A Precarious Exchange
http://www.100md.com
《新英格兰医药杂志》
If an anthropologist were to stumble into this room between 6 and 8 p.m. this evening, he might find the telltale signs of a ritual: a group of residents and interns huddled around a table, scribbling hieroglyphics on scraps of paper.
(Figure)
To a physician, this scenario is all too familiar — we call it "sign-out" — but in a way, the anthropologist would be right: it is a peculiar ritual, this daily transfer of patients from one medical team to another. As I write this, at the end of a frantic afternoon, 18 residents are simultaneously handing off patients to one another in the noisy emergency room. In the medical units of the hospital, hundreds of such exchanges happen every week. And yet, ubiquitous as the sign-out is, it remains one of the most poorly examined transactions in medicine. It is odd, then, that this rickety old liturgy may soon become the centerpiece of a complex debate on the future of medical education. But it is precisely at this transitional moment — in the frenzied blurting out of information and instructions — that some of the most contentious ideas about the residency system become most starkly defined.
It was on a similarly frantic evening two years ago that I discovered the precariousness of these daily exchanges. In April 2002, a young woman I'll call Anna was admitted to my team's care. That morning, her sister had found her curled up on the floor of her apartment with dozens of pills scattered around her. Over a two-hour period, Anna had swallowed a small pharmacy of drugs: ibuprofen, lorazepam, pseudoephedrine, and perhaps most ominously, an unusual antidepressant, phenelzine (Nardil). In the emergency room, she had asked for a glass of water and wrapped herself in an impenetrable nest of sheets. When the doctor had passed her off from the ER to the admitting intern, he had referred to her simply as "lethargic." The handoff had been harried — a rapid-fire summary of the laboratory studies — and no one had pressed him on exactly what he meant by that word.
When Anna arrived on the floor, it was 7:30 p.m. The admitting intern — I'll call him Dan — meticulously scoured through Anna's records looking for any abnormalities. Nardil, he discovered, had severe late side effects. When he went to see Anna, she was lying in bed, still wrapped in a shroud of sheets. He examined her, printed out a toxicology report for her chart, and returned to the workroom.
"How's Anna?" we asked.
"Exhausted and sleepy," he said.
"Lethargic?"
He agreed, nodding his head thoughtfully. Nothing in his voice suggested that Anna's status had changed — and if there was concern in it, we didn't register it. We left it at that.
Around 8:30, Dan's shift ended, and he went home. The on-call intern went to check on Anna. Moments later, she paged me urgently. Yes, Anna looked "lethargic," but it wasn't the sort of lethargy she had expected from Dan's voice. By the time I reached her room, Anna was beyond lethargic — she was almost unresponsive. Within minutes, a code was called. She was intubated and transferred to the ICU.
When the baton drops in a relay race, the sprint suddenly slows to an uneasy crawl. For a moment, the runners become ridiculous figures — madmen with sticks — and the seamless unity of the team collapses into an absurd tumult. And so it is when a critical miscommunication occurs in the hospital: talking itself seems fraught with fragility. Even ordinary words — "lethargy," "stable," "exhausted" — lose meaning; they become tripping wires laid out to make our batons slip. Anna's condition should not have progressed before our very eyes; it should not have taken us three hours to figure out that different people were using the same words in different ways. The chain of communication had been embarrassingly inadequate. Where had a mistake slipped in?
In 1994, a team led by Laura Petersen examined this sort of question in a rather simple experiment: they followed 3146 patients admitted to a medical service and recorded the preventable errors that occurred.1 When the investigators explored the risk factors for errors, they found something remarkable: coverage by a second team of physicians was one of the strongest predictors — almost three times as likely as coverage by a single team to correlate with an adverse event.
These results are even more salient today. Since July last year, residency programs have begun to ease into the 80-hour workweek — a stringent set of regulations mandated by the American Council for Graduate Medical Education (ACGME) that restricts working hours for residents and interns. That regulation means more physicians rotating through shifts, more cross-coverage, more sign-outs — and more opportunities for error. And there, perhaps, lies the rub: the new work regulations are supposed to make medicine safer by decreasing the number of overworked, sleepy doctors. Ironically, it may be precisely these changes that expose patients to errors made in the process of handoff.
But why does this transition bedevil us with such dreadful errors? Why did the handoff fall through in Anna's case? The simple answer is that the chain of communication broke down and Anna fell through the linguistic cracks. In 1998, when Petersen's team used a computerized list to help with sign-outs, the errors in sign-outs plummeted.2 Doctors, it seemed, needed tools to communicate effectively. In Anna's case, though, even sophisticated tools failed to work. Months after she had recovered, Dan confessed that he had been too embarrassed to ask the ER physician what he had meant by "lethargic." Even with computerized lists, we had stumbled on the slipperiness of language.
