Duty hours of residents don’t seem to make a systematic difference!!

It’s hard not reach this conclusion after reading the 2011 review concerning Patient Safety, Resident Education and Resident Well-Being Following Implementation of the 2003 ACGME Duty Hour Rules [J Gen Intern Med 26(8):907–19]. The authors warn us about comparing apples with oranges but the lack of any overall pattern regarding the impact on patients and residents is striking. For example, medical and surgical complications were interesting, with some improving and others worsening. The authors try to explain such differences as a product of less exhausted residents or worse continuity of care etc...As noted by the authors, the greatest limitation of the review is that conclusions rest upon studies demonstrating association, not causality. The authors collate a considerable amount of information, but the review (as acknowledged by the authors) doesn’t succeed in communicating the context. 

GPs decision making

A BMJ Open paper [BMJ Open 2013;3:e002982. doi:10.1136/bmjopen-2013-002982] evaluated compliance on treatment recommendations from clinical practice guidelines in their decisions on the management of heart failure patients. This was a vignette study with 451 Dutch GPs (but statistical power was weakened by low number of doctors that followed the recommendations). Maybe the most interesting results were; the fact that none of the 451 GPs took the four optimal decisions presented and that none of the relevant doctor characteristics was related to doctor compliance with clinical practice guidelines recommendations on all four treatment decisions. Obviously something else is at work here, but what?

What is the purpose of medical education?

There is an engaging article in the recent issue of medical education [MEDICAL EDUCATION 2013; 47: 942–949]. It’s actually an email dialogue between  Dr David Hirsh and Professor Paul Worley. They attempt to address three important questions; Who are medical schools for? What is medical education for? What is the telos (the ultimate aim) of medical education? There is a lot of rich material in the exchange and I can’t do it proper justice here, but I will select out the elements that I liked best:

1.    The goals and purpose of medical education should be community engaged. Thus, communities should be co-creators of the curriculum and its delivery.

2.    There is a need to move beyond student-centeredness in medical education.

3.    The article highlights Cuba and the Barrio Adentro programme in Venezuela as exemplars of community engagement, and suggests that such models could fuel discovery and innovation.

4.    The final line of the paper is quotable; “The systemic result is that the goal of transforming medical education to repair society may actually transform us!”

These are just four parts that I liked; the paper is definitely worth a read. It’s rare that we see a paper exploring the values needed in medical education

Contradictions between resident education and patient safety?

A recent JAMA paper [JAMA INTERN MED/VOL 173 (NO. 8), APR 22, 2013] reports on a randomised experiment that compares between the 2003 and 2011 duty hour restrictions for US residents. The 2011 rules mandate rest periods between duty periods, increased supervision for junior trainees, and a 16-hour limit on continuous duty hours for postgraduate year 1 (PGY-1) trainees (interns). In a nutshell, the new regulations equal more work compression. Compared with a 2003- compliant model, two 2011 duty hour regulation– compliant models were associated with increased sleep duration during the on-call period, but with deteriorations in educational opportunities, continuity of patient care, and perceived quality of care.

Viewing the paper from an organisational psychology perspective, there is a very bizarre narrative going on. There is an overwhelming sense in the paper that we can’t really shorten the hours of residents, and it almost reads like a ‘I told you so!!’ (my interpretation not the authors). Indeed, the authors cite many studies in their conclusion section that found similar results. Additionally, the new system increased handoff related mistakes.  Speaking as a non-physician, the important issue that was screaming out was; WHY ARE HOSPITALS/HEALTHCARE ORGANISED IN THIS WAY? This is a complicated question, but rather than getting everybody focused on more sleep for residents (which is desirable), I want to know the vision and values of everybody at these hospitals. I can imagine that the healthcare professionals are increasingly prompted towards self-preservation rather than a meaningful balance between patient safety and healthcare well being. Finally, there is a really interesting contradiction between less educational opportunities and time. So rather than having meaningful discussions about the way that residents spend their time (in educational terms), we are forced to accept that the system is that way it is. Physicians reading my opinions may be thinking the same way (i.e., we can’t really change the system), but surely the paper suggests that there is no other alternative but to reimagine the system. Let’s get serious about analysing the systems

Do physicians need empathy?

The answer depends on the papers you read. A 2011 paper [Acad Med. 2011;86:359–364.] found that higher empathy was related to better clinical outcomes for diabetic patients. Good news, yes? Well, it seems so until you read the paper and discover that the research was based in a sample of 29 family physicians (but 891 patients). The paper had good methodology but how far can we get with 29 people? In contrast to this, a 2012 paper [Medical Teacher- 2012; 34: e116–e122] looking at the importance of empathy on changing specialty among medical students (858/1321 students from 5 medical schools) found that is wasn't important and changed little over the course of one year. Finally,  a 2013 paper [Medical Teacher-2013; 35: e946–e951] examined empathy among 72 medical students longitudinally (during 5^th and 6^th year). The study threw two interesting findings; (1) students were reported less empathy over time, which the authors report as being due to additional clinical responsibility, more patient contact and more management decisions, and (2)  students who self-rated as having more empathy received lower competence evaluations  from their peers. In my opinion (not the authors), it sounds like the organisation is very effectively teaching them that empathy is not so important.

