Readers Write 12/5/11

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Note: this special edition of Readers Write features a special contribution from Sam Bierstock, for which the length limits were waived.

A 19th Century Perspective on Physician Adoption
By Sam Bierstock, MD

I first recognized that there was a pattern to the challenges of physician adoption of information technology in 2001. At that time, I convened a meeting of CMOs and clinical IT champions for hospital clinical information systems of all sizes, and quickly learned that they were all facing similar challenges. Basic human nature does not differ much, even in organizations that feel they are unique.

When I wrote about the importance of supporting what I called “Thoughtflow” as opposed to “workflow,” I was surprised by the widespread endorsement of the concept by clinicians, but disappointed by the sluggishness of vendor design processes to truly support the way clinicians think and work in an age of real-time data availability. I’ve been around long enough to start to see that begin to change, although I am not sure that this is because of vendor enlightenment or simply a generational turnover. The Israelites had to wander in the desert for 40 years to wait for a new generation of people to enter the Promised Land. Perhaps adoption is improving because of generational turnover as much as from demonstrable value.

A historical perspective dealing with the way healthcare was practiced during the second half of the 19th century, considering the patient safety issues of the day and the political climate, is intriguing. It says much about human nature, resistance to change – and the physician adoption champion of all champions, Joseph Lister.

In the 82 years between 1841 and 1923, six United States presidents died in office – four in the space of 40 years, five in 60 years. William Henry Harrison died of pneumonia and pleurisy in 1841. Zachary Taylor died of acute gastroenteritis in 1850 (with subsequent conspiracy theories suggesting that he was poisoned.) Abraham Lincoln was assassinated in 1864. James Garfield died after being shot by Charles Guiteau during his fourth month of service as president in 1881. William McKinley was assassinated by Leon Frank Czolgosz in 1901. William Harding died in office in 1920 of a “heart attack.”

We’ve had 10 presidents during the last 50 years. Comparing the timeframes, this rate of loss would be equivalent to us losing Kennedy, Nixon, Carter, Clinton, George Bush, Sr., and Obama while they were in office. Of the six presidents that died between 1841 and 1923, three had their fate tied to assassin’s bullets. Those occurred over the span of just 37 years (Lincoln 1864, Garfield 1881, and McKinley 1901.) One can only imagine the impact on the national psyche of these serial attacks on the lives of our presidents. One man in particular must have suffered a heavy emotional toll, for Robert Todd Lincoln bears the unique distinction of being the only person ever to be present at three presidential assassinations.

Regardless of the precipitating event, in many cases, the direct cause of death of these presidents was due to medical care that ranged from abysmal to totally incompetent.

In the later half of the 19th century, hospitals were not viewed as a place to go to recover from an illness or to have surgery. Hospitals were where you went to die. Surgeries were performed at home or similar environment. Illnesses such as influenza, mumps, diphtheria, or pneumonia – and especially infected wounds – were death sentences. In the absence of antibiotics, for instance, the vast majority of Civil War wounds resulted in death from infection.

Doctors’ standard operating garb were black smocks that they rarely washed or changed – if ever. A blood-encrusted smock was something of a status symbol and an indication of experience, and therefore presumed expertise. Surgical instruments were carried about in bacteria-laden, velvet-lined cases, and were not cleaned between operations beyond a quick wipe with a much-used handkerchief. If an instrument was dropped during a case, it was picked up off the filthy floor and used to continue the procedure (boots and shoes were not routinely cleaned off before entering the operating room). At Jefferson University in Philadelphia, the same table was used to dissect cadavers as was used to perform operations on live patients.

Things were so bad that the leading cause of death for hospitalized patients was termed “hospitalism.” Some thought that hospitalism was the result of toxic ether that surrounded hospitals.

In the 1880s, there were approximately 60 medical schools in the country – none certified by any organization – and students often had only one year of training. Until Lister came along — and for many years after he began to promote his theories about microbes causing infections — the idea of invisible organisms that could cause infection was laughable and readily dismissed by the vast majority of physicians.

Talk about a physician adoption challenge and patient safety!

In a political context, the state of presidential medical care went far beyond patient safety and had a direct impact on national policy and survival. This was a time when vice presidents were not hand-picked by the presidential candidates. They were selected by their party at their respective conventions, often by virtue of having the second largest number of nominating votes. As a result, the vice president and president were often of widely differing political views if not polar opposites, and often didn’t like each other very much.

