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Comfortably numb
  1. Robert W Tarr
  1. Correspondence to Dr R W Tarr, University Hospitals Case Medical Center, 11100 Euclid Ave, Ohio 44106, USA; robert.tarr{at}

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There is no pain you are receding

A distant ship's smoke on the horizon

You are only coming through in waves

Your lips move but I can't hear what you're saying

When I was a child I caught a fleeting glimpse

Out of the corner of my eye

I turned to look but it was gone

I cannot put my finger on it now

The child is grown the dream is gone

I have become comfortably numb

Roger Waters and David Gilmore—1979

I am sitting here, poolside at the La Costa resort, tying to come up with a topic for my next editor's column. The Louis Armstrong song ‘Beautiful world’ keeps replaying in my mind. Although the weather is a little cool for this time of year, the sky is crystal blue. My thoughts are intermittently interrupted by the sounds of splashes and laughter from children as well as the visual entertainment of shapely forms in bikinis. I am writing this opening paragraph not because it has any real connection to the rest of the column but because I realized this will be published in December, a month during which some of us may well be in need of a summertime interlude.

Despite the distractions at poolside I did eventually come up with a topic for the editor's column. That topic is the tardiness of the medical profession in adopting well established models used in other professions. One example of that delayed adoption is exemplified by the article ‘Establishing operation stability: developing human infrastructure’, by Gomez et al in this issue of JNIS.1 Gomez et al delineate an institutional experience with applying the LEAN operational philosophy to a reputable neurointerventional service. The LEAN operation philosophy has been used for years by Toyota. Toyota is a company which until very recently, for reasons explained in the article, has had a reputation for operational efficiency and excellence in quality.

I know some of you may be wondering what the operation of an automobile manufacturer has in common with the operation of a hospital service. For years, I was also under the naive impression that it would be wrong, anti-Hippocratic, and possibly immoral to run a hospital service using business principles. After all, we are not dealing with standardized rotors and transmissions but rather with the human condition and all of the variables inherent to it. However, when one examines a hospital service such as neurointervention it is apparent that a degree of operational standardization and stability is essential for patient safety.

An example of the necessity of standard operating procedures is the ‘VIP’ patient. I learned long ago that if I was ever admitted to the hospital, the last label I would want to have is ‘VIP’. I have witnessed too many examples where the process of treating a ‘VIP’ patient is linked to such well known World War II acronyms as SNAFU and FUBAR while the intent of the ‘VIP’ label was to ensure quite the opposite. Why is this? It is because this ‘special’ patient is placed outside the norm of whatever baseline operational stability exists for a particular hospital service. Perturbations from the norm can be particularly hazardous in a procedurally related service such as neurointervention. So, while I am not certain that the LEAN model is the perfect fit for a neurointerventional service, I do feel that striving for organizational consistency and operational stability by using well healed principles from business models is a worthwhile endeavor.

A second example where the medical field has been slow to adopt commonly practiced policies of other professions such as law enforcement is in regards to protecting the emotional stability of its practitioners. A colleague of mine was at a picnic earlier this year and was making casual conversation with the new general manager of a major sports franchise. When my colleague was asked about his profession he explained in a concise manner the field of neurointervention.

When he finished his explanation the response by the general manager was, “Wow, that sounds like risky business”. My colleague concurred that while many complex disorders are treated safely, by the nature of the profession there are inevitable complications and bad outcomes.

“So, what happens when there is a bad outcome?” the general manager queried.

“What do you mean?” my colleague responded.

“Well does the physician involved go through any counseling like a police officer would if he shoots someone in the line of duty?” the general manager asked further.

“No, they don't,” my colleague responded.

“Well they should,” the general manager opined.

Was the general manager right? Certainly medical practitioners, particularly in procedural based specialties such as ours, experience a share of complications and unexpected bad outcomes. In 1995, Grant Hieshima with the help of Steve Hetts, who was at that time a medical student, addressed this issue in a special report for AJNR entitled ‘… and do no harm’.2 Despite the candid observations of these authors, very little has changed in the past 15 years regarding a systematic approach geared towards protecting the emotional well being of practitioners. To the credit of our field we have incorporated discussions of complications at many of our meetings. However, these discussions are usually intellectual exercises which concentrate on the technical or thought process mistakes responsible for a complication. Little or nothing is said about the emotionality of a bad outcome. In fact, if emotion is brought up even in private conversation the setting usually becomes a bit awkward. The internalization of emotion combined with the increasingly superficial physician–patient relationships which are dictated by volume driven business plans can sometimes lead one to the surreal feeling of working in an operating room scene from the movie ‘M.A.S.H.’ after the helicopter has arrived.

While some appear to adjust to this mandatory emotional internalization process, others do not. Perhaps that is one reason the divorce and substance abuse rates in the medical field are among the highest compared with other professions.

So, in my opinion, it seems as though the adoption by the medical profession in general and the neurointerventional field in particular of models that drive operational and emotional stability is long overdue. I would hypothesize that striving towards these models will enhance the well being of our work force and the patients that we serve.


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  • Competing interests None.

  • Provenance and peer review Not commissioned; not externally peer reviewed.

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