Robert T. Gunby, Jr., MD Installation Remarks

I am so humbled and honored to be allowed to serve this next year as President of this nation's "Best State Medical Society" and to represent its more than 40,000 members.  It is because of each of you who volunteer your time and effort to improve the health of all Texans, and our magnificent staffs at both the state and county levels that we have earned the recognition as the "Best State Medical Society." At the same time, I feel a tremendous burden to make a difference in such trying times.

As Paul O'Neil said, "Leaders are responsible for everything in an organization, especially what goes wrong."

Medicine has been under constant assault from governmental policies that seek to ratchet down spending on health care, a push from the business community to decease their willingness to pay for employee insurance and large for-profit insurance companies seeking to increase their profits on the backs of physicians and be allowed to pay their CEO's exorbitant and obscene salaries.

These are 2003's compensation and % change in the stock for many of the companies we deal with daily.  How many of you would like to be the CEO of United Health Care for a mere $94 million a year and you might notice that the stock in these companies like PacifiCare jumped over 140%.  United Health increased earnings by 30% per quarter for 5 years running as related to the Associated Press by their CEO.

At the same time we're dealing with an explosion of more expensive technologies and informational systems, higher drug costs and an increasing elderly population.  Physicians have to balance all of this, when their reimbursements will barely pay their overhead - when liability insurance costs and rising expenses consume most of their income.  Dr. Allen shared with us last year, his dilemma and his decision to close his practice even though he still loved practicing medicine.  Many of us are under similar situations.

Elizabeth was relating a story that she saw on T.V. a few days ago  - they had done research on how much homemaker's did every day and how much it would be worth if you had to pay a nanny, a cook, a driver, a tutor, etc.  It would cost you $400,000/year.  I told her, "You might be able to get paid if you weren't married to a doctor."

We have been fighting for the last several years to restore fairness and equity to the health care system.  Otherwise, who will be there to look after all of us when we are the patient?  It's a pretty scary concept to think about. 

That reminds me of an Oscar Wilde quote, "We are born naked, wet and hungry and then it gets worse."

While TMA will continue fighting for our profession as it has done for many years, we must not be paralyzed by these negatives.

As one philosopher said, "When your heart is full of fear and frustration, there is no room for inspiration." We must stay excited and inspired to keep our profession on track.  We must remember why we went into medicine.  It is still the most rewarding profession I can imagine. 

I consider medicine a calling which is defined as "how I will use my talents and gifts to serve."  Therefore, while we struggle and need to demand these inequities be corrected, we must never lose our focus of why we are here.  We are here to serve our patients and that must always be our primary focus.

Someone once said, "I asked God:  How much time do I have before I die?"  God replied:  "Enough to make a difference."  This year I want us all to commit to make a difference for our patients, for us and for our families.

I want to focus this year on the large, complex issue of patient safety.  This can be controversial and uncomfortable for all of us.  But when I feel passionate about an issue and believe it is the right thing to do, I must go forward 100%.

When the Institute of Medicine report was released, we all reacted as predicted by the Kubler-Ross model.  We first were in denial - that this was a mistake and the report was fraught with errors.  We then were angry that anyone could dare point fingers when we all were working as hard we possibly could and trying to do what was best for our patients.

We are now settling into the reality that this is not personal criticism. System changes must occur to provide more of a safety net that will protect us all.

This is the classic Swiss cheese model that shows how in spite of multiple layers of caution and cross-checks, errors do occur.  To err is human.  Our job is to push for system changes that will make health care as close to fail safe as possible.  Other industries have accomplished this and have decreased errors and we can adopt some standardization within the health care system that will also decrease our likelihood of having mistakes happen.

Don Berwick and his Institute for Health Care Improvement have recently proposed six changes that can save lives in hospitals with the 100K Lives Campaign.

These include a Rapid Response Team that will immediately respond to anyone (nurse, family member, etc.) at the first sign of a patient's change in status.  No prior permission is required to call this team.   The attending physician will also be notified, but the in-house team can be making initial assessments and institute some basic lifesaving treatments until the physician arrives.