James Garfield hardly ever spoke to his vice president, Chester Arthur. Garfield was vehemently opposed to the patronage system that infested national politics and Arthur was a product of it (although to his credit, he underwent a significant change in attitude once he assumed office.) Grover Cleveland and his second vice president, Adlai Stevenson, Sr., differed markedly on the key issue of the day, the gold standard versus the silver standard in our monetary system – an issue that had dire implications during a period of severe economic crisis. Woodrow Wilson and his vice president Thomas Marshall did not see or talk to each other while Wilson was incapacitated by a massive stroke until the day that Wilson left office.

None of these presidents relinquished power while ill or unable to perform their duties. Not until 1967, when the 25th Amendment to the Constitution was enacted after the death of John Kennedy, was the country assured that the vice president would assume presidential powers in the event that the president became unable to exercise his duties.

The death of a president during these times, therefore, had enormous impact on the direction of the country. Physicians caring for ill presidents were under enormous pressure to be sure that they could save their patients.

To avert public panic, presidents often went to great lengths to hide their human frailties and illnesses from the press. Unlike today, they were generally successful at doing so. Unknown to the populace, Abraham Lincoln became extremely ill with influenza for one month shortly after delivering the Gettysburg Address and lingered near death. Garfield did not die until two months after being shot, and aside from being subjected to the most barbaric care of any president, was reported to be in good condition and recovering steadily in bulletins issued to a nervous public several times a day. Chester Arthur suffered from “Bright’s Disease” (chronic nephritis) which he persistently denied publicly, but which took his life within two years of his leaving office.

Grover Cleveland underwent a secret operation to remove a presumed squamous cell carcinoma on his palate shortly after beginning his second term. (He is the only president to be elected twice in non-contiguous terms). In order to maintain secrecy, the procedure was performed on a friend’s yacht by a team of doctors who removed about a third of his palate, four teeth, and a portion of his upper jaw. He simply disappeared from public view during this time. He even kept his surgery secret from his vice president. When Adlai Stevenson wanted to know where the president was, Cleveland sent him on a length trip to the West Coast to keep him in the dark and to avoid the possibility that Stevenson would muster support for his position on the silver standard. In 1967, pathologists were finally allowed to examine the tissue removed from Cleveland’s mouth, which turned out to be a verrucous carcinoma – tumors that do not metastasize, but which can cause death local extensive local invasion.

Nor did the public know that Woodrow Wilson was rendered non-functional by a severe stroke toward the end of his presidency. In fact, few people knew that he had suffered several strokes prior to being elected for his first term. For the remainder of his last term in office, virtually all presidential decisions were made by his wife Edith – who, as a result, is often referred to as our first female president.

Warren Harding’s doctor, Dr. Charles Sawyer, was undoubtedly the most incompetent of presidential doctors. Appointed as the president’s private physician because of a long personal relationship, Sawyer had only one year of medical school training. Sawyer liked to prescribe medication based upon the color of the pill – once prescribing a dose of soda water with two pink pills for the president. Even though Harding was hypertensive and had significant orthopnea, exhaustion, and shortness of breath, Sawyer failed to recognize the clear symptoms of congestive heart failure, which he dismissed as “a touch of food poisoning.” Harding died in the Palace Hotel in San Francisco in 1923 at age 57 after a grueling trip to Alaska.

The most egregious care administered to a president by far was that applied to James Garfield – a man who would have undoubtedly been destined to greatness, but having served only 200 days in office, has been delegated to historical footnote status. Garfield was popular, exceedingly capable, honest, and brilliant. A man of natural congeniality, he withstood the most unimaginable procedures without complaint and generally in silence.

Garfield was shot by Charles Guiteau in the Baltimore and Potomac Railroad Station in Washington, DC on July 2, 1881 (now the site of the West Building of the National Gallery of Art.) He did not die until September 19 of the same year. During the assassination attempt, he was hit by two bullets, the first grazing one arm and the second entering his back. As he lay vomiting on the filthy station floor, his doctor inserted an unwashed finger into the back wound in an effort to locate the bullet. This was repeated multiple times by a series of doctors (16 physicians gathered), after which the wound was repeatedly probed with unsterile instruments. At one point, a probe became lodged between fragments of Garfield’s eleventh rib and removed only with great effort and resultant pain to the president. Dr. D.W. Bliss then used his finger to widen the wound so he could probe further. Over the next two months, Garfield was subjected to repeated probing of the wound with unsterile fingers and instruments, non-aseptic incisions to drain abscesses, and other invasive procedures in an effort to locate the bullet, which was, in fact, located harmlessly in fatty tissue behind the pancreas. Eventually, the original three-inch deep wound was converted to a twenty-inch long contaminated, purulent gash stretching from the president’s ribs to his groin.