But the deeper and more troublesome explanation behind such stumbles lies in the shifting structure of residency. The residencies of the 19th century were imbued with an expansive sense of professional heroism that was linked to the self-image of doctors. For William Halsted, the founder of the surgical residency program at Johns Hopkins, residency was a test of mettle and faith, a superhuman initiation into a superhuman profession. "It will be objected that this apprenticeship is too long, that the young surgeon will be stale," Halsted wrote. "These positions are not for those who so soon weary of the study of their profession."3
The 80-hour workweek turns that concept on its head. It recasts residents as shift workers who do "soon weary" of the arduousness of their work. And residents find themselves trapped between two opposing images. By day, they are Halstedian heroes — tireless individualists tending to patients with complex conditions. But by night, as they pass off patients and responsibilities to each other, they morph into team workers, a role that requires completely different skills. And it's precisely at the brittle moment of transition — in the confusing, interstitial space between individual and collective responsibility — that critical errors occur. In retrospect, each of Anna's doctors had been thoroughly diligent about her care. But neither Dan nor our ER colleague had grasped the fact that Anna's safety didn't rest on any individual's performance; it depended on the interdigitated performance of the system as a whole. Asked to switch roles suddenly, they had been flummoxed by the transition.
That transition is, perhaps, the most controversial legacy of the ACGME's mandate. The scheduling contortions are just minor nuisances. The real challenge of the 80-hour workweek is that it demands a psychological transformation; it contorts the idea of residency itself. If the seamless passage of responsibility between doctors is a goal we take seriously, then we might need to do more than juggle schedules or tinker with the mechanics of communication. We may need to change the very ethos of residency — not just what residents do, but how they imagine themselves. This change isn't going to be easy. But even William Halsted — for whom residency was a comprehensive ideology rather than a piecemeal apprenticeship — might have been sympathetic to the breadth of this approach.
(Identifying details about the patient have been changed to protect her privacy.)
Source Information
From Dana Farber/Partners Cancer Care and Harvard Medical School, Boston.
References
Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 1994;121:866-872.
Petersen LA, Orav EJ, Teich JM, O'Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv 1998;24:77-87.
Halsted W. The training of the surgeon. Bull Johns Hopkins Hosp 1904;15:267-275.(Siddhartha Mukherjee, M.D)
(Figure)
To a physician, this scenario is all too familiar — we call it "sign-out" — but in a way, the anthropologist would be right: it is a peculiar ritual, this daily transfer of patients from one medical team to another. As I write this, at the end of a frantic afternoon, 18 residents are simultaneously handing off patients to one another in the noisy emergency room. In the medical units of the hospital, hundreds of such exchanges happen every week. And yet, ubiquitous as the sign-out is, it remains one of the most poorly examined transactions in medicine. It is odd, then, that this rickety old liturgy may soon become the centerpiece of a complex debate on the future of medical education. But it is precisely at this transitional moment — in the frenzied blurting out of information and instructions — that some of the most contentious ideas about the residency system become most starkly defined.
It was on a similarly frantic evening two years ago that I discovered the precariousness of these daily exchanges. In April 2002, a young woman I'll call Anna was admitted to my team's care. That morning, her sister had found her curled up on the floor of her apartment with dozens of pills scattered around her. Over a two-hour period, Anna had swallowed a small pharmacy of drugs: ibuprofen, lorazepam, pseudoephedrine, and perhaps most ominously, an unusual antidepressant, phenelzine (Nardil). In the emergency room, she had asked for a glass of water and wrapped herself in an impenetrable nest of sheets. When the doctor had passed her off from the ER to the admitting intern, he had referred to her simply as "lethargic." The handoff had been harried — a rapid-fire summary of the laboratory studies — and no one had pressed him on exactly what he meant by that word.
When Anna arrived on the floor, it was 7:30 p.m. The admitting intern — I'll call him Dan — meticulously scoured through Anna's records looking for any abnormalities. Nardil, he discovered, had severe late side effects. When he went to see Anna, she was lying in bed, still wrapped in a shroud of sheets. He examined her, printed out a toxicology report for her chart, and returned to the workroom.
"How's Anna?" we asked.
"Exhausted and sleepy," he said.
"Lethargic?"
He agreed, nodding his head thoughtfully. Nothing in his voice suggested that Anna's status had changed — and if there was concern in it, we didn't register it. We left it at that.
