Dr. Wachter said: “The study is telling us how hard improving safety really is. Process changes, like a new computer system or the use of a checklist, may help a bit, but if they are not embedded in a system in which the providers are engaged in safety efforts, educated about how to identify safety hazards and fix them, and have a culture of strong communication and teamwork, progress may be painfully slow.”
Earlier in the article however:
“A third of the errors in the intensive care unit disappear when residents work 16 hours or less,” Dr. Landrigan said, but noted that senior residents are still allowed to work longer.
Not having people work 16 hour days isn't hard, it's common sense. Of course there will be a few situations where it's beneficial but this is an instance where I see a cult of hard work having significant negative effects in the real world. I am certain it's not the only one. We need to stop talking about the hard work that goes into a 16 hour day as a good thing and start condemning it as reckless behavior. While the ill effects are clearest in medicine this is simply forcing people to do things we're not built to do. We need to build systems that work with people as they actually are, not as we wish them to be and to stop treating reckless behavior as something that should be honored. It reminds me of the bankers justifying their salaries through the long hours they work. My first reaction was that perhaps the system wouldn't have crashed if the lot of them had been getting enough sleep and weren't making stupid errors due to fatigue.
You know, I didn't get any further in medical school than laughing when someone suggested I should apply but my impression is that "working" includes a lot of sleeping. Doing five hours work in a sixteen hour period of being available doesn't seem too trying, if that's the story.
ReplyDeleteThat's a pretty amazing result. The money that pays residences comes from the federal government. I think they are paid from Medicare and Medicaid.
ReplyDeleteOf course, culture is part of it, but mostly its under-staffing. Paying hospitals to hire more residences would help (foreign ones, for example if the AMA would loosen standards or American ones that would have otherwise become researchers).
To fix the problem you'd have to start with better high school math and science education and give more scholarships to medical schools. There aren't enough students qualified to become doctors and medical school debts can keep doctors out of the most needed fields, like basic surgery and obstetrics.
Doug,
ReplyDeleteIt depends on the specialty. All I know is hearsay but my girlfriend, who's an opthamologist and has it relatively easy, says that many residents don't really get more than a 15 minute nap or so, and that's only if they're lucky. She mentioned general surgery and neurosurgery in particular. From what I've read elsewhere, there is a general cultural consensus that keeping someone on duty creates less problems than handing off cases. This has led to a number of studies, the ones I'm aware of all say that reducing staff hours leads to less mistakes on the whole but this has yet to shift the culture which seems to value long hours despite the evidence against it.
I also agree with the under-staffing. Something needs to be done about medical school debt and letting more foreign doctors in would help a lot as well. Though there can be problems in that some countries actually do have much lower requirements than ours meaning that it is hard to know if a doctor coming in could perform at our needed level, this seems surmountable if someone actually decided to tackle the problem however.
ReplyDelete