Year : 2013  |  Volume : 6  |  Issue : 1  |  Page : 1--2

Auditing our 'selves'


Shyam S Kothari 
 Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Shyam S Kothari
Department of Cardiology, All India Institute of Medical Sciences, New Delhi - 110 029
India




How to cite this article:
Kothari SS. Auditing our 'selves'.Ann Pediatr Card 2013;6:1-2


How to cite this URL:
Kothari SS. Auditing our 'selves'. Ann Pediatr Card [serial online] 2013 [cited 2019 Dec 15 ];6:1-2
Available from: http://www.annalspc.com/text.asp?2013/6/1/1/107223


Full Text

"It is not enough that we do our best, sometimes we have to do what is required," - famously said Sir Winston Churchill during the world war. Are we doing 'what is required' is a vital question engaging doctors all the time and perhaps even more so for doctors in the field of pediatric cardiac care. There is a voluminous literature on clinical auditing and quality of medical care in more recent times, and each of us is expected to be conscious of the basic elements of these issues. [1],[2] We tend to imbibe the fundamental tenets of good quality medical care intuitively during medical education, and we hope to get all the right practices by simply one key element of keeping the patient in the center of all our endeavors. However, modern medical care has become reasonably complex to not let us do 'what is required' in one single way; and all the multiple ways in which we render care are not equally effective either. Thus, there is a continuous need to introspect, even for the most well-trained technocrats amongst us.

The audit of clinical practice is required for all the centers, and is more required in the Indian setting, where there is a very wide heterogeneity in the structure and function of the centers. An informal survey of the major pediatric care centers in India reported some form of clinical audit practices in place as a routine in most centers, even though people tend to confuse clinical audit with many other activities. [3] Some centers confessed to the lack of any organized clinical audit practices, and this should be a matter of serious concern. Clinical audit pertains to how well an activity is being conducted in practice, compared to how well it should be done. In contrast to research activity, which is a theory-driven exercise and aims at generating new knowledge, clinical audit is practice- based and intends to improve the services. [3],[4] Further, audit is local and specific for a group, and therefore, has more local relevance. There can be audit of structures, of processes or of outcomes. The process of clinical audit is one of the important spokes in the wheel of clinical governance, as articulated by the National Health Service (NHS), for fostering an environment of excellence in which clinical care can flourish. [5] The habit of auditing will improve system efficiency, may generate new ideas, and energize the systems. The details may vary, but the habit of introspection is important.

While clinical audit of systems is an overarching word in the quality improvement initiatives, it is my impression that systems with different infrastructures need to tailor their auditing paradigms differently. With the type of infrastructure and systems in India, the contributions of individuals to the outcomes become much more than that elsewhere and consequently auditing of individuals and their practices is important. Of course incompetence, callousness or unethical practices need to be ruthlessly eliminated; there are insufficient mechanisms to address these currently. These are not common problems in pediatric cardiac practice, but the clinical audit can help identify or preempt these.

Although improving the systems and quality of care is the goal, the importance of auditing the psyche and approach of individual physicians and surgeons to the overall outcome is rarely discussed. I am impressed with the stereotype pattern of practice by the individual doctor over the years. For example, some of us practice medicine keeping the worst case scenario as the likely event and practice defensive medicine all the time. Some others are prone to gamble and take risks on patient's behalf in our paternalistic medical practice in India. It is easy to identify examples of extremes, especially in others. We can recollect physicians from our surroundings who confuse thoroughness with attention to trivia, interventionalists who mistake cavalier attitude for skillfulness, and skeptics who confuse science with faithlessness. It seems reasonable that different set of questions should merit different answers, but doctors breed true to their style of functioning, thus suggesting a lack of introspection and flexibility, or lack of conscious change in their approach.

Are surgeons capable of introspection? Cardiac surgeons have extraordinary skill, dedication, and judgement. The habit of introspection may seem like anathema to the life skills of action-oriented surgical specialty. [5] The surgeons certainly introspect about the surgical skills and outcomes, but their sharp focus leaves little room for self-doubt or introspection. There seem to be more 'fixed-idea surgeons' than 'fixed-idea physicians', whether this is an occupational hazard or selection bias is difficult to decipher. Nevertheless, there are unparalleled stories of expert surgeons seeking retraining of self and systems. [6] It matters even more, as the surgeon is often the team leader for Pediatric Cardiac Care. His mindset potentially can influence not only the operation, but the culture of the institution. In any case, ability to introspect is a universal requirement. Auditing our own psyche and our approach to patients, needs more introspection than auditing the systems, but is likely to be that much more rewarding individually and to the systems as well.

Introspect on the amount of health and disease we create in the lives and minds of our patients while practicing our craft, introspect on the amount of wasteful investigations we generate, and introspect on the missed opportunities to influence younger colleagues in our environment; and you would have a fair idea of how are we doing for ourselves and our society. Let us blow the whistle on ourselves.

References

1Reid PP, Compton WD, Grossman JH, editors. Building a Better Delivery System: A New Engineering/Health Care Partnership. National Academy of Engineering (US) and Institute of Medicine (US) Committee on Engineering and the Health Care. Washington (DC): National Academies Press (US); 2005.
2Shaw CD, Costain DW. Guidelines for medical audit: seven principles. BMJ 1989;298:498-9.
3Clinical audit: What it is and what isn't. Available from: http://www.rcpsych.ac.uk/pdf/clinauditChap1.pdf [Last accessed on 2013 Jan 6].
4Best practices for clinical audit. Available from: http://www.nice.org.uk/niceMedia/pdf/BestPracticeClinicalAudit.pdf [Last accessed on 6 Jan 2013]. Available from: http://www.uhb.nhs.uk/clinical-governance-components.htm [Last accessed on 2013 Jan 6].
5Page DW. Are surgeons capable of introspection? Surg Clin North Am 2011;91:293-304.
6de Leval MR, François K, Bull C, Brawn W, Spiegelhalter D. Analysis of a cluster of surgical failures. Application to a series of neonatal arterial switch operation. J Thorac Cardiovasc Surg 1994;107:914-23.