Three very different studies, with the first one relating to family physicians and the second two concerning medical students. Difficult to know what to conclude, but food for thought none the less. If we actually reinforce medical students not to be have empathy, maybe we should ask why?

Surgeons and illicit drug use

A recent paper in BMC Medicine [Franke et al. BMC Medicine 2013, 11:102] indicates that German surgeons use illicit and prescription drugs for both cognitive enhancement and mood enhancement. The researchers used two different methods, but overall the prevalence is estimated between 15-20%. The research didn’t have a satisfactory response rate (36.4%), but the fact that nearly 1 out 5 surgeons are using drugs in this way is a cause of concern. The survey looked a list of factors that influence such use, and pressure to perform at work, pressure in perform in private life and gross income were positively related to drug use. Interestingly the following factors were not associated with drug use; gender, age, family status, living with children, type of employer, employment status, hours of work, satisfaction with professional success, and evaluation of career opportunities. The authors of the research don’t mention it, but one is left wondering; (1) how did the surgeons ‘learn’ that such behaviour is appropriate/acceptable, and (2) what lessons such behaviour teaches future generations of surgeons. However, it’s too simple to lay the blame on the surgeons, and we must appreciate the way that patient expectations and public expectations about zero errors contributes to a performance culture which has its roots in medical education. 

Are physicians responsible for reducing costs?

According to a recent paper in JAMA [JAMA. 2013;310(4):380-388. doi:10.1001/jama.2013.8278], the answer seems to be no. The authors surveyed (randomly) physicians from the AMA masterfile. They had a decent response rate (56%) and sample size (n = 2556). Only 36% reported that practicing physicians have a responsibility to reduce costs. The authors argue that the picture is complex and that this raw statistic hides the devil in detail. For example, 78% reported that (78%) and that “doctors need to take a more prominent role in limiting use of unnecessary tests”. Looking at the data from an organizational perspective, I wonder whether the data reveal something important about the way that doctors feel that they do not belong to their organisations. Thus, the data might be a symptom of a more serious malady. The feeling that one does not fully belong to an organisation is unlikely to be fixed by changing payment plans.

Working conditions for Irish and UK doctors

The following is an article from an Irish online journal. It represents the views of an Irish doctor with regard to the general working conditions for non-consultant doctors. It’s obviously written with a certain political angle, but it does provide interesting food for thought with regard to the European Working time directive.

http://www.thejournal.ie/readme/column-a-campaign-of-misinformation-has-turned-the-public-against-doctors-969649-Jul2013/

It’s interesting to contrast the previous link with a blog entry on the BMJ about the ethics of taking time off when sick. The author alerts us to the inherent contradictions  around professionalism. Again the European Working Time Directive is involved.

http://blogs.bmj.com/bmj/2013/07/08/julian-sheather-do-younger-doctors-take-more-time-off-sick/

Well being and Performance

The first international meeting on "Doctors think. Doctors feel. Doctors do: Well-being and performance in medical practice" (WELL-Med) will take place in 2014. The meeting will explore how physician burnout and wellbeing are related to different aspects of medical performance in terms of clinical decision making, communication in clinical practice, and medical error. 

The WELL-Med conference will take place between May 28th - June 1st in Alexandroupolis, in the unexplored North Coast of Greece.

During the conference we will be informed about “new evidence”, engage in some “blue sky thinking”, learn from our mistakes in the “research gone wrong” section and  identify successful interventions in the "what works" section.  We will also link theory to practice in the "medical stories" section, especially addressing health professionals, and healthcare managers working outside academia.  Finally doctoral students will have the opportunity to receive expert feedback in the "research in progress" section.

Keynote speakers

·         Charles  A. Vincent, Professor of Clinical Safety Research, Imperial College London, UK

·         Christina Maslach, Professor of Psychology, University of California, Berkeley, USA

·         Eileen Gambrill, Professor of Social Welfare, University of California, Berkeley, USA

·         Jean Wallace, Professor of Sociology, University of Calgary, Canada

·         Deborah Kirklin, Editor of the BMJ journal Medical Humanities, UCL, UK

·         Jane Lemaire, MD, Vice-Chair of Physician Wellness and Vitality, University of Calgary, Canada

·         Liselotte N. Dyrbye, MD, Associate Professor of Medicine, Mayo Clinic, USA

·         Hardeep Singh, MD, Chief  of  Health Policy and Quality Program, Houston VA Health Services, USA

                                                                       

The deadline for abstract submission is October 15th. Please visit our website,  http://wellmed.gr  for abstract submission guidelines.

Diagnostic errors more common, costly and harmful than treatment mistakes

This is the headline for an important review paper in BMJ in Quality and Safety. The paper is a must read for everyone. As noted by the authors, diagnostic errors are more complex and open up a huge can worms relative to surgical and medication errors. Given that the review only looks at the worst cases, the extent of the problem is probably severely underestimated. The results are even more striking when we consider the increase in defensive medicine. Psychology, in collaboration with medicine, has a huge role to play here.

