Telluride Day 1 Reflection

“Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective, and potentially dangerous.”

Looking back on yesterday this quote was particularly meaningful to me. It is so true that medicine has made enormous advances over the decades and I am constantly amazed by the complexity of treatments and procedures that are available to patients. However, the more procedures that are performed, the more complex they become, and the more moving parts that are added to each hospital course, the more we experience mistakes and lapses in care.

A few thoughts I have in regard to approaching this issue:

  1. Teams that practice together perform well together. I run into this issue all the time. Even in a setting such as an outpatient medicine clinic, nurses, medical assistants, residents and attending physicians should be grouped into teams that work together each week. The interdisciplinary team can then develop a relationship, learn to trust each other, learn to respect each other. When concerns are brought up, they are taken more seriously. Members of the team have no question in their mind where to go to get their questions answered, to clarify any confusion. Teams provide an opportunity to develop a sense of responsibility for the patients, the care and service that is provided. Consistency provides an opportunity to learn and grow without the barrier of starting over each day and spending time re-evaluating the team dynamic. Moving to the inpatient space, this becomes infinitely more complicated to achieve, however there is still room for improvement. Interdisciplinary care teams should contribute to rounds together. Members should introduce themselves, and their contact information should be clearly displayed to the remainder of the team. Nurses should be easy to reach and should also not have any barrier to reaching the residents or attending physician caring for each patient. Turnover in care of each patient should be kept to a minimum and when it must happen the patient should be aware that their care team is changing. Each team member has to take ownership of their role within the team, avoid ever being a bystander and realize that no health care worker operates in isolation without the help of each and every one of those around them.
  2. The medical industry must account for the increased demands on physicians and recognize that the more complicated medicine becomes, the more we expect of our doctors. This is a constant issue. Hospitalists in very busy inner city hospitals are caring for up to 20-30 patients each. Residents are expected to work 30 hour calls sometimes without sleep or any break. Residency programs are strapped to GME requirements that dictate our small amounts of time off and our busy schedules, but there are no protections for any amount of administrative time or personal time as many other industries offer to their employees. This only occurs on a case by case basis but is never guaranteed. Interns are covering for hundreds of patients per night and the supervision varies in each hospital. Social workers are taking care of more patients that are homeless, without insurance, and can only work so fast, and as a result patients end up staying in the hospital for longer and are more vulnerable to avoidable diseases. The issues are endless. When will the medical field recognize that we are lagging significantly behind other fields in protecting our employees and providing them with benefits and policies that improve both morale and efficiency? How can we expect doctors, nurses and other medical employees to work toward minimizing errors and addressing them properly when so many of us are overworked, spread too thin and overtired? It is no secret that most physicians feel rushed day by day, we do not have enough time to address issues in 15 minute clinic appointments, we do not have enough hours in the day to conceptualize and address each issue that our hospitalized patients bring to our attention. We cannot possibly give each patient the time that they deserve overnight and on covering shifts when we are getting numerous pages and are expected to be multiple places at once. What it boils down to is that we cannot properly care for other people if we are not cared for – not only by ourselves but by the hospitals, companies and institutions that employ us. Doctors need to stand up to this exploitation, for the sake of not only ourselves but our patients.
  3. The hierarchical culture must change.It is true that medicine is more complex, medical problems are more complicated, we are keeping people alive for longer with conditions that were not survivable 50 years ago. Mistakes can and will happen, however less mistakes happen (and they are dealt with differently) when there is not a culture of intimidation and hierarchy. Each attending was a resident, each resident was a medical student. Nurses bear the responsibility of most of the the hands-on work that needs to be done each day and are a vital part of each team regardless of their degree or experience. It is easy to be frustrated at those at different levels when they have less of an in depth understanding or need help. However acting in a condescending/intimidating way and losing an opportunity to provide education is a harmful to not only the learner, but the team in general. This can also harm the patient and many future patients that depend on the education and confidence of their caretakers. Those who cannot treat others with respect and nurture other’s learning must be held accountable for contributing to the culture that in the end harms patients.