Wednesday, April 6, 2011

Culture Change is Hard Work

At one point in my association career I worked with medical specialty societies. They were very academic in their orientation, and invested a lot of their time and resources in creating, supporting and sustaining new training programs for their specialties. They cared passionately for the subject. As it is for many such societies, training young residents to be the next generation of specialists was critically important to them.

The principal aim of medical residency in the United States is to prepare recent medical school graduates to practice medicine independently. A fundamental require¬ment of resident education is in-depth, firsthand experience caring for patients. Dur¬ing the three to seven years of this training, residents often work long hours with limited time off to catch up on their sleep. They can experience fatigue on the job, which research shows is an unsafe condition that contributes to increased errors and accidents. However, many medical educators believe extensive duty hours are essen¬tial to provide residents with the rich and varied educational experiences necessary to become competent in the complexities of diagnosing and treating patients.

That’s the first paragraph from a brief on a special report published by the Institute of Medicine (IOM) in 2008. It succinctly states one of the fundamental challenges that medical residents face in learning how to be specialists—the long duty hours they are forced to work without sleep. Depending on the specialty, shifts of 24 or even 36 hours are not uncommon. As part of its report, the IOM asserted that revisions to medical residents’ workloads and duty hours were necessary to better protect patients against fatigue-related errors and to enhance the learning environment for doctors in training. In addition:

The report recommends that residency programs provide regular opportunities for sleep each day and each week during resident training. In addition, it recommends that the Accreditation Council for Graduate Medical Education provide better monitoring of duty hour limits and that residency review committees set guidelines for residents’ patient caseload. Patient handover procedures and supervision of residents should also be strengthened. Until these changes take place, residency programs are not providing what the next generation of doctors or their patients deserve.

It’s a fascinating report to read, especially from the point of view of a non-physician who, not steeped in the culture of academic medicine, didn’t exactly need a report from the IOM to be convinced that forcing young and inexperienced doctors to stay awake for 36 hours at a time might possibly result in poorer patient outcomes.

What’s more interesting, however, was the reaction by many of the physicians in my societies when they heard the IOM was preparing such a report. The IOM? many of them said dismissively. More government bureaucrats sticking their noses in where they don’t belong! Who are they to tell me how to train my residents? I learned how to be a specialist this way, and by god, so will they! Every doctor didn’t react that way but, to my way of thinking, a surprising number of them—especially those in senior leadership positions—did.

I don’t work with those societies anymore. My career has moved on, but I’ll occasionally stumble across something that reminds me of the dedicated people I worked with and the way they looked at the world. I was once sure the IOM was barking up the wrong tree, so imagine my surprise when I saw information about a press release from late last year announcing that the ACGME had approved new requirements for residency programs, based on the recommendations of the IOM report.

Wow, I thought, and wondered exactly what the ACGME had approved.

Following parts of specific duty hour recommendations from the IOM: The maximum number of work hours remains at 80 hours per week, averaged over 4 weeks; moonlighting, now both internal and external, is counted against the 80-hour weekly limit; and duty periods are limited to 16 hours (although only for first-year residents by ACGME).

I’ll be honest. This didn’t impress me. 80 hours a week…averaged over 4 weeks…moonlighting included…duty period limits only for first-year residents—it struck me as enough change to say something had been done, but not enough change to really fix the problem. One of the doctors in the ACGME tipped their hand, I thought, when he called the IOM’s recommendation for an uninterrupted 5-hour sleep period “unworkable.”

This is not a post about what it takes to become a doctor and whether or not working them long hours helps them or hurts patients. As the title suggests, this is a post about how hard it is for organizations to change their cultures. Despite all the evidence cited by the IOM on the link between long duty hours, resident fatigue, and medical errors, the decision-makers—highly-educated, vastly experienced, humanely-motivated physicians trained to let evidence guide their decision-making—were only willing to tweak their rules rather than change their culture.

There’s a lesson in there for all of us.

Artwork by John Herring, MD


David M. Patt, CAE said...

Hopefully, today's young interns will change things when they become leaders. Of course, today's leaders may have thought the same thing when they were young interns.

Eric Lanke said...

All I can say about the specific situation is that doctors perceive some value in the long hours residents are forced to work. Young doctors who complain about them grow into older doctors who see new wisdom in the approach. More broadly speaking, I believe this is often how entrenched culture works. Those who move into positions of influence often perpetuate the very system that bothered them when they hadn't the influence to do anything about it. The perspective is often different when the responsibility for making change is thrust upon someone.

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