The full paper can be found at: BMJ Qual Saf doi:10.1136/bmjqs-2012-001550

A short synopsis of the main results can be found at: http://m.hopkinsmedicine.org/news/media/releases/diagnostic_errors_more_common_costly_and_harmful_than_treatment_mistakes

Can we measure physician performance?

Can we measure individual physician performance? Social scientists have known for quite some time that performance evaluation can actually depress motivation. SO the question can actually become, not can we, but should we?  Cassell and Jain, in an interesting JAMA viewpoint paper [JAMA, June 27, 2012—Vol 307, No. 24] tackle the issue directly and present many compelling arguments as to why individual performance systems are likely to decrease intrinsic motivation and increase extrinsic motivation. The authors argue for more meaningful patient-centered goals that are clearly communicated. Ultimately, the authors recommend for more group/team based incentives. In my opinion, they are talking sense, and the paper is worth a read. Their paper is an interesting counter point to the idea of physicians as homo-economicus.  

Are GPs buckling under time pressure?

The need for physicians to see more people in less time is a stressor. The reduction in resources in healthcare means that such trends are set to continue and probably worsen. In a recent paper in BMJ Open (of which I’m a co-author) using an experimental approach, we found that under time pressure, adherence to guidelines concerning history taking and advice giving is compromised [BMJ Open 2013;3:e002700. doi:10.1136/bmjopen-2013-002700]. The research also found that GPs were less compliant with guidelines on giving advice on lifestyle, especially, concerning smoking habits. We should be mindful of how efficiency and effectiveness can travel in opposite directions. 

Are GPs buckling under time pressure?

The need for physicians to see more people in less time is a stressor. The reduction in resources in healthcare means that such trends are set to continue and probably worsen. In a recent paper in BMJ Open (of which I’m a co-author) using an experimental approach, we found that under time pressure, adherence to guidelines concerning history taking and advice giving is compromised [BMJ Open 2013;3:e002700. doi:10.1136/bmjopen-2013-002700]. The research also found that GPs were less compliant with guidelines on giving advice on lifestyle, especially, concerning smoking habits. We should be mindful of how efficiency and effectiveness can travel in opposite directions. 

Performing clinical tasks without proper training?

The first postgraduate year of medical training (currently termed as the ‘F1 year’ in the UK) is an important year in which junior doctors make the transition from medical student to trainee professional. A recent paper in BMJ Open [BMJ Open 2013;3:e002723. doi:10.1136/bmjopen-2013-002723] looks at the views of over 14,000 doctors (in 6 graduation years) with regard to this critical year of training. The most interesting result relates to the fact that approximately one in six F1 year doctors felt they had been required to perform clinical tasks for which they felt inadequately trained. It’s difficult to pinpoint what’s behind these views. The authors themselves provide alternative explanations. For example, they wonder whether the European WTD have resulted in lost opportunities for education and training. The research is an important insight into this critical year, and I wonder to what degree the culture of the organisation contributes to this phenomenon. It’s worthy of more in-depth investigation. 

Patient perspectives ARE in important! So, the evidence says...

Exploring the perspective of patients in how healthcare is delivered is desirable on ethical, utilitarian and empathetic grounds. Encouraging patient ownership of their medical journey leads to improved patient safety, clinical effectiveness, better adherence to medication and treatment. A recent systematic review of the area (Doyle, Lennox & Bell, 2013: doi:10.1136/bmjopen-2012- 001570) provides evidence. It concludes that patient experience is positively associated with clinical effectiveness and patient safety, and support the case for the inclusion of patient experience as one of the central pillars of quality in healthcare. Indeed, the authors of the review state that;  “Clinicians should resist sidelining patient experience measures as too subjective or mood-orientated, divorced from the ‘real’ clinical work of measuring and delivering patient safety and clinical effectiveness”.

Strong words, physicians take note....

What doctors won't do

There was an interesting article in UK Guardian Newspaper on Saturday http://www.guardian.co.uk/lifeandstyle/2013/jan/19/what-doctors-wont-do?INTCMP=SRCH
It's not a scientific article, but a collection of comments form British healthcare professionals about what medical treatments they would avoid or not do. It's quite a revealing and should make us reflect on why patients are reluctant and don't "adhere" in the way that are supposed too. Interestingly, and appropriately, there are contradictions between the respondents. Our healthcare professionals as patients is a subject that we need to know more about.

Is experience important?

On the subject of prescriptions, the answer might be NO? BMJ OPEN has an interesting paper on prescription errors in UK hospitals [http://bmjopen.bmj.com/content/3/1/e002036.full.pdf+html]. Of 4238 prescriptions evaluated, one or more error was observed in 1857 (43.8%) prescriptions. Of these, 1264 (41.9%) were minor, 1629 (54.1%) were significant, 109 (3.6%) were serious and 9 (0.30%) were potentially life threatening. It shouldn’t be terribly surprising that such errors can happen, but what was surprising was the fact that grade was not a significant predictor of errors being made. The paper contains lots of information about the factors influencing errors (e.g., number of medications), but the question as to why prescriber experience does not seem to be important is not fully explored. It sounds like this could be a great PhD these for a cognitive psychologist.