Introduction
During my fellowship almost 40 years ago, assisted by a single nurse, I could do 14
endoscopies on a given day. Nowadays, being a far more dexterous and experienced endoscopist
and being assisted by at least two nurses, I struggle to complete 10 procedures per
day. Although my actual procedural times have more than halved, the examination room
is hardly ever turned over in less than 45 minutes. If anesthesiology becomes involved
and the endoscopy takes place in the operating room, the turnover time and the number
of auxiliary personnel easily double. At each endoscopy, the physician at our institution
needs to fill out eight different forms, not to mention three separate forms completed
by the nurses. A lot of additional time is spent on various measures to prevent errors,
and assure quality control and patient safety. Part of this peri-procedural formality
resembles a ritual, using stilted language and being performed in a ceremonious fashion
without generating any new information or resulting in any tangible outcomes. What
are the factors that influence such behavior?
Medical procedure and invasion of the patient’s privacy elicit discomfort and fear.
They can also result in injury, disorder, or disruption. A ritual serves to reduce
fear, prevent disruption, and maintain order. The ritual is not part of the endoscopy
itself, but an act performed by someone officiated to do it, such as an administrator,
nurse, physician, or the shaman in all of us. Information, knowledge, and science
can influence the amount of fear, prevent disruption, and curtail unnecessary burgeoning
ritualistic behavior. The five factors (fear, disruption, ritual, shaman, and science)
represent the five broad domains, which interact with and influence each other. The
aim of the present decision analysis is to study the interactions amongst these factors
and compare the relative magnitude of their concurrent influences.
Methods
A Markov chain model is used to describe the interaction among the five factors fear,
disruption, ritual, shaman, and science in gastrointestinal endoscopy [1]
[2]
[3]
[4]. The top part of [Table 1] contains the Markov matrix of the interactions between the five factors. Each factor
depicted as a row can exert some influence on itself or any of the other four factors
also listed as column headings. Each influence is graded between 0 and 100 %. According
to the probability laws governing Markov chains, the sum of all influences acting
on an individual factor (contained in a single column) must add up to 100 % [1]
[2].
Table 1
Markov matrix of interacting factors in the emergence of medical rituals.
|
Fear
|
Disruption
|
Ritual
|
Shaman
|
Science
|
|
Markov matrix of interacting factors
|
|
Fear
|
20 %
|
33 %
|
20 %
|
11 %
|
10 %
|
|
Disruption
|
0 %
|
33 %
|
20 %
|
11 %
|
0 %
|
|
Ritual
|
40 %
|
33 %
|
20 %
|
33 %
|
0 %
|
|
Shaman
|
0 %
|
0 %
|
20 %
|
11 %
|
0 %
|
|
Science
|
40 %
|
0 %
|
20 %
|
33 %
|
90 %
|
|
Steady-state matrix
|
|
Fear
|
13 %
|
13 %
|
13 %
|
13 %
|
13 %
|
|
Disruption
|
3 %
|
3 %
|
3 %
|
3 %
|
3 %
|
|
Ritual
|
8 %
|
8 %
|
8 %
|
8 %
|
8 %
|
|
Shaman
|
2 %
|
2 %
|
2 %
|
2 %
|
2 %
|
|
Science
|
74 %
|
74 %
|
74 %
|
74 %
|
74 %
|
The strength of interactions among the five factors has been estimated based on personal
experience. For instance, fear is assumed to be equally assuaged by ritual or science
but also, to a lesser degree, to be self-perpetuating. Disruption is assumed to be
equally affected by fear, disruption, and ritual. Ritual is assumed to be equally
affected by all factors, including itself (meaning that a ritual can become self-perpetuating
and gain some life of its own). The position of the shaman is assumed to be mostly
influenced by science and the need for ritual and, to a lesser degree, by all other
factors. Lastly, science is to a small degree driven by needs to alleviate fear, but
mostly by forces within science itself. In a subsequent sensitivity analysis, these
probability values become varied over a broad range.
The steady-state of a Markov matrix is calculated by multiplying the matrix many times
(n > 16) with itself [1]
[2]
[3]
[4]. Such calculation is easily performed on an Excel spreadsheet using its built-in
MMULT array function. In the steady-state matrix, all row elements eventually become
identical. They depict the relative strength of influence of the individual factor
on the overall model.
Results
The bottom part of [Table 1] shows the steady-state of the Markov matrix with its identical row elements representing
the relative influence of the corresponding factor in the model. Of all factors, science
exerts the strongest influence, followed by fear and ritual as distant second and
third most relevant influences, respectively. Disruption and shaman exert only a minor
influence on the system of mutual interactions. This pattern remains largely insensitive
to variations in the strengths of individual influences chosen for the initial Markov
matrix. However, creating new or eliminating existing interactions between the five
factors and introducing new additional factors can ultimately change the outcome of
the model. The overall pattern suggests that updating and expanding the scientific
basis underlying gastrointestinal endoscopy would be the most effective means for
change and betterment of its performance.
Discussion
Over the last decades, the length of time required for endoscopic procedures has greatly
expanded. Administrative redundancies and filling of various paper and electronic
forms have been put in place because of the medicolegal climate in which most physicians
operate nowadays. These patterns are likely to be true in Europe and North America,
but may not apply to other countries where endoscopy is less regulated or physicians
are culturally less concerned about legal issues. In addition, medicine has become
more complex not only in its demands for documentation but also with respect to what
types of information can be documented. For example, when previously blood pressure
and pulse constituted the only parameters measured, nowadays we also record pulse
oximetry, electrocardiogram, and capnography.
The American Society of Gastrointestinal Endoscopy (ASGE) has published multiple guidelines
on the proper conduct of endoscopic procedures. The implied benefit of such guidelines
is that they generally improve the quality and safety of endoscopy [5]
[6]. Similar guidelines have been generated by the European Society of Gastrointestinal
Endoscopy (ESGE) [7]
[8]. Most endoscopists also operate within the boundaries set by hospital policies and
bylaws. The mantra of quality improvement and increased safety is rarely, if ever,
challenged [9], but how do we balance the perceived improved safety or quality of endoscopy with
the extra effort and costs of delivering them? The true benefits of recommended and
practiced quality measures have gone largely untested [10]. We need research and science to establish the cost-effectiveness of our practice
and to reject low-value rituals.
Some ritual in the performance of invasive procedures may be unavoidable, even desirable
or beneficial in easing patient fears, discomfort, and assuring quality control. It
has been pointed out that rituals are important not only for the patient but also
for the physician and other healthcare providers [11]
[12]. The present model is not meant to belittle their relevance altogether, but rather
to suggest that studying patterns of our ritualistic behavior and subjecting them
to means of scientific research could help eliminate redundancy, remove unnecessary
rituals, and thus make endoscopy overall more efficient.
