnostic findings, carrying in it our patient’s trust that we will use our hands to care and comfort.

 

It’s stepping up to the bedside and into our patients’ worlds each day grateful for the fact that our they let us see them.

 

In other words, excellence is challenging yourself to ensure your patients feel just how much you care.

 

If you find this idea daunting the way I do, I promise you’re already well on your way because you have years of practice being a human. And that is all this is. Being human.

 

But, amidst the competing demands of clinical care, humanity, while simple, is not easy.

 

Unfortunately, the incentives of our healthcare system do not always line up in ways that encourage you to choose emotion over efficiency, compassion over costs. So, as you chase excellence, you will stumble. I certainly have.

 

As a third-year student, I can remember the first time a patient asked me if he were dying.

 

At 55 years old, he was a few days removed from a big surgery when his liver and his kidneys started to fail. When I saw him early that morning, he had aspirated and was on the cusps of respiratory distress.

 

Between his labored breaths, he looked at me with wide, bloodshot eyes, and asked, “Am I dying?”

 

I panicked. I was so scared of offering the wrong response that I didn’t give myself the chance to ask the right questions.

 

I regurgitated a trite, scripted line about how I didn’t know what would happen, but could assure him we would do everything we could to keep him comfortable. He nodded and we stared at each other for a few seconds before my resident arrived– me, frozen, and our patient, gasping.

 

He died that night.

 

For the last two years I’ve thought about all the things I wish I had asked. The fears I wished I had uncovered, the end-of-life priorities we could have honored. Because, while his words came out as a question, the look on his face told me he knew the answer, and while my response may have been of fine quality, I missed an opportunity to show him how much I cared.

 

I’m convinced that these painful reflections are a necessity, as they allow us to discover ways we can infuse excellence into a world that sometimes over-prioritizes quality. When we do, when we move along the spectrum from meeting metrics to going far beyond them, we engage in the excellence that looks like the art of medicine.

 

But, excellence today isn’t the same as excellence 50 years ago, because medicine today isn’t the same as medicine 50 years ago.

 

Where there was once one person– the physician– followed by everyone else, there are now many, all working together. Physicians, NPs , PAs, nurses, social workers, respiratory therapists, patient navigators. And especially, our patients.

 

We deliver care in teams and we no longer work on the patient, but rather, with the patient.

 

If excellence lies in the work of finding ways to say, “I hear you. I’m with you. I’ve stepped into your world,” then team-based care, with the patient its center, brings the extra eyes that help us overcome our inherent biases and blind spots– the ones that have alienated, silenced, and discriminated entire populations for decades.

 

For we have a long way to go in understanding the judgments we cast. And our patients have more to teach us than we will ever get the chance to learn.

 

But to benefit from the power and perspective of team-based care, we have to, once again, be human.

 

We need the humility to admit, “I don’t know,” the curiosity to ask, “What do you think?” the courage to speak up and say, “This isn’t right” and the self-awareness to wonder, “Am I supporting those around me as best I can?”

 

Because, after all, we’re in this together.

 

Despite the culture of competition amongst medical students, the turf wars that can exist between specialties, or the frustrations that may arise between providers, each and everyone of us is in this because we’ve chosen the journey of making a difference.

 

So, your final responsibility as members of the Gold Humanism Honors Society is to care for one another the way you care for your patients.

 

In a time when provider burnout, depression, and suicide continue to rise, we all have a role in breaking the culture of silence that cultivates isolation and shame.

 

We can lean into the uncomfortable vulnerability of sharing our fears, our failures, and our anxieties. Of reaching out and saying, “You’re not alone. I know this because I’m feeling that way, too.”

 

Dancing with these difficult emotions does not require talents or gifts or other worldly skill. It is merely a practice. And if you treat it that way–as a daily ritual– it will change the way you engage with your patients and your peers.

 

You will be the person who leaves the lives of those you touch better off. Excellence and art will no longer be something you do. Instead, they will become a part of who you are.

 

With time and effort and practice, each one of you will embody the mission of the Gold Humanism Honors Society and bend the arc of medicine in the compassionate spirit of serving your patients.

 

Neither for acclaim nor accolades, nor awards or prestige, but for the person that brought you to medicine in the first place.

 

The patient. The patient. The patient.