“The end result of any committee is a new piece of paper that the physician has to fill out,” Dr. Thoelke says. “The perception is, it’s just one piece of paper. But it adds up to an incredible amount of time.”
3) Eliminate 24-hour shifts. Chris Landrigan, MD, MPH, studies the relationship between workplace safety and patient care, particularly the long hours residents tend to work.
In general, residents’ shifts are restricted to no more than 24 consecutive hours, plus up to six hours for paperwork and arranging patient care, according to the ACGME. Residents are to have 10-hour rest periods between duty shifts, and can work no more than 80 hours a week, averaged over four weeks.
“There’s no question that traditional shifts of 24 or more hours endanger residents and their patients,” says Dr. Landrigan director of the Sleep and Patient Safety Program, Brigham and Women’s Hospital, and research and fellowship director, Inpatient Pediatrics Service, Children’s Hospital Boston. “Twenty-four hour shifts are associated with an increased rate of serious medical errors, and residents frequently crash their cars on the way home from working these marathon shifts. In the last few years, I know of eight residents at Children’s alone who have had post-call crashes on the way home from work.”
In accordance with ACGME standards limiting residents’ work hours, hospitalists can encourage a cultural shift that would improve workplace safety and patient care, he says. “Hospitalists in some cases are the residency directors, or some of the key teachers, and have a lot of influence there,” he says. “They’re in a position to begin to challenge the traditional model, just as they have in other ways.”
Dr. Landrigan acknowledges this massive change will be slow to catch on, but it’s already started. At Brigham and Women’s Hospital, 24-hour shifts for surgical residents have been eliminated on most rotations, he says, and a few programs in New York, Ohio, and elsewhere have done the same. “The department of surgery at Brigham and Women’s viewed the data themselves, and they felt that this was an important issue,” Dr. Landrigan says. He plans to study the impact of eliminating 24-hour shifts in the surgical intensive care units at Brigham and Women’s.
4) Include leadership training in medical school curriculum. “When you go to medical school, you [learn] to make a diagnosis and interact with a patient essentially on a one-on-one level,” says Eric Howell, MD, assistant professor of medicine, faculty leader, Helen B. Taussig College, Johns Hopkins University School of Medicine in Baltimore, and the chairman of SHM’s leadership committee.
“But in the hospital, that teaching is almost counterproductive,” he explains. There, the physician-patient relationship expands into one with multiple players. The physician leads a team with the patient at its center that can include case managers, nurses, administrative staff, ancillary staff, social workers, and others.
Physicians get no training in school about how to manage multidisciplinary teams, or how to create change where change is needed; instead, they learn on the job, Dr. Howell says. At a summit in Chicago this fall, the Leadership Committee discussed the possibility of providing scholarships for residents to attend SHM’s leadership academies.
“That got a lot of positive reviews, even unofficially,” Dr. Howell says. “The other thing we’re doing is we’re trying to get the word out that many hospitalists have the tools to lead teams, and to manage teams, to non-hospitalist groups,” such as hospital administrators and the American College of Healthcare Executives. “We’re trying to get the word out that there are physicians in hospitals available to lead.”