We should be careful to get out of an experience only the wisdom that is in it and stop there; lest we be like the cat that sits down on a hot-stove lid. She will never sit down on a hot–stove lid again – but also she will never sit down on a cold one anymore.
A big part of the problem with having non-medical people such as legislators and regulators govern the process of medical care and medical education is that they’re just not very good at it. Of course this should hardly be surprising. Why should they be? At its very core, medicine is a scientific endeavor that happens to be tinged with decisions about the best use of scarce resources. The vast majority of Americans, Britons, Canadians, or indeed the citizens of any country don’t know enough about medical science or medical education to fill a thimble. Their elected representatives and regulators are in exactly the same boat. Yet they don’t seem to have any qualms about making snap decisions that will adversely affect whole generations of their fellow citizens.
Consider the flurry of laws that have been passed to limit the number of hours that medical students and residents may work in the course of their training. What could be more logical? Tired people make mistakes and mistakes are bad, therefore make sure that resident physicians are never tired. And if everything else were equal, that might be true. But in the real world things are rarely that simple. The problem is that inexperienced and unknowledgeable people make mistakes too; other things equal, would you rather have your doctor be tired, or inexperienced and unknowledgeable?
It may be hard for the average person to believe, but the notion of staying up for long hours to take care of patients didn’t just pop up out of nowhere. Part of the whole idea of intensive medical training with all-night call is to cram as much experience, knowledge and continuity of care as one can possibly fit into a fixed number of years. Time is a scarce and desirable (and therefore expensive) commodity. If we were to allocate more years to residency training in order to make up for all of those new hours off, it will inevitably add to the cost of healthcare. (And heaven knows that nobody wants that!) Of course the mistakes made by inexperienced physicians will add to healthcare costs as well, but that particular thought may not occur to a legislator or regulator who has never been through the process.
The process of training doctors takes so long that unintended side effects of poor policy decisions take years to appear. But appear they do. It’s only now, after a few years of having these laws around that we’re seeing the result. It’s not a pretty picture.
Just last week, a leading British surgeon who is routinely expected to work for hours on end during complex surgeries, publicly expressed his exasperation at European rules that prevent physicians in training from working more than 48 hours per week:
Edward Kiely, a consultant at Great Ormond Street Hospital, said the rule was based on a European directive “designed for Spanish lorry drivers” but was damaging to doctors’ training and disrupted “continuity of care” for patients.
He said: “It’s not correct that you can’t function properly when you’re tired. Mothers look after children. They’re often tired, but that’s the job and you get on with it.”
Kiely, who oversaw the 14-hour procedure in 2010 to separate conjoined twins Hassan and Hussein Benhaffaf, has 45 years’ experience as a surgeon, with 15,000 operations under his belt…
He said that under the old system, one surgeon would see a patient through from diagnosis to post-operative care, but now “many different doctors” would be involved.
“The continuity of care is disrupted and that is bad medicine,” said Kiely
And, of course, the limitation in hours is even worse when trainees are required to spend that time concentrating on “communication” and “teamworking” (not to mention “listening”, “sensitivity”, “ethics” and the endless typing required by electronic medical record systems) rather than the real science and practice of medical care. A study published last year in Postgraduate Medical Journal found that:
Junior doctors reported that they did not feel equipped to care for seriously ill patients in hospital and this may have got worse, it was found.
Changes to the medical school curricula that put a greater emphasis on communication and teamwork may have been to the detriment of the basics such as treatment, prescribing and managing emergencies, the study suggested.
An analysis of research papers looking at the perceptions of newly qualified doctors published between 1993 and 2011 found in most areas junior doctors felt better prepared for the job.
However in prescribing and acute care, the picture appears to have deteriorated, the researchers said…
Co-author Dr Sam Smith, said: “Junior doctors feel prepared in communication but don’t feel prepared in acute care. There has been a lot of emphasis in training on communication lately.
“One of the reasons that junior doctors might feel more prepared in some of the other domains is the emphasis on communication and teamworking . It is very difficult to keep the same level of emphasis on other things when new things are added in.”
Oops. One would have thought that taking care of acute illnesses would have been at the top of the medical education “to-do” list.
So how did this particular regulatory decision come to pass? In the United States, these rules were implemented in the immediate aftermath of sad and unfortunate Libby Zion case. And in one of the best, most educational and most enlightening explanations of the way in which many of these decisions are made in healthcare in the 21st century, we would like to bring your attention to the following except of a Medical Grand Round recently given in Portland, Oregon by Dr. Lisa Rosenbaum.
Dr. Rosenbaum is a gifted writer and speaker, who recently finished her own training in internal medicine and cardiology. She comes from a very medical family, and happens to be the granddaughter of Dr. Edward E. Rosenbaum. The elder Dr. Rosenbaum is the author of the book A Taste of My Own Medicine, which was later turned into the movie The Doctor. A description of her relationship her physician grandfather is woven throughout her hour-long presentation.
Regardless of whether you are a patient, an administrator or a medical professional, this video is well worth the nine minutes it takes to watch. It talks about how easy it is for us to learn the wrong lesson from associated events, and how important it can be have more than just a superficial knowledge of what it’s like – and how difficult it can be – to take care of patients in the real world.
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