Garfield’s original wound was entirely survivable even in the 1880s, and he would almost certainly have survived it had his doctors not repeatedly introduced sources of infection which ultimately resulted in his having systemic abscesses and resultant septicemia. Thousands of civil war veterans lived long lives with bullets embedded in their bodies. Garfield ultimately died of a ruptured splenic artery.

It is an interesting sidelight that a Herculean effort was made by Alexander Graham Bell to perfect his newly invented metal detector in time to save President Garfield. He worked tirelessly on the device day and night and devoted endless hours to this cause. X-rays had not yet been invented and it was deemed essential to locate the position of the bullet for possible removal. Bell was finally permitted to try his device on the president, and did so on two occasions. Garfield himself was apprehensive of the new device and was fearful of being electrocuted. Bliss, allowed Bell only to examine one side of Garfield’s body, being convinced that that was where the bullet was lodged (in fact, it lay on the opposite side.) To his great dismay, Bell detected a constant series of signals indicating metal over a diffuse area and could not understand why. He later learned that Garfield was lying on a brand new type of mattress – a coil mattress filled with metal springs.

And then there was the matter of facial hair.

In the second half of the 19th century, it was considered the norm for presidents to have facial hair, something unimaginable in our current image-conscious times.

Although John Quincy Adams and Martin Van Buren had extensive sideburns, presidents were clean shaven until Abraham Lincoln grew a beard when an 11-year-old girl suggested that he do so. For the next 52 years, facial hair became the trend, so much so that it became unimaginable for a president to be clean shaven. Beards were thought to prevent pulmonary problems and throat disease. The last president to serve with facial hair was Taft (who left office in 1913.) His successor Woodrow Wilson had a white beard during his illness and just prior to leaving office.

Beards and facial hair were almost an expectation of the day. One can only wonder about the magnitude of iatrogenic disease caused by the introduction of infectious agents by uncovered beards on physicians wearing blood-encrusted smocks and using filthy instruments during these times.

Enter Joseph Lister.

Lister spent much of the 1870s and 1880s trying to convince the world that germs existed and were the cause of wound infection. He was received with derision and frequent outright hostility. One medical journal editorial stated that, “We are as likely to be as ridiculed in the next century for our blind belief in the power of unseen germs as our forefathers were for their faith in the influence of spirits.” Doctors could simply not accept that microbes might be lurking in the air and on their hands.

In many cases, doctors might be persuaded to try antiseptic techniques by boiling their instruments prior to surgery, and at the same time be completely unaware of the need to maintain asepsis. If a previously sterilized instrument fell to the floor, it would be picked up and wiped off with an unsterile cloth and used to continue the operation. If infection resulted, the doctor would then dismiss Lister’s ideas.

Lister lectured and promoted his theories tirelessly, pointing to his own remarkable success in reducing post-operative infection. Gradually he began to gain a following, when doctors such as W.W. Keen began to use aseptic techniques in Philadelphia’s St. Mary’s Hospital after hearing Lister speak. The infection and mortality rates plummeted almost immediately, and other hospitals rapidly followed suit. Antiseptic techniques became the norm within a decade.

Lister died in 1912, having lived to see universal adoption of his aseptic techniques. He did not live to see the introduction of a household product bearing the unauthorized use of his name just two years later– Listerine mouthwash.

This historical perspective says much about human nature and resistance to change. Lister was committed to his cause, but encountered a 19th century version of the physician adoption challenges of the first decade of the 21st century. The possibility that a universal conversion to digitalized medicine will have the same impact on saving lives that aseptic techniques had seems unlikely, but it is clear that breaking through the boundaries of embedded practices has never been easy in our industry. Current day champions have a big set of shoes to fill.

Samuel R. Bierstock, MD, BSEE is the founder and president of Champions in Healthcare, LLC, a strategic consulting firm specializing in clinical information system implementation and healthcare IT business strategies.