First National Forum on Sepsis Speeches – Nirav R. Shah, MD, MPH
Autonomy vs. Accountability
By Nirav R. Shah, MD, MPH
Below is the transcript of the speech given by Dr. Nirav Shah at the First National Forum on Sepsis: Defeating the Killer, held in Washington DC, September 17, 2014.
“It’s my privilege to be with you today to honor the memories of Rory, Tommy, George, Erin, and thousands of others who have died of sepsis.
A few years ago in NY, whether you lived or died of sepsis was like winning the lottery… with mortality rates ranging from 15%-‐37% from one hospital to the next. Doctors approached the care of sepsis as a “complex systems problem,” too complicated to solve with fingers pointing variably to the “source” of the problem as the emergency room, lab, ICU, wards, or community but no accountability. How did we get here?
In America, our culture is predicated on independence. The lone cowboy, on an open frontier, best represents the classic American doctor. We are taught to rely on ourselves, to resort to heroics to save our patient. Yet sadly, the analogy has broken down, and while the cowboys of medicine are a dying breed, no good analogy exists to replace that penultimate American story.Today, more of how we practice medicine is about accountability, not just autonomy. Team-‐based care, where old hierarchies don’t exist, where a nurse – even a patient – can pull the cord that stops the assembly line – has overturned the sacred, top-‐down, patriarchal tenets of medicine.
So is it really a debate about accountability versus autonomy? About capitalism vs. socialism? About a moral dilemma for doctors trying to do the best for their patients? About the unfettered free market of doctors in a retail market created by high deductible health plans, vs. the unfeeling, cold algorithms of cookbook medicine imposed by HMOs, run-‐away regulators, and big government?In reality, the facts belie the truth. The best medicine today is practiced by those doctors who go the extra mile for their patients, who use their instincts to check one more test, or pull out the abstract from the pile of journals on their desk that informs the care of their patient. And the best medicine is also practiced by integrated delivery systems, like North Shore LIJ and Kaiser Permanente, who achieve stratospheric quality scores, have process improvement experts stationed at every corner, and can tell you – to the minute – when a patient’s lactate results will be available.
That is the paradox and the promise of our American healthcare delivery system. What I’ve learned from Rory’s Regulations is that Autonomy and Accountability are not mutually exclusive; it’s an “AND” not an “OR,” and when the fine balance of each is achieved, only then can our patient-‐centered paradigm be realized. We are beginning to realize that a culture of interdependence, not independence, can result in reliable excellence, where every patient with sepsis wins the lottery every time and has early recognition, aggressive fluids, and quick antibiotics.
In New York State, we have already documented 10,000 cases of sepsis and severe sepsis in the first quarter of this year. Imagine the possibilities for research and care improvement as a result! What Rory’s Regulations have shown us is that it is possible to make regulations general enough to work -‐-‐ in changing times with evolving science and evidence -‐-‐ yet specific to our needs. The previously unexplained, and I would argue unethical, unexplainable huge variability in survival rates are being diminished. Our job as caregivers to first do no harm, includes aggressively understanding and applying the evidence. I believe the moral dilemma has been replaced by an ethical imperative when it comes to sepsis, and I challenge everyone to take this on. Rory, Tommy, George and Erin deserve no less.”