Seeing that 100% of acute Myocardial Infarction patients get all the evidence based care (like administration of aspirin, Beta-blockers, smoking cessation counseling, ACE - inhibitors at discharge.  This has been shown to greatly decrease deaths from myocardial infarction.

Preventing Adverse Drug Events  

We will insist on Reliable "Medication Reconciliation". To assure that patients always get the correct medicines.  This one area alone will correct a massive number of daily medication errors that occur because of the multi-faceted layers that are required to deliver each dose of medicine at the correct time.

Preventing Central Line Infections by adhering to strict hand hygiene, maximal barrier precautions, appropriate antisepsis of the skin, etc.

Preventing Surgical Site Infections  

  1. prophylactic pre-operative antibiotic choice and correct timing of  that dose
  2. avoid shaving of skin - this has been shown to increase not  decrease  the chance of infection -   tight peri-operative glucose  control

Preventing Ventilation Associated Pneumonias  

  1. by elevating the head of the bed to prevent aspiration
  2. daily "sedation vacation"
  3. ulcer prophylaxis
  4. and appropriate anticoagulant therapy for a very ill bedridden patient

These are just 6 things that have been proposed to decrease unnecessary morbidity and mortality.  This is just the beginning of some very exciting innovations.

I ask you, as trusted leaders in your communities, to embrace the culture that can improve patient safety.  Daily - physicians and different oversight groups are beginning to realize what can be accomplished if we all seek to learn about what techniques will work in our own hospitals.

We have members among us who are willing to help us navigate this course like Josie Williams who is one our Board of Trustees.  Don Kennerly and David Ballard are heading up Patient Safety at the Baylor Health Care System where I work, and Kenneth Shine, the former director of the Institute of Medicine when they released the report that began this initiative.  He is now at the University of Texas in Austin, in our own backyard.  He spoke to us recently about these issues.

But for this to work, each of us must take ownership in our local communities.  To make it work, we must insist that evidence based best practices be adopted to move us from an error rate of 1 in 10 to hopefully 1 in 100K.

As you can see, some of our very best   hospitals have reduced adverse drug errors to 1 in 1,000.   And our colleagues in anesthesia should be congratulated because they have reduced anesthetic mishaps to 1 in 100,000.

Elizabeth McGlynn published in NEJM, that our current system of individually written orders and the chain of transmission as many of us do today, delivers totally accurate care only 55% of the time.  It will not be easy to change our entire culture that we've lived with for years.

An absurd example of really slow change was the treatment of scurvy that we all learned about in medical school.  It is reported that in 1499 Vasco De Gama lost 2/3 of his crew and Magellan lost more than 80% of his sailors in 1520.

In 1601, Captain James Lancaster experimented on one of four ships giving his sailors lemon juice daily - his crew remained well while the other three ships had severe losses from scurvy.  He reported this to the British Admiralty.

In 1747 Dr. James Lind did a randomized trial of six remedies.  He also gave his conclusions in 1748 to the British Admiralty.  In 1795 the British Royal Navy finally instituted this life saving policy.  It took only 194 years from when it was first known and reported. 

I hope we won't be that slow in changing our culture, but our communication and information systems are a little better than they were in the 1700s. It is still difficult to change traditions of 100 years of autonomy to a team approach and standardizations that can correct systems that allow errors to occur.  It must happen though, because of the change in complexity of the practice of medicine.  When most of us started practicing, we had relatively few drugs to use.  Now there are that many new drugs that are released every single year.

It is because of the large number of studies and vast amount of information that comes out each year that makes it impossible to stay totally current.  So we have to have help in keeping up with new data.  We will have to adopt electronic technology to help us improve our quality of care.  Dr. Goodman, our very innovative Executive Vice President and CEO, is even now seeking ways to help all of us have the availability of this new technology in an affordable manner.

