Old habits are hard to break. We all get used to doing things in certain ways, and the longer we do it, it becomes increasingly difficult to do them differently. We clearly are clinging to old habits in the healthcare industry, despite compelling evidence that we need to figure out better ways of doing business. Our industry has been in a crisis for a very long time—rising costs, drastic reimbursement reductions from payors, and continually escalating risks and medical errors.
Clearly, something is not working.
This is a time when hospitalists should start thinking about dropping some of our Pulaskis.
Handy, Useful, Versatile, Reliable
A Pulaski is a versatile tool that combines an axe and an adze; it’s most commonly used in firefighting, but it is also used in trail-blazing, gardening, and woodworking (see right). The Pulaski was invented by Ed Pulaski, a forest ranger in the 1910s who almost died in a forest fire after being trapped in an old mine tunnel. After he barely survived, he invented the Pulaski as a means to reduce the risk of future firefighters being trapped in his same situation. For more than 100 years, this tool has come in handy in countless situations. It is versatile, irreplaceable, reliable—a must-have. Unless you don’t need it. And then it becomes a 22-pound handicap.
Donald Berwick, MD, MPP, spoke about the Pulaski 13 years ago in a powerful speech to the National Forum on Quality Improvement in Health Care; his presentation was titled “Escape Fire.”1 He described the Mann Gulch fire of 1949, which took the lives of 13 young men when the fire did not behave as expected. The men were forced to outrun this fire, up a hill at a 76% slope, with the fire racing at them at 7 miles per hour, at an air temperature of 100 degrees. Only two firefighters survived. Those who perished tried to run up the hill with all of their gear, including their Pulaski, which served, at the time, only to slow them down. One survivor was lucky; he managed to get to the top of hill before the fire engulfed him. The other survivor, Wagner Dodge, was heroic. He realized the situation was hopeless and created a radical, innovative, and immediate solution to the problem at hand: He not only dropped his 22-pound handicap, but he also stopped running up the hill, stood still, and lit his own escape fire to avoid the larger fire at hand. The rest of the pack clung to the only option they could conceive of, which was outrunning the beast, despite the fact that it was traveling twice as fast as they were.
During his speech, Dr. Berwick also spoke of some of his personal experiences within U.S. hospitals that were filled with fear, uncertainty, and at times downright outrage; of misunderstandings, despicable care transitions, and daily medical errors or near misses. About how he and his wife struggled for security, appropriate treatments, and more answers than questions. He spoke of being in some of the best hospitals in the nation, and of being more organized and informed than most patients. Most patients would not possibly fare as well as the Berwicks, being under- or uninsured, of low health literacy, undereducated, or uninformed. It is incomprehensible that we have created a system that is so complicated and difficult to navigate that even the best and the brightest cannot traverse it unscathed. So it seems that sometimes the key to doing something better (or surviving, in the case of the Mann Gulch fire) is not knowing what new tools to adopt, but instead knowing what tools to get rid of.
Seize the Day
There is a dog park near my house that we take our dog to whenever we get a chance. There is a dog that frequents the park, a brown Labrador by the name of Gracie. Gracie’s favorite activity is fetching tennis balls; she dutifully catches the ball (usually in midair) and brings it back to her owner. When she gets back to her owner, she stands in front of him waiting for her order: “Drop it, Gracie.” As soon as Gracie hears the order, she drops the ball immediately. But she won’t drop the ball until ordered to do so—even though, by keeping the ball, she is that much further away from her next favorite activity. It seems like, to do the best for herself, she should come back and drop the ball, which would bring her that much closer to the one thing she loves best.
But she doesn’t. She waits dutifully for someone else to tell her when to drop the ball.
And interestingly, Gracie will not just drop it for anyone. When others at the park want to play with Gracie, and follow the lead of Gracie’s owner, and say “Drop it, Gracie,” she will look at the visitor, and then at her owner, looking for the approval that it really is in fact OK for her to drop it. Even after an approving look, she will hesitatingly drop the ball, and only after the stranger is a safe distance away, in case she needs to retrieve it sooner than later.
Many of us in the healthcare industry often wait for someone else to tell us when to start doing new things, but rarely do we expect, do we hear, or do we initiate the order to stop doing something. We need to think deeply about all the things we do that are useless Pulaskis, and about how to radically change the industry in which we work. Because this inching along is not going fast enough, and there is little evidence that we have made much progress in the last decade. So if you find yourself lugging around a Pulaski (or two), don’t just think about how to drop it, or when to drop it, or whether to drop it on certain days of the week. Just drop it, Gracie.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at firstname.lastname@example.org.