I have blogged about the changes in medical education before. I who have been through it, like others more educated in the process of training doctors, don’t think that the organizations that run the training and certify it are getting it right.
Published in the New York Times on August 5, 2011 is an article by Dr. Sanghavi who is chief of pediatric cardiology at University of Massachusetts Medical School who outlines the problems with the number of hours that trainees work but also points to what are the real problems.
As I have written, this issue goes back 27 years ago to Libby Zion. Her unnecessary death was laid at the feet of the residents who were caring for her, and in retrospect, her care is more an indictment of our healthcare system than on the number of hours a resident physician is working.
Last month the newest rule went into effect. Individuals in training can not work more than 16 hours without being sent off to sleep. Ostensibly this will produce less medical errors, but like many things that we believe that aren’t true, this also doesn’t seem to be the case. (This issue of what we believe and what seems to be the facts is one of the main reasons I write the blog.)
In 2009, a massive study of 14 million VA and Medicare patients showed that the medical error rates was the same in 2009 as it was in 2003. This finding was across all hospital types and sizes. This is not a small problem as data shows that roughly 20% of hospitalized patients suffer a medical error and almost 100,000 die each year. We may in fact be making the problem worse. How?
The real culprits in these errors are the lack of communication and supervision on many levels. In fact, communication at all levels of the healthcare paradigm is becoming far worse. It is not uncommon to see patients on multiple drugs that other doctors don’t know anything about. This is in fact what probably killed Libby. She was on an antidepressant known as phenelzine, and she was given drugs that interfered with it and caused a “serotonin syndrome." 7,000 patients a year die from it. Most doctors, including me, have never heard of it, and our vaunted electronic medical record does not routinely identify it. This is a knowledge, communication and supervision deficit that is not solved by improving the amount of sleep we get.
This article has perhaps the best analogy of medical systems that I have ever read. Proposed in 2000 by the British psychologist James Reason, he said that medical systems were like slices of swiss cheese that were stacked up. Every once in a while the holes in the slices line up and that is when a patient falls through the cracks and is needlessly harmed. Libby fell into the crack.
Her private dentist and her private doctor both gave her medications that worsened her problem, not made it better. Our fragmented medical system with our lack of communication lit the fuse and the bomb finally went off when she was admitted to the hospital.
In today's practice of medicine, we don’t need to train everyone to practice triage medicine in the hospital. People need to be trained in clinical medicine as most medical care is driven in an outpatient setting. This includes Emergency Room care as it has become the default care system for many Americans.
Separate training to those that need it and concentrate the communication and supervision. Medical care can never be error-free, but we can vastly improve over where we are now. It takes leadership and acknowledgement that maybe we, again, made a mistake in training. It will never be too late to fix it, but patients no longer need to be harmed as they are now. We no longer need to spend money on the same tests over and over. Patients no longer need to die.