I want to share with you some real life examples of how easy it can be in a complex health care environment to have mistakes cause mortality.

Ruth, a 79 year old woman was admitted with pneumonia.  Her doctor ordered Tobramycin 120 mg daily.  In this hospital, it was the policy that every daily medication be given at 8AM.  This always caused a complete overload on the pharmacy to get all the daily meds ready and to the floors to be administered.

Unfortunately, the regular pharmacist was ill that morning and a substitute was quickly brought in to deal with the urgent situation.  In this hospital there was one physician who had heard of using 1200 mg of Tobramycin in I.V. fluid as an irrigation solution.  Unfortunately on the computer screen this 1200 mg dose was listed immediately below the 120mg dose.  In his hurry to get the job done, when the pharmacist's clicked, the cursor was closer to the 1200 mg and that error in dosing showed up on the order.  The tech filled it, the nurse hung it and Ruth developed renal failure and died of those complications.

Bill was having a coronary artery bypass .  At his hospital men still got their chests shaved prior to surgery rather than having the hair clipped.  We have known for many years that shaving may actually add to the chance of infections because of nicks in the skin and subsequently more severe wound infections.

Bill developed deep mediastinitis and eventually died of complications.  In a hospital that has "outlawed" shaving pre-operatively, it has now been 19 months without a single wound infection.  You can't argue with this kind of compelling data.

Juan, a 24 year old construction worker fell and had multiple trauma.  He had to have a central line placed and the resident told the nurse he didn't need to gown and use a mask for this minimal, non-invasive procedure and because most of the surgeons in this hospital only used gloves when putting in central lines.  The patient developed sepsis and was found to have an infected line.  It could be argued that with the multiple traumas he could have developed sepsis anyway - but why take a chance.  We have evidence that has proven that there is a greatly decreased chance of central line sepsis if strict surgical sterility is used in the placement of these lines.

Martha, age 83 was brought in with a urinary tract infection with high fever.  She told the nurse that she was expecting her first great grandchild, so she had to get well quickly so she could see this precious child.  She later became a little restless and seemed more confused which worried the nurse for almost 7 hours, but her vital signs had not changed so she was unsure if she had enough evidence to call her physician.  She suddenly became blue and had an arrest.  Had the Rapid Response Team been available to evaluate the patient 7 hours earlier, before her arrest, she might have been saved.  Once a patient arrests, the chances of survival without severe impairment is very small.  In some hospitals it is reported that the Rapid Response Team has reduced their cardiac arrests by 60%.

But at a more personal level to me and actually caused an intense interest in improving and assuring patient safety is the following case.  It has haunted me since I initially learned about it.

Lorrie was the beautiful 27 year old daughter of Nancy, one of my wife Elizabeth's tennis partners.  Nancy is in the audience and was brave enough to allow us to use her story.   She hoped that her personal story can help us make a positive change that will help others.

Lorrie developed "food poisoning" and eventually was admitted to the hospital because of weakness and severe dehydration.  She was admitted for observation and placed on I.V. fluids and was actually beginning to get better and was almost ready to go home.

They were attempting to correct her electrolytes before discharging her.  It is unclear exactly what happened, but it appears that she was given a massive overdose of an incorrect medication.  The nurse noticed that something strange was happening and that crystallization was even occurring in the I.V. tubing.  When her doctor saw this he ordered that bag of fluid be taken down, but it was too late.   She became very short of breath and panicky feeling and subsequently arrested and died in front of her mom and her doctor.

Therefore, I plead for your involvement and your enthusiastic support to drive immediate improvements in patient safety and help something positive come of these terribly unfortunate tragedies.

Not because of the I0M report or that Medicare is starting to monitor this, but because it is the right thing to do.

I ask you to think about your friends and family who could suffer one of these tragedies and do everything in your power to see to it, that  nothing  like this ever happens again.

I ask you to do it for Ruth and Bill and Juan and Martha.

And I ask you to do it for Nancy and her beautiful daughter Lorrie.


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