Around 8:30, Dan's shift ended, and he went home. The on-call intern went to check on Anna. Moments later, she paged me urgently. Yes, Anna looked "lethargic," but it wasn't the sort of lethargy she had expected from Dan's voice. By the time I reached her room, Anna was beyond lethargic — she was almost unresponsive. Within minutes, a code was called. She was intubated and transferred to the ICU.
When the baton drops in a relay race, the sprint suddenly slows to an uneasy crawl. For a moment, the runners become ridiculous figures — madmen with sticks — and the seamless unity of the team collapses into an absurd tumult. And so it is when a critical miscommunication occurs in the hospital: talking itself seems fraught with fragility. Even ordinary words — "lethargy," "stable," "exhausted" — lose meaning; they become tripping wires laid out to make our batons slip. Anna's condition should not have progressed before our very eyes; it should not have taken us three hours to figure out that different people were using the same words in different ways. The chain of communication had been embarrassingly inadequate. Where had a mistake slipped in?
In 1994, a team led by Laura Petersen examined this sort of question in a rather simple experiment: they followed 3146 patients admitted to a medical service and recorded the preventable errors that occurred.1 When the investigators explored the risk factors for errors, they found something remarkable: coverage by a second team of physicians was one of the strongest predictors — almost three times as likely as coverage by a single team to correlate with an adverse event.
These results are even more salient today. Since July last year, residency programs have begun to ease into the 80-hour workweek — a stringent set of regulations mandated by the American Council for Graduate Medical Education (ACGME) that restricts working hours for residents and interns. That regulation means more physicians rotating through shifts, more cross-coverage, more sign-outs — and more opportunities for error. And there, perhaps, lies the rub: the new work regulations are supposed to make medicine safer by decreasing the number of overworked, sleepy doctors. Ironically, it may be precisely these changes that expose patients to errors made in the process of handoff.
But why does this transition bedevil us with such dreadful errors? Why did the handoff fall through in Anna's case? The simple answer is that the chain of communication broke down and Anna fell through the linguistic cracks. In 1998, when Petersen's team used a computerized list to help with sign-outs, the errors in sign-outs plummeted.2 Doctors, it seemed, needed tools to communicate effectively. In Anna's case, though, even sophisticated tools failed to work. Months after she had recovered, Dan confessed that he had been too embarrassed to ask the ER physician what he had meant by "lethargic." Even with computerized lists, we had stumbled on the slipperiness of language.
But the deeper and more troublesome explanation behind such stumbles lies in the shifting structure of residency. The residencies of the 19th century were imbued with an expansive sense of professional heroism that was linked to the self-image of doctors. For William Halsted, the founder of the surgical residency program at Johns Hopkins, residency was a test of mettle and faith, a superhuman initiation into a superhuman profession. "It will be objected that this apprenticeship is too long, that the young surgeon will be stale," Halsted wrote. "These positions are not for those who so soon weary of the study of their profession."3
The 80-hour workweek turns that concept on its head. It recasts residents as shift workers who do "soon weary" of the arduousness of their work. And residents find themselves trapped between two opposing images. By day, they are Halstedian heroes — tireless individualists tending to patients with complex conditions. But by night, as they pass off patients and responsibilities to each other, they morph into team workers, a role that requires completely different skills. And it's precisely at the brittle moment of transition — in the confusing, interstitial space between individual and collective responsibility — that critical errors occur. In retrospect, each of Anna's doctors had been thoroughly diligent about her care. But neither Dan nor our ER colleague had grasped the fact that Anna's safety didn't rest on any individual's performance; it depended on the interdigitated performance of the system as a whole. Asked to switch roles suddenly, they had been flummoxed by the transition.
That transition is, perhaps, the most controversial legacy of the ACGME's mandate. The scheduling contortions are just minor nuisances. The real challenge of the 80-hour workweek is that it demands a psychological transformation; it contorts the idea of residency itself. If the seamless passage of responsibility between doctors is a goal we take seriously, then we might need to do more than juggle schedules or tinker with the mechanics of communication. We may need to change the very ethos of residency — not just what residents do, but how they imagine themselves. This change isn't going to be easy. But even William Halsted — for whom residency was a comprehensive ideology rather than a piecemeal apprenticeship — might have been sympathetic to the breadth of this approach.
(Identifying details about the patient have been changed to protect her privacy.)
Source Information
From Dana Farber/Partners Cancer Care and Harvard Medical School, Boston.
References
Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 1994;121:866-872.
Petersen LA, Orav EJ, Teich JM, O'Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv 1998;24:77-87.
Halsted W. The training of the surgeon. Bull Johns Hopkins Hosp 1904;15:267-275.(Siddhartha Mukherjee, M.D)