Fixing Health Care

Resident Education: Top Gun or busboy

Medical residents still make the same amount of errors despite a restriction of work hours to 80 hours per week. (see the recent New York Times article here.)  Just as bad, residents had just as many accidental needle-sticks and car wrecks as they did before the workweek changes.  This is not a surprising finding.   

Consider the following:

1.  80 hours is still unreasonable. Do the math and see:
80 hours per week divided over six days (residents have a mandatory 24 hours off per week) = 13 hour days. 
And if you consider that some of those days get sucked into at least one thirty-hour call shift, the week may look like this:
Sunday off, Monday-Tuesday 30 hour overnight call shift (7am Monday to 1 pm Tuesday),  Wednesday-Saturday 12.5 hour days

AND…

2.  The dysfunctional incentives that created an abusive system also created a substandard environment for training.   That means that the long work hours are a symptom, not a cause.  The “solution” therefore missed the mark.

If what we are trying to do is train the workforce to care for our ailing bodies as we age, why have we allowed such a system to continue?   We should would want my surgeon trained like a fighter pilot at Top Gun, not like a cafeteria busboy hustling to turn over tables at a busy restaurant.  That means that from day one, their entire schedule should be optimized around becoming great doctors. 

This does not mean picking up the slack at academic centers by filling out forms which otherwise would be relegated to office staff.  This also does not involve sleep deprivation, nutritional compromise, and isolation from social support mechanisms.

In general, resident education is left to whatever studying they can accomplish in their “free time” in combination with chance.  By chance I mean that the resident hopes that they will manage a broad range of diseases. 

When I am old and in need of frequent care, I want the fighter pilot, not the busboy, to give it to me.

What question do we need to be asking?

The ultimate goal of our healthcare system is to improve the lifespan and the quality of life of our population. Why is improving our healthcare delivery system so hard?

Healthcare has become a quagmire of interests that are unnaturally intertwined. Each of these interests is motivated differently, and few are motivated to the ultimate goal. Many seek to find financial opportunity in the system: insurance companies, the pharmaceutical industry, and vendors. Others seek to save money, namely the government and employers. Physicians focus on their individual patients while remaining isolated, for the most part, from the remainder of the practicing community. Patients demonstrate varying levels of interest in their own health. Some demonstrate behavior that is destructive to their own existence. Others do their best to keep themselves healthy.

How can all of these interests be aligned so that we can affect meaningful change? I do not have the answer, however, I am hoping that discussions on this site and others may work towards the answer.